This document outlines Felisha Miller's philosophy of advanced practice nursing. It begins with a brief history of how the nurse practitioner role developed in response to physician shortages. It then discusses the Modeling and Role-Modeling nursing theory that best fits Miller's values in providing holistic and individualized care. Miller believes collaboration between providers is important for patient care, not competition. The document also notes that the public lacks understanding of the nurse practitioner role and that NPs will continue playing a key role in addressing primary care physician shortages.
This document outlines Felisha Miller's philosophy of advanced practice nursing. It begins with a brief history of how the nurse practitioner role developed in response to physician shortages. It then discusses the Modeling and Role-Modeling nursing theory that best fits Miller's values in providing holistic and individualized care. Miller believes collaboration between providers is important for patient care, not competition. The document also notes that the public lacks understanding of the nurse practitioner role and that NPs will continue playing a key role in addressing primary care physician shortages.
This document outlines Felisha Miller's philosophy of advanced practice nursing. It begins with a brief history of how the nurse practitioner role developed in response to physician shortages. It then discusses the Modeling and Role-Modeling nursing theory that best fits Miller's values in providing holistic and individualized care. Miller believes collaboration between providers is important for patient care, not competition. The document also notes that the public lacks understanding of the nurse practitioner role and that NPs will continue playing a key role in addressing primary care physician shortages.
Running head: ADVANCED PRACTICE NURSING PHILOSOPHY 1
Advanced Practice Nursing Philosophy
Felisha Miller Submitted to Dr. Chris Finn in partial fulfillment of NR 640 Advanced Practice Roles and Concepts Regis University June 1, 2014
PHILOSOPHY OF ADVANCED PRACTICE NURSING 2
Advanced Practice Nursing Philosophy
I know as a nurse practitioner (NP), I will assess patients, order lab and diagnostic tests, provide a diagnosis, and prescribe medications; but how do I articulate my philosophy of a nurse practitioner? In order to formulate a philosophy, I first need to understand the history and definition of advanced practice nursing. History of Advanced Practice Nursing On January 8, 1964, in his annual message to the congress on the state of the union, President Lyndon Johnson declared an unconditional war on poverty in America (American Presidency Project, 2014). To aid in this fight against poverty, Congress amended the Social Security Act by establishing the Medicare (Title XVIII) and Medicaid (Title XIX) programs. Medicare was established in response to the specific medical care needs of Americans over 65. Medicaid was established to provide health care coverage for low-income Americans (Klees & Wolfe, 2013) The increase in healthcare coverage due to Medicare and Medicaid coupled with the Vietnam War, and the mal-distribution of physician services, the United States faced a national health care manpower shortage (Wilson, 2003). Dr. Henry Silver indicated that this shortage of scientific manpower and the increase of the population growing at a faster rate than the increase in medical and nursing personnel would result in health services not being able to be maintained at an optimum level. Silver reported that if the pattern of delivering health care was not drastically improved, particularly to children of lower socioeconomic status in both urban and rural areas, those groups would suffer from increasing inadequate health management (Silver, Ford, & Stearly, 1967). The solution to this shortage of medical personnel was the development of the first nurse practitioner program. Silver, along with Loretta Ford established PHILOSOPHY OF ADVANCED PRACTICE NURSING 3
the first pediatric nurse practitioner (PNP) program at the University of Colorados Schools of Medicine and Nursing (Hoekelman, 1998, pp. 245-247). Definition According the Colorado law, the definition of an advanced practice nurse is a professional nurse who is licensed to practice, who obtains specialized education or training, who applies to and is accepted by the board for inclusion in the advanced practice registry. The law also states that a nurse who meets the definition and requirements of an advanced practice nurse, may be granted prescriptive authority; may document a patients current health status, authorize continuing treatment, tests, services, or equipment; and give advance directives for end-of-life care. (Colorado Revised Statutes 12-38-111.5, 2013) Effective as of July 2013, Colorado law further stated that, on and after July 1, 2008, the requirements for inclusion in the advanced practice registry shall include the successful completion of an appropriate graduate degree and on and after July 1, 2010, a professional nurse shall obtain national certification from a nationally recognized accrediting agency. (Colorado Revised Statutes 12-38-111.5, 2013) Nursing Theory There are so many different nursing theories out there. It was quite a task trying to find one that I identified with. I identified with many of the theoriesBetty Neumans Systems Model, Martha E. Rogers Theory of Unitary Human Beings, Rosemarie Rizzo Parse's Human Becoming Theory, Jean Watsons Philosophy and Science of Caringbut I did not agree with everything they said. How could I narrow it down to one? Maybe I could take a little of this theory and a little of that theory and create my own theoryThe Miller Methodbut that will have to wait for my next degree! The one thing I found in common with all the theories I PHILOSOPHY OF ADVANCED PRACTICE NURSING 4
identified with was they are all holistic theories. The theory I decided on that best fits my personal and professional values is The Modeling and Role-Modeling (MRM) Theory, developed by Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain and published in their book Modeling and Role Modeling: A Theory and Paradigm for Nursing, in 1983. The Modeling and Role-Modeling theory integrates concepts from several interdisciplinary theories, including Erik Eriksons stages of psychosocial development, Jean Piagets cognitive development, Abraham Maslows hierarchy of needs, and Han Selyes stress adaptation (Peterson, 2013, p. 235). The theory addresses the fact that we are all unique. We differ physically, genetically, in how we view the world, in how we adapt to internal and external stressors, and in our self-care knowledge and practices (Alligood & Toomey, 2010, p. 543). Modeling is defined as the process the nurse uses as she develops an image and understanding of the clients worldan image and understanding developed within the clients framework and from the clients perspective (Erickson et al., 1983, p. 95). To understand the clients prospective, the nurse must collect and analyze data about the client and unconditionally accept the client as a unique, worth-while, important individual (Alligood & Toomey, 2010, p. 541). Role-modeling is defined as the facilitation of the individual in attaining, maintaining, or promoting health through purposeful intervention (Erickson et al., 1983, p. 95). The nurse plans and implements interventions that are individual to the client based on the clients own model of the world (Alligood & Toomey, 2010, p. 541). The best way to provide intervention is to: (a) build a trusting relationship between the nurse and client, (b) promote hope and positive self-esteem, (c) promote the clients perception of control, (d) assist the client to identify and use their own strengths, and (e) set goals that have PHILOSOPHY OF ADVANCED PRACTICE NURSING 5
been mutually agreed upon that promote health and allow the client to meet basic needs (Sappington & Kelley, 1996). Collaboration In Colorado, nurse practitioners practice autonomously and do not need to have a collaborative agreement with a physician (Buppert, 2012, p. 48). Effective July 1, 2010, Colorado law states that a collaborative agreement between an advanced practice nurse and physician for prescriptive authority is no longer required. To obtain prescriptive authority an APN must complete an 1800 hour preceptorship, complete an 1800 hour mentorship, and develop an articulated plan for safe prescribing (Department of Regulatory Agencies (DORA), 2014). The American Nurses Association (ANA) defines collaboration as a partnership grounded in a reciprocal and respectful recognition and acceptance of: each partners unique experience, power, and sphere of influence and responsibilities: the commonality of goals; the mutual safeguarding of the legitimate interest of each part; and the advantages of such a relationship (ANA, 2010, p. 64). That definition sounds like teamwork to me. I have heard some NPs make collaborative agreement sound like a bad word and felt some tension between some NPs, and physician assistants (PAs) or physicians. There should not be a competition between providers for patients; our jobs should be about the patient and not our egos. To take proper care of our patients, we need to collaborate with many different disiciplines. Future of the Advanced Practice Nurse Role The American Association of Nurse Practitioners (AANP) opposes the use of terms such as mid-level provider and physician extender when referring to nurse practitioners (NPs). The association states that these terms imply that the care provided by NPs is less than a higher PHILOSOPHY OF ADVANCED PRACTICE NURSING 6
standard and it calls in to question the legitimacy of NPs to function as independent licensed practitioners. The AANPs position is that these terms further confuse the health care consumers and the general public, as they are vague and are inaccurately used to refer to a wide range of professions (AANP, 2013). In doing research into the advanced practice nursing role, I now understand that we need to define what our job ismany people to not know what a nurse practitioner is as evidenced from the Bill OReilly Show earlier this year when Bill OReilly debated the Affordable Care Act with Ezekiel Emanuel. When Ezekiel mentioned taking children to walk-in clinics instead of a Pediatrician, Mr. OReilly said, They are not doctors. If I want a strep throat diagnosis, I dont want Lenny who just came out of a community college. Emanuel replied, It is just putting a swab back there (Fox News Insider, 2014). This shows me that the public does not understand how much educations we have and what is involved in our rolewe are not just comminity college graduates and there is more to seeing a patient than just putting a swab back there. The Association of American Medical Colleges (AAMC) predicts that by 2020 the U.S. will be short more than 45,000 primary-care physicians (PCPs) and they report only about 20% of medical residents actually go into primary care (AAMC, 2010). One of the reasons the U.S. is facing a shortage of PCPs is because graduates are specializingspecialists earn more than PCPs and the average student debt after medical school graduation is more than $166,000 (Sadick, 2013). Dr. Silver saw this increase in demand for primary care back in 1965 and he believed the answer to the problem was nurse practitioners. With the Affordable Care Act increasing access to healthcare for hundreds of thousands of currently uninsured patients and the PHILOSOPHY OF ADVANCED PRACTICE NURSING 7
geriatric population growing because people are living longer, the demand for primary care providers is has only intensified. Vision In the future, as the public is educated about the advanced practice nurse role, I hope to not always need to explain what I do as a nurse practitioner or why I just did not become a physician. If the public is better informed as to our role, it will be easier to overcome state laws preventing us from practicing to our fullest capacity, it will be easier to overcome barriers to payment policies preventing us from being reimbursed at the same rate as physicians for the same services, and hopefully it will help to overcome professional tensions between NPs and Pas and NPs and physicians. As communications technology continues to improve, I see increased opportunities for nurse practitioners to collaborate with specialists and other professionals using telemedicine and telepresence systems. This can only serve to improve the quality of cares as well as the depth and breadth of services provided. Goals As a nurse with a graduate degree, I want to specialize as a geriatric nurse practitioner and serve the older adults in my community. People are living longer and have more complex needs chronic diseases, cognitive difficulties, pain, depression, loneliness, polypharmacy, and a healthcare system that has become more complex. Patients aged 65 and over are a rapidly growing population and there is a need for practitioners that will advocate for quality care for older adults. Many people do not think of geriatrics as a specialty, but an 80 year old has different needs from a 30 year old. The geriatric community has more comorbidities, thus, they see many PHILOSOPHY OF ADVANCED PRACTICE NURSING 8
different practitioners in different specialties. This can lead to over- medicating, unintended medication conflict and interactions, as well misunderstandings. Older adults need someone that can take the time to get all of the pieces and look at the big picture and help them navigate through the often confusing and complex diagnosis and treatment(s). I eventually would like to have my own geriatric practice. In order to have a successful practice, I need to first gain experience and confidence as a practitioner and build relationships with other health care professionals and build an interdisciplinary team. Taking care of a patient holistically, means working with a team to take care of all of the patients needs. I may need to refer my patient to, or consult with a dietitian, a social worker, a psychologist, a cardiologist, or a nephrologist (to name a few) if something is beyond the extent of my knowledge. We need to remember to put our patients first and put our egos to the side. My Philosophy Everyone needs to be treated as an individual. What works for one person may not work for another; and what works for a particular patient at certain point in time may not work for that same patient at another time as circumstances change. We need to be fluid in our theory of how to treat our patients. A patients situation is in relation to their environmentwe need to remember that a patient is an extension of his or her family and community. One persons definition of quality of life, goals, and values may differ from our own and that should be respected. Providers need to take the time to listen to patients and remember that they are experts on themselveswe need to treat them as partners in their carewe need to educate them so that they can be their own advocate. All of our interactions with our patients are used to form their perceptions and it is vital to remember that our patients perception is their reality.
PHILOSOPHY OF ADVANCED PRACTICE NURSING 9
References Alligood, M. R., & Toomey, A. M. (2010). Nursing theorists and their work (7th ed.). Maryland Heights, Missouri: Elsevier Health Sciences. American Association of Nurse Practitioners. (2013). Use of terms such as mid-level providers and physician extender position paper. Retrieved from http://www.aanp.org/images/documents/publications/useofterms.pdf American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed., p. 64). Silver Spring, Maryland: Nursebooks.org. American Presidency Project. (2014). Annual message to the congress on the state of the union, January 8, 1964: Lyndon B. Johnson. Retrieved from http://www.presidency.ucsb.edu/ws/?pid=26787 Buppert, C. (2012). Nurse practitioner's business practice and legal guide (4th ed., p. 48). Bethesda, Maryland: Jones & Bartlett Learning. Colorado Revised Statutes, Colorado Nurse Practice Act, 12-38-111.5 (2013). Department of Regulatory Agencies. (2014). Retrieved from http://cdn.colorado.gov/cs/Satellite/DORA-Reg/CBON/DORA/1251633109128 Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and role-modeling: A theory and paradigm for nursing. Prentice Hall. Fox News Insider. (2014). Debate: Are doctors fleeing the Obamacare exchange? Retrieved from http://foxnewsinsider.com/2014/03/04/bill-o%E2%80%99reilly-ezekiel-emanuel- debate-whether-doctors-are-fleeing-obamacare-exchange Hoekelman, R. A. (1998). Commentary. A program to increase health care for children: the pediatric nurse practitioner program, by Henry K. Silver, MD, Loretta C. Ford, EdD, PHILOSOPHY OF ADVANCED PRACTICE NURSING 10
and Susan G. Stearly, MS, 102. Retrieved from http://pediatrics.aappublications.org/content/102/Supplement_1/245.full.html Klees, B. S., & Wolfe, C. J. (2013). Brief Summaries of Medicare & Medicaid, Title XVIII and Title XIX of the Social security Act as of November 1, 2013. Office of Actuary, Centers for Medicare & Medicaid Services. Retrieved from http://https://www.cms.gov/Research- Statistics-Data-and-Systems/Statistics-Trends-and- Reports/MedicareProgramRatesStats/downloads/MedicareMedicaidSummaries2013.pdf Peterson, S. J., & Bredow, T. S. (2013). Middle range theories: Application to nursing research. (3 rd ed., p. 235). Philadelphia, Pennsylvania: Lippincott Williams & Wilkins. Sadick, B. (2013). In search of more primary-care doctors. The Wall Street Journal. Retrieved from http://online.wsj.com/news/articles/SB10001424052702303902404579151510997182566 Sappington, J., & Kelley, J. H. (1996). Modeling and role-modeling theory: A case study of holistic care. Journal of Holistic Nursing, 14(2), 130141. Silver, H., & Ford, Loretta K., and Stearly, Susan G. (1967). A program to increase health care for children: the pediatric nurse practitioner program. Pediatrics, 39(5), 756760. Wilson, D. (2003). Nurse practitioners: The early years (1965-1974). Retrieved from http://www.mnpa.us/NPHistory.pd