role development assignment

Elizabeth Ho NUS APN Role AssignmentYr 05/06 Cohort

Ph ilosophy of Nursing

Nursing is both a science and an art. An evolving science which requires a strong

education foundation, built on strong knowledge and evidence of research works.

An art which demands a continuous search for innovative ways to understand

human beings and create a caring relationship with people from all walks of life.

Persons are viewed as unique individuals, beautiful in each own ways. Each

person is also viewed as a functional individual with specific social roles that hold

meaning to him/ her. Persons’ behaviors are influenced by cognitive, spiritual,

psychosocial, cultural, contextual and biological dimensions of the individual.

Persons’ responses towards health are the focus of nursing practice, research,

education and administration. The concept of person extends beyond the

individual to the families and communities.

Health is a state of balance an individual achieves to allow him/her to function

effectively in his/her world. It is a complex state of balance between the aspects

of biological, psychological, spiritual and sociological functioning. Illness will thus

be viewed as a disruption in health, causing an unbalance of the different aspect

thus preventing effective functioning.

Environment is viewed as an important influence to Person’s behavior towards

health. Environment can be a stressful stimulus in Singapore’s fast paced

culture. However, environment can also be a nurturing stimulus towards a

Person with illness from supportive healthcare professionals, and understanding

family members.

“A Nurse Practitioner/Advanced Practice Nurse is 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” (International

Council of Nursing, 2003).

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Nursing practice for the Advanced Practice Nurse (APN) is a continuous path of

learning through practice. A higher level of nursing practice is demonstrated in

every clinical decisions and possible situations. This comes from the choice to

make a conscious effort synergizing the concepts of persons, health, nursing and

environment together to make a clinical nursing decision based on strong clinical

knowledge. Nursing practice for APN will serve as a stimulus for learning and

individual self-growth through constant reflection and critical analysis of own

thoughts and actions.

Nursing is viewed as an academy of Life, where lessons are taught to me from

each clinical encounter. Lessons of hope, death, strength, fear, respect and love,

etc are taught by individuals from all walks of life. Nursing is a profession which

has not only brought me into a world of healing science but also the art of living

and loving.

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Proposed Roles of APN

These proposed roles of the Advanced Practice Nurse are for Singapore primary

community care setting. In Singapore, primary community care is divided mainly

into 2 sectors, the private sectors and the government related clinics known as

polyclinics. These polyclinics deal mainly with primary care which involve (1)

children and women health and (2) adult health which includes treating acute

illnesses and managing chronic diseases. In the polyclinics, nurse clinicians who

are specially trained in managing patients with chronic diseases specializes in

disease management are known as care managers. The following proposed

roles discussed will be specific for the Advanced Practice Nurse in care

management. In Singapore, the title Case Manager is reserved for registered

nurses involving in disease management within the hospital and the title Care

Manager is reserved for registered nurses involving in disease management in

the primary and community settings.

Expert Clinical Care Manager

The characteristics of the patient population served by this APN include adult

patients with the following chronic diseases:

Diabetes Mellitus (mainly Type 2)

Hyperlipidemia/ hypercholestremia

Hypertension

Heart Failure

Stroke

Asthma

Chronic Obstructive Pulmonary Diseases

The main component for the role of expert clinical care manager is clinical

excellence. APN is to clinically manage patients with chronic diseases within the

organization. She works collaboratively with the physician in charge in the clinical

management of the patient. Health promotion and health education remains the

main component of her care towards her patients. Care management of the

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patients with chronic diseases include: changing and promoting health behaviors

through health education and counseling strategies, involving the family in the

care of the patient and teaching skills to empower patients in self-management.

Coordinating services among care sites and multiple providers is also a main

component of care managing.

The role of the APN as an expert clinical care manager in managing patients with

chronic diseases besides setting the standard of nursing care is to incorporate

advanced nursing skills in the duty of care. The advanced nursing skills include

thorough health assessment, physical examinations and the ability to furnish

medications. The advanced skills provided can also benefit the patients in terms

of reducing clinic waiting time and costs of healthcare.

Her roles towards her patients include sub-roles of being a nurse, a care

manager, an educator, a friend and an advocator. Her role towards caring for her

patients extends to include the family into the plan of care. Patient focus is the

center of her nursing care. An APN views each individual patient as a unique

individual, with a delicate balance of biological, psychological, spiritual and

sociological dimensions, and individualizes her plan of clinical nursing decisions

for each patient encounter.

The care that is delivered by the APN is been through a careful conscious

thought process using critical thinking skills. Formulation of accurate and

appropriate differential diagnoses in clinical encounters, recognizing important

risk factors contribution to diseases, identifying early indicators of problem are

some of the skills needed to provide a timely preventive action for the patients.

These skills require not only a strong clinical medical as well as nursing

knowledge, but also a diligent and “suspicion” attitude towards ill-defined

symptoms that might be presented. An APN’s care decision also requires a high

level of cultural sensitivity and awareness of ethical dilemmas.

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Though there are studies that measure the effectiveness of case management in

the clinics, there is no evidence of effectiveness of the distinguished features

between APN Case Manager and Nurse Case Manager in clinic disease

management till date (Mahn and Zazworsky, 2000). The job descriptions of the

nurse practitioners and the patient population in the study by Mundinger et al

(2000) are the same as the proposed clinical role in chronic disease

management. The results of the study showed that the outcomes are comparable

to the primary care physicians. Also a study by Litaker et al (2003) showed that a

new chronic disease management program involving a nurse practitioner-

physician team model of care significantly reduced 0.7% HbA1C level and 6%

increase in HDL levels. The subjects in the new model of care also showed

improved satisfaction in the care and health-related quality of life.

Collaborator, Consultant and Leader

The role of being an expert collaborator requires the following characteristics:

collegiality, communication (good interpersonal skills), goal sharing (common

purpose), task interdependence, clinical competence and a sense of humor

(Hanson, Spross and Carr, 2000). The role as an expert collaborator is important,

as an APN needs to influence and be a change agent in improving or maintaining

the standards of nursing at a broader level.

As a recognized expert clinical care manager, she functions as a consultant for

the nursing personnel in consult of issues relating to clinical management of

patients with chronic diseases. She also serves as a consultant for other

healthcare providers in consult of nursing management issues and holistic care

management issues of the patients. She being a consultant requires the

fundamental basis of a continuous learning attitude from clinical experiences and

evidenced based studies. A consciousness to base her decisions on concepts

and theories and constant reflection on her personal clinical encounters also help

in developing her to be an all rounded consultant.

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An APN functions as a leader in disease management programs and health

promotion services. Being an effective collaborator will only enhance her

leadership skills in being a effective change agent when it comes to develop and

implement care guidelines, protocols, care management pathways or decision

algorithms. APN’s involvement in direct clinical care benefit her role as a leader

in clinical quality improvement committee, as she is constantly exposed to

critically analyzed care delivery systems for costly inconveniences and

inefficiencies that can “threaten” quality care. Below are person attributes for an

effective APN leader (Hanson and Malone, 2000, p. 288):

Vision, coupled with the ability to set priorities

Good sense of timing

Self confident, assertive and willingness to take risks

Expert communication skills

Boundary management

Respect for cultural diversity

Balance in personal and professional life

Willingness to collaborate, change and negotiate, fail and begin again.

Researcher

The role of APN as a researcher used to focus on conducting research. Currently

the focus is on the following: interpreting research findings, utilizing research in

clinical settings and promoting the usage of evidenced based practice. To carry

this role out effectively, the APN has to reach a certain level of research

competency. Research competencies include (1) interpretation and use of

research in practice (2) evaluation of practice and (3) participation in

collaborative research (McGuire and Harwood, 2000). The APN ultimately is

expected to perform at an advanced level of (1) developing programmatic and/or

departmental research utilization process (2) identifying and/or developing

practice specific outcome indicator criteria and finally (3) leading and conducting

of evaluation studies. The focus of all these research studies and research

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utilization will be on disease care management, health promotion, health

education, and counseling strategies.

Educator/ Mentor

An APN as a clinical expert, collaborator, leader, consultant and researcher, is

the best or rather the most appropriate person to be the role model of the nursing

in the organization. I will be the first APN intern in Singapore community and

primary nursing profession. It is definitely important that the knowledge I have

had learnt is shared and continued. Encouraging nurses to take on the challenge

to join me as a team of APNs, personal mentoring is essential at the beginning to

help potential and passionate nurses in disease management.

Diagram of APN Proposed Roles

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CONSULTANT and MENTOR (10%)

RESEARCHER (15%)

EXPERT CLINICAL CARE MANAGER (75%)

(5%)Administrator COLLABORATOR

and LEADER (always)

COLLABORATOR and LEADER

(always)


Goals of Service

Clinical Goals

Achieve organization’s targeted medical outcomes (e.g. HbA1C < 7%,

HDL >1mmol/L etc.).

Increase patient knowledge of disease process and disease self

management.

Increase patient compliance with medications.

Increase patient compliance with health promoting behaviors (e.g. proper

diet intake, increase exercise activities, smoking cessation, weight

reduction, etc.).

Increase patient compliance with disease monitoring behaviors (e.g. blood

sugar monitoring, weight taking for CHF patients, blood pressure

monitoring, etc.)

Achieve 100% diseases complication screening attendance (e.g. diabetic

retinopathy, diabetic foot screening, urinary microalbumin screening, etc.)

Decrease occurrence or delay secondary complications of chronic

diseases.

Improve patient quality of health (e.g. evidence of increase symptoms

control etc.)

Organization Goals

Impact patient satisfaction surveys

Reduce clinic waiting time

Improve nursing knowledge and skills

Impact clinical practice through promoting utilization of evidence based

practice.

Increase nursing involvement in evidenced based activities.

Reduce clinic resource utilization costs

<Curriculum Vitae and Organization APN Job Description

are left out intentionally>

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References

Hanson, C.M. and Malone, B.L. (2000). Leadership: empowerment, change agency, and activism. In A.B. Hamric, J.A. Spross and C.M. Hanson (Eds), Advanced nursing practice – an integrative approach, 2nd ed., (pp. 279 – 313). Philadelphia: W.B. Saunders Company.

Hanson, C.M., Spross, J.A. and Carr, D.B. (2000). Collaboration. In A.B. Hamric, J.A. Spross and C.M. Hanson (Eds), Advanced nursing practice – an integrative approach, 2nd ed., (pp. 315 – 347). Philadelphia: W.B. Saunders Company.

International Council of Nursing (2003). Nurse practitioner/ advanced practice network – frequently asked questions. Retrieved 24 October 2005 from http://www.aanp.org/INP%20APN%20Network/FAQ/FAQ.asp

Litaker, D., Mion, L.C., Planavsky, L., Kippes, C., Mehta, N. and Frolkis, J. (2003). Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care. Journal of Interprofessional Care, 17(3), 223 – 237.

Mahn, V.A. and Zazworsky, D.J. (2000). The advanced practice nurse case manager. In A.B. Hamric, J.A. Spross and C.M. Hanson (Eds), Advanced nursing practice – an integrative approach, 2nd ed., (pp. 549 – 606). Philadelphia: W.B. Saunders Company.

McGuire D.B. and Harwood, K.V. (2000). Research. In A.B. Hamric, J.A. Spross and C.M. Hanson (Eds), Advanced nursing practice – an integrative approach, 2nd ed., (pp. 245 – 278). Philadelphia: W.B. Saunders Company.

Mundiner, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W., Cleary, P.D., Friedewald, W.T., Siu, A.L. and Shelanski, M.I. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians – a randomized trial. Journal of American Medical Association, 283 (1), 59 – 68.

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http://www.aanp.org/INP%20APN%20Network/FAQ/FAQ.asp

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