Role Of An Advanced Practice Nurse Nursing Essay

Role Of An Advanced Practice Nurse Nursing Essay

Role Of An Advanced Practice Nurse Nursing Essay

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Waukesha Memorial Hospital is a community-based not-for-profit hospital located near Downtown Waukesha, Wisconsin. The hospital was originally founded in 1914 and moved to its current location in 1930 after receiving sponsorship through the local Kiwanis Club. The hospital has now grown to over 300 inpatient beds and employs over 2,700 staff members. The hospital is part of a larger healthcare network known as ProHealth Care. ProHealth Care was created in 1998 when the Waukesha Hospital System and Oconomowoc Hospital joined forces. The organization is now comprised of 26 primary care clinics, home health care, inpatient and home hospice services, long-term care, senior residency communities, and a health and fitness center (Waukesha County, 2010).Role Of An Advanced Practice Nurse Nursing Essay

ProHealth Care has created a worldview for an optimal healing community which encompasses their mission, vision, and value statement. The mission of the organization is to “promote and deliver extraordinary health care in the communities it serves”. The vision is to “continue to be the provider of choice in the markets they serve as an optimal healing community distinguished by high-quality, cost-effective care and excellent service in an environment of safety, respect, and compassion”. The organization values a response of excellence service, respect, and compassion. The mission, vision, and values influence four strategic keys to the organization’s plan for success: Value Proposition, Physician Development and Relations, Employee Excellence, and Partnership with Patients and the Community (ProHealth Care, 2010). The espoused theory of the organization is that the influences of the mission, vision, and values on the strategic planning will create an optimal healing community. The theory in action appears to be congruent with the espoused theory as Waukesha Memorial Hospital was named one of the top 100 hospitals in the 2009 Thomson Reuters Health System Benchmark Study. Winners of the award had better patient outcomes and fewer complications, fewer safety errors, and higher patient satisfaction rates than their peers (Thomson Reuters, 2010).Role Of An Advanced Practice Nurse Nursing Essay

The leadership of Waukesha Memorial Hospital is organized into a professional bureaucratic design. A Mintzberg model of the organizational structure can be found on page 4. Within the microsystem of the hospital, there are many subsystems. Subsystems are grouped together in one of specialty areas: Medical Staff Excellence, Clinical Excellence, Operational Excellence, Patient Experience, or Environment. Each of these categories has a Chief Operating Executive who then reports to the President/CEO of the hospital. Skills of professionals are standardized throughout the entire system; however, each subsystem functions relatively independently of the other subsystems within their category. The strength of the support staff in each subsystem creates the core of operating professionals (as demonstrated in the Mintzberg diagram). The techno-structure is present around the outside of the operating core; however, it does not have a strong influence on the core leadership.Role Of An Advanced Practice Nurse Nursing Essay

The Waukesha Memorial Hospital system is influenced by several regulatory agencies including JCAHO (Joint Commission on Accreditation of Healthcare Organizations), CMS (Centers for Medicare & Medicaid Services), and the Wisconsin DHS (State of Wisconsin Department of Health Services). Accreditation of the system is obtained through JCAHO after an on-site evaluation/survey of the system is completed. Surveys take place every 18-39 months. During the survey, the hospital is evaluated on compliance of specific standards determined by JCAHO for that accreditation year. These standards are determined to ensure that patients

receive care in a safe and secure environment. While accreditation is not required for a hospital to be in operation, there are many benefits to accreditation through JCAHO; mainly it is required by CMS to be eligible for Medicare reimbursement (The Joint Commission, (2010).Role Of An Advanced Practice Nurse Nursing Essay

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CMS influences the system by determining which services provided by the hospital are eligible for reimbursement through Medicare and Medicaid. CMS dictates core patient care measures by which the hospital is expected to perform. If these goals are not met and there is not supporting documentation stating why the goal wasn’t met, CMS may withhold reimbursement for portions of the hospital’s billing. CMS also sets standards of care that will no longer allow reimbursement for certain complications of a hospital stay, i.e. acquisition of a pressure ulcer or hospital-acquired infection. Therefore, all services rendered in these instances must be paid for by the hospital system. This has forced the hospital system to initiate preventative and aggressive measures to ensure a higher level quality of care to all patients.

The State DHS Division of Quality Assurance also influences the system by developing rules and standards for the improvement of quality of patient care. State licensure and federal certification are obtained through the DHS and required for operation of the acute care facility. Like JHACO, the DHS also performs on-site surveys to ensure patient safety and/or investigate any complaints against the facility (Wisconsin Department of Health Services, 2008). The system has also been affected by legislation at the local level. For several years, a competitor system attempted to move into ProHealth’s market area. Local municipalities passed legislation that temporarily kept the competitor out of the area, but eventually, the competitor was allowed to build an acute care hospital within several miles of a ProHealth acute care system.Role Of An Advanced Practice Nurse Nursing Essay

Waukesha Memorial Hospital is also influenced by other specialty and/or professional organizations. Involvement with an outside organization is generally determined by each category/subsystem within the hospital system. For example, the category Clinical Excellence is influenced by the American Nurses Association and Wisconsin Nurses Association. Nurses within the hospital system may choose to become active members in these societies to join forces in order to influence healthcare related legislation and its effects on patients and nursing staff. Within the subsystems categorized for Clinical Excellence, the ICU is involved with the American Heart Association, the American Association of Critical-Care Nurses, etc, whereas the OR is involved with the Association of Perioperative Nurses. These nursing organizations help create higher standards of care within their specialty area, promote continuing education to nurses, and provide certification for nurses within their area of expertise. Nurses at Waukesha Memorial Hospital are encouraged to become certified in their area of work as the hospital seeks to apply for Magnet Status from the American Nurses Credentialing Center. Achieving Magnet Status testifies that the hospital demonstrates excellence in nursing care. One of the requirements for application for the certification is that a certain percentage of nurses within the organization pass a certification exam within their area of care (med/surg, critical care, etc).Role Of An Advanced Practice Nurse Nursing Essay

The hospital system has also created partnerships with several community organizations such as the Kiwanis Club, the United Way and the Waukesha Memorial Foundation. These partnerships promote the overall well-being of the community as well as a respectable public image for the hospital. In a now more competitive market, Waukesha Memorial’s continued commitment to the community has helped maintain the public’s loyalty to the organization.Role Of An Advanced Practice Nurse Nursing Essay

The community surrounding Waukesha Memorial provides a diverse payer-mix for services rendered, however, exact statistics could not be found. The hospital serves patients with private insurance, no insurance or governmental coverage (Medicare/Medicaid). No person is denied hospital care based on inability to pay. The hospital does budget a substantial amount of funds yearly to help cover costs to those who are uninsured and unable to pay, however, the cost is not able to be deferred for all patients within these circumstances. While this patient group may receive needed care, the cost can be unbearable, forcing these individuals to forego needed therapies. This negatively impacts the community, making it more ill, financially strained, and under duress. As part of the strategic initiatives set by the hospital for 2010, patient education and health promotion plans were initiated to help decrease preventable hospital admissions and continue movement toward an optimal healing community.Role Of An Advanced Practice Nurse Nursing Essay

Part 2: Description and Analysis of a Professional Nursing Role within the Healthcare System
In the past year, Waukesha Memorial Hospital has considered adding an Acute Care Nurse Practitioner role in the management of patients in the Intensive Care Unit (ICU). Currently there is one advanced practice nurse (APN) role assigned to the ICU and this individual functions as the unit Nurse Educator. In contrast to the Nurse Educator, the addition of the Acute Care Nurse Practitioner (ACNP) role would place the APN at the bedside. The role of the ACNP within the ICU would focus on direct patient care. This would include but is not limited to daily patient care rounds, interdisciplinary patient rounds, family/patient conferences, ventilator management, and endotracheal tube and vascular catheter placements. The ACNP would also be responsible to ensure that evidenced-based practices are maintained within the unit’s standards of care.Role Of An Advanced Practice Nurse Nursing Essay

The ACNP in the ICU at Waukesha Memorial would be required to maintain state licensure as a registered nurse, certification in critical care through the American Association of Critical Care Nurses, and certification as an ACNP-BC through the American Nurses Credentialing Center. The ACNP would function within the ICU subsystem of the Clinical Excellence Category of the Leadership Organizational Chart. Key organizational relationships would need to exist between the ACNP and the ICU manager and director, the WMH Intensivist physician group, and the Performance Improvement nursing committees within the ICU. Collaboration with staff nurses, nurse specialists, and interdisciplinary team members would be essential to ensure quality, efficient, and safe patient care. Nursing collaboration would include the Diabetes Nurse Practitioner, the Stroke Nurse Coordinator, the Infection Control Nurse, the Nurse Care Coordinator/Discharge Planner, and the unit Nurse Educator. Collaboration with the Diabetic NP is essential as many patients in the ICU suffer from hyperglycemia which can inhibit healing and promote infection. The Stroke Coordinator is vital to the ICU of a Primary Stroke Center (certified by JCAHO) and with collaboration brings best practice to the patient suffering from stroke. Partnership with the Infection Control Nurse will decrease rates of hospital-acquired infections which are more likely to occur in the ICU. Alliance with the Nursing Care Coordinator allows for improved patient/family satisfaction in the emotional and spiritual aspects of illness. Finally, teamwork with the ICU Nurse Educator ensures improved education of staff nurses and therefore improving care of the patient at the bedside.Role Of An Advanced Practice Nurse Nursing Essay

Adding an ACNP role to the ICU collaborative team has the potential to greatly improve the ICU environment and patient outcomes. In an article published by Kleinpell, Ely, and Grabenkort in 2008, studies completed on the use of ACNPs in an ICU demonstrate that the ACNP improves collaboration and communication within the unit between medical, nursing, interdisciplinary, and support staff. Patient management by ACNPs within the ICU has shown to decrease overall length stay, days on mechanical ventilation, and total cost of care for the ICU patient. ACNPs are more likely to adhere to best practice guidelines and ensure their implementation at the bedside. The increased autonomy of the ACNP allows for a holistic, patient-centered care approach over a more curative care approach often provided by a physician or physician’s assistant. This approach has been shown to increase patient’s satisfaction with their hospital stay. These studies validate the strengths of the ACNP role within the ICU.Role Of An Advanced Practice Nurse Nursing Essay

The weakness of the ACNP role within the ICU is the continued lack of understanding of the role by the healthcare team, by patients, and by the community. There continues to be confusion regarding what an ACNP is and what they can do and what an ACNP is not and what they cannot do. It is up to the Advanced Practice Nursing community to continue to educate their peers, patients, and communities about the benefit of their role in the collaborative health team.


Today, the American healthcare system faces many challenges to provide adequate healthcare. As the country’s population grows, coupled with the passing of the Affordable Care Act, the country not only has a shortage of healthcare providers, but now has the increased responsibility to provide coverage to those previously without affordable healthcare. Advanced Practice Nurses (APNs), a group of highly qualified, educated clinicians are ready to play integral roles in the reform of healthcare. Unfortunately, because APN regulation is determined on the state level, the scope of practice for APNs varies state to state. Consequently, national unpredictability, both administratively and legislatively creates an unfavorable environment for APNs to provide consistent, proper care. The following paper will attempt to not only provide a brief history regarding the development of the APN, but additionally review the roles of the four recognized general areas of APN specialization. Furthermore, each APN role will not only be expanded upon such to differentiate, but compared and contrasted, as well as analyzed from a local, state, national, and international perspective such to conclude by providing assertions regarding the current state of the advanced nursing practice.Role Of An Advanced Practice Nurse Nursing Essay

History of APN

All APN roles have a long history in healthcare; certified nurse anesthetists (CNAs) were introduced in the late 1870s, certified nurse practitioners (CNPs) in the 1960s, certified nurse midwives (CNMs) in the early 1920s, and the clinical nurse specialist (CNSs) role developed in the late 1940s. However, even though APNs have had well recognized roles in medicine for well over a century the officially recognized APN role originated in the 1960s. Ironically, as history often repeats itself, the APN role emerged due to a shortage of primary care physicians that coincided with the expansion of national healthcare coverage. With the initiation of Medicare and Medicaid, the first APN program was developed at the University of Colorado in 1965 by Professors Loretta Ford, PhD,Role Of An Advanced Practice Nurse Nursing Essay

RN and Henry Silver, MD to prepare pediatric APNs to focus on health and wellness. Working together with physicians, APNs were taught to not only identify symptoms, but to diagnose and manage the healthcare problems in children. In the 1970’s the program’s focus changed to primary care such to provide primary healthcare access for large and underserved populations. In 1971, the Secretary of Health, Education and Welfare issued primary care intervention recommendations whereas nurses and physicians could now share responsibility, implying support for nurses. Subsequently, federal monies were made available to support APN programs nationally. By the mid-1970’s, at one point therewere in excess of over 500 certificate programs which then shifted to Master’s Degree programs in the 1980’s as accrediting bodies required enhanced education. The Balanced Budget Act of 1997 included the Primary Care Health Practitioner Incentive Act, perhaps the most important payment reform to affect advanced practice nurses allowing direct Medicare reimbursement to the APRN, but at 85% of the physician fee rate. Graduate education prepares APNs to be key players in the most complex of systems, and nursing theory provides APNs with a strong conceptual base for practice. Furthermore, as nursing research uncovers evidence to utilize skills enabling APNs to bring fresh ideas and proven interventions to health care consumers; now, complex, evolving reimbursement requires the APN to also be educated in financial management and health policy issues. Unfortunately, for continued growth related to reimbursement the APN faces the lack of third-party reimbursement, prescriptive ability, and hospital admission privileges whether acting as part of a team, or collaboratively.Role Of An Advanced Practice Nurse Nursing Essay

An APN is a not only a registered nurse, but a nurse that has completed at least a graduate level of education, is certified by a nationally recognized certifying body, and is also recognized as APN in one’s state. Today, the current APN educational curriculum not only focuses on the attainment of key competencies (American Academy of Nurse Practitioners) but also includes pathophysiology, health assessment, pharmacology, and clinical diagnosis and treatment. This

education prepares the APN to diagnose, treat, and prescribe. Furthermore, APNs must demonstrate a dedication to learning and are required to obtain continuing education in order to maintain their national certification. As of 2000, APNs were legally recognized to practice, to some capacity, in every state throughout the United States, and are utilized internationally, too.Role Of An Advanced Practice Nurse Nursing Essay

Comparison and Contrast of APN Roles

Certified Nurse Practitioners (CNPs)

Although nationally recognized through several professional certification boards, a CNP’s scope of practice is regulated by one’s individual state board of nursing. Subsequently, employment can be found locally through a myriad of choices that is restricted only by one’s scope of practice,Role Of An Advanced Practice Nurse Nursing Essay

and/or the working relationships that are established in one’s healthcare community, and/or in one’s setting of choice for employment. CNPs perform comprehensive assessments and promote health and the prevention of illness and injury. Additionally, they diagnose, develop differentials, and interpret diagnostic and laboratory tests, order, conduct, and supervise. CNPs are also able to prescribe pharmacologic and non-pharmacologic treatments in the direct management of acute and chronic illness and disease. From providing health and medical care in primary, acute, and long-term care settings, CNPs can serve in various settings as researchers, consultants, and patient advocates for individuals, families, groups and communities. Additionally, CNPs may specialize in areas such as family, geriatric, pediatric, primary, or acute care to name a few.Role Of An Advanced Practice Nurse Nursing Essay

Nevertheless, depending on the state, CNPs can practice autonomously and/or in collaboration with other healthcare professionals to treat and manage patients’ health programs. Currently, eighteen states and the District of Columbia allow CNPs to practice and prescribe independently (without any direct physician supervision or collaboration). The remaining states regulate NP practice with requirements such as direct physician supervision for diagnoses, treatment and/or prescriptive authority. Relative to CNMs and CNAs, CNPs have a relatively short history in the

health care delivery system. Internationally, CNP’s roles have yet to reach the development that they have in the United States, with few countries affording the role, or confused with how to progress.Role Of An Advanced Practice Nurse Nursing Essay

Certified Nurse Anesthetists (CNAs)

Certified nurse anesthetists (CNAs) are registered nurses who have received specialized education in the field of anesthesia. Similar to CNPs, even though CNAs are nationally recognized through professional certification boards, the scope of their practice is regulated by each individual CNA’s state board of nursing. Moreover, depending on the individual’s state requirements, CRNAs are occasionally regulated through the federal government’s Centers for Medicare and Medicaid. Ironically, even though no state statute requires anesthesiologist supervision of CNAs, the Centers for

Medicare and Medicaid (CMS) state in their rules for participation that CNAs must be supervised by a physician. In 2001, CMS amended this requirement by providing an opt-out or exemption ruling. To date, sixteen state governors have requested and received exemption from the CMS, the point being in many rural hospitals is that the only person on staff for anesthesia is the CNA. CNAs nationally, statewide, and locally provide anesthetics before and after surgical, obstetric, and therapeutic procedures; they practice in hospitals, ambulatory surgical centers and dental offices and are often the sole anesthesia providers in many rural hospitals (AANA). Moreover, internationally, CNAs are very widely used. Where CNP and CNS roles are still developing, CNAs are presently utilized in greater than half of the world’s nearly two hundred countries.Role Of An Advanced Practice Nurse Nursing Essay

Clinical Nurse Specialists (CNSs)

Clinical nurse specialists, similar to CNPs, are nationally recognized through professional certification boards, and a CNS’s scope of practice is regulated by one’s individual state board of nursing. The CNS role affords tremendous diversity within the title. Nationally, statewide, or locally, a CNS can provide advanced nursing care in acute care facilities such as hospitals, provide acute and chronic care management, develop quality improvement programs, mentor and educate staff, or work as a researcher or consultant. The CNS role was based on the premise care is

interrelated, that patient care would improve when advanced practitioners with specialized knowledge and skills are there to create environments that foster caring and problem solving on multiple spheres: patient, nurse, and system (National Council of State Boards of Nursing). Internationally, CNSs continue to develop as APNs, similar to the CNP. Currently, CNSs are seen as healthcare promoters and problem solvers.

Certified Nurse Midwives (CNMs)

CNMs, certified through rigorous national examinations, similarly to the three previously mentioned APN roles, have their scope of practice regulated by each state’s board of nursing (American College of Nurse and Midwives, 2010). CNMs provide primary care for women, adolescence through menopause, and beyond. CNMs focus on reproductive healthcare including health promotion, pregnancy, childbirth, postpartum, family planning and gynecological care (American College of Nurses and Midwives, 2008). In providing primary care, CNMs prescribe medications, order laboratory and other diagnostic testing, offer health education and counseling and collaborate with other healthcare providers. Nationally, statewide, and locally CNMs work in hospitals, birthing centers, community clinics, and in patient homes one on one. Internationally, CNMs similarly to CNAs have been utilized for decades, throughout 80 countries.Role Of An Advanced Practice Nurse Nursing Essay

Analysis of Advanced Practice Nursing Current State

Certified Nurse Practitioners (CNPs)

NPs are highly skilled at providing comprehensive assessments resulting in clinical decision making

that is safe and cost effective. Nurse practitioners have favorable outcomes in acute care by reducing length of stay and hospital-associated costs (Carruth & Carruth, 2011).

Reductions in healthcare costs are associated with APRN directed care, as evidenced in a recent study showing annual cost reductions from $5,210 to $3,061 among chronically ill patients (Meyer, 2011).

Settings such as hospitals Fully utilized APRNs offer primary and specialty care and can reduce costs to the system (Chen, et al., 2009).Role Of An Advanced Practice Nurse Nursing Essay

In the over 40 year history of the NP profession, a multitude of studies have demonstrated that NPs have performed as well as physicians caring for similar patients with respect to health outcomes, proper diagnosis, management, and treatment (Newhouse, et al., 2011).

Certified Nurse Midwives (CNMs)

in the Appalachian Mountains of Kentucky the nurse midwife model of care emerged. Here, the Frontier Nursing Service provided community-based care to disadvantaged pregnant women, children, and families. (Ernst & Stone, 2013).This historical perspective demonstrates that CNMs have always provided safe, quality care. Low-risk women are routinely subjected to medical interventions, many of which are unsupported in research as beneficial, such as continuous fetal monitoring, induction of labor, intravenous therapy, epidural anesthesia, and elective cesarean births. Pregnant women cared for by CNMs are less likely to undergo invasive interventions, which reduce health care costs without sacrificing quality (Johantgen et al., 2012). Finally, CNMs deliver care that is similar to that provided by physicians and CNMs have lower rates of cesarean sections, lower epidural use, and lower labor induction rates; while, maintaining infant and maternal outcomes (Newhouse, et al., 2011)Role Of An Advanced Practice Nurse Nursing Essay

Clinical Nurse Specialist (CNSs)

Clinical nurse specialists are experts in their specialties. The costs of managing chronic illness decrease when a CNS is involved in management of the patient. Research supports the utilization of a CNS as part of the interdisciplinary team to lower hospital costs and improve the outcomes of patients with chronic illness (Moore & McQuestion, 2012). Implementation of the CNS role is associated with improvement in patient outcomes (Newhouse, 2011).Role Of An Advanced Practice Nurse Nursing Essay

Certified Nurse Anesthetist (CNAs)

certified registered nurse anesthetists (CRNAs) provide safe, high-quality anesthetic care. Currently, 70% of all anesthetics in rural hospitals are safely delivered by CRNAs (Gardner et al., 2011)

Research has not shown that patient care, safety or quality compromised when a CRNA practices without physician oversight. In addition to education and training costs, CRNAs practicing independently can provide anesthesia services at 25% lower costs (Jordan, 2011).

CRNAs are associated with equivocal complication and mortality rates when contrasted with physicians (Newhouse, et al., 2011).Role Of An Advanced Practice Nurse Nursing Essay

International APN

Pulcini, Jelic, Gul, & Loke (2010).

Sangster-Gormley, Martin-Misener, Downe-Wamboldt, & DiCenso (2011).


Advanced practice nurses find themselves caught within an incredibly complex situation. As the country faces new, expanded challenges for access to healthcare, APNs have continued to not only increase their qualifications and provide evidentiary support such to establish a federally regulated, nationally recognized platform regarding autonomy, but stand ready to act. Unfortunately, barriers that exist both administratively and legislatively due to a lack of consistency in state to state scope continue to delay long-awaited healthcare relief for our citizenry, as well as professional consistency amongst APNs, too. This paper presented a brief history regarding the APN, as well as a review of APN roles from a national, state, local, and international perspective. Additionally, this paper compared and contrasted the roles of the APN while drawing assertions to the current state of the advanced practice nurse. In conclusion, presented examples regarding the qualifications of the APN roles are obvious; however, the barriers identified reinforce the overwhelming need for immediate change.Role Of An Advanced Practice Nurse Nursing Essay