Enhancing psychiatric nursing practice: role of an advanced practice nurse.

In response to demands for alternative health models that deliver cost-effective quality care, one large Midwestern medical center implemented a change in their nursing practice model. The change involved the introduction of unit-based nursing leadership teams that included advanced practice nurses (APNs). This article reports the findings from an investigation that employed a case study design to evaluate the process and outcomes of integrating an APN on a psychiatric unit with experienced nurses. Data collection methods included a nursing survey (n = 34), interviews with nine randomly selected nurses, and two multidisciplinary open forums. Consistent with the staff nurses' survey ratings of important advanced practice role functions, responses from the nursing interviews and open forums suggested nurses' professional development to be the most positive outcome. Role confusion was identified as a negative outcome. Recommendations for improved integration and use of APNs in today's psychiatric health environments were identified.     

Measuring advanced practice nursing outcomes

The measurement of outcomes has become an important component of evaluating health care. Although it is clear that measuring outcomes is necessary to establish the effectiveness of advanced practicing nursing, which outcome measures to use and how to conduct an effective outcomes assessment remain unclear. The purpose of this article is to present an overview of advanced practice nursing outcomes research, review outcome measures important to advanced practice nurses (APNs), and discuss sources of outcome measures and instruments that can be used by APNs to establish the effectiveness of the role.     

The development of advanced practice roles: implications in the international nursing community

This article examined the critical elements that have been identified in the development of advanced practice roles of nurses in four countries: Brazil, Thailand, the United Kingdom and the United States of America. Several sociopolitical and professional forces were examined for possible insights and ways in which they may have shaped the development and evolution of the roles of advanced practice nurses (APNs). These forces were: the socio-political environment; the health needs of society; the health workforce supply and demand; governmental policy and support; intra- and interprofessional collaboration; the development of nursing education; and documentation of effectiveness of the advanced role. The development of APN roles in the four social systems was reviewed to illustrate how socio-political and professional forces may have shaped nursing roles in each health care delivery system. Commonalities and distinguishing features across the four health and social systems were analysed to assess the predictive forces that may be identified as advanced roles in nursing have evolved in the global community.     

Trends in mental health: implications for advanced practice nurses

PURPOSE: To examine current trends in mental health care for vulnerable populations and suggest how advanced practice nurses (APNs) can incorporate mental health care into primary care practice. DATA SOURCES: Original research and evidence-based clinical articles, government publications, and professional practice guidelines. CONCLUSIONS: Vulnerable populations, such as racial and ethnic minorities, adults with chronic mental illness, the elderly, the incarcerated, and those living in rural areas have long been ignored as recipients of quality, integrated health care services. There is a compelling need for APNs to participate in the integrated delivery of physical and mental health care to all Americans, especially to vulnerable populations. IMPLICATIONS FOR PRACTICE: Under the umbrella of advanced practice nursing, a variety of nurse practitioners (NPs) and clinical nurse specialists (CNSs) can offer a holistic approach to the provision of evidence-based health care in a wide variety of settings to an array of vulnerable and underserved people. By serving on provider panels, partnering with consumer groups, and advocating for the unmet health needs of vulnerable populations, APNs can have a positive impact on the health care delivery system.     

Outcomes for community health nursing practice.

OBJECTIVE: The purpose of this study was to develop an easy, practical list of outcomes amenable to community health nursing interventions. This study sought to answer the following question: What outcomes are sensitive to nursing interventions in the community health setting? SUMMARY BACKGROUND DATA: Nursing literature discusses many client outcomes. However, available outcome lists are not always sensitive to nursing interventions by community health nurses. Nurses need a precise list to measure client outcomes resulting from contact between nurses and clients in a variety of community health settings. METHODS AND SUBJECTS: The study used a modified Delphi technique to ensure adequate response from the subjects. Initially, focus groups generated items for the Delphi questionnaires. Using items from the focus groups, the researchers developed three rounds of questionnaires. In each round, nurses stated a level of agreement with each item as an outcome for community health nurses. Twenty-two community health nurses in one Southeastern state participated in four focus groups. One hundred fifty-two community health nurses returned round 1 questionnaires, 68 nurses returned round 2 questionnaires, and 48 nurses returned round 3 questionnaires. RESULTS: The researchers grouped the outcomes into four domains: client's psychosocial components of care, client's physiologic components of care, nursing intervention/implementation components of care, and environmental/community safety components of care. CONCLUSIONS: The findings produced an easy, practical list of 48 nursing outcomes for use in decision making and research by community health nurses in all settings.     

Confidence and knowledge regarding ethics among advanced practice nurses

As the scope of advanced practice nursing expands and the educational requirements increase, so do the ethical responsibilities. How prepared are advanced practice nurses (APNs) to manage the ethical challenges in advanced practice? The purpose of this study was to determine APNs' ethics knowledge and perceived level of confidence in their ability to manage ethical problems in advanced practice. Assuming ethics knowledge and abilities of APNs are similar to those of medical residents, a survey instrument for medical residents was modified for use with APNs. Responses to the modified survey indicated a fairly high level of confidence but a fairly low level of knowledge. Studies show that ethics education can be effective in improving knowledge, confidence, and ethical behavior. Given the expanding role of APNs as doctors of nursing practice, research is needed to determine the ethics knowledge needs and teaching strategies to better prepare nurses for the challenges of advanced practice.     

Advanced practice nurses' perspectives on the use of health optimization strategies for managing chronic disease among older adults in different care settings: pushing the boundaries of self-management programs

This study examines the intention of advanced practice nurses (APNs) to utilize health optimization programs (HOPs) for addressing clients' chronic disease in various work settings (i.e., nursing homes or other care settings). A paper-based survey was administered to 270 APNs at a continuing education conference to determine their intentions to refer patients to HOPs for chronic disease management. APNs working in nursing homes were 0.23 times as likely to utilize HOPs for management of their patients' chronic disease compared with their counterparts working in other care settings (odds ratio = 0.23, confidence interval = 0.06-0.80, P = .021). APNs who had previously used a HOP for management of their patients' chronic disease were 5.2 times as likely to do so again relative to those who had not previously used a HOP for management of their patients' chronic disease (odds ratio = 5.17, confidence interval = 1.78-14.99, P = .002). Educational and organizational interventions are recommended to disseminate further HOPs for chronic disease in nursing home settings as part of an overall health optimization strategy.     

Clients' Evaluation of Health Care Services in a Battered Women's Shelter

Abstract There is a dearth of evaluation research regarding shelter health care. Health needs outweigh health services which are rarities within shelter settings (Gross & Rosenberg, 1987). The purposes of this article are to review the need for shelter health care, describe how shelter-based advanced practice nurses (APNs) addressed health care needs and program goals in one shelter setting, and report findings from an impact evaluation study where APN services were rated by shelter clients ( n = 69) for themselves and their children ( n = 95). APNs have the ability to manage health care in shelter settings, but need to seek creative funding by documenting their worth. A 21-item evaluation survey was designed to measure components of health assessment and education provided to clients by APNs. Content and construct validity were addressed by a statistician and nursing experts, and the internal consistency reliability coefficient (Cronbach's alpha) was measured at .91. Results showed that clients (96.1%) identified strongly positive responses to health services provided with some weak areas detected. Implications include the need to continue programs that serve vulnerable populations in times of cutbacks. Measuring program effects via impact evaluation is recommended for services in process to monitor quality and to give impetus to funding opportunities.     

Nursing Research Priorities for Ireland

PURPOSE: The purpose of the study was to identify and rate clinical, managerial, and educational nursing research priorities in Ireland. DESIGN: The study design was a three-round, decision Delphi survey to identify and rate the importance of clinical, managerial, and educational research issues. A discussion group workshop was also undertaken to identify timeframes within which research on the issues identified should be conducted. A total of 1,695 nurses from all divisions of the nursing register in Ireland were initially surveyed. Response rates varied over the three rounds of the Delphi survey. A total of 122 nurses attended the discussion group workshop. This is the largest known survey of nurses to identify research priorities reported in the literature. RESULTS: Twenty-four nursing research priorities were identified. The five highest priorities were three clinical issues: outcomes of care delivery, staffing issues in practice, communication in clinical practice; and two managerial issues: recruitment and retention of nurses, and nursing input into health policy and decision-making. CONCLUSIONS: These research priorities identified for nursing in Ireland indicate, to an extent, the nursing research priorities identified in other European countries and in North America. The research priorities identified in this survey indicate that outcomes of care and the need to make nursing visible are attaining a higher priority than seen in previous studies. Also evident is that nursing shortages and increasing skill-mix in the clinical area have indicated a need for research into nurse recruitment, staff turnover, and staffing levels and how these issues affect patient outcomes. The priorities suggest research programmes that target the health service concerns identified in the national health agenda, such as the need to identify protocols and procedures that improve patient and client care outcomes and to examine and test solutions to workforce problems.     

Advanced practice nurses as faculty.

This article details a program through which two child health faculty members who are advanced practice nurses (APNs) combined practice with teaching undergraduate students in a community-based clinical experience on nursing case management. A collaborative agreement between a university-based Children's Special Services Team (CSST) and school of nursing faculty was developed to extend services into the home communities of children with special healthcare needs. Senior students made visits to the homes of the team's clients, conducted assessments, interacted with families, and provided additional care. The team, which included physicians, nurses, a social worker, and therapists (occupational and physical) identified children and families who would benefit from home visits by students nurses who were directed by APNs. Both service and educational goals were accomplished by this community-based case-management experience. The children and their families received additional care from multiple healthcare providers. Students practiced components of community-based case management, and the CSST obtained vital information about their clients' living environments.     

Nurse perspectives of nurse-sensitive indicators for positive patient outcomes: A Delphi study

BackgroundPatient safety, quality of care, and nurse-sensitive indicators are common areas of focus in international research relating to patient outcomes. Recent literature relating specifically to nurse-sensitive indicators has leaned towards an emphasis upon negative outcomes, such as ‘missed care’, ‘delayed care’, ‘failure to rescue’ or a reduction in adverse events rather than focus on nursing activities that lead to positive outcomes. In addition, little is known about nurse perspectives of nurse-sensitive indicators for positive patient outcomes.ObjectiveTo identify and describe priority nurse-sensitive indicators linked to positive patient outcomes in the acute care setting.DesignA modified Delphi Technique consisting of three rounds of electronic questionnaires to 90 Clinical Nurse Specialists and Charge Nurse/Managers working in acute care settings in New Zealand.MethodsDelphi round one survey collected data on key nursing activities and tools important to patient outcomes. Delphi round two survey presented round one data for rating importance to patient outcomes using a rating scale question design. Delphi round three survey presented round two data to participants within the ‘Patient Experience Indicators’ identified by the New Zealand Health Safety and Quality Commission’s domains for ranking in order of importance via a ranking question design. Round one data were analysed to discover themes emerging from the responses to formulate activity options. In round two, responses were given an average rating score, calculated on the weight assigned to each answer choice. In round three the ranking average was calculated using weighting and response count.ResultsThe results from the third round presented activities from each domain and these were ranked from highest to least importance, with 75% or greater indicating consensus. Of highest importance within each domain were: Communication: Listening; Partnership: Establishing trust, building relationships; Coordination: The threshold of 75% consensus was not reached; Physical and Emotional Needs: Identification of rapid change/deterioration, observation/identification of patient status, and increased assessment skills.ConclusionSome nursing activities were difficult to rank in terms of importance as nurses perceived they were inter-related and of equal importance. The soft applied skills of nursing practice have been highlighted as important nursing activities by experienced nurses in this research, which poses a challenge for health care and nursing education sectors to label, value and support enactment of these skills in the nursing workforce as legitimate contributions to positive patient outcomes.     

Outcome indicators for direct and indirect caregiving

Informal caregiving and outcomes for caregiving are an important part of health care and of particular importance in nursing. The purpose of this research is to report the results of a survey mailed to nursing experts for validation of the outcome labels Caregiver Role Performance: Direct Care and Caregiver Role Performance: Indirect Care and their accompanying indicators. Experts were asked to rate how important the identified indicators were for assessing those two outcomes. In addition, the respondents were asked to what extent nursing interventions influence the achievement of each identified indicator for Caregiver Role Performance: Direct Care and Caregiver Role Performance: Indirect Care. In general, the validity of the concept analysis work by the caregiver focus group was supported. Ten indicators for Caregiver Performance: Direct Care were retained, 1 was dropped that was considered most appropriate for indirect care, and 3 new indicators were added to reflect the nurse experts surveyed. For Caregiver Performance: Indirect Care, all of the indicators were retained.     

Does education level influence the practice profile of advanced practice nursing?

BackgroundAdvanced practice nursing is recognised globally as central to meeting this community need. Whilst there is increasing recognition that advanced practice nurses should be educated to at least a master degree level, there is scant evidence on the influence of higher education on the practice profile of advanced practice nursing.AimTo investigate the relationship between level of education and domain practice scores of nurses in advanced practice roles.MethodsThe validated Advanced Practice Nursing Role Delineation (APRD) tool was used to measure the practice profile of advanced practice nurses at different postgraduate education levels, across five domains of nursing practice activities. A cross-sectional electronic survey of nurses was used.FindingsAPNs with higher degrees performed at a higher level across all five domains of the APRD tool compared to those who did not hold a higher degree. This was highly significant for the domains of Research and Leadership, followed by the Optimising Health Systems and Education domains, but not significant for the Direct Care domain.DiscussionQuestions are often raised about the benefits of investing in nurses’ education, particularly the need for a higher degree for advanced practice nurses. APNs with higher degrees have a different emphasis in their role activities than those without a higher degree. This difference could be significant given current global health challenges.ConclusionHigher education changes the practice profile of APNs. Those with higher education are more likely to be involved in research and leadership with knowledge integration across all practice domains.     

Incorporating outcomes research into clinical practice: the four-step approach

Outcomes research is designed to develop new and generalizable knowledge about care delivery, interventions, and patient outcomes. Advanced practice nurses are asked not only to participate in outcomes research but also to develop and maintain outcomes research projects and databases and to demonstrate the effectiveness of their own care practices through outcomes research. A four-step approach is described as an easy way in which to help advanced practice nurses engage in outcomes research at any site and with any patient population. The four steps are: Step I: identify and describe current practice in nursing-medical care and its outcome(s); Step II: data collection; Step III: data analysis; and Step IV: praxis: putting the research into practice. Participating in outcomes research will allow advanced practice nurses to improve healthcare services and to secure the role of advanced practice nurses in the changing healthcare arena.     

Graduate education in geropsychiatric nursing: findings from a national survey

By 2030, the numbers of older adults with mental illness will strain our health care system. Sufficient advanced practice nurses (APNs) with specialized knowledge to provide care will be critical. All 339 graduate nursing programs in the US were surveyed regarding the extent and nature of geropsychiatric nursing (GPN) content in their curricula. Of 206 schools responding, 15 reported having a GPN subspecialty. Regarding the 60 schools with a psychiatric/mental health nursing (PMHN) graduate program, only one third (n = 23) included some GPN content, while more than half (n = 116) of all schools reported integration of GPN content in a non-psychiatric nurse practitioner program. Thus, currently, the greatest numbers of APNs receiving education on mental health needs of older adults are prepared in non-psychiatric nurse practitioner programs. This article discusses the implications for nursing education and practice.     

Clinical education in managed care for advanced practice nurses: A case example

Managed care is a major component in the current practice environment of advanced practice nurses (APNs). Professional nursing organizations are incorporating managed care concepts into their requirements for nursing curriculum. Partnerships for Quality Education (PQE) was developed to foster partnerships designed to incorporate managed care skills into clinician education. This paper describes how one PQE-funded nurse practitioner project joined with a federally qualified community health center (FQCHC) to provide a foundation in managed care theory and practice to nursing students, clinicians, and other support staff.     

Advanced practice nurses in emergency care settings: A demographic profile.

INTRODUCTION: Very little is known about clinical nurse specialists and nurse practitioners (advance practice nurses [APNs]) who practice in emergency care settings. The Advanced Practice Committee of the ENA sought to determine a profile of these individuals. METHODS: Surveys were distributed to all registrants at 2 ENA conferences and posted on the ENA Web site. This survey asked 17 questions concerning the demographic characteristics of the APN respondents (eg, education, experience, certification, state recognition, and practice area). The survey was completed by 166 APNs. RESULTS: APNs had considerable experience as ED registered nurses before becoming an APN. They obtained their APN education at the master's degree or post-master's degree level. State recognition was required for 89.2% of the APNs. The majority of APNs (61.4%) obtained their certification through the American Nurses Credentialing Center. Nurse practitioners were predominantly family nurse practitioners (43%), and clinical nurse specialists were either critical care clinical nurse specialists (8.9%) or had other certifications (5.9%). APNs provided services in both the main emergency department and the fast track (45.7%) and were relatively new to their role as an APN. DISCUSSION: Consistent with current educational and certification requirements, the vast majority of APNs held a master's degree. Although relatively new to their role as APNs in emergency care, they were nonetheless very experienced as ED registered nurses. The majority of APNs were certified, even though that is not required for practice in all states. Continued research is needed to identify the most effective utilization of APNs, document their contributions to patient care outcomes, and develop strategies to meet their educational and practice needs.     

A community-oriented primary care nursing model in an international setting that emphasizes partnerships

PURPOSE: To present an interdisciplinary, community-oriented primary care nursing model that effectively draws upon the strengths of advanced practice nurses (APNs), both nurse practitioners and community health nurses. DATA SOURCES: Articles in professional nursing journals, international data sources, and the clinical experiences of the authors, both domestic and international. CONCLUSIONS: The model, developed domestically, was utilized successfully by APNs internationally in a medical mission endeavor in rural Haiti. Many partners, domestic and Haitian, worked as an interdisciplinary team to deliver quality health care to an impoverished population. Graduate nursing students participated in the program, which offered opportunities and challenges for both novice and expert nurses. IMPLICATIONS FOR PRACTICE: Nurse practitioners, community health nurses, and nursing faculty members can use this model to enhance their professional practice. They can learn that clients can be optimally cared for whether the community served is domestic or international. Nursing faculty can teach graduate nursing students about the value of partnerships and collaboration.     

Home health care nursing research priorities

The purpose of this study was to determine research priorities for home health care nursing. A Delphi study was undertaken to generate and prioritize research topics. The first round consisted of members of the Home Health Nurses Association Research Committee (n = 27); subsequent rounds also included nurse researchers who had conducted research in home health care (n = 17). Consensus emerged after three rounds, with the four most important priorities identified as outcomes, health policy, the use of advanced practice nurses, and models of care/best practice. These areas are consistent with the regulatory events in home health care in the last 10 years.