Christopher Manacci, MSN, ACNP

The National Flight Nurse Academy

Frances Payne Bolton School of Nursing

Case Western Reserve University

Advanced Nurse Practitioner Education in Advanced Nurse Practitioner Education in the USA;Past, Present and Futurethe USA;Past, Present and Future

Discuss the definition and educational requirements for becoming a Nurse Practitioner

Understand the differences between Nurse Practitioners and other providers.

Discuss the Acute Care Nurse Practitioner scope of practice

Late 1950’s-Ingles/Stead

1960-CNS

Mid 1960’s-NP’s

1990 ACNP

• 1970-Neonatal NP

• 1997-Balanced Budget Act

• Early 1990’s-NP required have master’s degree urban settings

• 2000-CTP passed

• 1994-ACNP scope of practice

• 2002-Prescriptive Authority fully implemented

Historical PerspectiveHistorical Perspective

Clinical Nurse Specialist

Certified Nurse Midwife

Certified Registered Nurse Anesthetist

Certified Nurse Practitioner

Registered nurses who:◦Are master’s or doctoral prepared◦Has become an expert clinician in a specialty

area. ◦National certification is optional.

The functions of the CNS include clinician, leader, educator, and change agent to improve quality of care.

Ohio Association of Advanced Practice Nurses, 2001

Registered nurses who:◦Have advanced training in Women’s health and

midwifery. ◦Have a master’s degree and ◦Are nationally certified

The functions of the CNM include labor and delivery, prenatal, postpartum, newborn and routine gynecological care

Ohio Association of Advanced Practice Nurses, 2001

Registered nurses who:◦Have critical care training◦Have a master’s degree in the delivery of

anesthesia◦ Is nationally certified

CRNA functions include: administration of anesthetic agents/drugs for surgical, diagnostic procedures, and acute and chronic pain control

Ohio Association of Advanced Practice Nurses, 2001

Registered nurses who:◦Have a master’s degree or doctorate◦Are nationally certified ◦Have advanced training and education in a

specialized area of health care CNP functions include: management of

acute and chronic illnesses and disease prevention to a variety of age ranges in a variety of care settings

Ohio Association of Advanced Practice Nurses, 2001

Neonatal nurse practitioner Family nurse practitioner Adult nurse practitioner Acute Care Nurse Practitioner

Nurse Practitioner◦CNP works under his/her license

◦Responsibility rests on competence of individual

◦ In collaborative arrangement, parties interact under mutual respect and authority.

Written guideline which defines responsibilities, accountabilities, and obligations of the specific CNP practice.

Limited by:◦State legislation◦Standard Care Agreement◦Credentialing institution ◦Collaborating Physician Scope of Practice

Physician licensed to practice medicine in Ohio who agrees to work with the Advanced Practice Nurse in order to mutually establish a procedure for patient care

Ohio State Board of Nursing, 2001

Systematic formal guide for planning and evaluating health care.

State of Ohio Board of Nursing, 2001

Written agreement between CNP and collaborating physician regarding guidelines of care and scope of practice.

Clinical Research Educator Consultant Administrator

Nurse Practitioner

Rounds H&P’s/discharges Physical exams Evaluation/initiation of

plan of care◦diagnostics◦pharmacotherapy◦multidisciplinary

collaboration

Intubation Line placement: central, Swan, arterial Tube Thoracostomy Wound Closure Lumbar drain Subdural drain removal CSF specimens C-spine clearance Laceration repair VP shunt reprogram

Identify research opportunities Collaborate to develop research

study/design Incorporate evidenced based practice Identify quality/performance issues Communicate specialty knowledge through

professional publications

Prioritize patient/family learning needs

Conduct formal/informal teaching

Provide teaching to other health care disciplines or community agencies as requested

Clinical resource and continuity

Quality assurance involvement

Multidisciplinary contact to assist with patient flow/resource utilization

Formulary ACNP

Family/Adult

Approved for intravenous:

Approval for oral/ may not prescribe IV:

• Inotropes • Inotropes• Nitrates • Nitrates• Antiarrhythmics • Antiarrhythmics• Vasodilators • Vasodilators• Beta blockers • Beta blockers• Antihypertensives • Antihypertensives• Vasopressors • Vasopressors

Blood Plasma Expanders Parenteral vitamins Parenteral

electrolytes

Systemic alkalinizers

Anticoagulants IV-Aminoglycosides NSAIDS-prescription

Key elements of the acute care nurse practitioner :

•Advanced clinical expertise•Development of differential diagnoses•Use of medical diagnostic reasoning to formulate the plan of care•Order and prescription of pharmacologic and non-pharmacologic therapy

Key elements of the acute care nurse practitioner :

•Planning and management of patient care across the acute care continuum•Utilization and performance of invasive and non invasive interventions and procedures to promote physiologic stability or obtain diagnostic information•Surveillance of care•Accountability and authority for patient care outcomes across settings and boundaries

Key elements of the acute care nurse practitioner:Key elements of the acute care nurse practitioner:

•Evidence-and research-based clinical practice.•Monitor, evaluate and refine care in a continuous fashion•Accountability and authority for patient outcomes across settings •Clinical leadership•Managing and negotiating health care delivery systems,•Prevention and promotion of health•Provide care for awareness of the uniqueness of the individual.

• Diagnostic reasoning• Advanced pharmacology• Invasive interventions• In keeping with the standards of the nursing profession• Introducing graduate level academic preparation for

research and practice.

Formal PreparationFormal Preparation

•Provide the highest level of care to those most in Provide the highest level of care to those most in need.need.

•Create a mechanism for the distribution of Create a mechanism for the distribution of research into clinical practice.research into clinical practice.

•Advance science and Nursing.Advance science and Nursing.

•Reduce cost by early intervention.Reduce cost by early intervention.

•Educate those already trained and meet today’s Educate those already trained and meet today’s societal needs.societal needs.

ACNPACNP

ROTORROTORMobileMobileICUICU

AMETAMET

FixedFixed

WingWingGlobal Global

ResponseResponse

ResponseResponse

Transport Transport

& Care& Care

Differential Diagnosis

Evaluation

& Triage

Mobilization

Resources

Prescriptive Plan / Intervention

Data CollectionResearch

Outcome

Evaluation

Potential Revenue Stream Consultation

Potential Revenue Stream Clinical Mgt

Potential Revenue Stream Funded Projects

Advanced Practice ModelAdvanced Practice Model

The Case Western Reserve University Frances Payne Bolton School of Nursing, in collaboration with our clinical partners:

The First UniversityThe First University Degree ProgramDegree Programwith Subspecialty in Flight Nursingwith Subspecialty in Flight Nursing

Louis Stokes Cleveland Louis Stokes Cleveland VA Medical CenterVA Medical Center

Semester 1 (Fall) NURS 405NURS 405 Inquiry I (3)Inquiry I (3) NURS 438NURS 438 Theoretical Foundations of Acute Care Nursing (4)Theoretical Foundations of Acute Care Nursing (4) NURS 453NURS 453 Physiologic Foundations of Adv Practice Nursing (4)Physiologic Foundations of Adv Practice Nursing (4) NURS459NURS459 Advanced Assessment (3)Advanced Assessment (3)

Semester 2 (Spring)Semester 2 (Spring) NURS406NURS406 Flight Nursing Seminar I (1)Flight Nursing Seminar I (1) NURS415NURS415 Inquiry II (4)Inquiry II (4) NURS430NURS430 Pharmacology and Therapeutics (3)Pharmacology and Therapeutics (3) NUNP 443NUNP 443 Acute Health Problems of the Adult II (6)Acute Health Problems of the Adult II (6)

Plan of Study; Full-time study 48 semester hours

Semester 3 (Fall) NURS 404 Emergent Care of the Child (2) NURS 407 Flight Nursing Seminar II (1) NURS 443 Professionalism in Advanced Practice (3) NURS 444 HC Delivery, Legal and Ethical Issues in APN (3) NURS 503 Inquiry III (2) NUNP 444 Advanced Management of Acutely Ill Adults (4)

Semester 4 (Spring) NURS 523 Advanced Internship in Flight Nursing (1-5)

Headquartered at the Frances Payne Bolton School, the Flight Headquartered at the Frances Payne Bolton School, the Flight Nurse Academy features environmental and human simulators Nurse Academy features environmental and human simulators for in-flight training.for in-flight training.

Synthetic Natural EnvironmentSynthetic Natural Environment

Summer CampSummer Camp

Synthetic Natural EnvironmentsSynthetic Natural Environments

Human SimulationHuman Simulation

Summer CampSummer Camp

““Taking critical care from the bedside Taking critical care from the bedside to the roadside”to the roadside”