Introduction
Advanced practice nursing is rapidly gaining support from health care providers because the use of different advanced practice roles and competencies improves healthcare quality and lowers health care costs. Comparison and contrast of advanced practice nursing roles can help to examine the specialty of primary care family nurse practitioners focusing on the scope of practice, core competencies, certification requirements, legal aspects, practice environment, population, future peers, and colleagues. Moreover, analysis of leadership attributes and health care policies of primary care family nurse practitioners is essential to meet high standards of advanced practice nursing.
Advanced Practice Roles in Nursing
Understanding of different advanced practice roles and core competencies of direct (nurse practitioners) and nondirect (nurse educator, nurse informatics, and nurse administrator) caregivers is one of the key factors for the effective performance of advanced practice nursing (APN).
To deliver high-quality health care service for a reasonable price, it is essential for direct and non-direct care providers “to rely on a core set of role expectations” in clinical practice, primary care, education, administration, and research (Hamric, Hanson, Tracy, & O’Grady, 2014, p. xii). Thus, the implementation of core competencies according to their roles will allow health caregivers to work as an effective and successful team.
In clinical practice and primary care, both direct and nondirect health care providers should be competent in theoretical and clinical knowledge for “health promotion, health protection, disease prevention, and treatment” (Population-focused nurse practitioner competence, 2013, p. 15). Implementation of knowledge competence in clinical practice and primary care requires “current knowledge of patient care delivery systems and innovations” from nurse administrators, educators or informatics to maintain to “determine when new delivery models are appropriate, and then envision and develop them” (The AONE nurse executive competencies, 2005, p. 6). Likewise, NPS “critically analyze data and evidence for improving advanced nursing practice” (Population-focused nurse practitioner competence, 2013, p. 9). However, NPS in contrast to nondirect health providers should be competent in “assessment skills to differentiate between normal, variations of normal and abnormal findings”, which employs “screening and diagnostic strategies”, prescribing medications, and managing “the health/illness status of patients and families over time” (Population-focused nurse practitioner competence, 2013, p. 15). Hence, both providers should be competent in providing high-quality health in clinical practice and primary care.
Moreover, common competence in “patient-centered care” requires from non-direct care providers “effective communication” to resolve conflicts, “relationship management” and “shared decision-making” to engage medical staff to cooperate (The AONE nurse executive competencies, 2005, p. 4). Direct care providers should be competent in interpersonal communication developing “therapeutic communication principles, techniques and ethics (e.g., boundaries, phases of the therapeutic relationship, conflict of interest, self-awareness, negotiation and collaboration)” (Population-focused nurse practitioner competence, 2013, p. 73). Thus, strong communicational skills are needed for both direct and non-direct healthcare providers in order to ensure high-quality health care according to advance practice nursing standards.
When implementing communication and relationship-building competence, nurse administrators, educators and informatics should “assess the current environment and establish indicators of progress toward cultural competency” and “define diversity in terms of gender, race, religion, ethnicity, sexual orientation, age” (The AONE nurse executive competencies, 2005, p. 4). Similarly, NPS shares “relationship-building values and the principles of team dynamics” to perform effectively, “to plan and deliver patient/population-centered care that is safe, timely, efficient, effective and equitable” (Population-focused nurse practitioner competence, 2013, p. 23). Thus, direct and non-direct health care providers should develop and promote impartiality and open-mindedness.
As to administration, direct and non-direct caregivers are required to develop different skills. For example, one of the specific core competencies for nurse administrators is developing business skills in “understanding of health care financing”, “human resource management and development”, “strategic management”, “information management and technology”, and marketing (The AONE nurse executive competencies, 2005, p. 10). Hence, competence in business is essential for non-direct care providers as they should be keen in accounting, charging, team managing, and workforce planning; effectively cope with workers’ problems; use modern techniques for team motivating and stimulating; know and implement new recruitment strategies; conduct SWOT and marketing environment analysis; and design new marketing strategies (The AONE nurse executive competencies, 2005, p. 10). On contrary, NPS does not need to be keen on marketing or recruitment, but they should develop competence in “organizational theory, “principles of management”, “models of planned change”, “collaborative practice”, “healthcare system financing”, “reimbursement systems”, “cost, quality, outcome measures”, “resource management”, “evaluation models”, and “peer review” (Population-focused nurse practitioner competence, 2013, p. 26). Therefore, developing managing and organizational skills is essential for both providers.
In regards to education, implementation of professional competence of both direct and non-direct caregivers is “evidence-based” (The AONE nurse executive competencies, 2005, p. 8). Nurse administrators, for example, should “teach and mentor others to routinely utilize evidence-based data and research” (The AONE nurse executive competencies, 2005, p. 8). Consequently, NPS should provide education “on preventive health care and end-of-life choices”, “educational initiatives that translate health information to children and families”, “self-management of acute/chronic illness with sensitivity to the patient’s learning ability and cultural/ethnic background” (Population-focused nurse practitioner competence, 2013, pp. 20-26). Thus, both direct and non-direct health care providers should develop skills to deliver their knowledge to patients, peers, and the community.
Concerning research, nurse administrators, informatics, and educators should “utilize research findings for the establishment of standards, practices and patient care models in the organization” and also “participate in studies that provide outcome measurements” (The AONE nurse executive competencies, 2005, p. 6). Similarly, NPS should develop “new practice approaches based on the integration of research, theory, and practice knowledge” (Population-focused nurse practitioner competence, 2013, p. 9). Both direct and non-direct health care providers should be able to put new knowledge into practice, apply “clinical investigative skills”, develop knowledge on “research process and methods”, “information databases”, “critical evaluation of research findings”, “research dissemination” (Population-focused nurse practitioner competence, 2013, p. 21). To implement innovative health care systems, health caregivers should actively participate in research.
Clinical practice, primary care, education, administration, or research functions require both direct and non-direct caregivers to develop leadership skills. NPS should demonstrate “leadership that uses critical and reflective thinking” to advocate “for improved access, quality and cost-effective health care” (Population-focused nurse practitioner competence, 2013, p. 22). In the same way, non-direct care providers “address ideas, beliefs or viewpoints that should be given serious consideration” and also “demonstrate reflective leadership” (The AONE nurse executive competencies, 2005, p. 8). Therefore, improving leadership skills is an integral part of qualitative and cost-saving health care for advanced practice nursing.
Primary Care Family Nurse Practitioner
My selected advanced practice role is primary care family nurse practitioner in New Hampshire.
According to New Hampshire Statutes (2009), the Nurse Practice Act has the force of law, and its section RSA 326-B states that “scope of practice and authority for advance practice registered nurse shall consist of a combination of knowledge and skills acquired in basic nursing education” (para. 11). Moreover, APRNs should practice according to “standards established by a national credentialing or certification body recognized by the National Council of State Boards of Nursing and approved by the board in the appropriate APRN role and specialty” (para. 2). By New Hampshire Statutes (2009), the certification requirement in New Hampshire for APRN includes “a current license as a registered nurse”, “a graduate degree earned in an accredited advanced practice registered nurse education program”, and current certification “by a board-recognized national certifying body in the specialty for which the applicant was educated” (para. 18). Hence, advanced practice nurses should comply with regulatory, legal and certification requirements in their work in New Hampshire.
A professional organization available for membership based on family nurse practitioner role is New Hampshire Nurse Practitioner Association, which is “a non-profit, professional advocacy organization, dedicated to preserving the strength and integrity of advanced practice nursing” (New Hampshire Nurse Practitioner Association, n.d., para. 1). In my opinion, membership in this organization will be beneficial for my career.
Considering my specialty as primary care family nurse practitioner, I expect to practice in a hospital setting that takes care of the medical-surgical patient and is sized from 100 to 180 patients. The suggested population of my specialty should consist of different age children including newborns, infants, and teenagers; adults including pregnant and postpartum women and aged citizens. Predicting future colleagues, I suggest there will be primary care providers (physicians, physician assistants, nurse practitioners, certified nurse-midwives, registered nurses, licensed practical nurses, medical assistants), clinical team members (social workers, psychologist, clinical pharmacists, dentists, nutritionists), and other healthcare givers (clerical assistants, translators, health educators, coaches and consultants, receptionists) (Fauteux, 2012, p. 8). Hence, I can suggest that I will work in an interprofessional team of direct and non-direct care providers that have specific core competencies.
Principally, family nurse practitioners’ competencies place to care for individuals and families across the lifespan in the center.
One of the core competence for NP is to provide “the full spectrum of health care services to include health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, palliative, and end-of-life care. The role includes” (Population-focused nurse practitioner competence, 2013, p. 15). However, FNP focuses on “family theories and development stages to individualize care provided to individuals and families” (Population-focused nurse practitioner competence, 2013, p. 16). Hence, FNP should be mainly devoted to family care in a community context.
Besides, practitioner-patient relationship competence requires maintaining and developing partnerships with individuals, families and other caregivers “to address sensitive issues” (Population-focused nurse practitioner competence, 2013, p. 18). Thus, the strong communication skills of FNP are crucial for interpersonal relationships with patients as they have a great impact on therapeutic outcomes.
Furthermore, FNP competence of “guidance, teaching, coaching, collaborating (with the patient, family, and community)” requires teaching “patients, families and groups about treatment options with respect to developmental, physiological, cognitive, cultural ability and readiness” (Population-focused nurse practitioner competence, 2013, p. 18). Consequently, FNP should know and use different teaching and coaching approaches to efficiently provide necessary information to individuals and families.
Next, the professional role of FNP relates to advancing “practice through the development and implementation of innovations incorporating principles of change” (Population-focused nurse practitioner competence, 2013, p. 10). Hence, FNP should participate in community and professional organizations to enhance the role of family nurse practitioners.
Another core competence for FNP applies to “knowledge of organizational practices and complex systems to improve health care delivery” and requires facilitating, developing and evaluating health care systems (Population-focused nurse practitioner competence, 2013, p. 13). Moreover, FNP should be competent in “planning, development, and implementation of public and community health programs” (Population-focused nurse practitioner competence, 2013, p. 13). Therefore, FNP should closely consider how the health care delivery system can influence individuals and families in a community.
Further, quality health care competencies of FNP require the use of “best available evidence to continuously improve quality of clinical practice” (Population-focused nurse practitioner competence, 2013, p. 11). Moreover, FNPS should monitor and evaluate their practice, conduct research and keep professional development (Population-focused nurse practitioner competence, 2013, p. 11). Thus, consultations and collaboration with peers and other professionals are essential for providing high-quality health care.
In addition, “technology and information lite” competencies of FNPS require the use of “available technology that enhances safety and monitors health status and outcomes” (Population-focused nurse practitioner competence, 2013, p. 12). Hence, to improve health care, FNPS should develop their technological and informational knowledge.
Furthermore, FNPS should develop their cultural competencies and incorporate “the patient’s cultural and spiritual preferences, values, and beliefs into health care” (Population-focused nurse practitioner competence, 2013, p. 16). In particular, FNPS develops “patient-appropriate educational materials that address the language and cultural beliefs of the patient (Population-focused nurse practitioner competence, 2013, p. 17). Therefore, culturally diverse patients should be treated respectfully to their values and belief.
Finally, leadership competence requires FNPS to “provide leadership to foster collaboration with multiple stakeholders” (Population-focused nurse practitioner competence, 2013, p. 10). Namely, FNPS should engage patients, peers, and the community in developing health care and acknowledging the need for integral relationships between all members of the treatment process.
Leadership Attributes of the Family Nurse Practitioner
My leadership style was determined as “participative” one by which leaders “offer guidance to its group members, but also participate in the group and allow input from other group members about making decisions and solving problems” (Cherry, 2006, para. 8). In my opinion, I understand situations in my workplace and adjust my behavior in response to the task at hand.
As a leader, I am firm but not overbearing as I am open to feedback from my peers. Although participative leaders should “encourage group members to participate but retain the final say in the decision-making process”, I sometimes lack self-confidence and face problems with decision making (Cherry, 2006, para. 9). However, advanced nurses need to master clinical excellence to empower staff, to have a vision for the future, to be self-confident in their abilities, and to remain accountable for their decisions (Germain & Cummings, 2010). Therefore, I should develop my decision-making skills and work on mentoring to become a positive role model to the staff.
In my opinion, I can deal with the consequences of my decisions as my communicative skills are well developed, and I communicate clearly and effectively. According to Germain and Cummings (2010), “strong communication among nurses and their leaders” can help to build “trusting relationships” (p. 434). Thus, I always thank the staff and apologized for any misunderstandings that happened during my shift.
Moreover, I’m always monitoring the development of my skills. By Hassmiller and Truelove (2011), nurses need to “take every opportunity to develop and hone their leadership qualities and skills” (p. 61). Hence, I know my leadership skills need to be developed but I believe that will come with time, in the continuum of learning.
Health Policy and Family Nurse Practitioner
Nowadays, primary care providers are looking for new models to improve health care and save costs. Thus, health policy should be changed to improve healthcare quality with the help of new healthcare models that actively use the advantages of advanced nursing.
For example, “a reactive, visit-focused approach” should be replaced with “the Care Model Process” or “Wagner Chronic Care Model”, which emphasizes “the delivery of evidence-based care to an informed and activated patient by a team of prepared and proactive practitioners” as it was done in Minnesota by HealthPartners (Fauteux, 2012, p. 3). The new model suggests the creation of collaborative teams of different clinicians (NPS, pharmacists, diabetes educators) providing a full range of services.
As FNP, I can review patients’ health records via the Internet and then order tests before a patient visits a hospital. I can visit or phone patients to make sure they understand and implement all prescriptions. For example, there is an online service called “virtuwell”, a “low-cost alternative to traditional office visits” that “logged nearly 30,000 completed visits in its last 20 months and continues to attract new visitors” (Fauteux, 2012, p. 3). Hence, participation in this new model will allow me to access diagnosis and conduct treatment of common conditions fast and easily.
The effect of this model in Minnesota demonstrated that for HealthPartners “total cost of care was 10 percent below the statewide average in 2010”; moreover, “avoided ER visits for patients with diabetes saved $900,000 in one year alone” (Fauteux, 2012, p. 3). Hence, I believe that the implementation of this model in other states can lead to a significant increase in healthcare quality and ensure cost savings for patients.
Furthermore, primary care providers can use Vermont’s Blueprint for Health initiative to improve health quality and save costs. This innovative primary care model includes the creation of “community health teams that deploy nurses, social workers, behavioral health counselors, and others to work within clinics and private practices” (Fauteux, 2012, p. 4). The teams are privately and publicly supported with the community funds, and they provide primary health care to all state residents. Besides, “advanced primary care practices (APCPs)” get “supplementing fee-for-service payments with monthly per-patient payments based on quality” (Fauteux, 2012, p. 4). Consequently, funding is distributed between state payers and the community, and advanced NPS can practice in the regions short on physicians.
In this model, I can be a team leader, visit patients personally and then make sure that “they receive the preventive and coordinated care that the state is banking on to keep its citizens healthy” (Fauteux, 2012, p. 4). Hence, as FNP I can practice my core competencies: leadership, health promotion, health protection, disease prevention and treatment, practitioner-patient relationship, team-coaching, managing and negotiating health care delivery systems, monitoring and ensuring the quality of health care practice.
As a result, Vermont Medicaid uses the teams to reduce “contracted disease management programs” (Fauteux, 2012, p. 4). Consequently, “APCPs was serving more than 353,000 of the state’s 637,000 residents” in 2012 in Vermont (Fauteux, 2012, p. 4). In my opinion, the use of such teams will reduce the costs of health care for a state taking into account a current trend of aging.
In addition, the Patient-Aligned Care Team (PACT) was introduced by the U.S. Department of Veterans Affairs (VA) to work “in areas as diverse as patient education and system improvement” (Fauteux, 2012, p. 8). PACT includes five members: “a primary care provider”, “a nurse care manager”, “a clinical associate”, “a clerical associate”, and “a veteran who is encouraged to take an active part in making decisions about his or her health” (Fauteux, 2012, p. 8). When regular clinic visits are impossible for a patient, consulting is done via telephone or “telehealth devices” (Fauteux, 2012, p. 2). In terms of this model, health care promotes “a collaborative team culture, with all members working at their highest level of competency”, develops “electronic health records”, and uses new “telehealth” technology (Fauteux, 2012, p. 8). Hence, PACT focuses on patients’ needs and preferences when using a veteran as the fifth member of the team.
As FNP, I can take place of a primary care provider in PACT. To promote efficient health care, I can fulfill a role of “clinically nurse leader” that provides “evidence-based leadership within the care setting regarding issues” such as “quality and safety”, “interprofessional collaboration”, “patient satisfaction”, and “system redesign” (Fauteux, 2012, p. 8). For this role, I should develop my leadership, communicative and professional skills.
The outcome of this innovative model of primary care can be demonstrated by the figure of over 100,000 patients who “opted into secure messaging” in one year; moreover, “phone utilization in primary care rose from 4 percent to 23 percent, and two-day post-discharge contact increased from 6 percent to 35 percent” (Fauteux, 2012, p. 8). Hence, cost savings of this model showed a reduction in “ER/urgent-care visits and acute-care hospital admissions by 43 percent and 47 percent, respectively” (Fauteux, 2012, p. 8). Therefore, the use of this innovative policy across the United States will ensure health care quality and cost savings.
Advanced nursing is capable of solving many problems that healthcare providers face by improving healthcare quality and lowering health care costs.
References
Cherry, K. A. (2006). Leadership styles. Web.
Fauteux, N. (2012). Charting nursing’s future. Implementing the IOM future of nursing report–part III: How nurses are solving some of the primary care’s most pressing challenges. Robert Wood Johnson Foundation. Web.
Germain, P. B., & Cummings, G. G. (2010). The influence of nursing leadership on nurse performance: a systematic literature review. Journal of Nursing Management, 18(4), 425-439.
Hamric, A. B., Hanson, C. M., Tracy, M. F., & O’Grady, E. T. (2014). Advanced practice nursing: An integrative approach. (5th ed). St. Louis, MO: Saunders.
Hassmiller, S.B, & Truelove, J. (2014) Are you the best leader you can be? American Journal of Nursing 114(1), 61.
New Hampshire Nurse Practitioner Association. (n.d.) Web.
New Hampshire Statutes. (2009) Web.
Population-focused nurse practitioner competence: Family/across the lifespan, neonatal, acute care pediatric, primary care pediatric, psychiatric-mental health, & women’s health/gender-related. (2013). Web.
The AONE nurse executive competencies. (2005). Chicago, IL: The American Organization of Nurse Executives.
