ADVANCED PRACTICE WITHIN A NURSING PARADIGM
The most important word in the title of advanced practice registered nurse (APRN) is the last one: nurse. Advanced education enables nurses to expand their knowledge base and expertise in nursing so that their practices differ not only from those of nurses with an associate's or bachelor's degree but also from those of other health professionals, particularly physicians or physician assistants. Nurses often underestimate the profound positive effect that their care can have on improving individual and population outcomes and the impact on quality of care. Florence Nightingale, in Notes on Nursing (1859/1992), noted that people in her day often thought of nursing as signifying "little more than the administration of medicines and the application of poultices" (p. 6). Efforts are still necessary to convey the full scope of nursing practice to other professionals and to the public so that nurses' contributions to positive health outcomes are understood, respected, valued, and reimbursed. So often the media have focused on the physical assessment skills, tasks, and prescriptive privileges of APRNs rather than on the distinctive and unique knowledge, education, abilities, and expertise that characterize advanced practice registered nursing practice.
As advanced practice nursing moves rapidly toward the practice doctorate as entry into practice, an excellent opportunity exists to reconceptualize how advanced practice nursing is taught in APRN programs. Burman et al. (2009) challenge educators to focus on health promotion and disease management, incorporating theories from a variety of disciplines to improve health behavior and change their pedagogies as doctorate of nursing practice (DNP) programs and curricula continue to develop. Chism (2013) supports the need for DNP curricula to focus on the leadership of chronic disease management and the care of our aging population.
WHAT IS NURSING?
Definitions of Nursing
For many years the nursing profession has sought to define nursing and to identify its scope of practice. It is critical that APRNs and those aspiring to this role have a clear understanding of what nursing is in order for them to provide a clear understanding of nursing's unique contributions to health care outcomes in their interprofessional interactions. Therefore, several of the many definitions of nursing that have been put forth over the years are reviewed.
Florence Nightingale (1859/1992) formulated one of the earliest definitions of nursing, which went beyond caring for ill patients. She emphasized the whole person, including diet and environment. The aim of nursing care, according to Nightingale, is to put the individual in the best possible condition so that nature can act upon the person. Nightingale's Notes on Nursing, although written 150 years ago, speaks to the substantive basis of nursing. Not only does Nightingale elaborate on interventions nurses can employ, she also underscores the necessity of thorough assessments before planning nursing care. Reading Notes on Nursing should therefore be a part of every APRN curriculum.
In Virginia Henderson's (1966) definition of nursing, emphasis is placed on the nurse collaborating with the individual to enhance the individual's health status. Henderson defined nursing as assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as soon as possible, (p. 15)
Henderson's definition contains many elements that constitute the substantive nature of nursing. Health promotion is a key component of her definition. In addition, the caring aspects of nursing are emphasized. Not all individuals will recover from their diseases or injuries. It is the nurse's role to assist the individual to achieve the goals he or she has established. Myss (1996,2004) noted in her well-known works on healing that in curing modalities the individual is passive, but she argues that the individual must take an active role to be healed. APRNs can play a key role in assisting individuals in their healing process because APRNs are able to bring additional expertise to these interactions and to perform holistic health assessments. Henderson stresses helping the individual gain independence. Independence is a Western belief and may not be a value in all cultures. Thus, it is important for the nurse to ascertain the personal values of each individual and realize that independence may not be one of their preferences.
Nojima (1989), a Japanese nursing theorist, defined nursing practice as "a human activity carried out by nurses to help individuals organize their health conditions so that they are able to live optimally and realize their potential" (pp. 6-7). In her definition, the focus is on a person's quality of life. The partnership between the nurse and the individual is evident in Nojima's definition of nursing. With the advent of globalization, it is important to review the characteristics of nursing outside of Western medicine (Nojima, Tomikana, Makabe, & Snyder, 2003).
The American Nurses Association (ANA) has defined nursing as follows:
Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. (ANA, 2010, p. 10)
Previously, the definition of nursing focused on persons and their responses to health problems, rather than specific illnesses. This definition of nursing developed in 2003, which emphasizes health promotion and optimal health, remains unchanged in current discussions of the ANA's Social Policy Statement (ANA, 2010). The focus on health differentiates nursing from the practice of medicine.
Despite the frequent reference to the ANA definition of nursing, many APRNs have encountered difficulty practicing from a nursing model. They have been seemingly forced to launch their practice within the medical model in part because of medical diagnoses used for billing and coding and in part because of the medical community's and the public's perception of APRNs. Although it is important to know the cause of a person's pain or stress, much of nursing care remains the same despite the cause. It has been encouraging to see the Agency for Healthcare Research and Quality (AHRQ) consider problems or responses, rather than disease entities, as the focus of practice guidelines. The AHRQ website (ahrq.gov) is an excellent resource for evidence-based practice and current clinical practices.
Advanced practice nursing builds on the competence of the professional nurse and is characterized by the integration and application of a broad range of theoretical and evidence-based knowledge (ANA, 2010). APRNs are prepared in one of the four roles: certified nurse-midwife, clinical nurse specialist, nurse practitioner, or certified registered nurse anesthetist. The APRN consensus model (2008) defines the APRN as a "provider that is certified in one of the four roles, educated in health promotion, assessment, diagnosis, management, pharmacotherapeutics, and direct care to individuals, populations, and communities" (Stanley, 2012, p. 244). Licensure, accreditation, certification, and education (LACE) should be consistent with role population (APRN Consensus Workgroup & APRN Joint Dialogue Group, 2008). Specialization within advanced practice focuses beyond the six populations (family/individual across lifespan, adult-gerontology, neonatal, pediatrics/women's health/gender related, psychiatric/mental health) and provides depth within a population. One of the most important aspects of specialization in nursing is that the distinct specialization is always a part of the whole field or discipline of professional nursing (ANA, 2010).
The APRN consensus model, LACE has stipulations that APRNs be educated within an accredited program with advanced pathophysiology, advanced health assessment, advanced pharmacology—the three Ps; complete a minimum of 500 clinical hours; and be nationally certified. The licensure of an APRN is "defined as a legal title and credentials to be granted to all advanced practice registered nurses meeting the definitional criteria. Boards of nursing are responsible for granting a second license to APRNs in all four roles" (Stanley, 2011, p. 248). Rounds, Zych, and Mallary (2013) further state that the LACE model is not only relevant to the national movement of improving nursing regulation but has been shown to improve the professional transition for APRNs. Safety is once again emphasized as the primary motivator for national regulation of advanced nursing practice (Rounds et al, 2013).
The ANA's A Social Policy Statement (2010) emphasizes the characteristics of nursing practice to include human responses, theory application, evidence-based nursing actions, and outcomes. These characteristics build the foundation for professional nursing (ANA, 2010). Within this model, nursing's professional scope of practice, code of ethics, specialization, and certification laid the base for professional nursing. Building on this base in a pyramid model are individual state's nurse practice acts, rules, and regulations. From this level, institutional policies and procedures guide nursing practice, with self-determination as the top level of the pyramid model. This model lays the foundation not only for professional nursing but for all its expanded roles and specializations.
