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
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”
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 lifespanAdult/Gerontology Neonatal Pediatrics Women’s Health/ Gender-related Psych/ Mental Health
APRN Roles
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
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.
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
The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.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
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
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Letters
Author's Reply to Readers' Responses to
"Advanced Practice Nurses Say 'No' to a Mandatory
Doctor of Nursing Practice Degree"
Wendy H. V
ogel, MSN, FNP
, AOCNP
Published: 01/25/2007
Should I do NP
or DNP
in the near future?
I know that the DNPdegree 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 be 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?
