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Developments in Advanced Practice Nursing Roles: US Perspective in Context of the HIV Epidemic

Debra Trimble, RN, MS, FNPC, AACRN University of Texas Medical Branch (UTMB), Galveston, TX Houston Area Community Services (HACS) Joseph-Hines Clinic Texas Woman’s University, College of Nursing, PhD Program Director At Large, Association of Nurses in AIDS Care

APRNs in the United States

What is an APRN? An APRN is a nurse   Who completed accredited graduate level education program in

recognized APRN role   Passed national certification exam in APRN role   Who has acquired advanced clinical knowledge and skills   Whose practice builds on competencies of RNs by demonstrating

greater depth & breadth of knowledge, synthesis of data & complexity of skills

  Who is educationally prepared to be responsible & accountable for health promotion, maintenance as well as diagnosis & management of problems, including pharmacological

  Who has clinical experience to reflect intended license   Who has obtained license to practice in 1 of 4 APRN roles—CRNA,

CNM, CNS or CNP Consensus Model for APRN Regulation: Licensure, Accreditation, Certification &

Education. (2008). APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee

NP FAQs HIV FAQs   43 years—began 1965

University of Colorado   125,000 practicing   600 million visits to NPs

each year   6000 new each year   325 programs of

education   How many provide HIV

care?

  Epidemic in US 1980   Evolving care paradigm—

acute to ambulatory with advent of HAART

  1990’s some schools developed specialty tracks; fellowships

  2002 & 2003—HANCB develops advanced cert exam & AAHIVM admits NP’s & PA’s to be “HIV Specialists”

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Where Do APRNs Practice? APRNs & Multidisciplinary Teams

APRN Regulatory Model (projected for 2015)

APRN Specialties Focus of practice beyond role & population

linked to health care needs

Population Foci

Family/individual

across lifespan Adult/Gerontology

Neonatal Pediatrics

Women’s Health/ Gender-related Psych/

Mental Health

CRNA CNM CNS CNP

APRN Roles

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APRN Regulatory Model: LACE   Licensure—granting authority

to practice (states)   Accreditation—formal review &

approval by recognized agency of educational degree & certification program

  Certification—formal recognition of knowledge, skills, & experience demonstrated by achieved professional standards

  Education—formal preparation of APRNs in graduate degree or post-graduate certificate programs

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APRN Specialties

  Optional; but must build on basic competencies   Focused on special populations   Criteria for defining built upon ANA Criteria for

Recognition as a Nursing Specialty   Preparation cannot replace educational preparation in one of 6

population foci   Preparation cannot expand scope beyond the role or population

focus   Addresses a subset of the population focus   Title may not be used in lieu of licensing title   Is developed, recognized & monitored by the profession

Quality of APRN Care

  Multiple studies  Horrocks, Anderson & Salisbury. (2002). Systematic

review of whether NPs working in primary care can provide equivalent care to doctors. BMJ, 324, 819-823.

 Mundinger, et. al. (2000). Primary care outcomes in patients treated by NPs ofr physicians: A randomized trial. JAMA, 283(1), 59-68.

 Wilson, Landon, & Hirschhorn. (2005). Quality of HIV care provided by NPs, Pas, and physicians. Annals of internal medicine, 143, 729-736.

Cost effectiveness of APRN Care

  In general—no statistical difference in direct patient care costs between NPs and MDs

 However NPs salaries/compensation usually less than MDs

Medical Malpractice Issues

  NPDB--cumulatively through 2006 235,942 reports—79% physician  Obstetrics still highest 8.7%

  In 2005, CNA Insurance Companies wrote a Nurse Practitioner Claims report based on claims from 1994 through 2004. There are relatively small numbers of malpractice cases involving NPs. But this study reports that 81.6% (n = 523) of the claim allegations against NPs fell into the categories of diagnosis, treatment, and medication occurrence. One hundred seven or 86% of the closed claims with indemnity payments fell within these same categories and are congruent with the findings of a 14-year study by the National Practitioner Data Bank. Miller (2007). The nurse practitioner, vol. 3.

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Medical Malpractice Issues   What are some of the potential solutions to decrease the malpractice

risk for NPs?   Clinical practices must be evaluated to see whether the best practices are being used;

  NPs don't have to know all the answers. They should continue to seek consultations with other knowledgeable providers;

  NP education programs must reevaluate their curriculums to see if they have strong programs in diagnosis, treatment, and the use of medications;

  NPs need to focus on basic risk management reduction programs: documentation of what is done or is not done is the core of risk management. Clear and comprehensive communication is the other basic essential skill to prevent malpractice litigation; and

  NPs must know the state NP scope of practice and not exceed those regulations. NPs must understand that staying within the rules keeps them within a circle of legal protection. Miller, (2007). The nurse practitioner, volume 3.

  Hilton (2005). NurseWeek: 20-30% care delivered via phone & this increases liability

Barriers to NP Practice

Barriers to NP Practice

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Current controversies—the DNP   On October 25, 2004, the members of the American Association of Colleges

of Nursing (AACN) endorsed the Position Statement on the Practice Doctorate in Nursing. AACN member institutions voted to move the current level of preparation necessary for advanced nursing practice from the master's degree to the doctorate level by the year 2015.

  How will the transition to the Doctor of Nursing Practice (DNP) occur?

The AACN Board of Directors formed a Task Force on the Roadmap to the DNP to study the full array of implications and issues resulting from this new direction in nursing education. The task force completed its charge to examine DNP program development, master's-to-doctoral transition programs, regulations and licensure, reimbursement for advanced practice nurses (APN) and other issues. The task force's final report was accepted by the AACN Board in July 2006. AACN will continue to work with an array of stakeholders, including APN groups, the higher education community, and healthcare providers to determine the best ways of implementing the DNP.

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DNP (cont)   How will consistency be assured across institutions offering the DNP?

Academic institutions will determine the focus of their DNP programs, as is currently the case for all graduate nursing programs, while adhering to a consistent set of standards titled the Essentials of the Doctoral Education for Advanced Practice Nursing (DNP Essentials), which identify foundational curriculum content and outcome-based competencies essential for all students pursuing the DNP. The Commission on Collegiate Nursing Education (CCNE), the nation's premier accrediting agency for baccalaureate and graduate nursing programs, has agreed to initiate a process for the accreditation of DNP programs that are offered by institutions of higher education.

  What will be the career progression from entry into nursing and the DNP? Multiple routes and mechanisms for career progression will be possible and ultimately decided by each educational institution. The proposed model allows for progression from the BS or MS or PhD to the DNP.

  Will the DNP diminish the need or support for PhD programs?

There is no evidence that practice doctorates compete with programs aimed at developing nurse researchers. The specific type of program that doctoral applicants choose depends on whether their preferred emphasis is in the practice arena or in scientific investigation. The practice doctorate is designed for those in direct clinical practice and areas that support clinical practice-administration, organizational management and leadership, and policy. AACN will continue its work to expand the pipeline of nursing scientists prepared in PhD programs. Research doctorates are a critical resource for supplying the evidence base for nursing practice.

  How will the DNP differ from the PhD, DNS, or DNSc in terms of curriculum content, research competencies, outcomes and roles occupied?

The Essentials of the Doctoral Education for Advanced Practice Nursing presents the specifics of this education and role. DNP programs will incorporate the APRN content currently included in master's programs. The DNP focuses on providing leadership for evidence-based practice. This requires competence in translating research in practice, evaluating evidence, applying research in decision-making, and implementing viable clinical innovations to change practice. Considerable emphasis is placed on a population perspective, how to obtain assessment data on populations or cohorts, how to use data to make programmatic decisions, and program evaluation. If a DNP desires a more formal research role, additional preparation will likely be required-similar to a MD completing a PhD. The PhD and DNS/DNSc programs are research intensive. In many cases PhD graduates accept academic or governmental positions where research is a major expectation. The DNP graduates will likely seek practice leadership roles in a variety of settings-management of quality initiatives, executives in healthcare organizations, directors of clinical programs, and faculty positions responsible for clinical program delivery and clinical teaching would be appropriate.

From http://www.aacn.nche.edu/DNP/DNPFAQ.htm

Headlines…editorials

  New Doctoral Degree Aims to Advance Nursing Practice New programs for DNP are enrolling students, but many issues remain unresolved. By Lorraine Steefel, RN, MSN, CTN May 9, 2005

Medscape General Medicine > Departments >

Letters Author's Reply to Readers' Responses to

"Advanced Practice Nurses Say 'No' to a Mandatory

Doctor of Nursing Practice Degree"

Wendy H. Vogel, MSN, FNP, AOCNP

Published: 01/25/2007

Should I do NP or D

NP in the near future?

I know that the DNP degree is replacing

the NP in the near future.

I'm thinking of starting an to NP program

after I've had a year or so of hospital

experience after completing my MSN,

which will mean that I'll be applying NP

schools by the end of 2010.

Will it still b

e a good idea to go for the NP

at that late date? Or will it make more

sense to prepare for the change by getting

a DNP instead?

DNP resources

  http://www.nann.org/pdf/DNPEntry.pdf   http://www.aanp.org/NR/rdonlyres/

105556AC-24FC-4FFF-A9EE-08CDC6DB1BE5/0/DNPGROUPLETTER608wcopyrightandattribution61908.pdf