Models Useful for Advanced Practice Nurses in Their Practice
Models Useful for Advanced Practice Nurses in Their Practice
Advanced Practice Nursing Transitional Care Models
There are several models of transitional care in which APRNs provide care. Early work by Brooten et al. (1988) continues to inform these models of APRN care (e.g., Partiprajak, Hanucharurnkul, Piaseu, Brooten, & Nityasuddhi, 2011) and illustrates how a theory of clinical care can be studied to obtain a better understanding of the work of APRNs. It is a model that has evolved but has steadily contributed to understanding and improving APRN practice. This theoretical and empirical steadfastness has significantly influenced the new policies evolving as the United States undergoes health care reform.
Using a conceptual model proposed by Doessel and Marshall (1985), Brooten et al. integrated this framework into their evaluation of outcomes of APRN transitional care with different clinical populations. APRN transitional care was defined as “comprehensive discharge planning designed for each patient group plus APN home follow-up through a period of normally expected recovery or stabilization” (Brooten et al., 2002, p. 370). Brooten’s model was intended to address outlier patient populations (e.g., those whose care, for clinical reasons, was likely to cost more). Across all studies, care was provided by NPs and/or CNSs whose clinical expertise was matched to the needs of the patient population. In these studies, APRN care was associated with improved patient outcomes and reduced costs.
Research by Brooten, Naylor, and others (Bradway et al., 2012) who have studied transitional care by APRNs has provided empirical support for several elements important to a conceptualization of advanced practice nursing. In a summary of the studies conducted, the investigators identified several factors that contribute to the effectiveness of APRNs: content expertise, interpersonal skills, knowledge of systems, ability to implement change, and ability to access resources (Brooten, Youngblut, Deatrick, Naylor, & York, 2003). This finding provides empirical support for the importance of the APRN competencies of direct care, collaboration, coaching, and systems leadership.
Two other important findings were the existence of patterns of morbidity within patient populations and an apparent dose effect (i.e., outcomes seemed to be related to how much time was spent with patients, number of APRN interactions with patients, and numbers and types of APRN interventions; Brooten et al., 2003). Subsequently, based on this finding of a dose effect, Brooten and Youngblut (2006) proposed a conceptual explanation of “nurse dose.” Their explanation suggests that nurse dose depends on patient and nurse characteristics. For the nurse, differences in education and experience can influence the dose of nursing needed.
The concept of nurse dose, which has empirical support, may enable the profession to differentiate more clearly among novice, expert, and advanced levels of nursing practice. Taken together, findings from this program of research suggest that characteristics of patients and characteristics and dose of APRN interventions are important to the conceptualization of advanced practice nursing. Finally, the fact that this program of research has used NPs and CNSs to intervene with patients provides support for a broad conceptual model of APRN practice that encompasses APRN characteristics, competencies, patient factors, environment, and other concepts that can inform role-specific models.
Although there have been other studies of APRNs providing transitional care, Brooten’s work is highlighted because of the additional analyses that were done and the ultimate influence on health policy of this program of research (e.g., Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). The findings help to understand the APRN characteristics and interventions that contributed to the success of the interventions and a model of care that evolved from the skilled care provided by APRNs.
The impact of the research conducted by Naylor, Bowles, et al. (2011) using the Translational Care Model, in which APRNs are the primary coordinators of care, provide home visits, and collaborate with the patient, family caregivers, and health care colleagues (physicians, nurses, social workers, and other health team members), is evident in many of the provisions of the ACA and its implementation (Naylor, 2012). The Community-Based Care Transitions Program was created by Section 3026 of the ACA and is being implemented by the Centers for Medicare & Medicaid Services Partnership for Patients (2017).
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