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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

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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
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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
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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
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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
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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
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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
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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.


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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
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Fox News Insider. (2014). Debate: Are doctors fleeing the Obamacare exchange? Retrieved
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debate-whether-doctors-are-fleeing-obamacare-exchange
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and Susan G. Stearly, MS, 102. Retrieved from
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Peterson, S. J., & Bredow, T. S. (2013). Middle range theories: Application to nursing research.
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