Conceptual Models of APRN Practice: United States Examples
Conceptual Models of APRN Practice: United States Examples
Fenton’s and Brykczynski’s Expert Practice Domains of the CNS and NP
Some of the early work describing the practice domains of APRNs (CNSs and NPs) was conducted by Fenton (1985) and Brykczynski (1989), using Benner’s model of expert nursing practice (Benner, 1984). To fully appreciate their contributions to the understanding of advanced practice, it is important to highlight some of Benner’s key findings about nurses who are experts by experience. Although Benner’s seminal work, From Novice to Expert (1984), has been used in the conceptualization of advanced practice nursing, it is important to note that Benner has not studied advanced practice nurses; her model was based on the expert practice of clinical nurses. Fenton’s and Brykczynski’s studies represent an extension of Benner’s findings and theories to advanced practice nursing.
The early work of Benner and associates informed the development of the first NONPF competencies, graduate curricula in schools of nursing, models of practice, and the standards for clinical promotion. A noted contribution of this early work was that it “put into words what they had always known about their clinical nursing expertise but had difficulty articulating” (Benner, Tanner, & Tesla, 2009). It is perhaps this impact that led to the sustained integration of Benner’s studies of experts by experience into the APRN literature, including descriptions and development of competencies.
Through the analysis of clinical exemplars discussed in interviews, Benner (1984) derived a range of competencies that resulted in the identification of seven domains of expert nursing practice. Within this lexicon, these domains are a combination of roles, functions, and competencies, although the three were not precisely differentiated. The seven domains are the helping role, administering and monitoring therapeutic interventions and regimens, effective management of rapidly changing situations, diagnostic and monitoring function, teaching and coaching function, monitoring and ensuring the quality of health care practices, and organizational and work role competencies.
Fenton (1985) and Brykczynski (1989) each independently applied Benner’s model of expert practice to APRNs, examining the practice of CNSs and NPs, respectively. Fenton and Brykczynski (1993) jointly compared their earlier research findings to identify similarities and differences between CNSs and NPs. They verified that nurses in advanced practice were indeed experts, as defined by Benner, showing they were experts by more than experience alone. They identified additional domains and competencies of APRNs (Fig. 2.5). Across the top of Fig. 2.5 are the seven domains identified by Benner and the additional domain found in CNS practice (Fenton, 1985), that of consultation provided by CNSs to other nurses (rectangular dotted box, top right). Under this box are two new CNS competencies (hexagonal boxes). The third (rounded) box is a new NP competency identified by Brykczynski in 1989. In this study of NPs, Brykczynski identified an eighth domain (the management of health and illness in ambulatory care settings) and recognized it as a qualitatively different expression from the first two domains identified by Benner. For NPs, the new competencies were a result of the integration of the diagnostic-monitoring and administering-monitoring domains.
The figure also reveals new CNS and NP competencies identified by Fenton and Brykczynski’s work. New CNS competencies were identified under the organization and work role domain (e.g., providing support for nursing staff) and the helping role, in addition to the consulting domain and competencies. New NP competencies were noted in seven of the eight domains (e.g., detecting acute or chronic disease while attending to illness under the diagnostic-administering domains). By examining the extent to which APRNs demonstrate the seven domains found in experts by experience and uncovering differences, the findings offer insight into the differences between expert and advanced practice. In addition, Fenton and Brykczynski’s work also described ways in which the CNS and NP roles may differ with regard to practice domains and competencies.
These early findings suggest that a deeper understanding of advanced practice could be beneficial to understanding and conceptualizing advanced nursing practice. Benner’s methods could be applied to studies of advanced practice nursing, with the following aims: (1) to confirm Fenton and Brykczynski’s findings in CNS and NP roles and identify new domains and competencies across all four APRN roles, (2) to understand how APRN competencies develop in direct-entry graduate and RN graduate students, and (3) to compare the non–master’s-prepared clinician’s competencies with the APRN’s competencies to distinguish components of expert versus advanced practice nursing. Studies focused on how APRNs acquire expertise in APRN and interprofessional competencies could inform future conceptualizations of advanced practice nursing.
Calkin’s Model of Advanced Nursing Practice
Calkin’s model (1984) was the first to explicitly distinguish the practice of experts by experience from advanced practice nursing of CNSs and NPs. Calkin developed the model to help nurse administrators differentiate advanced practice nursing from other levels of clinical practice in personnel policies. The model proposed that this could be accomplished by matching patient responses to health problems with the skill and knowledge levels of nursing personnel. In Calkin’s model, three curves were overlaid on a normal distribution chart. Calkin depicted the skills and knowledge of novices, experts by experience, and APRNs in relation to knowledge required to care for patients whose responses to health care problems (i.e., health care needs) ranged from simple and common to complex and complicated (Fig. 2.6). A closer look at Fig. 2.6A, shows that patients have many more human responses (the highest and widest curve) than a beginning nurse would have the knowledge and skill to effectively manage. The impact of experience is illustrated in Fig. 2.6B. The highest and widest curve is effectively the same, but because of experience, expert nurses have more knowledge and skill. However, although the curves are higher and somewhat wider, the additional skill and knowledge of expert nurses do not yet match the range of responses they may encounter in the patients. In Fig. 2.6C, APRNs, by virtue of education and experience, do possess the knowledge and skills that enable them to respond to a wider range of human responses. The three curves in Fig. 2.6C are parallel each other, suggesting that even as less common human responses arise in clinical practice, APRNs are able to creatively and effectively respond to these unusual problems because of their advanced knowledge and skills.
Calkin used the framework to explain how APRNs perform under different sets of circumstances—when there is a high degree of unpredictability, new conditions, new patient population, or new sets of problems, and a wide variety of health problems requiring the services of “specialist generalists.” What APRNs do in terms of functions was also defined. For example, when patients’ health problems elicit a wide range of human responses with continuing and substantial unpredictable elements, the APRN should do the following (Calkin, 1984):
· • Identify and develop interventions for the unusual by providing direct care.
· • Transmit this knowledge to nurses and, in some settings, to students.
· • Identify and communicate the need for research or carry out research related to human responses to these health problems.
· • Anticipate factors that may lead to unfamiliar human responses.
· • Provide anticipatory guidance to nurse administrators when the changes in the diagnosis and treatment of these responses may require altered levels or types of resources.
A principal advantage of Calkin’s model is that the skills, education, and knowledge needed by nurses are considered in relation to patient needs. It provides a framework for scholars to use in studying the function of APRNs in a variety of practice situations and should be a useful conceptualization for administrators who must maximize a multilevel interprofessional workforce and need to justify the use of APRNs. In today’s practice environments, this conceptualization could be modified and applied in other settings based on whether a situation requires an APRN or RN and which mix of intra- and interprofessional staff and support staff is needed when settings have a high degree of predictability versus those that have high clinical uncertainty.
The model has been left for others to test; although Calkin’s thinking remains relevant, no new applications of the work were found. However, Brooten and Youngblut’s work (2006) on the concept of “nurse dose,” based on years of empirical research, offers a similar understanding of the differences among beginners, experts by experience, and APRNs. They proposed, as did Calkin, that one needs to understand patients’ needs and responses and the expertise, experience, and education of nurses to match nursing care to the needs of patients, but they did not cite Calkin’s work. Similarly, the Synergy model in critical care is based, in part, on an understanding of patient and nurse characteristics consistent with Calkin’s ideas (Curley, 1998).
Strong Memorial Hospital’s Model of Advanced Practice Nursing
APRNs at Strong Memorial Hospital developed a model of advanced practice nursing (Ackerman, Clark, Reed, Van Horn, & Francati, 2000; Ackerman, Norsen, Martin, Wiedrich, & Kitzman, 1996; Mick & Ackerman, 2000). The model evolved from the delineation of the domains and competencies of the acute care NP (ACNP) role, conceptualized as a role that “combines the clinical skills of the NP with the systems acumen, educational commitment, and leadership ability of the CNS” (Ackerman et al., 1996, p. 69). The five domains are direct comprehensive patient care, support of systems, education, research, and publication and professional leadership. All domains have direct and indirect activities associated with them. In addition, three unifying threads influence each domain: collaboration, scholarship, and empowerment, which are illustrated as circular and continuous threads (Ackerman et al., 1996), (Fig. 2.7). These threads are operationalized in each practice domain. Ackerman et al. (2000) noted that the model is based on an understanding of the role development of APRNs; the concept of novice (APRN) to expert (APRN) is foundational to the Strong model (see later).
Direct comprehensive care includes a range of assessments and interventions performed by APRNs (e.g., history taking, physical assessment, requesting and/or performing diagnostic studies, performing invasive procedures, interpreting clinical and laboratory data, prescribing medications and other therapies, and case management of complex, critically ill patients). The support of systems domain includes indirect patient care activities that support the clinical enterprise and serve to improve the quality of care. These activities include consultation, participating in or leading strategic planning, quality improvement initiatives, establishing and evaluating standards of practice, precepting students, and promoting APRN practice. The education domain includes a variety of activities (e.g., evaluating educational programs, providing formal and informal education to staff, educating patients and families, and identifying and disseminating educational resources). The research domain addresses the use and conduct of research, while the publication and professional leadership domain includes APRN functions involved with disseminating knowledge about the ACNP role, participating in professional organizations, influencing health and public policy, and publishing. APRNs are expected to exert influence within and outside their institution.
The unifying threads of collaboration, scholarship, and empowerment are attributes of advanced practice that exert influence across all five domains and characterize the professional model of nursing practice. Collaboration ensures that the contributions of all caregivers are valued. APRNs are expected to create and sustain a culture that supports scholarly inquiry, whether it is questioning a common nursing practice or developing and disseminating an innovation. APRNs support the empowerment of staff, ensuring that nurses have authority over nursing practice and opportunities to improve practice.
The Strong model is a parsimonious model that has many similarities with other advanced practice conceptualizations. For example, its domains are consistent with the competencies delineated in Hamric’s model. However, unlike Hamric’s model, which posits direct care as the central competency that informs all other advanced nursing practice competencies, all domains of practice in the Strong model, including direct care, are considered “mutually exclusive of each other and exhaustive of practice behaviors” (Ackerman et al., 1996, p. 69).
It is notable that this model was the result of a collaborative effort between practicing APRNs and APRN faculty members. One could infer that such a model would be useful for guiding clinical practice and planning curricula, two of the purposes of conceptual models outlined earlier in this chapter. The Strong model has informed studies of advanced practice nursing in critical care since its publication (e.g., Becker, Kaplow, Muenzen, & Hartigan, 2006; Chang, Gardner, Duffield, & Ramis, 2010; Mick & Ackerman, 2000). Further work by Gardner et al. (2013) in Australia used the Strong model to delineate the practice of APRNs (Grade 7) from the practice of registered nurse/midwife roles (Grade 5) and to delineate and define advanced practice nursing (Gardner et al., 2016). Ackerman, Mick, and Witzel (2010) have proposed an administrative model for managing APRNs and a central leadership model for hospital-based NPs (Bahouth et al., 2013).
Texas Children’s Hospital Transformational Advanced Professional Practice (TAPP) APRN Model
The Strong Memorial Hospital model has also influenced the development of the Texas Children’s Hospital transformational advanced professional practice (TAPP) APRN model (Elliott & Walden, 2015) (Fig. 2.8). To better reflect the current conceptualization of the APRN role, two additional domains of professional practice were added to the Strong model: quality and safety, and credentialing and regulatory practice. Professional ethics was also added as a unifying conceptual strand.
The essence of the APRN role within this model is direct, comprehensive, family-centered care. The TAPP model includes this single patient care domain along with six professional development domains: organizational priorities; quality and safety; evidence-based practice and research; education; transformational professional practice; and credentialing and regulatory practice. The model recognizes that the amount of time and effort APRNs devote to the execution of the six professional development domains may vary dependent on needs of the system, patient population, and strengths and interest of individual APRNs.
An added strength of the TAPP model is the description of APRN practice along three continuums: clinical expertise, health, and role. The clinical expertise continuum is reflective of the Benner (1984) model of expert practice (novice to expert), with expertise varying dependent on years of APRN and specialty experience and differing roles. The health continuum includes APRN care for patients who are healthy; for those who have common, stable or chronic health conditions; and for those who have complex, acute, critical, or rare health conditions. The role continuum of professional practice ranges from dependent on colleagues and mentors to assume a more independent role in each of the patient care and professional domains of practice.
Although the authors indicate the model can be easily adapted to all four APRN roles, they also include physician assistants, thereby diluting the emphasis on models that conceptualize the unique practice of APRNs. In addition, because the NONPF core competencies (Thomas, Crabtree, Delaney, et al., 2011) were used along with the APRN Consensus Model (APRN Joint Dialogue Group, 2008) to develop the TAPP model, future work should test the appropriateness of this model for APRN roles in other than NP roles.
Shuler’s Model of NP Practice
The historical importance of Shuler’s model as an early NP model is briefly discussed here (Shuler & Davis, 1993a). Readers should refer to the original article to see the full model.
Shuler’s experience integrating nursing and medical knowledge skills into the NP role led to the development of a conceptual model that would illuminate the unique contributions and expanded role of NPs. Shuler’s Nurse Practitioner Practice Model is a complex systems model that is holistic and wellness oriented. It is definitive and detailed in terms of how the NP-patient interaction, patient assessment, intervention, and evaluation should occur (Shuler & Davis, 1993a). Table 2.1 outlines key model constructs and related theories. Knowing that these familiar concepts are embedded in this comprehensive model may help readers appreciate its potential usefulness.
Shuler’s model is intended “to impact the NP domain at four levels: theoretical, clinical, educational, and research” (Shuler & Davis, 1993a). The model addresses important components of advanced practice nursing: (1) nursing’s metaparadigm (person, health, nursing, and environment); (2) the nursing process; (3) assumptions about patients and NPs; and (4) theoretical concepts relevant to practice. The model could be characterized as a network or system of frameworks.
Clinical application of Shuler’s model is intended to describe the NP’s expanded nursing knowledge and skills “into medicine,” the benefits for NP and patient, and a framework whereby NP services can be evaluated (Shuler & Davis, 1993b). Shuler and Davis (1993b) published a lengthy template for conducting a visit. Although it is difficult to imagine ready implementation into today’s busy NP practices, Shuler and colleagues’ clinical applications of the model have been published by Shuler (2000), Shuler and Davis (1993b), and Shuler, Huebscher, and Hallock (2001). In the current health care environment, the Circle of Caring model (Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011) may be more useful for addressing some of the issues that led Shuler to create her model—integrating nursing and skills traditionally associated with medicine while learning the NP role, and retaining a nursing focus while providing complex diagnostic and therapeutic interventions.
The post Conceptual Models of APRN Practice: United States Examples appeared first on Custom University Papers.