Conceptual model for advanced practice nursing in primary adult care

¶ … advanced practice nursing that provides framework for job description of primary adult nurse practitioner.

Introduction-- definition of advanced practice nursing

Advanced practice nursing itself is popularly known as a concept that embraces three dynamics: 1. The specialization or provision of care for a specific population of patients with complex and usually unpredictable health needs; 2. The possession of knowledge, skills, and research that exceeds the traditional scope of nursing practice and particularly nursing practice in this specific field; and 3, advancement, which includes specialization and expansion in the field (ANA, 1995). The three conditions are interrelated and focus on the four primary conditions of nursing: health, environment, patient, and nursing.

In short, advanced practice nursing may best be defined in the words of ANA (1995) as an innovative, continuous development of skills, synthesis of experience, knowledge, and skills, and a holistic, patient-centered focus to the craft all constituent in what is known as 'advanced practice nursing' (Watson, 1995).

All agree that the title implies an integration of practice and skills where the objective is to improve patient health through education, research, clinical practice, and organizational leadership. Critical thinking is required and so is synthesis of disciplines. (e.g. Calkin, 1984). Advancement, by far, exceeds the traditional conceptualization of nursing in that it exceeds the role of nursing per se and enters into a diversity of other fields where applicable concepts are extracted and applied to nursing.

Sykles and Lewis (2000) see advanced practice nursing (APN) as a pyramid where the base stands on environmental factors that influence the nature and purpose of nursing. These include the local conditions, the nursing profession the health care system, culture, the government, and the APN community itself. In other words, all contracts, policies and procedures that drive and undercut the health care service and the nurse practitioner role within that service. The rest of the pyramid has layers within which the various roles of APN interact one with the other. The base however of the environment structure both guides the permutations of the pyramid and provides resources whereby APN can best function and actualize itself.

B.-- personal philosophy of nursing and its influence on your role as a primary adult nurse practitioner (must include the four concepts of nursing: health, patients/person, environment, and nurse/nursing)

The philosophy of nursing that has made the greatest impact on me and involves all four aspects of health, patient, environment, and nursing itself is the AACN model.

The AACN paradigm was launched in the 1990s by the American Association of Critical-Care Nurses that convened in order to formulate a paradigm for nursing that would guide the profession. It was agreed that certified nursing should be based on meeting the patient's needs and on qualitative care rather than on following a set of rigidly delineated methods (Hardin, 2005).

The AACN model is deductive in that it was formulated around a set of eight characteristics that the patient presents and around another set of eight competencies that the nurse possesses. These eight patient characteristics (resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability) define the basis of AACN care, and nurses direct their set of skills (clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, response to diversity, facilitation of learning, and clinical inquiry) accordingly (AACN, 2006).

The basis of the AACN model is that it is the patient's needs that drive the competencies of the nurse and that synergy is accomplished when the patient's needs are met. To the extent that the patient's needs are met is skilled nursing achieved.

The four concepts of the nursing meta paradigm are thus conceptualized in the following manner:

1.Patient's characteristics are of concern to the nurse, 2. The nurse's competencies are important to the patient, 3. The patient's characteristics drive the nurse's competencies, and, 4. Optimal nursing is achieved when the patient's characteristics and the nurse's competencies match and are synergized (Hardin & Kaplow, 2005).

The AACN Model for Patient Care is constructed on the following 5 assumptions:

1. Patients are presented in a holistic manner at a particular stage of their development and the whole (biological, psychological, social, and spiritual) must be considered in treatment.

2. Patient, family, and community all provide context for nurse in her nursing relationship with the patient.

3. Patients can be described by a variety of characteristics that must be seen in unison rather than apart.

4. Nurses, similarly, can be described by a set of interrelated characteristics, or skill dimensions that describe the overall skill, competency, and expertise of the nurse.

5. The objective of nursing is to move the patient towards the optimal end-result required and defined by the patient. Sometimes, this may be death. In which case, the objective of nursing would be to achieve a peaceful and relaxing death for the patient (AACN, 2006).

The AACN model is congruent to my work as adult nurse practitioner, in that it is easy to become diverted by many tasks and many different patients, therefore, miscarry on tasks and attentions. Adults, too, can be more critical than children and more apt to complain and be demanding. It is too easy to become acrimonious and bitter. Focus on patient, as the center of nursing is something that I aim to focus on often.

By focusing on the needs of the patient, and on how the nurse, using her competencies and knowledge can best meet these needs, nursing is moved forward from a robotic, task-driven curricula to a more intentional, patient-focused discipline. In this manner, too, better work and quality results are achieved whilst the essence of nursing is accomplished.

Attached to preference of the AACN model is also my belief in evidence-based nursing that Professor David Sackett, one of its pioneers, has decribed EBP in the following manner, as consisitng of:

"The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research (Sackett et al., 1996; p. 71)

EBP, essentailly, admonishes nurses to practice crical thinking and become independent researchers instead of relying on a traditional classroom-mode of teaching where instruction is transmitted in a doctrainaire sort of fashion.

According to Jennings and Loan (2001), EBN has caused a paradigmatic shift in the field because, instead of nurses following authority opinion, as was previously the case, the caregiver now based his practice on data-based evidence, using research skills to collect and appraise her evidence. It is the research findings, now, that provide the basis of clinical decisions, and, in order that this be so, contemporary student nurses are taught the nuances and skills of reading, interpreting, and conducting research. This is quite a paradigm shift, since research and statistics had been omitted from nursing curriculum in the past having been considered inessential to the discipline.

The two together epitomize best for me what advanced practice nursing is all about: namely, the integrated matrix of practice and skills for the betterment of nursing as both particular skills and transcending particular skill.

3). Conceptual Model-- a schematic drawing which identifies the major components of advanced nursing practice as a primary adult nurse practitioner based on the four concepts of nursing: health, patients/person, environment, and nurse/nursing

The Primary adult nurse practitioner employs all of her nursing skills to the betterment of the health of adults. Here, specialty in other words is adolescents and adults. How APN would fall into play here would be by maximizing her knowledge and skills and improving the delivery of the health care services.

A schematic and conceptual model would be the PEPPA framework that provides a participatory, patient-centered, evidence-based orbit from which to work and sets out the major components of advanced nursing practice. Applicable to any form of nursing, it is ideal for the adult health nurse practitioner since it incorporates the four concepts of nursing. And does so within an integrated skills / knowledge / practice diagram.

Described as 'a democratic process for involving individuals in organizations education systems, and communities in promoting health and social change" (e.g. Deshler & Ewert, 1995). The PEPPA model centers on collective investigation, reflection, valuing others people's knowledge and experience, analysis; learning; monitoring one's actions; and conscious production of new knowledge (Bryant-Lukosius & Dicenso, (2004)).

It contains nine steps:

1. Define patient population and describe current model of care: Our patient population -- is of course the adult population. The nurse would analyze her current practice and methods as regards the components of health, patient, environment, and the state of nursing components itself. More elaborately, Smith (1997) extends this to an analysis of how patients and families enter the health care system and interact with the nurse over the period of time that service is provided. The patient is the center of the model, and other issues, such as environment and nursing, are evaluated.

2. Identify stakeholders and recruit participants: Stakeholders here include patients, families of patients, volunteers, physicians, nurses -- in fact everyone related to the patient and to his or her context in patient's healing. The assumption is that the adult health worker is not alone but rather contributes a unit of impacting forces and these can better or obstruct her services in all the four aspects of health, patient, environment, and the state of nursing components itself. None are in isolation; all are conjoined, and for optimum effects, all have to work in unison and form one integrated, directed process focused on patient's improvement and comfort. Also related is that patient should not be overburdened by too many stakeholders. The sufficient and relevant stakeholders should be involved, no more and no less, and, if family and friends are supportive, these should be included as well. This is partly so since as patient-focused model of care, patient's culture plays a great deal in impacting and contributing towards his recovery. In order to be a better adult nurse, the nurse has to understand patient's particular cultural values and see him or her as holistic whole placed within those cultural perimeters. The families and friends provide another dimension that must be incorporated. Finally, the facilitators and physicians are important here. But this is beyond the nurse's orbit of concern.

3. Determined need for a new model of care. Here, the adult nurse reflects on her present actions and level of knowledge. Her reflections involve the four areas of her general nursing strategies and promulgation of those strategies; the way her health-care is distributed; the effects of the environment on the patient; and her attitude toward the patient himself. Questions include: what are patients and family health needs? The context and consequences of those needs; factors that contribute to those needs, and so forth. Research is invested in understanding and meeting these needs better. Health problems must be distinguished form patient health needs. Needs (as per Maslow (1970) for instance) are objectives or enhanced self so health is missing from the patient's life and that can be measured according to specific psychological instruments. Problems, on the other hand, are diseases or adversities that the patient is suffering from (such as pneumonia). Problems come before needs, although -- in a psychosomatic type of explanation -- the two are intertwined, needs sometimes (although not always) causing problem, and problems sometimes eventuating in needs, It may be that frequently both need to be dealt with. It is in this manner, for instance, that an adult health care nurse following the EPN approach and possessing a broad knowledge base, is best suited to optimize her profession.

4. Identify priority problems and goals: just as needs and problems are two separate issues, patients may have a hierarchy of needs and problems and it is up to the adult health care nurse to distinguish between these problems and prioritize them so that those that are most significant receive foremost attention and care.

5. Define the new model of care and APN role: This is the action stage where the adult health care nurse conceptualizes, plans, and implements research, research discussion, analyses, and ways to insert this research into practice. Here, she considered her goals and how new methods and particular research findings could be implemented in ways to expand these and reach these goals. Contextual features of environment, health, and patients, as well as nursing in general are considered as the whole invested in her routine so that all is intercalated aorudn patient.

6. Plan implementation strategies: This stage primary consists of planning where the nurse practitioner evaluates how her research can best be employed within a clinical context for the good of the patient and the family. Research is evaluated, discussed, deliberated on, and reviewed within a collaborative setting. Planning involves education; administrative supports; regulatory mechanisms; and support of patients and all connected with patient; as well as support of colleagues, physicians and relevant personnel. It is n this way, and throughout the model that the four conditions of expert clinician, educator, researcher, and consultant are met.

7. Initiate APN role implementation plan: Role implementation is a continuous process, and communication must be constant between all parties. This is particularly so since countless variables must be met and culminate in satisfactory nursing. Care must be taken therefore that all involved are on 'the same page' and that all work towards the same goal: patient's improvement and satisfaction.