Which of the following nursing roles are considered an advanced practice role

DIRECT PATIENT CARE

To ensure seamless care, continuous leadership and accountability are requisite. Professional nurses act on these responsibilities in acute care units, ambulatory care clinics, long-term care facilities, homecare agencies and other sites where the need for geriatric care can be fulfilled.

At least three different types of nursing expertise, using different levels of critical thinking and clinical decision-making skills, are available to older patients to assist them in meeting their healthcare needs:

Staff nurses have clinical, technical and humanistic skill in one-to-one interaction so they can strengthen and support the biopsychosocial processes of recovery, rehabilitation, healing, preventing disease and disability, and dying with dignity. Nurses functioning in this role practice in acute care settings, skilled nursing facilities, home health settings and hospices, and a smaller number practice in ambulatory care clinics or doctors’ offices.

Advanced practice nursing roles in gerontological nursing primarily include clinical specialists and nurse practitioners. These master's degree or doctorally prepared nurses function in a variety of roles to support this challenging patient population.

Geriatric clinical nurse specialists have expertise in working with complex nursing care problems and draw from their advanced skills in hands-on clinical care, critical analysis and decision-making, teaching, counseling, and coordination and follow-up of interdisciplinary care plans. They practice in acute and long-term care settings and may be consultants to community clinics and home-based geriatric care programs. They may also conduct research, evaluate program outcomes, and coordinate quality improvement activities.

Geriatric nurse practitioners have expertise in performing comprehensive physical assessments, interpreting symptoms and physiological abnormalities, and developing treatment, management and follow-up plans for medical problems, in partnership with the primary care physician and other team members. Their practice is closely linked with primary care services in ambulatory clinics, although a growing number of these nurses are providing services to elderly patients in long-term care facilities, adult day health programs, and physicians’ offices as well as inpatient settings.

Direct patient care

To ensure seamless care, continuous leadership and accountability are necessary. Professional nurses act on these responsibilities in acute care units, ambulatory care clinics, long-term care facilities, homecare agencies and other sites where the need for geriatric care can be fulfilled.

At least three different types of nursing expertise, using different levels of critical thinking and clinical decision-making skills, are available to older patients to assist them in meeting their healthcare needs:

Registered nurses have clinical, technical and humanistic skill in one-to-one interaction so they can strengthen and support the biopsychosocial processes of recovery, rehabilitation, healing, preventing disease and disability, and death with dignity. Nurses functioning in this role practice in acute care settings, skilled nursing facilities, home health settings and hospices, and a smaller number practice in ambulatory care clinics or doctors’ offices. Licensed vocational or practical nurses may also work in these settings under the supervision of the registered nurse.

Advanced practice nursing roles in gerontological nursing primarily include clinical specialists and nurse practitioners. These master’s degree or doctorally prepared nurses function in a variety of roles to support this challenging patient population:

Gerontologic clinical nurse specialists have expertise in working with complex nursing care problems and draw from their advanced skills in direct clinical care, critical analysis and decision-making, teaching, counseling, and coordination and follow-up of interdisciplinary care plans. They practice in acute and long-term care settings and may be consultants to community clinics and home-based geriatric care programs. They also have roles in organizational leadership, research, evaluation of program outcomes and coordination of quality improvement activities.

Gerontologic nurse practitioners have expertise in performing comprehensive physical examination and assessments, ordering and interpreting laboratory and diagnostic testing, differential medical diagnosis, and developing pharmacologic and non-pharmacologic management plans, and outcome evaluations for medical problems, in partnership with other team members. Primary care nurse practitioners provide services in ambulatory clinics, long-term care facilities, and adult day health programs while acute care nurse practitioners see patients in mostly inpatient settings. Crossover may occur between these settings and the primary care and acute nurse practitioner roles (National Organization of Nurse Practitioner Faculties, 2012).

3 Nurse Practitioners and Physician Assistants

Nurse practitioners, also known as advanced practice nurses, and physician assistants are two relatively new additions to the medical division of labor, both originating in the USA in the 1960s. Nurse practitioners represent more of an evolution in the profession of nursing than a distinct new occupation while physician assistants constitute a new allied health profession.

Nurse practitioners (NPs) are registered nurses with advanced clinical training (Mezey and McGivern 1999). In the USA a master's degree is required for certification in advanced practice nursing. Nurse practitioners provide generalist care including routine physical assessment, treatment of uncomplicated episodic illness, continuing care for persons with stable chronic conditions, and acute care in hospital settings. Nurse midwives, a type of advanced practice nurse, provide routine obstetrical care including normal deliveries as well as routine health care for women. Nurse practitioners have successfully defined a legal scope of autonomous practice although attempts by physicians to exert control over their practice and remuneration is a continuing source of conflict (Sage and Aiken 1997).

Physician assistant (PA) education is generally 24 months in length. Programs exist in four different academic pathways: certificate programs, associate degree programs, bachelor's degree programs, and master's degree programs although the PA component is the same regardless of degree level (Hooker and Cawley 1997). A major difference between physician assistants and nurse practitioners is that physician assistants have accepted a legally dependent role working under the direction of a physician while nurse practitioners have fought for and obtained a legal scope of practice that does not require physician supervision (Sage and Aiken 1997).

Nurse Practitioner Education

Advanced practice nursing education involves graduate training for NPs, nurse anesthetists, clinical nurse specialists, and nurse midwives (American Nurses Association Nursing World, 2014). In the past, educational programs were delivered to graduate nursing students who attended on-campus classes using face-to-face lectures. Recently, however, the proliferation of asynchronous and synchronous distance education programs for NPs has allowed students to attend school while remaining at home in their own communities. This FNP graduate program awards a master of science in nursing and prepares advanced practice nurses who possess the knowledge, skill, attitudes, and values to meet the challenges of the 21st century health care delivery system. This 2½-year full-time program is accredited by the Commission on Collegiate Nursing Education and prepares FNPs to provide community-focused primary care for culturally diverse families in rural or medically underserved areas. The 46- to 47-credit hour, primarily online, clinical education emphasizes primary health across the life span for underserved rural or urban populations (University of North Carolina Wilmington (UNCW) Graduate Academic Catalogue, 2013-2014). For clinical courses, students are required to come on campus for full day experiences, so the program is delivered using a hybrid format.

Professional NP organizations have endorsed curricular content focusing on functional assessment across the life span, including the elderly. The National Organization of Nurse Practitioner Faculties encourages curricular content to support NP core competency #3: comprehensive assessment that includes the differentiation of normal age changes … with co-occurring health problems including cognitive impairment (NONPF, 2013). For this reason, faculty developed and delivered a case scenario using SPs to teach comprehensive geriatric assessment in the first clinical NP course.

1 Introduction

The concept of Advanced Nursing Practice is not new. Although the first Advanced Nursing Practice degree programs were developed in the middle of the 20th century (Caverly, 1996; Cukr et al., 1998; Drew, 2014; Elsom et al., 2006, 2005) there is still no uniform definition of the term. Hamric (2014) defines Advanced Nursing Practice as “the patient-focused application of an expanded range of competencies to improve health outcomes for patients and populations in a specialized clinical area of the larger discipline of nursing”. Nurses working in Advanced Nursing Practice roles are called Advanced Practice Nurses (APN). According to the International Council of Nurses (ICN) an APN can be defined as “a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master's degree is recommended for entry level.” (International Council of Nurses, 2020).

While APN roles have been successfully implemented in many settings in most countries around the world, the implementation of Advanced Nursing Practice is still in its infancy in many European countries (Sheer and Wong, 2008), especially in the German-speaking countries (Tannen et al., 2017) and in the domain of psychiatric care (Blum et al., 2018).

The future requirements for psychiatric nursing and health care professions can be described as highly complex. The reasons for this are, for example, the increasing number of multimorbid and chronically mentally ill people, the demand for evidence-based nursing interventions as well as structural changes such as cross-sector and increased interdisciplinary healthcare. This high complexity of nursing tasks requires competences that can only be acquired at university level (Ali and Watson, 2011; Spitzer and Perrenoud, 2007; Spitzer and Perrenoud, 2006). Psychiatric nurses with a Master's degree who plan, coordinate, carry out, evaluate and conduct research into direct patient care are more in demand than ever before. In concrete terms: the integration of Psychiatric Mental Health APNs is required for the delivery of care for complex clinical conditions and for the coordination or adequate advancement of complex psychiatric-mental health care systems (Bjorklund, 2003; Drew, 2014; Dyer et al., 1997).

Psychiatric Mental Health Advanced Practice Nurses (PMH-APNs; or Advanced Practice Psychiatric Nurses, APPNs) acquire knowledge, skills and abilities, „to provide continuous and comprehensive mental health care, including assessment, diagnosis, and treatment across settings“ (American Nurses Association et al., 2014). Psychiatric Mental Health APNs take on roles as clinicians, educators, consultants and researchers, „who assess, diagnose, and treat individuals and families with behavioral and psychiatric problems and disorders or the potential for such disorders“ (American Nurses Association et al., 2014).

As in general Advanced Nursing Practice, different subroles have developed over the last decades in specialized advanced psychiatric nursing practice: Psychiatric/Mental Health Clinical Nurse Specialists (CNS), Psychiatric/Mental Health Nurse Practitioner (PMH-NP) and the "blended role" (PMH-CNS/NP), in which the PMH-CNS and the PMH-NP are displayed as a combined role (e.g., McCabe and Grover, 1999; Moller and Haber, 1996). In accordance with this systematization, a recent systematic review by Scheydt et al. (2020) showed that there is not the one or the other APN practice role. Whether and how an APPN role with all its dimensions and facets develops depends on many different factors such as the influence of the practice setting, the patient population, regional needs or organizational structures (Caverly, 1996). Even if certain core elements of an Advanced Nursing Practice can certainly be described (DeGeest et al., 2008; Hamric et al., 2014; Mantzoukas and Watkinson, 2007), each APN role, whether CNS or NP, can be characterized as individual and the content and characteristics of each role as dynamic over time (Scheydt et al., 2020).

To adequately describe the advanced psychiatric nursing roles and to distinguish them from the other roles of psychiatric and general nursing care (e.g. International Council of Nurses, 2008; Scheydt and Holzke, 2018b), it is necessary to explore the concrete tasks and activities and the scope of practice of Psychiatric Mental Health APNs. While systematic summaries of tasks and activities already exist for general APN roles (Ackerman et al., 1996; Jokiniemi et al., 2012), such systematic descriptions have not yet been identified for Psychiatric Mental Health APN roles (Scheydt et al., 2020). Therefore, the aim of this article is to extract, summarize and systematize the tasks and activities of the Psychiatric Mental Health APN from the international scientific literature. The analysis was carried out on the basis of the following research question: Which tasks and activities of the Advanced Practice Nurses in the psychiatric-mental health context can be extracted, summarized and systematized from the international literature?

Abstract

This paper discusses the development of advanced nursing practice in China in the context of global development. The scope of nursing is evolving over time, with increasing demands for the management of complex healthcare situations at individual, community and system levels. These demands are aggravated by the specialization of medical practice, with advanced treatment plans and patients requiring care in focused areas. The qualifications and competencies of the initial entrants into nursing practice are not adequate to deal with these demands. Advanced nursing practice (ANP) developed first in response to service demands, and education programs were introduced to prepare nurses for practicing at a higher level. This paper will first review the historical development of ANP in China, followed by a discussion of the differentiation of competence levels in nursing practice and the classification of specializations. It concludes by exploring how education in combination with experience protected by regulation of practice can support nurses to gradually evolve from registered nurse, specialty nurse to advanced practiced nurse.

Clinical Scenario

The local leadership of the Advanced Practice Nursing group, along with the key players, developed the clinical scenario. Guiding principles, which they used in developing the scenario included

Designed it to level of the learner (Durham & Alden, 2008; Jeffries & Rogers, 2012) because a scenario developed for a seasoned practitioner can frustrate a novice learner and vice versa.

Defined learning outcomes in measurable terms (Anderson & LeFlore, 2008; Jeffries & Rogers, 2012). For instance, if “effectively manage an airway” was the measurable outcome, the targeted behavioral markers of “effective” were selected the appropriate size mask, opened the airway to sniffing position, visualized the chest rise and fall with each ventilation, etc. (Anderson & LeFlore, 2008).

Developed an observation evaluation tool that matched the desired learning outcomes (Anderson & Leflore; Jeffries & Rogers, 2012). The tool consisted of dichotomous items. For example, “selected the appropriate size mask” was scored “Yes or No” (Anderson & LeFlore, 2008).

Identified all equipment necessary for the scenario (Anderson & LeFlore, 2008). A list of equipment is essential to assure the participant has the opportunity to be successful.

Wrote the “stem” for the clinical scenario (Anderson & LeFlore, 2008). This is the information provided to the participant before entering the simulation. It should be consistent with information provided in a real-life situation.

Developed appropriate open-ended questions to guide the postsimulation debriefing (Anderson & LeFlore, 2008).

It was necessary to identify the detail described in “2” and “3” above to determine if we could evaluate the markers remotely. In other words, were the cameras set up in a way to capture the NNPs behaviors and could they be visualized using the audio and/or video capture. The feasibility testing, conducted on March 26, 2012, began with an orientation to the volunteer NNPs to the equipment. Many clinicians and the regional management team members wanted to observe the testing and were present during the scenario.

The scenario scene was set in a delivery room where a post-term infant had been delivered through thick meconium-stained amniotic fluid. During the standard stabilization process, the infant developed respiratory distress, and the RN caring for the patient implemented escalating procedures by calling for the NNP in the neonatal intensive care unit (NICU).

The scenario began when the RN caring for the infant called the NNP on duty in the NICU. When the NNP arrived with a team of providers, which included a RN and a RT, they found a term infant in respiratory distress. SimBaby™ was lying in a cold radiant warmer, not connected to a cardiac apnea monitor. He was preprogrammed to be grunting and retracting with bilateral rhonchi that could be noted on auscultation. On entering the scenario, the team, which now included a neonatologist acting in his usual role, was told that the infant had meconium-stained umbilical cord and nail beds.

One of the NNPs began by turning on the warmer, asking questions of the delivery room nurse in the room (the facilitator), performing a focused physical assessment, and placing a portable oximeter probe on SimBaby™. At the moment the probe was placed, the Prof clicked on the monitor controls and SimBaby's™ monitor was activated at the clinical site, which provided the readout of the heart rate (HR) and oxygen saturation. The monitor was located at SimBaby's™ bedside and indicated a HR of 165 and an oxygen saturation of 87%. A NNP asked for a nasal cannula to be placed and started at a flow of 3 L/minute. When it was visualized that the cannula was put in place and the oxygen flow meter was turned up, “oxygen on” event was selected, and the oxygen saturation reading on the monitor began to gradually increase. Thinking that the infant was stabilized, the team began to place warm blankets on the infant. Then suddenly (when “decompensation” was selected), the oxygen saturations began to decrease and continued to decrease despite increasing the liter flow of oxygen. Once the oxygen saturations reached 80%, bag-valve-mask ventilation was initiated. Although bag-valve-mask ventilation was effective (as indicated by visualizing air filling SimBaby's™ lungs and observing chest wall movement on the graphical user interface [GUI] on the control site laptop), the oxygen saturations did not improve. The infant was successfully intubated (as indicated on the GUI by visualizing air filling the lungs) and positive pressure ventilation was provided by endotracheal tube (ETT). Once the oxygen saturations reached 90%, the team called for a transport. As the infant was being moved to the transport isolette, the oxygen saturations began to fall; then, the HR briefly increased followed by an acute decline (this was initiated by selecting “left pneumothorax” on SimBaby's GUI). The team placed the infant back on the radiant warmer, assuming the ETT had been dislodged. All the participants began to auscultate the lungs, followed by a brief questioning of whether the breath sounds (BSs) were equal and bilateral. As the infant continued to decompensate, the RT initiated bag and/or ETT ventilation while auscultation was continued by the NNP. It was finally determined that the ETT remained in the trachea, but the BSs were not equal. It was also noted that there was decreased movement of the left chest, and the heart sounds seemed to be shifted. A diagnosis of pneumothorax was made, and the team successfully performed a needle thoracostomy. The patient was stabilized and was successfully and safely transported to the NICU.

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