Advanced Practice Roles in Nursing
Hamric, Hanson, Tracy, and O’Grady (2014) describe the advanced practice nurse (APN) as a nurse who has met advanced educational and clinical requirements. Previously, the term advanced nursing practice (ANP) was used to describe these roles, but in attempts to unify the profession, the term APN has been adopted (Hamric et al., 2014). APNs include Nurse Practitioners (NPs), Certified Nurse-Midwives (CNMs), Clinical Nurse Specialists (CNSs), and Certified Registered Nurse Anesthetists (CRNAs). The American Nurses Association (2019) describe each of these roles:
“Nurse practitioners provide health care to the population through assessment, diagnosis, and treatment of illness and injury. Nurse-Midwives focus on gynecological and reproductive care. Clinical Nurse Specialists focus their attention on supporting their fellow nurses and bringing about organizational changes. Lastly, CRNAs are experts in pain management and anesthesia.”
There are also other nursing roles that require certifications and additional education such as a master’s degree and contribute greatly to the nursing profession and healthcare in general. These include the nurse educator, nurse informaticist, and nurse administrator/executive. The nurse educators teach, the nurse informaticist are involved in technology, and the nurse administrator or executive is in a position of management and authority.
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Each of these roles are diverse in their specialty and patient population but have similar educational requirements and ultimately rely on core nursing values to guide their practice. I will be focusing on the role of the nurse practitioner in this paper since this is what I will be studying at South University.
According to Hamric et al. (2014), nurses began providing primary care to the population as early as the nineteenth century. Those nurses primarily focused their attention on rural areas with little to no access to medical care. In the 1960’s the modern nurse practitioner role was established, which serviced the pediatric population (Hamric, Hanson, Tracy & O’Grady, 2014). Now, in 2019, after much advocacy and pioneering, there are a multitude of specialties and settings in which the nurse practitioner can function. The specialty determines the patient population and type of illness or disease the provider will be working with. Nurse practitioner specialties include, but are not limited to, intensive care, family care, gerontologic, neonatal, emergency, cardiology, pediatric, psychiatric, oncologic, pain management, and women’s health. The setting a provider works in is also important. Nurse practitioners function in a clinical role, which means they directly treat and care for patients (Hamric et al., 2014). They can practice in a hospital (acute care) or they can work in the outpatient setting (primary care).
I am specializing in family care and will become a family nurse practitioner (FNP) upon graduation. According to “Role and Scope of Practice of a Family Nurse Practitioner” (2019), family nurse practitioners focus on the patient throughout their lifespan and work alongside primary care physicians to provide disease management, health promotion, and preventative services. Family nurse practitioners have a wide knowledge base, work with a diverse patient population, and can function in many different settings (Role and Scope of Practice of a Family Nurse Practitioner, 2019). I would love to work in the outpatient primary care setting caring for the adult population.
I have loved my nursing career thus far. While working in oncology and bone marrow transplant, I have come to appreciate the importance of screening and prevention, educating patients and their families, advocating for those who are unable to advocate for themselves, and providing emotional support during hard times. I believe that these experiences have led me to pursue this new role and have sparked my passion and desire to care for patients at a higher level.
After reflecting on these issues, my knowledge, values, and the things I have learned I have developed a personal philosophy for my career as an FNP. As an FNP, I will treat patients and their families with the upmost respect. I will care for them as I would want my own mother or father cared for. I pledge to be an honest and trustworthy provider. One that my patients can trust and confide in. I will provide a safe environment for my patients and be their biggest advocate. I will maintain a holistic, patient-centered approach regarding the patients care and health. I will follow this philosophy and it will guide my practice each day.
Holliday (2017) evaluated patient outcomes in a study conducted at a level one trauma center. The hospital wanted to improve patient outcomes by focusing on their APNs. Once the study started, they required the NPs to attend multidisciplinary rounds in the intensive care unit (ICU), had the NPs manage trauma patients, and they opened a clinic so that the patients could be seen by the NP after discharge (Holliday, 2017). This study followed and monitored 3,284 trauma patients from September 2012 to August 2015 (Holliday, 2017). They found that with the new system changes, hospital length of stay decreased by 0.98 days in the first year, ICU length of stay decreased, length of time from admission to placement of rehab center deceased, discharge orders were placed sooner and there was a decrease in readmissions (decreased by 1.8%), missed injuries, complications from pneumonia, and DVTs (Holliday, 2017).
Another research study was conducted to evaluate patient satisfaction related to nurse practitioner services. The study analyzed the experiences of 53,885 patients from the Consumer Assessment of Healthcare Providers and Systems survey. According to Kippenbrock, Emory, Lee, Odell, Buron, and Morrison (2019), the survey showed that the overall NP satisfaction ratings were very high and Medicaid patients rated NPs communication skills as high as other providers. They determined that by utilizing nurse practitioners in the primary care setting could lead to greater patient satisfaction (Kippenbrock, Emory, Lee, Odell, Buron, & Morrison, 2019).
To better understand the role of the family nurse practitioner, I shadowed and interviewed one. I conducted an interview with Greg Guinoo on Thursday, August 22, 2019. The interview is as follows. When asked, what made you want to become a nurse practitioner, Greg explained that he originally wanted to be a doctor. He said that he loved diagnosing, treating and prescribing and knew that he could also do this as a nurse practitioner (personal communication, August 22, 2019). Greg completed medical school in the Philippines and then moved to the United States. He was unable to find a school that would accept him into residency, and he heard that Kennesaw State University (KSU) in Georgia started a program to bridge foreign trained medical students into nurses and then nurse practitioners in a fast tract program. He completed nursing school first with his bachelor’s degree and worked on a medical-surgical floor at Emory Hospital in Atlanta. He then went on to obtain his master’s degree (Greg Guinoo, personal communication, August 22, 2019). His typical day is as follows: He wakes up and takes Marta from south of Atlanta into Sandy Springs, where Northside Atlanta is. He works three twelve-hour shifts per week. He explains that he typically gets his assignment emailed to him the night before his first shift of the week (sometimes he will do some research on the patient the night before). Once he gets to work, he sits down at his computer in his office and starts to look over the electronic medical record (EMR) for each of his patients assigned that day. He checks the labs, vital signs, diagnostic results, nursing notes, and medications for each patient. He starts with the planned discharges and critical patients first. Once he finishes checking the EMR, he starts his rounds. Rounds are composed of an introduction and quick assessment. Around 0900 the physician arrives to the floor for an interdisciplinary meeting. The meeting includes the manager of the unit, the charge nurse, the attending doctor, the nurse practitioners working on the floor, occupational therapy, physical therapy, pharmacy, the psychologist, and nutritionist. They go through the critical patients, planned discharges, bone marrow transplants, and any significant events happening for the day. Once the meeting is over, the doctor starts his rounds. Greg will follow the doctor to round with him on his assigned patients. They will discuss how treatment is going, any changes, and the plan. Once Greg has finished rounding with the MD and his personal rounding, he can then chart on each of his patients. He also is available to answer questions and collaborate with the floor nurses that are caring for his patients. His role is to collaborate with the physicians to treat, monitor, and manage the patient’s conditions (Greg Guinoo, personal communication, August 22, 2019). Greg informed me that the hardest part of his job was losing patients (personal communication, August 22, 2019). He also said that currently the program has a lot of patients who are hospitalized and not enough NPs, so they are taking more patients than usual, which has been a challenge (personal communication, August 22, 2019). Greg feels respected by everyone at Northside. He does not feel any tension with the doctors. He explained that every doctor is different. Some are easier to talk to and ask questions, while others are more set in their ways. He says that the doctors respect the NPs and allow them to be independent. He went on to explain that the only thing they must get approved is chemotherapy orders and transplants (personal communication, August 22, 2019). Greg says that seeing patients cured is the best part about his job. He says he enjoys challenging cases. Greg is very satisfied with his job and especially the hospital where he works. He says he loves being a nurse practitioner, but the environment also plays a big role (personal communication, August 22, 2019). The biggest piece of advice that he gave was the importance of time management and organization. He says this is the key to being a successful NP (personal communication, August, 22, 2019).
Georgia Scope and Stands of Practice
The scope and standards of practice for advanced practice nurses (APNs) vary from state to state. According to the state of Georgia (2019), the scope and standard of practice is as follows, “the nurse practitioner provides advanced practice nursing care and medical services specific to the nurse practitioner respective specialty to individuals, families and groups, emphasizing health promotion and disease prevention as well as the diagnosis and management of acute and chronic diseases. The nurse practitioner collaborates as necessary with a variety of individuals to diagnose and manage clients’ health care problems”. To practice as a nurse practitioner in Georgia one must have a current registered nursing license, complete the state board application, pay the application fee, provide proof of completion of educational requirements (master’s degree in nursing, advanced pharmacology, advanced health assessment, and advanced pathophysiology), and become certified by the appropriate certifying board (State of Georgia, 2019).
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The state of Georgia has also put into place rules, regulations, and restrictions regarding the practice of APNs. They require the development of a “nurse protocol agreement” between the physician and advanced practice nurse (State of Georgia, 2019). The nurse protocol agreement should be in writing and include the role of the nurse practitioner in writing prescriptions for controlled substances and narcotics and addresses the consultation and delegation process (State of Georgia, 2019). Unless practicing in a hospital, school or university, free health clinic, or birthing center there is only four APNs that can enter into the nurse protocol agreement per one physician. They are also limited regarding prescriptive authority. They cannot write prescriptions for scheduled one or scheduled two medications or medications for abortions (State of Georgia, 2019).
There is much controversy surrounding APNs, restriction and regulation of practice, and reimbursement. For example, according to the Department of Health and Human Services Centers for Medicare & Medicaid Services (2016), “services are paid at 85% of the amount a physician is paid under the Medicare Physician Fee Schedule (PFS)” (p. 9). This means that for the exact same service, a doctor is reimbursed 100% while the NP is only reimbursed 85% when they bill under their own name. This has obviously brought about many discussions and debates. In my opinion, the person preforming the service should not matter. If the practitioner is practicing in accordance with their state laws and regulations, then the reimbursement and payment should be equal. This process is undermining the value of APNs and other mid-level providers.
To bring about change in this arena one would have do much research on the topic and become very knowledgeable about insurance, billing, and reimbursement. Once one feels comfortable about the issue at hand, then they could create a committee or join an existing committee with people of the same beliefs and values. This would also include interviewing experts and getting various opinions on the matter. The individual would then have to contact their representative in Congress and present the research findings as well as the proposed change.
There are many organizations available to the APN and nurse practitioner. There are international, national, state, and even more specific organizations that focus directly on the selected specialty. These organizations provide access to other members, continuing education, job opportunities, and up to-date information and policies. An example of a national organization for nurse practitioners is the American Association of Nurse Practitioners (AANP). The organization for the state of Georgia is the United Advanced Practice Registered Nurses of Georgia.
Leadership is an important part of the advanced practice nursing role in patient care, the nursing profession, and the organization in which an individual is employed. Policy changes, improvement of regulations, and improvements in patient outcomes all require leaders in nursing to initiate change. My leadership style is democratic. According to Cherry (2019), a democratic leadership allows each member to be creative, express their ideas, and participate in decision making. This leadership style allows the members to feel empowered and therefore be more engaged. Transformational leadership occurs when “the purposes of the leader and follower become fused, creating unity, wholeness and a collective purpose” (Hamric et al., 2014, p 272). When the leader and the follower are on the same page and both feel empowered great things get accomplished and changes can be made. When practicing in the primary care setting, I intent to continue my democratic leadership style with patients and other members of the healthcare profession. I hope to leave my patients and their families feeling empowered to take control of their health.
In conclusion, there are many diverse roles of the advanced practice nurse. Each one unique and important to the nursing profession and the healthcare system as a whole. While each of the roles have their responsibilities, they also face many challenges in their practice. It is important for us to be educated and informed about these challenges and rise up as leaders in the profession to bring about positive change that ultimately improves outcomes for our patients and their families.
- American Nurses Association (2019). Advanced Practice Registered Nurses (APRN): American Nurses Association. Retrieved from https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/aprn/
- Department of Health and Human Services Centers for Medicare & Medicaid Services (2016, October). Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants. Medicare Learning Network. 3-17.
- Hamric, A. B., Hanson, C. M., Tracy, M. F., & O’Grady, E. T. (2014). Advanced practice nursing an integrative approach (5th ed.).
- Holliday, A. (2017). An Outcome Analysis of Nurse Practitioners in Acute Care Trauma Services. Journal of Trauma Nursing, 24(6), 365-E2. https://doi.org/10.1097/JTN.0000000000000327
- Kippenbrock, T., Emory, J., Lee, P., Odell, E., Buron, B., & Morrison, B. (2019). A National Survey of Nurse Practitioners’ Patient Satisfaction Outcomes. Nursing Outlook. https://doi.org/10.1016/j.outlook.2019.04.010
- Ramira, M. L., Peraza-Smith, G. B., McLeod, R., & Clark, M. J. (2018). Challenges, Barriers, and Satisfiers of Foreign Educated Physicians with the Family Nurse Practitioner Role in the United States. Journal of Cultural Diversity, 25(1), 12–22. Retrieved from https://search-ebscohost-Com.southuniversity.libproxy.edmc.edu/login.aspx?direct=true&db=rzh&AN=129125509&site=eds-live
- Role and Scope of Practice of a Family Nurse Practitioner. (2019). Retrieved from https://nursejournal.org/family-practice/role-scope-of-practice-of-a-family-nurse-practitioner/
- State of Georgia. (2019, August). Rules and Regulations of the state of Georgia, 410-11.03.
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