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Copyright, iv
Preface, v
Contributors, vii
Reviewers, xi
Acknowledgments, xiii
Unit 1. The Evolution of Advanced Practice, 1
1. Advanced Practice Nursing: Doing What has to be Done—Radicals, Renegades, and Rebels, 2
Precursors and Antecedents, 3
Nurse-midwives, 4
Nurse Anesthetists, 7
The Clinical Nurse Specialists, 9
The Evolution of the Nurse Practitioner Role: “A Disruptive Innovation”, 12
The Continuation of “Disruptive Innovation”: The Doctor of Nursing Practice, 19
Conclusion, 20
2. Emerging Roles of the Advanced Practice Nurse, 23
Emerging Roles of the Advanced Practice Nurse, 23
Scope of Practice, 24
Regulation of the Advanced Practice Registered Nurse, 25
Clinical Nurse Specialist, 26
Ambiguity and the Clinical Nurse Specialist Role, 28
Nurse Practitioner, 29
Changing Roles for the Primary Care Nurse Practitioner, 30
Nurse Practitioners in the Community, 31
Nurse Practitioners in Transitional Care Settings, 32
The Psychiatric Mental Health Nurse Practitioner, 33
Acute Care Nurse Practitioner, 33
The Acute Care Nurse Practitioner in Pediatric Settings, 34
Adult Acute Care Nurse Practitioners, 35
Acute Care Nurse Practitioners on Specialty Services, 35
Acute Care of the Elderly, 36
Nurse-Midwifery, 37
Historical Perspective, 37
Primary Care Focus in Nurse-Midwifery, 38
Issues Related to Primary Care Practice, 38
Nurse-Midwife as First Assistant for Cesarean Section, 39
Nurse Anesthetist, 39
Future Directions for Advanced Practice Nurses, 42
3. Role Development: A Theoretical Perspective, 46
A Theoretical Perspective On Role: An Overview, 46
Role Development, 47
Reference Groups, 48
Socialization, 48
Role Acquisition, 49
Socialization Deficits, 52
Stress and Strain, 53
Antecedents of Stress and Strain, 53
Classifying Role Stress, 53
Responding to Role Strain, 55
Managing Role Strain, 56
Conclusion, 56
4. Education for Advanced Practice, 58
The Question: Is the Doctor of Philosophy Or Doctor of Nursing Practice the Right Degree Model for Future Advanced Practice Nurses?, 58
The Doctorate of Philosophy in Nursing: A Degree in Crisis?, 60
The Rapid Emergence of the Doctor of Nursing Practice Degree, 61
Compelling Arguments for and Against the Doctor of Nursing Practice Degree, 65
A New Doctoral Nursing Degree Creates Tension: The Doctor of Philosophy Versus the Doctor of Nursing Practice, 66
The Future of Doctoral Nursing Education: A New Vision, 67
Conclusion, 68
5. Global Perspectives on Advanced Nursing Practice, 72
Introduction, 72
The Role of the International Council of Nurses, 73
Ambiguities and Issues of Controversy, 74
An Uncertain Identity Contributing to Poor Role Clarification, 74
Proliferation of Titles, 74
Lack of Recognition by Others in the Health-Care System, 75
Varied Levels of Autonomy, 76
Fragmented and Variable Standards and Quality of Education Programs, 76
Issues of Regulation, Credentialing, and Standard Setting, 76
Authority to Prescribe Medicines and Therapeutics, 77
Global Review—Country Illustrations, 79
Africa: WHO-AFRO, 79
Botswana, 79
Republic of South Africa, 79
Western Africa, 81
Americas: WHO-AMRO, 82
Canada, 82
Jamaica, 83
Eastern Mediterranean: WHO-EMRO, 84
Bahrain, 85
Iran, 85
Oman, 86
Europe: WHO-EURO, 86
Finland, 86
France, 87
Ireland, 87
Israel, 87
Netherlands, 88
Sweden, 89
Switzerland, 89
United Kingdom (England, Northern Ireland, Scotland, and Wales), 89
South-East Asia: WHO-SEARO, 90
Thailand, 90
Western Pacific: WHO-WPRO, 91
Australia, 91
Hong Kong, China, 92
Islands of the Western Pacific (Cayman Islands, Fiji, and Samoa), 92
Cayman Islands, 92
Fiji, 93
Samoa, 93
New Zealand, 94
South Korea, 96
Singapore, 97
Taiwan, 97
Conclusion, 97
Unit 2. The Practice Environment, 101
6. Payment for Advanced Practice Nursing Services: Past, Present, and Future, 102
Introduction, 102
Background, 102
Billing Options and Impact on Advanced Practice Nurses, 105
Strategies that have Been Successful for Advanced Practice Nurses in their Pursuit of Reimbursement, 109
Future Reimbursement Challenges for Advanced Practice Nurses, 112
Conclusion, 116
7. Advanced Practice Nurses and Prescriptive Authority, 119
Development of Authority to Practice, 119
Nurse Practitioners and Prescriptive Authority, 119
Nurse-Midwives and Prescriptive Authority, 122
Clinical Nurse Specialists and Prescriptive Authority, 122
Nurse Anesthetists and Prescriptive Authority, 123
The Road to Statutory and Regulatory Change to Authorize Prescriptive Authority, 124
Patterns of Statutory and Regulatory Authority, 125
Regulator Established Formulary, 125
Negative or Exclusionary Formulary, 125
Collaborative Formulary, 126
Open Formulary, 126
Advanced Practice Nurse-Physician Relationships in Statute and Regulation, 126
Barriers to Prescriptive Practice, 126
Advanced Practice Prescribing Patterns, 128
Conclusion, 129
8. Credentialing and Clinical Privileges and the Advanced Practice Nurse, 130
Introduction, 130
Credentialing, 130
Credentialing Application and Procurement of Data, 131
Verification of Advanced Practice Nurse Application Data, 131
Analysis of Credentialing Application, 132
Sources of Organizational Standards for Credentialing of Advance Practice Nurses in Institutions, 133
Privileging, 133
Rationale and Background, 133
Process, 136
The Career Portfolio, 137
Practitioner Contact Information, 138
Practice-Based Evidence Component, 138
Credentials Component, 140
Attestation Page, 140
Issues, 140
Maintaining Data About Performance, 140
Managed Care Panels, 141
Burden of Credentialing with Multiple Organizational Venues, 141
Models for Second Licensure of Advanced Practice Nurses, 141
9. The Kaleidoscope of Collaborative Practice, 143
A History of Changing Relationships, 143
Physician-Nurse Relationships Over Time, 144
Status of Collaborative Practice in Advanced Practice Roles, 146
The Certified Registered Nurse Anesthetist, 146
The Certified Nurse-Midwife, 147
The Clinical Nurse Specialist, 148
The Nurse Practitioner, 149
A Framework for Collaboration, 150
The Concept, 150
The Components, 150
The Intensity Continuum, 152
The “Iceberg” Effect, 154
Barriers to Collaboration, 155
Educational Isolation, 155
Professional Elitism, 156
Organizational Hierarchy, 157
Unrecognized Diversity, 158
Role and Language Confusion, 158
Inadequate and Inappropriate Communication Patterns, 161
Professional Dissonance, 162
The Bottom Line, 162
Strategies for Success, 162
Create an Effective Team, 163
Accept Growth and Development as a Joint Responsibility, 164
Use Protocols and Guidelines Wisely, 164
Watch Your Language, 165
Socialize Students to Communication Skills Needed for Collaborative Interactions, 166
Collaborative Models, 166
Primary Nursing Model, 166
Differentiated Practice Model, 167
Collaborative Practice Model in a Clinic, 167
Evercare: Collaboration in Long-Term Care, 167
Create the Future, 168
10. Participation of the Advanced Practice Nurse in Managed Care and Quality Initiatives, 172
Introduction, 172
Advanced Practice Nurses, 172
Managed Care Plans, 173
Competencies Necessary in the Managed Care Environment, 174
Contracting with Managed Care Plans, 175
Reimbursement, 176
Advanced Practice Nurse Participation in Managed Care Plans, 178
National Quality Efforts, 180
Advanced Practice Nurse Participation in Quality Initiatives, 181
Recognition and Consumer Support, 186
Conclusion, 187
11. Resource Management, 191
Introduction, 191
Structure, 191
Revenue, 193
Expense, 194
Cost Concepts, 195
Variable Versus Fixed Costs, 195
Direct Versus Indirect Costs, 195
Total Versus Unit Costs, 196
Incremental Versus Opportunity Costs, 196
Budgeting, 197
Types of Budget, 197
Budgeting Process, 200
Managing Resources, 202
Maximizing Revenue, 202
Containing Costs, 205
Implications, 209
12. Mediated Roles: Working Through other People, 211
Advanced Practice and Partnerships, 211
Core Competencies, 211
Models of Collaboration, 214
Clinical Relationships, 216
Interdisciplinary Teaming, 217
Professional Nursing Connections, 220
Exemplars: Enacting Advanced Practice Roles, 221
Advanced Practice Nurse Interview Questions, 221
Summary, 228
13. Reporting Relationships: Follow the Money, 230
Introduction, 230
Recurrent Themes, 230
The Business of Relationships, 231
Following the Money, 231
Internal and External Forces, 234
Specialty Alignments, 235
Advanced Practice Nurse Clinical and Fiduciary Leadership, 236
Reimbursement: Can the Position Pay for Itself?, 238
Conclusion, 241
Unit 3. Competency in Advanced Practice, 243
14. Evidence-Based Practice, 244
Introduction, 244
Evidence-based Practice: Defined, 244
Research on Clinical Judgment and the Relationship to Evidence-based Practice, 245
The Clinician’s Background Is More Influential on Clinical Judgment Than Objective Data, 246
Good Clinical Judgment Requires Knowing the Patient and Responding to their Concerns, 247
Clinical Judgment Is Influenced by the Context in Which Care Occurs, 247
Clinicians Use a Variety of Clinical Reasoning Patterns Alone or in Combination, 248
Analytic Processes, 248
Intuition, 248
Narrative Thinking, 248
Reflection on Practice is often Triggered by a Breakdown in Clinical Judgment, 249
Model of Clinical Judgment, 250
Summary, 250
Accessing and Evaluating Research Evidence to Improve Clinical Judgments, 251
Competencies that Support Evidence-Based Practice, 251
Focusing on Outcomes, 251
Asking Answerable Questions, 252
Using the Clinical Literature, 252
Appraising Evidence from Studies, 254
Sources of Primary Clinical and Research Literature, 255
Using Appraising Summaries, 255
Meta-Analysis, 255
Integrative Research Review, 256
Practice Guidelines, 256
Locating Sources of Summaries, 256
Clinical Significance and Appraisal Process, 257
Evidence-based Practice and Attitude, 257
15. Advocacy and the Advanced Practice Nurse, 261
Introduction, 261
Roots of Advocacy in Nursing, 261
Evidence Base for Advocacy, 262
Definitions of Advocacy, 263
Levels of Advocacy, 263
Advocacy at the Individual and Family Levels, 263
Advocacy Exemplar: Individual and Family Level, 264
Systems-Level Advocacy, 267
Advocacy Exemplar: Freeing People from Nursing Homes, 267
Consumer-Driven Systems-Level Advocacy, 271
Advocacy Exemplar: A Nurse Consumer in Suicide Prevention, 271
How Nurses Learn Advocacy, 273
Conclusion, 274
16. Case Management and Advanced Practice Nursing, 277
Historical Background, 277
Case Manager Role Competitors, 279
Differentiating the Levels of Nurse Case Management Practice, 280
Nurse Case Management Models, 282
Case Manager Responsibilities and Skills, 283
Tools and Strategies, 284
Disease Management and the Role of the Advanced Practice Nurse, 287
The Advanced Practice Nurse: Disease Management Examples, 288
Example 1: The Advanced Practice Nurse in the Disease Manager Role in a Managed Care Setting, 288
Example 2: The Advanced Practice Nurse’s Role in Continuous Quality Improvement, 289
Reimbursement and Marketing of Case Management Practice, 289
Education for Nurse Care Management Practice, 290
Certification and Associations for Case Management, 290
Conclusion, 292
17. The Advanced Practice Nurse and Research, 295
Research As A Role Component, 295
Attributes, 296
Research Skill Development, 297
Facilitative Role and Collaboration, 297
Leadership, 298
Advanced Practice Nurse Behaviors and the Development of a Philosophy of “Research is Part of What We Do”, 298
Problem Solving and Evidence-Based Practice, 299
Mentoring and Leadership, 301
Change Agency and a Systems Approach, 302
Removing Barriers to Advanced Practice Nurse Research, 302
Clinical Access and Clinician Buy-In, 303
Administrative Support, 303
Time and Money, 304
Completing the Research (“Closing-the-loop”): Advanced Practice Nurse Scholarship, 304
An Approach to Clinical Research: The Experience of One Institution, 304
A Professional Nursing Staff Organization Research Program, 304
Temperature Changes with Oral Fluid Intake, 305
Blood Pressure Measurement in an Ambulatory Cardiology Clinic, 305
Peripheral Intravenous and Central Venous Line Securement Methods, 306
Summary, 306
Conclusions, 306
18. The Advanced Practice Nurse and Complementary Therapies, 309
Introduction, 309
Holistic Nursing, 311
Milestones in the Development of Complementary-integrative Holistic Practice, 311
White House Commission on Contemporary and Alternative Medicine Policy, 312
A Nursing Summit on Integrative Care, 313
Research on Contemporary and Alternative Medicine Use, 313
National Center for Contemporary and Alternative Medicine as a Resource, 314
Complementary-integrative Modalities and Advanced Holistic Nursing Practice, 315
Examples of Complementary-Integrative Holistic Practice Modalities, 316
Mind-Body Therapies and Advanced Nursing Practice, 316
Guided Images, 316
Energy Therapies and Holistic Complementary-Integrative Nursing Practice, 317
Therapeutic Touch, Healing Touch, and Reiki, 317
Biological Remedies, 318
Aromatherapy, 319
Spirituality, 319
Creating a Healing Environment, 320
Practice Issues for the Advanced Practice Nurse and Complementary-integrative Therapies, 320
Educational Considerations for Complementary-Integrative and Holistic Nursing, 321
Complementary-Integrative Therapies in Regulated Nursing Practice, 321
The Advanced Practice Nurse and Holistic Nursing Research and Complementary Therapies, 324
Role Development and Avenues and Models for Advanced Practice Nurses as Complementary-Integrative Practitioners, 324
Ethical Considerations, 325
Conclusion, 326
19. Basic Skills for Teaching and the Advanced Practice Nurse, 330
Framework for Teaching, 330
Learning, 330
Teaching, 331
Supportive Environment for Learning, 331
Qualities of Effective Teachers in Nursing, 331
Assessment of Learner, 331
Assessment of Learning Needs, 331
Assessment of Readiness to Learn, 333
Other Assessment Areas, 334
Strategies for Assessment, 335
Questioning Learners, 335
Questionnaires, 335
Pretests, 335
Observations, 335
Development of Objectives, 335
Taxonomies of Objectives, 336
Development of a Teaching Plan, 337
Teaching Methods, 340
Lecture, 340
Discussion, 342
Clinical Conference, 343
Clinical Case, 344
Case Study, 344
Unfolding Cases, 344
Grand Rounds, 344
Multimedia, 346
Self-Directed Instructional Methods, 347
Demonstration, 348
Simulations, 348
Evaluation of Learning, 348
Role of Advanced Practice Nurse As Educator, 349
Conclusion, 349
20. Culture as a Variable in Practice, 352
Scope of the Need, 352
Walk a Mile in Someone Else’s Shoes, 357
Theoretical Basis for Cultural Competence in Advanced Nursing Practice, 357
Moving From Theory Into Practice, 359
Health Literacy, 360
Patient Navigator Programs, 365
Assessment, 367
Knowledge, 371
Communication, 374
Professional Accreditation and Legal Considerations, 375
Next Steps, 377
21. Conflict Resolution: An Essential Competency in Advanced Practice, 381
Conflict Management Strategies of Nurses, 382
Changing Paradigms of Alternative Dispute Resolution, 383
The Word From the Trenches, 384
Responding to the Challenge: Exercises in Alternative Dispute Resolution, 386
Conclusion, 387
Unit 4. Ethical, Legal, and Business Acumen, 389
22. Evaluation of the Advanced Practice Nurse: Cost Efficiency, Accomplishments, Trends, and Future Development, 390
Introduction, 390
Practice Settings of the Advanced Practice Nurse, 391
Changes and Challenges in Health Care, 392
The Impact of Advance Practice Nurses, 393
Outcomes of Care and the Advanced Practice Nurse, 393
Certified Nurse-Midwives, 394
Certified Nurse Anesthetists, 394
Nurse Practitioners, 395
Clinical Nurse Specialist, 396
Practice Characteristics and Reimbursement, 397
Future Directions and Future Considerations, 398
Skills Versus Knowledge, 398
Advancing the Discipline, 398
Conclusion, 400
23. Promoting Advanced Practice Nurses to the Public, 403
Introduction, 403
A Primer in the Principles of Marketing, 404
The Framework: A Marketing Plan, 405
The Foundation for Service: A Philosophy of Care and Mission Statement, 406
Moving Beyond Convention, 407
Dialogue: Defining the Need and the Service, 408
Listening First, 408
If You Build It, They May Come, 411
Getting There, 411
First Impressions, 412
Advanced Practice Nurses: A Good Value for the Public, 412
Creating Buzz, 413
Crafting the Message, 414
Outreach: Education, Events, and the Advanced Practice Nurse in Public, 415
Evaluating Successes and Missteps, 416
Exemplars in Promoting the Advanced Practice Nurse: This is Just the Beginning, 420
24. Starting a Practice and Practice Management, 421
Advantages to Independent Practice, 421
Barriers to Independent Practice, 421
First Things First, 423
Key Questions, 423
Develop a Clear-cut Strategy, 424
Determine the Area’s Need for the Service, 424
Develop a Time Line for Business Start-up, 425
Determine Licensing, Tax, and Insurance Requirements, 427
State Nursing License and Advanced Practice License or Certification, 427
State Narcotics License, 427
Federal Narcotics License, 427
Medicaid Provider Number, 428
Medicaid Managed Care, 428
Medicare, 428
Universal Provider Identification Number, 429
National Provider Identifier, 429
Clinical Laboratory License, 429
Employer Identification Number, 430
State Tax Identification Number, 430
Professional Liability Insurance, 430
Conventional Commercial Insurance Policies, 431
Select Your Consultants, 431
Decide on the Appropriate Business Structure, 432
Sole Proprietorship, 432
Partnership, 433
Corporation, 433
Limited Liability Corporation, 433
Create the Business Name and Image, 434
Select a Practice Location, 435
Geographical Location, 435
Economics, 435
Professional Relationships, 435
Professional Climate, 436
Develop a Business Plan, 436
Summary, 436
Business Concept, 436
Market Analysis, 436
Competition, 437
Competitive Analysis, 437
Marketing Plan, 437
Management Team and Personnel, 437
Operations, 438
Financial Plan, 438
Repayment Projections, 438
Determine Financing Options, 438
Develop Fees, Reimbursement, and Billing Procedures, 439
Establishing Fees, 439
Reimbursement, 440
Billing, 440
Purchase Equipment and Select Suppliers, 441
Hiring and Management of Personnel, 442
Develop an Organized Documentation and Quality Assurance Process, 443
Documentation, 443
Quality Assurance, 444
Developing Policies and Procedures, 446
Develop Marketing Strategies, 446
25. The Advanced Practice Nurse as Employee or Independent Contractor: Legal and Contractual Considerations, 449
Introduction, 449
Employee Or Independent Contractor: What Difference Does It Make?, 449
Professional Liability Considerations, 449
Financial and Tax Implications, 450
Factors Used to Determine Status, 450
The Advanced Practice Nurse as Employee, 452
The Advanced Practice Nurse as Independent Contractor, 453
Contract Issues for APN Employees and Independent Contractors, 454
Types of Contracts, 454
Common Contractual Terms Included in Written Agreements, 455
Scope, 455
Effective Date, 455
Relationship of the Parties, 455
Responsibilities of the Parties, 456
Confidentiality, 457
Conflict of Interest, 457
Compensation, 457
Indemnification and Subrogation, 458
Dispute Resolution, 458
Term, Renewal, and Termination, 459
Remedies for Breach, 459
Notices, 459
Modification, 460
Assignment, 460
Severability, 460
Conflict of Laws, 460
Legal Authority, 460
Force Majeure, 461
Covenant Not to Compete, 461
Signatures, 461
Other Provisions to Consider Included in Written Agreements, 461
Avoiding Legal Pitfalls Associated with Written Agreements, 462
Conclusion, 463
26. The Law, the Courts, and the Advanced Practice Nurse, 465
Introduction, 465
The Broad Context for Law, 465
Sources of Law, 466
Legislation, 466
Rule-Making, 467
The Court System, 469
What Courts Do, 469
Structure of the U.S. Court System: Federal and State, 469
Why Court Opinions Matter: The Role of Precedent, 470
Why Many Issues Never Result in Legal Opinions, 470
Selected Legal Issues, 470
Legal Scope of Practice Issues, 470
Advanced Practice Nurses in the Courts, 472
Professional Discipline, 474
Fraud and Abuse, 475
Assessing Risk and Avoiding Fraud and Abuse, 478
Antitrust Law, 479
Enforcement of the Antitrust Laws, 482
Conclusion, 482
27. Malpractice Insurance, 485
Introduction, 485
Nursing Tradition and the Paradigm Shift, 485
The Risks of Advanced Practice Nursing, 486
Civil Lawsuits, 486
Licensure or State Certification Exposures, 486
Federal Health Program Exclusion, 487
Malpractice and the Advanced Practice Nurse, 487
The National Practitioner Data Bank and Healthcare Integrity and Protection Data Base, 488
Trends in Malpractice Claims, 488
Malpractice Lawsuits and State Laws, 494
Advanced Practice Nurses and the Malpractice Crisis, 494
Practice Settings and Specialty Practice Risks, 496
Employed Advanced Practice Nurses, 496
Independent Practice, 497
Collaborative Practice, 498
Malpractice Insurance As a Risk Management Tool, 499
Identify the Carriers, 499
Coverage Selection Criteria, 499
Costs of Malpractice Insurance, 501
Contractual Obligations, 501
What Happens When a Lawsuit is Filed, 501
Trial, 503
Risks Inherent in Witness Testimony, 503
Managing Risks by Fostering Positive Relationships, 505
The Patient and Family, 505
Staff Relationships, 506
Collaborating Physician and Medical Staff Colleagues, 507
Conclusion, 507
28. Ethics and the Advanced Practice Nurse, 510
Practice-based Bioethics, 511
Rights, 511
Advanced Practice and a Practice-Based Bioethic, 512
The Contemporary Ethical Theories, 513
The Rational Form of Bioethical Decision Making, 515
The Importance of Context, 516
The Levels of a Context, 517
The Flourishing of an Apn, 518
The Nurse/patient Agreement, 519
The Agreement One has With Oneself, 520
The Advanced Practice Nurse and the Ethical Agreement, 520
Bioethical Standards, 521
The Necessity of the Agreement, 522
The Virtues of an Advanced Practice Nurse, 522
About Case Study Analysis, 525
Musings, 526
Index, 531

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