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22Articles
J Health Dev 2018; 2(27) Supplement:44-48
THE ROLE OF NURSES IN ENSURING QUALITY AND SAFETY OF MEDICAL CARE
ADVANCED PRACTICE NURSES: DELIVERING QUALITY AND COST- EFFECTIVE HEALTH CARE
Primeau M.S.
1 University of Alabama in Huntsville, College of Nursing, Coordinator of Global Health and Medical Mission Program, USA
Abstract
Providing healthcare in the future is acknowledged by many to be challenging at both the national and international levels. Globally, advanced practice nurses are in an excellent position to assist in achieving the goals of effective, high-quality, and cost effective care, and to facilitate redesign and improvement of healthcare systems. To do this, though, nurses around the world must be committed to growth as a profession, and dedicated to ensuring that nurses, and especially advanced practice nurses, become key players in the rapidly-changing global healthcare arena.
This article is devoted to importancy of advanced nursing practice in provision of high-level medical care.
Key words: advanced nursing practice, medical care quality.
Жогары мамандандырылган кец профильдi мешрбикелер: Сапалы жэне Kipici мол медицинальщ квмек усыну
Тужырымдама
Жа;ын болаша;та сапалы медициналы; квмек кврсету мемлекеттiк ;ана емес халы;аралы; мэселе pemiHde ;арастырылатын болады. Халы;аралы; тэж^рибеае суйенсек, жогары мамандандырылган кец профильдi мейiрбикелер сапалы жэне KÍpid мол медициналы; квмек усыну ;ызметiнде мацызды рвл ат;арады. Олар сапалы api кiрiс мол медициналы; ;ызмет кврсетуае ат салысып ;ана ;оймай, буюл денсаулы; са;тау жуйеан ;айта куру мен дамытуга септiаiн тиаiзеpi свзаз. Осы ма;сат;а жету жолында эрвр мейipаеp взiн дамытуга кулшынып, жылдам дамып жат;ан денсаулы; са;тау жyйесiндеаi жогары мамандандырылган кец пpофильдi мейipаеpлiк ;ызметтiц алар орнын тусше блуi керек.
Ма;ала жогары мамандандырылган медициналы; квмек квpсетудеаi мейipаеpлiк yздiк тэжipибенiц мацыздылыгына
арналган.
Krnmmí свздер: уздж мейipаеpлiк тэж^рибе, медициналы; ;ызметтiц сапасы.
Медицинские сестры широкого высокоспециализированного профиля:
Предоставление качественного и рентабельного медицинского обслуживания
Резюме
В будущем предоставление качественного медицинского обслуживания станет проблемой как на государственном так и на международном уровнях. В международной практике, медсестры широкого высокоспециализированного профиля занимают немаловажную позицию в помощи достижения целей эффективной, высококачественной и рентабельной медицинской помощи, а также в содействии реорганизации и улучшения системы здравоохранения в целом. Для этой цели, медсестры всего мира должны стремиться расти в профессиональном плане и понять, что, особенно медсестры широкого профиля, являются ключевыми фигурами в динамично меняющейся всемирной арене здравоохранения.
Статья посвящена значимости передовой сестринской практики в оказании высококачественной медицинской помощи.
Ключевые слова: передовая сестринская практика, качество медицинских услуг.
УДК 614; 614.2; 614:33
Recieved: 14.06.2018 Accepted: 18.06.2018
Corresponding author: Marlena Primeau, DNP, FNP-BC, NHDP-BC, BSHECS, Clinical Associate Professor Coordinator, Global Health and Medical Mission Program University of Alabama in Huntsville, College of Nursing, USA
Address: 301 Sparkman Drive. NB 321. Huntsville, Alabama USA 35899 Phone: + 01 (256) 824-2449 E-mail: Marlena.Primeau@uah.edu
Introduction
It is no surprise that, just as the world gets more and more complex, healthcare has become increasingly complicated and fragmented. Global and national healthcare systems have numerous critical issues on the horizon, and healthcare is changing dramatically in an effort to find viable solutions. Although every country has its own unique set of concerns and issues, there are certain common healthcare themes and needs; better access to care for everyone, improved healthcare equity for diverse populations, provision of quality care within acceptable financial boundaries, adequate numbers of health workers, and successful patient outcomes [1]. Longer life expectancies and increasingly complex chronic diseases add additional dimensions to the traditional healthcare concerns.
Advanced Practice Nursing (APN), currently utilized in some form in an estimated 70 countries worldwide [2], has proven to be an excellent answer for many healthcare challenges, including a lack of primary care providers, a need for better access to care, more cost-effective care, and an increase in quality outcomes.
Table 1 - Advanced levels of practice of different countries [5]
Countries
Australia, Canada, Finland, Ireland, Netherlands, New Zealand, UK, US
Austria, Belgium, Croatia, Cyprus, France, Germany, Iceland, Israel, Lithuania, Norway, Spain, Sweden, Switzerland
Belgium, Czech Republic, Denmark, Estonia, Hungary, Italy, Latvia, Luxembourg, Malta, Poland, Portugal, Slovenia
Although continued research and documentation is critical, numerous studies have already been conducted to study APN outcome data in relationship to that of physicians, and to date, the literature solidly supports the contention that APN care has excellent outcomes, often with lower costs and reduced use of resources [3,4]. Proper utilization of advanced practice nurses has the potential to transform health care systems, improve public health and wellbeing, and reduce overall healthcare spending.
However, there continue to be barriers and challenges in the global utilization of advance practice nurses. Practice levels for nurse practitioner range widely, from high-level practice settings to simple expansion of nursing roles that do not yet meet the level of advanced practice knowledge and expertise required (see Table 1). Although progress is being made, barriers to practice range from challenges from outside sources, such as territorial and practice concerns from other healthcare professions, to internal issues, such as the lack of standardized educational and practice requirements, and the lack of professional unity.
Advanced Practice Levels Established APN Practice (High levels of advanced clinical practice) Emerging APN Practice
(Education programs available, but practice not at advanced clinical level)
Extended Nursing Roles
(No APN-level practice or education)
To assist in clarifying the issue, it would be helpful to understand the differences between nursing and medicine. Medicine's focus and expertise is on pathology; the pathology of the cell, the organ, the system, and the human body, and how to resolve that problem. Nursing comes from a holistic viewpoint and focuses on wellness, and on how to assist the whole person in getting well and staying well. Nursing is a synthesis discipline; it draws on knowledge from a variety of disciplines to facilitate wellness in each patient. Nursing and medicine are independent and complimentary professions, not hierarchical. They work best in tandem, and the use of interprofessional collaboration and healthcare teams is becoming essential to safe and successful patient care [6]. Advanced practice nursing often provides a bridge between nursing and medicine, and effectively blends the best of both.
Advanced Practice Nursing
Advanced Practice Nurses (APNs) are clinicians and healthcare professions who have the education, credentials, and clinical expertise to work in an expanded nursing role, and are becoming an integral part of the healthcare systems in many countries. APNs function effectively in primary care, whether in or out of an office, as well as in a wide variety of specialties. APNs provide holistic care while diagnosing and treating illness or disease, and at the same time emphasizing health promotion and healthy living.
There are numerous types of APNs, all providing needed and necessary healthcare around the world [7]. APNs are called by a variety of names and have a variety of job descriptions, but there are a few characteristics that are at the core of the APN role. They include autonomous practice, patient centered and values-based care, the ability
to think and make decisions critically, and the importance of supporting and modeling nursing leadership. Authority and responsibility to diagnose illness, prescribe medications, provide treatment, refer clients to specialists, and admit patients to hospitals are all common characteristics that APNs are educated and trained to do.
Utilizing APN titles from the US, the most common types of Advanced Practice nurses are Nurse Practitioners, Nurse Anesthetists, Nurse Midwives, and Clinical Nurse Specialists.
Nurse Practitioners (NP) are clinicians, and provide assessment, diagnosis, and treatment for acute and chronic conditions in a wide variety of healthcare settings and for a wide variety of patients and populations. NPs were originally established in the US in the mid - 1960s. Family nurse practitioners (FNP), the largest subgroup of NPs, are primary care providers and see patients across the lifespan. There are also NP specialties working with women, acute care, pediatric, geriatric, and psychiatric populations.
Nurse Anesthetists (CRNA) work with surgical teams to ensure the safe administration of anesthesia through all phases of surgery and related procedures, including pain management.
Nurse Midwives are considered primary care providers, and specialize in caring for women across their lifespan, including pregnancy and birth.
Clinical Nurse Specialists are registered nurses, often at the bedside, who have advanced knowledge and clinical skills. They work in a wide variety of health care settings, and are usually specific to a particular patient population.
Education of APNs is currently non-standardized and practice requirements are non-uniform. Although many countries are still working toward this, the goal for APN education is to require a Master's degree. Some APNS, especially NPs, are moving toward doctoral preparation as a requirement to practice.
Benefits of Advance Practice Nurses
Utilization of APNs in various healthcare settings provides a quite lengthy and varied list of benefits that can be identified and that are well supported in the literature [1, 3, 4, 6, 8 -14]. The studies are international in scope, reflect primary care as well as a variety of specialties, and cross age and cultural boundaries. A good start has been made globally in identification of healthcare issues to overcome, as well as widespread acknowledgement of the potential for substantial healthcare improvement through the use of APNs.
Benefits identified in the literature for utilization of APNs include:
• APN care is cost-effective.
• Clinical outcomes on par with physician outcomes.
• Improved efficiency of services for patients.
• Improved patient access and waiting times.
• Increased patient-centered and holistic care.
• Increased patient and family satisfaction.
• High level of quality care perceived by patients.
• Fewer hospital readmissions and emergency room visits.
• Higher levels of patient compliance and knowledge.
• Smoother transitional care from hospital to home and community.
Barriers and Challenges
The long list of benefits for developing and integrating APNs into the healthcare system is unfortunately equaled by the list of barriers and challenges that still remain. There are numerous studies in the literature that identify the various barriers and challenges to the global integration of APNs into the current healthcare environment [6, 8, 15 -19]. These barriers include:
• A lack of international agreement on APN roles, titles, and scope of practice.
• Lack of consistent and common goals between all types of APNs.
• Absence of a strategic plan for APN integration into healthcare systems.
• Difficulty in altering the traditional hierarchy among healthcare professionals.
• Difficulty in overcoming traditional gender roles.
• Lack of acceptance by other healthcare disciplines and the public.
• Deficient numbers of qualified faculty to teach in APN programs.
• Lack of a standardized educational curricula and certification requirements.
• Lack of education and training in nursing leadership and policy skills.
• Restrictions in practice freedom and scope of practice by outside entities.
• APN lack of knowledge of and access to policy decision-making
So what does all this mean, and where can we go from here?
APN policy and regulation
Nurses must be educated in regulatory and funding processes, and learn ways to successfully interact with key stakeholders. There needs to be better communication and interaction between governmental or facility policy makers and APNs. APNs need to take the lead in joining and participating in policy discussions and negotiations. Governmental and institutional policy changes need to be made to facilitate and support full use of APNs, which may need to be addressed on an organizational culture change level [18].
Education/Certification
Educational programs should be redesigned to meet practice standards and allow for future needs in a profession where change can occur rapidly. Increased education on technological and genomic innovations related to the provision of healthcare should also be embedded into APN educational programs [20]. In addition, certification
requirements need to be standardized, and ideally standardized globally. Once educational and certification requirements are met, APNs should have the opportunity to practice to the full extent of their knowledge and training.
Interprofessional Collaboration
Advanced practice nurses need to acknowledge the importance and benefits of collaborating with other healthcare professions and disciplines. Interprofessional collaboration has become a key factor in successfully addressing critical healthcare and workforce issues [21, 22]. In addition to improved patient outcomes, there are numerous benefits of interprofessional collaboration to all involved health disciplines, including assisting healthcare professionals to overcome long-standing professional hierarchies and territorial issues [6].
Nursing leadership
Nurses, especially APNs, should view leadership knowledge and practice as an integral part of their profession. APN students should be educated on civic, professional, and social duties that will often be part of their job description, and become more comfortable in working in partnership with policy leaders. Nurses also have a responsibility to mentor each other and assist newer nurses as their careers progress. As Reed (2017) notes, nurses have to learn to clearly articulate their unique strengths and contributions to healthcare, and this is especially true for nurses in advanced practice roles [1].
Professional Unity
Globally, nurses at all practice levels must learn to encourage and support each other's roles, rather than spend time and energy on infighting. Mentoring, creating a supportive environment, building trust, and focusing on common goals are all positive ways for nurses to facilitate professional unity. Career progress for each nurse advances the entire nursing profession.
Reimbursement for healthcare services
It is nice to hear that APNs are beginning to be full and respected members of the healthcare team, but that must be reflected in pay and reimbursements structures. If the same service is provided, reimbursement should be equitable no matter which type of clinician is providing the care [23].
To achieve that, it is important to document APN revenue production as well as APN care quality and patient
References
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Research
APNs are in a unique position to contribute many things to nursing and medical science. Underserved and poor communities have traditionally been served by APNs, and those populations are very underrepresented in research studies. We are now in the age of precision medicine, with genomic-based treatments and tailored healthcare immediately on the horizon. APNs are ideally placed to contribute research on populations where such research is sorely needed [24]. Nurses also need to continue research on APN-provided patient outcomes and cost effectiveness.
Scope and Standards of Practice
A goal of global consensus on both the boundaries of APN practice and the standards of APN patient care is crucial to integrating APNs into healthcare systems. Policies that restrict APN care often increases costs and decreases access to care, especially for underserved populations [23]. One difficult hurdle may be that of outside regulation; too many advanced practice nurses currently cannot practice to the full extent of their training due to supervision requirements or restrictions from other healthcare professions.
Conclusion
For countries that are developing an APN program or are trying to embed APNs in a redesigned healthcare system, there are several things to consider. Decisions about educational and clinical preparation, certification requirements, scope of practice boundaries, standards of practice, and reimbursement issues should be debated and a consensus reached early in the process. One more important point should not be ignored in the development and decision making process: regulation of advanced practice nursing, and the autonomy of the APN role.
Providing healthcare in the future is acknowledged by many to be challenging at both the national and international levels. Globally, advanced practice nurses are in an excellent position to assist in achieving the goals of effective, high-quality, and cost effective care, and to facilitate redesign and improvement of healthcare systems. To do this, though, nurses around the world must be committed to growth as a profession, and dedicated to ensuring that nurses, and especially advanced practice nurses, become key players in the rapidly-changing global healthcare arena.
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