2. • Nurse Practitioners :Nurse practitioners are the health
care professionals educated and trained to provide health
promotion and maintenance through diagnosis and
treatment of acute illnesses and chronic conditions.
or
• APN:- Nurse who has completed an accredited graduate-
level education program preparing her or him for the role
of certified nurse practitioner, certified registered nurse
anesthetist, certified nurse midwife, or clinical nurse
specialist; has passed a national certification examination
that measures the APN-, role-, and population-focused
competencies; maintains continued competence as
evidenced by recertification; and is licensed to practice as
an APRN.
3. • Core competencies: a standard set of performance
domains and their corresponding behavioural standards
which a nurse is required to demonstrate.
• Competency: the necessary knowledge, skills and
attitudes a nurse must possess in order to perform a set
of defined activities to an expected standard.
• Competence: the ability of a nurse to demonstrate the
knowledge, skills, judgment and attitudes required to
perform activities within the defined scope of practice at
an acceptable level of proficiency.
• Competent: being able to demonstrate the necessary
ability, knowledge, skills and attitudes across the
domains of competencies at a standard that is
determined to be appropriate for that level at which a
nurse is being assessed.
4. RESEARCH
COMPETENCIES
The term competencies refers to a broad area of skillful
performance.
1. Applies sound research knowledge and skills in conducting
independent research in critical care setting
2. Participates in collaborative research to improve patient
care quality
3. Interprets and uses research findings in advanced practice
to produce EBP.
4. Tests / Evaluates current practice to develop best practices
and health outcomes and quality care in advanced practice.
5. Analyzes the evidence for nursing interventions carried out
in critical care nursing practice to promote safety and
effectiveness of care.
6. Develops skill in writing scientific research reports.
5. OTHERS COMPETENCIES
Seven core competencies combine to distinguish nursing practice at this level.
1. Direct Clinical Practice
2. Guidance and Coaching
3. Consultation
4. Evidence-Based Practice
5. Leadership
6. Collaboration
7. Ethical Decision Making
6. DIRECT CLINICAL PRACTICE
Direct care is the central competency of advanced practice
nursing. This competency informs and shapes the
execution of the other six competencies. Characteristics of
advanced direct care practice and strategies for enacting
them
• Use of a holistic perspective
• Formation of therapeutic partnerships with
patients
• Expert clinical performance
• Use of reflective practice
• Use of evidence as a guide to practice
• Use of diverse approaches to health and illness
management
7. Use of a Holistic Perspective
CHARACTERISTICS
• Take into account the complexity of human
life.
• Recognize and address how social,
organizational, and physical environments
affect people.
• Consider the profound effects of illness,
aging, hospitalization, and stress.
• Consider how symptoms, illness, and
treatment affect quality of life.
• Focus on functional abilities and
requirements.
8. Formation of Therapeutic
Partnerships With Patients
CHARACTERISTICS
• Use a conversational style to conduct health care
encounters.
• Optimize therapeutic use of self.
• Encourage the patient, and family as appropriate, to
actively engage in decision making.
• Look for cultural influences on health care discourse.
• Listen to the indirect voices of patients who are
noncommunicative.
• Advocate the patient's perspective and concerns to
others.
9. Expert Clinical Performance
CHARACTERISTICS
• Acquire specialized knowledge.
• Seek out supervision when performing a new skill.
• Invest in deeply understanding the patient situations in which
you are involved.
• Generate and test alternative lines of reasoning.
• Trust your hunches—check them out.
• Be aware of when you are time-pressured and likely to make
thinking errors.
• Consider multiple aspects of the patient's situation when you
are deciding how to treat.
• Make sure that you know how to use technical equipment
safely.
• Make sure that you know how to interpret data produced by
monitoring devices.
• Pay attention to how you move and touch patients during
care.
• Anticipate ethical conflicts.
• Acquire technology-related skills for accessing and managing
patient data and practice information.
10. Use of Reflective Practice
CHARACTERISTICS
• Explore your personal values, belief systems, and
behaviors.
• Identify your basic assumptions about health care, the
advanced practice registered nurse role, and the rights
and responsibilities of patients.
• Consider how your assumptions affect your judgments.
• Talk to colleagues and your teachers about your clinical
experiences.
• Consider use of a journal to document experiences.
• Assess your current skill and comfort in reflection.
11. Use of Evidence as a Guide
for Practice
CHARACTERISTICS
• Learn how to search health care databases for studies
related to specific clinical topics.
• Read research reports related to your field of practice.
• Seek out systematic revision of research and evidence-
based clinical guidelines.
• Acquire skills in appraising the various forms of
evidence.
• Work with colleagues to consider evidence-based
improvements in care.
12. DiverseApproaches and Interventions for Health
and Illness Management
CHARACTERISTICS
• Use interpersonal interventions to guide and coach
patients.
• Acquire proficiency in new ways of treating and helping
patients.
• Help patients maintain health and capitalize on their
strengths and resources.
• Provide preventive services appropriate to your field of
practice.
• Coordinate services among care sites and multiple
providers.
• Acquire knowledge about complementary therapies.
13. Key points of Direct Care
• Direct care is the central APN competency.
• The six characteristics of direct care are: use of a holistic
perspective, formation of therapeutic partnerships with
patients, expert clinical performance, use of reflective
practice, use of evidence as a guide to practice, and use
of diverse approaches to health and illness management.
• While APNs provide many strategic functions
throughout and over the course of their role, time needs
to continue to be spent in direct clinical care with
patients in order to maintain differentiation between the
APN role and other DNP-prepared non-APN roles.
• Mastery of these six characteristics of direct care
delineates the differentiation of practice at an advanced
level and sets the foundation for attaining skill in the
other APN competencies.
14. GUIDANCE AND COACHING
There are relational approaches that focus on helping a person
create change in his or her life to advance individual autonomy,
well-being, and goal attainment. Although there is overlap
among the approaches, several aspects differentiate them, such
as length of time of engagement and the focus of the interaction.
GUIDANCE/COACHING
Guidance is a broad term that means the provision of help, instruction, or
assistance, and there are several forms of guidance. The distinguishing
feature of guidance as compared to coaching is that guidance requires the
provision of advice or education, whereas coaching is an inquiry, an
excavation of answers from a person.
COACHING
Coaching is a broad umbrella term that encompasses different
approaches, philosophies, techniques, and disciplines. Four main
components of a coach's responsibility:
• Discover, clarify, and align with what the client wants to achieve
• Encourage client self-discovery
• Elicit client-generated solutions and strategies
• Hold the client responsible and accountable
15. The “Four As” of the Coaching
Process
Agenda
Setting
Awareness
Raising
Actions / Goal
Setting
Accountability
16. Coaching Phase APRN Skill Examples
Agenda elicited Excavate what is most meaningful
Clarify needs
What is most
important/meaningful/helpful to
you at this time? What do you need
from our time together?
Awareness raised Ask powerful questions ,Shift
consciousness
Let the person do most of the talking
Explore assumptions with curiosity
Promote “generative moments”
What are you not willing give up? If
you say “YES” to X,
what do you say raised Shift
consciousness
Who do you need to become to
make it happen?
Actions/Goal setting Link raised awareness to specific
goals to forward into action
Brainstorm Determine self-efficacy
Challenge if the person could do
more (gently and once)
What do you want to do and when
do you want to do it? On a scale of 1
to 10, how successful do you think
you will be? What is going to get in
your way? What is the remedy to
that obstacle? Can I challenge you
to … (do more)?
Accountability Help person use resources, not
pursue goals alone Partner with
supportive others
Use technology Confirm agenda met
How do you want to be
accountable? What will you do if
you go off your plan? What is your
“when-then” plan? Did you get
what you needed today?
17. KEY POINTS OF GUIDANCE
AND COACHING
• Guidance and coaching require deep listening and strong
empathic skills.
• All patients must be assessed for appropriateness of guidance
and/or coaching.
• Guidance requires exploring what the patient already knows.
• Patients must be assessed for readiness to change before the
coaching methodology is used.
• Integrating guidance and coaching is integral to patient-
centered care.
• Although there is broad agreement that patient centered care
is important, developing ways to support it has been
challenging.
• Integrating coaching with guidance establishes the patient as
the center of care and as the full source of control.
18. CONSULTATION
The term consultation is used in many ways. It is
sometimes used to describe direct care—the
practitioner is in consultation directly with the
patient.
The word consultation is defined, the more likely
consultation will be used for its intended
purposes of enhancing patient care and
promoting positive professional relationships that
result in true collaboration and optimal patient
outcomes.
Consultation is defined as “any professional activity
carried out by a specialist” (Caplan & Caplan, 1993).
19. Principles of consultation
1. The client is the layperson who is the focus of the
consultation.
2. The consultant is not responsible for implementing
interventions or remedial actions.
3. The consultee continues to have professional
responsibility for any corrective action.
4. The consultee is free to accept or reject any of the
consultant suggestions.
20.
21. Principles for the Model of Advanced
Practice Nursing Consultation
The consultation is usually initiated by the
consultee.
The relationship between the consultant and
consultee is nonhierarchical and collaborative.
The consultant always considers contextual factors
when responding to the request for consultation.
The consultant has no direct authority for managing
patient care.
The consultant does not prescribe, but makes
recommendations.
The consultee is free to accept or reject the
recommendations of the consultant.
The consultation should be documented.
22. KEY POINTS OF CONSULTATION
• Consultation is an essential part of APN practice
regardless of role or specialty.
• Consultation differs from co-management, referral,
supervision, and collaboration.
• Consultation, as described as an independent,
autonomous nursing function, though APN must be
aware of specific state regulations that impact APN
consultation activity.
• It is important for the consultant and consultee to define
expectations and responsibilities of the consultation, and
there should be closed-loop communication to ensure
successful closure of the consult.
23. EVIDENCE-BASED PRACTICE
It is systematic inter-connecting of scientifically generated
evidence with the tacit knowledge of the expert
practitioner to achieve a change in a particular practice for
the benefit of a well defined client /patients group.
EBP is defined as the conscientious, explicit, and judicious
use of current best research-based evidence when making
decisions about the care of individual patients .
Components tend to overlap, three levels of this core
competency for APN practice can be identified:
(1) interpretation and use of EBP principles in individual
clinical decision making;
(2) interpretation and use of EBP principles to determine
policies, standards, and procedures for patient care;
and
(3) use of EBP to evaluate clinical practice.
24. A formal, four-step process for
identifying and determining EBP has
been defined; it consists of:
(1)Formulation of a clinical question
(2)Identification and retrieval of pertinent
research findings based on literature
review;
(3)Extraction and critical appraisal of data
from pertinent studies; and
(4)Clinical decision making based on
results of this process
25. Steps in practice of EBP
IDENTIFY the problem situation that require clinical
decision making
SEARCH for the available evidences
CRITIQUE evidence for validity , impact and
applicability
INTEGRATE knowledge gained into practice
DEVELOP clinical guideline /protocol
EVALUATE the effectiveness of change
26. Interpretation and Use of
Evidence in Practice• Evidence-based practice has become an umbrella term for research
utilization, research-based practice, and outcomes research .
Integration of new scientific findings and science-based knowledge
influences the development and evaluation of new approaches to
clinical practice
• For APNs, the interpretation and use of research and other evidence
often begins with a clinical question identified by the CNS or staff
with whom he or she works. Knowledge is the basis for practice but,
too frequently, routine practice may not be based on sound evidence.
• The foundation of improved quality of care and patient outcomes is
the analysis of research-based evidence and expert consensus
dependent practice changes to ensure best practice and achieve
quality patient care.
• Inherent in the APN role is the evaluation of the appropriateness of
evidence and the application of its findings to clinical practice. An
APN is the ideal clinician to assess factors that are barriers and
facilitators to change and to develop, implement, and evaluate EBP.
• EBP is integrated into clinical procedures, administrative policies,
educational materials for patients and staff, and care guidelines. An
APN's involvement in developing policies and procedures means
that evidence informs clinical practices and standards.
27. APN contributions to improving patient outcomes by providing
evidence based care include the following:
1. APN-led implementation of innovative strategies that led to
a decrease in central line–associated blood stream infections
2. Implementation of an intervention to improve medication
adherence in adult renal transplant recipients (Russell, 2010).
3. Development of clinical pathways for cardiac patients
resulting in trends in decreased median time to myocardial
infarction intervention, decreased length of stay, and a
stronger connection between cardiac and community
rehabilitation (Avery & Schnell-Hoehn, 2010).
4. Early Extubation in patients after open heart surgery,
resulting in decreased length of stay and pulmonary
complications (Soltis, 2015).
5. APNs had a leadership role in transforming a policy and
procedure committee into a clinical practice council to
promote practice that was evidence based.
28. Key points of EBP
Evidence-based practice is a central competency of advanced
practice nursing.
Evidence-based clinical decision making arises from a four-step
process beginning with identification of a pertinent clinical
question, systematic literature review, extraction of pertinent data,
and implementation of findings into clinical practice.
The APN is well prepared to synthesize existing research findings
needed to translate current best evidence into clinical practice on
an individual, unit wide, facility-wide, or health system–wide
basis.
Translating current best evidence into clinical practice requires
more than simply introducing new policies or procedures in order
to achieve meaningful or sustained changes in clinical practice.
Formation of an inter-professional team of key stakeholders,
clinical support, and clinical leadership on a facility-wide level
from an APRN and others, along with unit-based support from
clinical champions, is essential for achieving sustained changes in
clinical practice.
29. LEADERSHIP
• Leadership is the quality of an individual’s behavior
whereby he is able to guide the people or their
activities towards certain goals.
• Leadership is a process of influencing a group in a
particular situation at a given point of time and in a
specific set of circumstances that stimulate people to
strive willingly to attain the common objectives and
satisfaction with the type of leadership provided.
30. The leadership model uses a 4D cycle:
• Discovery—an exploration of what is;
finding organizational strengths and
processes that work well
• Dream—imagining what could be;
envisioning innovations that would work
even better for the organization's future
• Design—determining what should be;
planning and prioritizing those processes
• Destiny—creating what should be;
implementing the design
31. Global Competencies for Nurse
Leaders
Develop global mind-set and worldview:
• Global environmental awareness
• Cultural adaptation
• Awareness of social, political, and economic trends
Understand needs of technology:
• Enhanced ability of communication and technology
• Create global networks
• Individuals can now drive change just as businesses used to
drive change
Respect diversity and cultivate cross-cultural competencies:
• Institutional mergers and growth
• Multicultural work force
• Multicultural patient populations
• International Council of Nurses
• World Health Organization
• Sigma Theta Tau International
• Pan American Health Organization
32. KEY POINTS OF
LEADERSHIP
• Leadership is a core APN competency, requiring deep
knowledge of the art and science and an emphasis on
interpersonal skills.
• The health care system is evolving continuously,
requiring APNs to create mastery around change
management.
• Effective leaders use mentors, mentor others, network,
and learn how to follow.
33. COLLABORATION
The term collaboration is often used in health care and is
associated with team and partnership.
The American Nurses Association's (ANA's) Nursing's
Social Policy Statement (ANA, 2010) clarifies that
collaboration for nurses, including APNs, means a true
partnership in which there is a valuing of expertise, power,
and respect for all members. Collaboration also means
recognizing and accepting each participant's sphere of
activity and responsibility.
“Collaboration is a dynamic, interpersonal process in
which two or more individuals make a commitment to
each other to interact authentically and constructively to
solve problems and to learn from each other to accomplish
identified goals, purposes, or outcomes. The individuals
recognize and articulate the shared values that make this
commitment possible”
34. Characteristics of Collaboration
•Clinical competence and accountability
•Common purpose
•Interpersonal competence and effective
communication
•Trust
•Mutual respect
•Recognition and valuing of diverse,
complementary knowledge and skills
•Humor
35. Barriers to Collaboration
• Disciplinary Barriers : Each profession is a culture with its own values,
knowledge, rules, and norms, and education programs reflect this
culture. Additionally, education programs are frequently conducted at
different types of colleges and universities where there may be little
opportunity for shared learning. some policymakers from all disciplines
may be based on stereotyped beliefs about disciplinary roles and
responsibilities, rather than reflecting consideration of the issues or
what is best for patients.
• Ineffective Communication and Team Dysfunction:- Dysfunctional
styles of interactions among health care professionals that particularly
undermine collaboration include being difficult, bullying, or abusive.
Clinicians whose behavior is disruptive display arrogance, rudeness,
and poor communication .
• Sociocultural Issues:- Tradition, role, and gender stereotypes are
obstacles to collaboration. Nursing remains a predominantly female
profession and, despite the influx of women into medicine, pharmacy,
and dentistry, gender role stereotypes still exist and affect collaboration.
Gender stereotypes dominate images of staff nurses in the media and
how APNs are commonly portrayed on television. However, the rules
are changing as all of health care becomes increasingly female.
• Organizational Barriers:-Competitive situations arise that can interfere
with collaboration
• Regulatory Barriers:-Legislation and regulations pose a number of
barriers to the implementation of collaborative roles.
36. Strategies to Promote Effective
Communication and Collaboration
Be respectful and professional.
Listen intently.
Understand the other person's viewpoint before expressing your opinion.
Model an attitude of collaboration, and expect it.
Identify the bottom line.
Decide what is negotiable and non-negotiable.
Acknowledge the other person's thoughts and feelings.
Pay attention to your own ideas and what you have to offer to the group.
Be cooperative without losing integrity.
Be direct.
Identify common, shared goals, and concerns.
State your feelings using “I” statements.
Do not take things personally.
Learn to say “I was wrong” or “You could be right.”
Do not feel pressure to agree instantly.
Think about possible solutions before meeting and be willing to adapt if a more
creative alternative is presented.
Think of conflict negotiation and resolution as a helical process, not a linear one;
recognize that negotiation may occur over several interactions.
37. Participation in Collaborative
Research
• Although the number of PhD-prepared APNs with the training to conduct
research is increasing, most APNs are prepared at the master's and DNP level
and can be partners in collaborating on research relevant to practice.
• Collaborative research between a CNS and researcher increases the
likelihood of translating research findings to clinical practice. Researchers
provide APNs with new evidence for patient care practices and the
assessment of their impact.
• The PhD prepared APN collaborates with peer CNSs by using advanced
research skills to appraise journal articles critically and set up research study
designs, as well as facilitate contacts with other faculty. They can be the
bridge between basic research and patient care. In turn, master's- and DNP-
prepared APNs stimulate researchers to investigate the science that explains
their observations of patients and populations.
• A APN-led initiative to foster collaboration between hospital staff nurses and
university faculty resulted in increased partnerships between faculty and
nursing staff and the initiation of research projects focusing on quality
improvement.
38. • A APN is the clinical expert, understands clinical issues, has
access to patients, and can anticipate clinical and system
challenges that may occur throughout the research process.
• A nurse researcher is a research expert, knows research
methodology, and has access to the resources that support
research. The APN is optimally positioned to stimulate a
researcher's interest because of her or his direct clinical
association with patients or participant populations.
• Before participating in a research project, a APN must
determine whether there is readiness and receptiveness in the
practice setting and administrative support, and whether
research activities are a realistic performance goal. Inter-
professional collaborative research offers opportunities for
innovative solutions to complex issues, improved
collaboration, richness of expertise and perspectives, and more
comprehensive care improvements
• APNs know the organizational and social facilitators and
barriers to clinical research, can bridge the academic-clinical
gap, and can assist in recruiting and retaining research
participants.
• Whatever the model, a APN is a key player in developing and
implementing relevant nursing-sensitive and inter-
professional quality indicators for measuring patient and
system outcomes through EBP, quality improvement, and
research.
39. Key points of collaboration
There is a need for a better understanding of the
organizational structures, communication processes, and
interactive styles that enable clinicians to collaborate in ways
that benefit clinical processes and outcomes.
APNs can contribute to this understanding in several ways:
By documenting and analyzing their experiences with
collaboration in published case studies.
By serving as preceptors for students and helping them
develop the skills essential for collaboration.
By working with researchers who are studying the
characteristics and clinical implications of collaboration.
Effective collaboration must be at the heart of any redesign of
the health care delivery system whether that redesign occurs
in a unit, in a clinic, within and between organizations, or
globally.
40. ETHICAL DECISION MAKING
• Evidence suggests that when people face ethical decisions,
they engage in mental processes outside their conscious
awareness and their decisions may be affected by their
emotional state.
• Ethically challenging situations often evoke strong emotions.
Guarding against emotional responses in ethically challenging
situations requires APNs to rigorously and continuously
practice self-awareness, becoming exquisitely sensitive to their
own hidden biases, which in turn helps them develop strong
moral agency.
• The Code of Ethics for Nurses includes a provision calling
attention to the duties nurses owe to themselves, including
preservation of wholeness of character and integrity (ANA,
2015). This attention to the self enables nurses to hold
themselves and others accountable even and especially in
emotionally charged situations.
42. CHARACTERSTICS OF
ETHICAL COMPETENCIES
Place the interests of patients and populations at the center of inter-
professional health care delivery.
Respect the dignity and privacy of patients while maintaining confidentiality
in the delivery of team-based care.
Embrace the cultural diversity and individual differences that characterize
patients, populations, and the health care team.
Respect the unique cultures, values, roles and responsibilities, and expertise
of other health professions.
Work in cooperation with those who receive care, those who provide care,
and others who contribute to or support the delivery of prevention and health
services.
Develop a trusting relationship with patients, families, and other team
members.
Demonstrate high standards of ethical conduct and quality of care in one's
contributions to team-based care.
Manage ethical dilemmas specific to inter-professional patient/population-
centered care situations.
Act with honesty and integrity in relationships with patients, families, and
other team members.
Maintain competence in one's own profession appropriate to scope of
practice.
43. BARRIERS TO ETHICAL PRACTICE
• Barriers Internal to the APN :-Lack of knowledge about
ethics; lack of confidence in one's own ability to name,
define, and resolve ethical conflicts; lack of skill in
communicating in high-stakes situations; and a sense of
powerlessness are potent barriers to the APN achieving
competence in ethical decision making. To address these
barriers, APRNs need to seek out opportunities for ethics
education through schools of nursing and professional
organizations.
• Inter-professional Barriers:-Different approaches among
health care team members can pose a barrier to ethical
practice. For example, nurses and physicians often
define, perceive, analyze, and reason through ethical
problems from distinct and sometimes opposing
perspectives
44. • Patient-Provider Barriers:-Additional barriers to
ethical practice arise from issues in the patient provider
relationship. Health care providers, employees of the
health care institution, and patients and families all
contribute to the settings in which most APNs practice,
offering opportunities for both personal enrichment and
cultural conflict
• Organizational and Environmental Barriers:-Lack of
support for nurses who speak up regarding ethical
problems in work settings is a potent barrier to ethical
practice. Unfortunately, early research and recent
literature have revealed disturbing examples of
environments in which nurses' concerns were minimized
or ignored by physicians, administrators, and even other
nurses
