Module 1 lecture notes role of NP

AANP definition of an NP's scope of practice includes:

"Nurse practitioners (NPs) are licensed, independent practitioners who practice in ambulatory, acute and long-term care as primary and/or specialty care providers. Nurse practitioners assess, diagnose, treat, and manage acute episodic and chronic illnesses. NPs are experts in health promotion and disease prevention. They order, conduct, supervise, and interpret diagnostic and laboratory tests, prescribe pharmacological agents and non-pharmacologic therapies, as well as teach and counsel patients, among other services."

Consensus Model for APRN Regulation

-APRN Consensus Work Group and National Council of State Boards of Nursing (NCSBN) APRN Advisory Committee -Address irregularities in regulation of advanced practice registered nurses across states

Nurse Practitioner scope of practice An adequate legal description is important for the following reasons:

-Allows NPs to perform at their level of education and training -Avoids any charges of practicing medicine without a license -Avoids imputation of liability for medical malpractice to someone other than the NP -Accountability is placed squarely on the NP -Provides a basis for inclusion of NPs in the legal definition of primary care and/or specialty or acute care providers -Establishes the NP as a professional entity, not a non-physician or physician extender -To get reimbursement for physician services when provided by the NP

•Two organizations certify nurse administrators:

-American Nurses Credentialing Center -American Organization of Nurse Executives -Both offer certification exams in basic and advanced nursing administration

How will patient flow be handled?

-Appointments -Payment and clinical intake Information -Provider visits -Follow-up

•Four distinct phases of other models:

-Assessing the problem/need for change -Setting change objectives -Implementing change -Evaluating the outcomes of the change

Advantages of solo practice include:

-Autonomy -Efficiency of one-person decision making -Less income necessary to support one person than multiple -No chance that another person's lack of productivity will affect one's business -No one can fire the nurse practitioner

Responsibilities of the practice owner:

-Confidentiality -Registering practice name with government -Disposing of hazardous wastes -Complying with fire marshal -Lab maintenance -Credentialing providers -Hiring and firing legally -Malpractice coverage -General liability After-hours contact information, coverage

Will reimbursement cover expenses?

-Cost is about -200,000 annually -Expense includes: rent, payroll, quarterly state and federal taxes, office expenses, utilities, answering services, supplies, hazardous waste disposal, payment on start up loans, professional dues, fee to register, accounting fees, attorney fees, business travel, gifts to staff, cleaning, insurance, application fee for hospital privileges, cell phones, advertising

-Advantages of ownership for the NP include:

-Decides length of patient visit -Decides how practice is run -Chooses employees -Controls quality -Controls referrals -Titrate workload to income -Keeps profits -Patient gets the benefit of NP and MD -Patients gets more face-to-face time with provider -Pays less, or gets more for the money -Better access to health care

•First half of 20th century

-Democratic, participatory style with positive, supportive relationships between manager and followers -Leader must pay attention to organizational goals -Theories and research studies supported behaviors and attitudes of leader affect follower satisfaction and group performance

In many states, the NP scope includes:

-Diagnosis -Treatment -Prescriptive authority -Admission of patients to hospital

•Complexity science

-Embraces theories and concepts from the natural sciences: chaos, complexity, quantum theories -Provides a new understanding -Complex adaptive system •Reformulates thinking to view systems as messy, disorganized, and unpredictable •Views systems holistically -Focuses on interconnection of the elements -Recognizes elements can change and grow based on these connections Embeddedness: emphasizes environment is also a complex adaptive system

•APRNs educated in at least one of the following population foci:

-Family/individual across the life span -Adult-gerontology -Pediatrics -Neonatal -Women's health/gender-related -Psych/mental health

Primary care management of women's health

-Focuses on pregnancy, childbirth, postpartum period, care of newborn, family planning, gynecologic needs of women

-Barriers of practice ownership

-Getting on commercial insurance provider panels -Getting and keeping a collaborative MD -Getting referrals from ER -Getting privileges at hospital -Lack of legal authority to admit patients to nursing home

Where will reimbursement come from?

-Government payers: Medicaid and Medicare -Private insurers: HMOs, MCOs, and indemnity insurers -Patients who pay their own bills -Contracts -Grants

Advanced practice nurses challenged to lead changes in healthcare organizations to:

-Improve quality -Decrease adverse events -Reduce costs -Enhance patient satisfaction -Transformational leadership preferred leadership style to accomplish these goals

1980s

-Leadership theory underwent major paradigm shift -From a focus on tasks and systems of controls -To one of building organizational culture to provide environment in which people are successful and organizational outcomes positive

Business plan for an NP practice should include

-List of services -Evidence of need for those services -Projections for the practice's income, expenses -Description of the principles involved -Organizational plan -Day-to-day operations plan -Investment needs -Potential problems and risks -Work life balance -Investment of time and money to start -Inconsistent income in the early stages of the practice start-up -Uncertainty about success -Anxiety about coworkers holding up their end of the responsibilities

-There are at least three good reasons to keep a portfolio:

-Many states require written documentation NP is trained to perform various procedures -Some states defer NP scope to those adopted by professional organizations -NPs in such states should have the appropriate organization's scope in their portfolios -Portfolios are an excellent replacement for resumes when interviewing for jobs

How will I get patients to come?

-Marketing -Repetition is a must -Create a sense of affiliation with the practice -Create an image for marketing message -Strive to exceed the patient's expectations -Patients kept worth thousands -Old patients (when applicable) -Word of mouth -Advertising

Advanced practice registered nurse (APRN)

-Master's-prepared nurses who provide direct clinical care. •Nurse practitioner (NP) •Certified nurse-midwife (CNM) •Certified registered nurse anesthetist (CRNA) •Clinical nurse specialist (CNS)

- NP scope of practice usually includes:

-Medical diagnosis -Medical treatment

Prior to starting a practice, research

-Need for service -Community interest in service -Size of potential patient pool -Willingness of community to use NP services -Willingness of third-party payers to reimburse NP services

RN scope of practice usually includes:

-Nursing diagnosis Nursing interventions/treatments

services provided by NPs

-Obtaining medical histories and performing physical examinations -Diagnosis and treatment -Ordering and interpreting labs, X-rays -Prescribing medications -Prenatal and family care -Well child and immunizations -Providing gynecologic examinations -Education and health risks, illness prevention, health maintenance -Independent decisions for management, treatment of medical problems -Makes hospital visits, follows hospital care of established patients

Responsibilities of an employer:

-Paying employment taxes -Ascertaining that a employees are American citizens, or legal immigrants -Worker's compensation insurance -Ensuring employee credentials -Training and maintaining training -Safe work environment -Complying with ADA

Other names for NP's

-Physician extenders -Mid-level practitioners -Nonphysician practitioners -Advanced practice nurses

Where will I get malpractice insurance?

-Policies and premiums change so the new practice owner will need to inquire about coverage, limits, and requirements 30-60 days before opening §A practice owner needs a policy that covers the NP practice owner as well as other staff or other clinicians working there

Advantages of group practice include:

-Possible greater access to capital -Possible shared call and office coverage -Another source of expertise -Social support -Possible economies of scale

What sort of quality and productivity measures will the practice institute?

-Productivity -Clinical performance

Clinical nurse leaders

-Responsible for patient care outcomes -Integrates and applies evidence-based information to design, implement, and evaluate healthcare systems and models of care delivery -Provider and manager of care at the point of care for individuals and cohorts of patients anywhere healthcare is delivered

•Results: organized by IOM's (2001) recommendations for quality health care

-Safe -Effective -Patient-centered -Timely -Efficient -Equitable

State statutes fall into six categories

-Scope of practice is clearly defined by statute -Scope of practice is clearly defined by regulation -Scope of practice is vaguely defined by the statute -Scope is not defined -Scope of practice is defined by exception from a state law prohibiting practice of medicine without a license -Scope of practice is defined by the individual physician who may delegate to an NP by law

What form will the business take?

-Sole proprietor -Partnership -Limited Liability Company -Corporation -Advantages, disadvantages to each?

Statutory vs regulatory Np scope of practice

-Some states define scope of practice in statues enacted by state legislature -In other states, the legislature grants authority to the board of nursing -Either way is enforceable and regulations carry the same force of law as statues

Mandated physician involvement with NP practice

-Supervision -Collaboration -Written protocols -Written agreement between NP and physician -Delegation -Direct

Nonphysician Practitioner

-Term used by Centers for Medicare and Medicaid Services and Medicare contractors -For Medicare purposes, includes nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant.

-Examples of NP practices:

-Travel medicine -Pediatric primary care -Wound care consultations -Home visits -Family health center -Urgent care -Cosmetic procedures

-Sermchief v. Gonzales (1984)

-Two obstetric-gynecologic NPs were working in a family planning clinic in Missouri -State board of medicine charged the NPs were practicing medicine without a license -Lower court agreed with the state board -NPs later prevailed when the state's supreme court overruled -Court noted the state legislature had removed a physician supervision requirement

•1947: Kurt Lewin

-Unfreezing: challenging the status quo to gain support that a change is needed -Freezing: making a change -Refreezing: solidifying the change into the culture

Physician Extender

-Used by physicians' associations, generally aimed at the physician market Refers to NPs collectively

Before starting a practice, also consider

-What form will the business take? -What systems need to be set up for: -Getting supplies? -equipment-and repairs? -Depositing cash? -Disposing of hazardous wastes -Who will be hired?

There are ten major business considerations when starting a practice:

-Who will I practice with? -Where will reimbursement come from? -Will reimbursement cover expenses? -How will we get patients to come? -Where will the practice be located? -If the state require a collaborative agreement, how will that be handled? -What sort of quality measures will be instituted? -How will patient flow be handled? -Will the practice use an electronic medical record, and if so, which one? -Where will I get malpractice insurance?

It is the NP's responsibility to perform

-only the services and care the NP is educated and certified to provide.

What services do NP's provide?

Diagnosis, and management of common, and complex medical conditions

According to a state nurse practitioner organization, What are NPs?

Registered professional nurses, prepared through advanced graduate education and clinical training, to provide a range of health services

Mid-Level Practitioner

Some states use this term for reimbursement DEA uses this term for licensure Licensed to dispense controlled or dangerous substances

Advanced Practice Nurse

Umbrella term used by some states to cover NPs, CNS, nurse midwives, CRNA

An NP is an RN who has earned a separate license

as an NP through advanced clinical nursing education and experience in a distinct specialty area of practice.

Another definition of an NP is that they are clinicians that blend

clinical expertise in diagnosis and treatment, with added emphasis on disease prevention, and health management.

First nurse-midwifery school

established in 1925

NPs with a DNP are finding

faculty positions at universities and executive positions in health networks as well as in government

Establishment of NP programs

from federal funding in 1970s

First education program emerged

from the University of Colorado in 1965

Today, nurse-midwifery programs

housed in colleges and universities

NPs may prescribe with physician oversight

if required by state law

The Doctor of Nursing Practice (DNP)

is for NPs who want a terminal degree but want to maintain a clinical, policy, or operations focus rather than produce, analyze, and evaluate research.

1978, James McGregor Burns

proposed transformational leadership in Leadership

Np role was developed as a way to

provide primary care for the underserved

NPs may construct a private practice

that conforms to state law by hiring a physician consultant

In response to physician shortage in 1960s,

the NP was created to solve the gaps in health care

First NPs started to practice in

the late 1960s

NPs who cannot be designated as providers may perform

the patient care if a physician is designated as the official provider

According to Federal Law. how are NPs are described?

those who perform, such services as such individual is legally authorized to perform in accordance with state laws and who meets such training, education, and experience required as the Secretary has prescribed in regulations."

Doctor of Nursing Program (DNP)

•2004, AACN formally approved the DNP degree •Focused on clinical practice •Reasons for the degree •Optimal to have clinicians who are well-educated in the areas of health policy, quality improvement, evidence-based practice, and outcomes evaluation

Health Delivery System Competencies

•Applies knowledge of organizational practices and complex systems to improve healthcare delivery. •Effects healthcare change using broad-based skills, including negotiating, consensus building, and partnering. •Minimizes risk to patients and providers at the individual and systems level. •Facilitates the development of healthcare systems that address the needs of culturally diverse populations, providers, and other stakeholders. •Evaluates the impact of healthcare delivery on patients, providers, other stakeholders, and the environment. •Analyzes organizational structure, functions, and resources to improve the delivery of care. •Collaborates in planning for transitions across the continuum of care.

Leadership Competencies

•Assumes complex and advanced leadership roles to initiate and guide change. •Provides leadership to foster collaboration with multiple stakeholders (e.g., patients, community, integrated healthcare teams, and policymakers) to improve health care. •Demonstrates leadership that uses critical and reflective thinking. •Advocates for improved access, quality, and cost-effective health care. •Advances practice through the development and implementation of innovations incorporating principles of change. •Communicates practice knowledge effectively both orally and in writing. Participates in professional organizations and activities that influence advanced practice nursing and/or health outcomes of a population focus

Nurse Practitioners' Unique Role

•Authentic Listening •Empathy •Negotiating •Going Above and Beyond •Impact of interpersonal skills

The Master's Essentials

•Background for practice from sciences and humanities •Organizational and systems leadership •Quality improvement and safety •Translating and integrating scholarship into practice •Informatics and healthcare technologies •Health policy and advocacy •Interprofessional collaboration for improving patient and population health outcomes •Clinical prevention and population health for improving health •Master's-level nursing practice

•Eight Steps of the Change Process -Step 6: Implementing Change

•Be visible, seek feedback, provide encouragement, communicate, resolve problems as they occur

•Pillars of Leadership Inspirational motivation

•Behaviors of transformational leaders that motivate and inspire followers

•Pillars of Leadership Interpersonal relationships

•Building positive interpersonal relationships by engaging with individuals and groups in a way that is characterized by open and honest communication

Clinical nurse sepcialists

•Care to patients with complex cases across healthcare settings •Role originated due to need for nurses who could provide advanced care to psychiatric populations •Educate nurses across specialties: oncology, medical-surgical, pediatric, critical care nursing

•Definition of an advanced practice registered nurse (APRN)

•Completed accredited graduate-level program for a recognized APRN role •Passed and maintains certification •Acquired advanced clinical knowledge and skills for providing direct care •Builds on competencies of RNs •Educationally prepared to assume responsibility and accountability for health promotion and maintenance of patient problems •Has clinical experience of sufficient depth and breadth •Has obtained a license to practice as an APRN in one of the four APRN roles

•Eight Steps of the Change Process -Step 2: Leading or Serving on an Interprofessional Change Team

•Contributions of many can lead to the most successful, sustained change

Scientific Foundation Competencies

•Critically analyzes data and evidence for improving advanced nursing practice. •Integrates knowledge from the humanities and sciences within the context of nursing science. •Translates research and other forms of knowledge to improve practice processes and outcomes. •Develops new practice approaches based on the integration of research, theory, and practice knowledge

Advanced Practice Nursing Focus

•DNP graduate must demonstrate practice expertise, specialized knowledge, and expanded responsibility and accountability •APN direct practice characterized by the use of a holistic perspective •Mandatory to have separate course for each of the three content areas •Advanced health/physical assessment •Advanced physiology/pathophysiology •Advanced pharmacology

Policy Competencies

•Demonstrates an understanding of the interdependence of policy and practice. •Advocates for ethical policies that promote access, equity, quality, and cost. •Analyzes ethical, legal, and social factors influencing policy development. •Contributes to the development of health policy. •Analyzes the implications of health policy across disciplines. •Evaluates the impact of globalization on healthcare policy development. •Advocates for policies for safe and healthy practice environments.

The foundation- Trust

•Enhanced employee performance •Improved organizational effectiveness •Greater commitment to the organization •Good communications and information sharing •Less resistance to organizational change •Improved team functioning •Improved job satisfaction/retention •Greater participation •Character: who you are; one's integrity and intent •Competence: your strengths and the results you produce; one's talents, skills, knowledge to work with others, and proven ability to deliver results

•Eight Steps of the Change Process -Step 4: Identifying and Analyzing Forces of Change

•Force field analysis •Assess forces and consider strategies to strengthen the facilitating forces and to decrease the resisting forces

Independent Practice Competencies

•Functions as a licensed independent practitioner. •Demonstrates the highest level of accountability for professional practice. •Practices independently, managing previously diagnosed and undiagnosed patients. Provides patient-centered care recognizing cultural diversity and the patient or designee as a full partner in decision making. •Educates professional and lay caregivers to provide culturally and spiritually sensitive, appropriate care. •Collaborates with both professional and other caregivers to achieve optimal care outcomes. •Coordinates transitional care services in and across care settings. Participates in the development, use, and evaluation of professional standards and evidence-based care

•Eight Steps of the Change Process. -Step 3: Developing a Team Vision and Charge

•Helps team appreciate meaning and purpose of the work of the team, aligns team toward common goal, commits team to a desirable future •Charter documents team purpose, vision, team processes, team expectations, deliverables

Technology and Information Literacy Competencies

•Integrates appropriate technologies for knowledge management to improve health care. •Translates technical and scientific health information appropriate for various users' needs. •Demonstrates information literacy skills in complex decision making. •Contributes to the design of clinical information systems that promote safe, high-quality, and cost-effective care. •Uses technology systems that capture data on variables for the evaluation of nursing care.

Ethics Competencies

•Integrates ethical principles in decision making. •Evaluates the ethical consequences of decisions. Applies ethically sound solutions to complex issues related to individuals, populations, and systems of care

Nurse educators

•Key resources in preparing nursing workforce to provide quality care to meet healthcare needs of a rapidly aging and diverse population •Must be competent clinicians •Debate in nursing education on clinical expertise for nurse educators

Nurse anesthetists

•Licensed as independent practitioners •Provide care autonomously in collaboration with surgeons, dentists, podiatrists, anesthesiologists •Provide evidence-based anesthesia and pain care services to patients at all acuity levels in a variety of settings for procedures

Nurse Practitioners' Approach to Patient Care

•Patient satisfaction with interpersonal skills of NPs •What Nurse Practitioners Do •Holistically oriented goals for self-care •Incorporates the vital elements of nursing and philosophical theories, communication skills, diagnostic skills, coaching and educating, and, developing reciprocal relationships with patients •Nursing Theories for Nurse Practitioners •Henderson's 14 basic needs •Watson's 10 Caritas Processes •5 As

Eight Steps of the Change Process -Step 1: Making Sense/Unfreezing

•People need to understand internal and external environments driving need for change

•Eight Steps of the Change Process -Step 5: Developing a Work Plan for Change Implementation

•Plans that are flexible •Taking multiple actions for one or more objectives •Pilot tests •Evaluations of structures, processes, outcomes •Need for people to learn new behaviors and ways of doing the work

•Eight Steps of the Change Process -Step 8: Incorporating Changes into the Culture/Refreezing

•Provide positive feedback; powerful tool to sustain change •Show appreciation for people who implemented change •Share widely successes attained

Practice Inquiry Competencies

•Provides leadership in the translation of new knowledge into practice. •Generates knowledge from clinical practice to improve practice and patient outcomes. •Applies clinical investigative skills to improve health outcomes. •Leads practice inquiry, individually or in partnership with others. •Disseminates evidence from inquiry to diverse audiences using multiple modalities. •Analyzes clinical guidelines for individualized application into practice.

Nurse practitoners

•Providing care to vulnerable populations in rural and urban areas since 1960s •Role born out of shortage of primary care physicians able to serve pediatric populations •Today, they are largest group of advanced practice nurses and provide high-quality, safe, and cost-effective care

proposed transformational leadership in Leadership

•Relationships between leaders and their colleagues characterized by engagement versus passivity •Transformational leaders bring out the best in the team and performance beyond expectations •Based on empowering team to work together toward a common vision versus power over others and imposing one's ideas and will •Ethical and focuses on the goals of the organization and development of all the team versus self-aggrandizement and personal gain at expense of others •

DNP Essentials

•Scientific underpinnings for practice •Organizational and systems leadership for quality improvement and systems thinking •Clinical scholarship and analytical methods for evidence-based practice •Information systems/technology and patient care technology for the improvement and transformation of health care •Healthcare policy for advocacy in health care •Interprofessional collaboration for improving patient and population health outcomes •Clinical prevention and population health for improving the nation's health •Advanced nursing practice •Components required for the DNP Scholarly Project

•Pillars of Leadership Professionalism

•Self-awareness from reflecting on one's experiences, skills, knowledge, values and attitudes, and feedback from others

•Pillars of Leadership -Business skills

•Types of business competencies

Quality Competencies

•Uses best available evidence to continuously improve quality of clinical practice. •Evaluates the relationships among access, cost, quality, and safety and their influence on health care. •Evaluates how organizational structure, care processes, financing, marketing, and policy decisions affect the quality of health care. •Applies skills in peer review to promote a culture of excellence. Anticipates variations in practice and is proactive in implementing interventions to ensure quality

-Step 7: Evaluating Outcomes and Refining as Needed

•Whether the objectives of the change project, as set out in the work plan, have been met