The Expanding Roles of Advance Nurse Practitioners
The roles of advance practice nursing have continued to develop around the globe in response to the need for specialized nursing care offered at advanced practice levels (Kleinpell, Scanlon, Hibbert, Ganz, East, Fraser, Wong & Beauchesne, 2014). Kleinpell et al., (2014) also acknowledge the development of roles for advance practice nursing to encompass components such as to perform diagnosis, prescribe treatment regimens, prescribe drugs, perform and interpret tests to aid in diagnosis. These expanded roles are also recognized by the International Council of Nursing (2013).
Their definition of advance practice nursing is the practice by a registered nurse who poses complex decision-making skills, expert knowledge base and clinical competencies that prepare her for expanded practice. The International Council of Nursing (2013) further reports that the characteristics of practice are influenced by the context of different countries. While a master’s degree is sufficient in some countries, others such as United States recommend training for advance practice nurses at the doctorate level (Kleinpell et al., 2014). Even so, a leadership dynamic exists at the state level where some states allow certain advance practice nursing expanded practice while other states allow a limited practice.
This leadership dynamic is characterized by various factors. These factors denote the challenges that influence the practice of advance practice nurses. Hanson (2013) argues that some of these challenges include the proliferation of titles in advance practice nursing. Some of the prevailing titles include certified nurse-midwife, clinical nurse specialist, psychiatric clinical nurse specialist, and nurse anesthetist among others (Stokowski, 2015). Other challenges highlighted by Hanson (2013) differences in the educational requirements for practice.
As highlighted above, a master’s degree in nursing is sufficient in some quarters while requirements elsewhere require advance practices nurses to be trained at the doctorate level (Kleinpell et al., 2014). The differences in the education requirements fuel the debates regarding the competence of advance practice nurses for expanded practice. Other challenges that characterize the leadership dynamic include the variability in the standards of practice and the appropriateness of the educational programs that prepare nurses for these expanded roles (Hanson, 2013).
However, the most significant of all challenges is the conflicts regarding the scope of expanded practice. Certified Registered Nurse Practitioners and Certified Nurse Midwives who practice in Maryland are given the prescriptive authority (Stokowski, 2015). Further authority is given by the Maryland Division of Drug Control to give prescriptions for controlled substances. This is different from New York where even if the same professionals are given prescriptive authority, the educational and clinical requirements are different from those of Maryland (Stokowski, 2015). For instance, Nurse Practitioners and Certified Nursing Midwives practicing in New York require pharmacotherapeutic training. They also require to practice in collaboration with a physician for 3600 hours before they are given prescriptive authority. The regulation of Nurse Practitioners is not the mandate of the New York Nursing Board but that of the New York Department of Education (Stokowski, 2015). These differences highlight the challenges noted by Hanson (2013) and contribute to the leadership dynamic.
There have been calls to allow advance nurse practitioners to perform their practice without any restrictions to the extent of their training. Hain & Fleck (2014) argues that this would require the resolution of the challenges highlighted by Hanson (2013) in addition to other challenges. These calls are significant, especially when considered in the backdrop if an increase in healthcare costs which is not commensurate with to the quality offered. The calls are also not without merit especially considering the role of nurse practitioners since 1965 in meeting the healthcare demands of underserved people (Hain & Fleck, 2014). The advancement in the preparation of nurses since then also underscores the need for the involvement of nurses through their expanded role in order to sustainably transform the health sector.
Ethics of Care versus Ethics of Justice Perspectives
The ethics of care is an important concept in nursing. Butts & Rich (2015) argue that the ethics of care perspective lays emphasis on personal relationships between the nurse and the patient. This approach also lays emphasis on relationship responsibilities. By considering the patient, the nurse develops a relationship which further creates responsibilities. The ethics of care concept lays emphasis on these relationship responsibilities (Butts & Rich, 2015). In this respect concepts that are central to this ethical approach are empathy, compassion, concern for others, sympathy, and caring from others (Butts & Rich, 2015).
The ethics of care has the potential to improve patient outcomes and the quality of healthcare. Butts & Rich (2015) argue that when faced with moral conflicts in practice, ethics of care requires a nurse to apply critical thinking in order to understand the context of the problem as influenced by the circumstances, relationships, and the causes of the problem. In ventilating on the complex situation, ethics of care also require due consideration, helpfulness, understanding, generosity, care, sympathy and the will in nurses to take responsibility where it is indicated (Butts & Rich, 2015). Ethics of care have an impact on patient outcomes and quality of care because the nurses consider individual contexts and the peculiarities if a given situation rather that the impersonal principles and universal principles (Butts & Rich, 2015).
There is evidence in practice to support the argument that ethics of care lead to improved patient outcomes and quality of care. A study by Meterko, Wright, Lin, Lowy & Cleary, (2010) showed that patients who were hospitalized as a result of myocardial infarctions that who reported to having experienced more positive care were shown to have improved health outcomes. Meterko et al., also showed that mortality rate for patients who had been hospitalized because of myocardial infarctions were significantly lower in the first year following their discharge. Post, (2011) also reports that undermining the dignity of patients who are committed to end-of-life care was strongly associated with anxiety, hopelessness, depression, desire for death, the feeling that one is a burden and poor quality of life.
Unlike the ethics of care, ethics of justice are focused on the fair, just, and equitable treatment of patients in the healthcare sector. The ethics of justice perspective in healthcare also focuses on the distribution of resources (Butts & Rich, 2015). Ethics of justice perspective is also concerned with the fair allotment of benefits as well as burdens (Sorrell, 2012). Some of the questions that nurses in practice ask with regards to this approach to care is how do they determine to whom treatment is to be administered. Do they base these decisions on the apparent needs, on the age of the patients or on the prognosis of the disease? Even with these challenges, this approach to care seeks to ensure that the principles of equity and fairness are used in the delivery of care (Sorrell, 2012).
An impact of ethics of justice on healthcare is the increase in coverage. This is very evident as the principle in the recent reforms in healthcare. The Patient Protection and Affordable Care Act is an approach towards healthcare reform that is informed by the ethics of justice perspective (Sorrell, 2012). By prohibiting insurance provides from denying access to individuals, increasing eligibility for Medicaid, as well as subsidizing the cost of insurance, the healthcare services are more accessible to more populations. Populations that were underserved before now get the medical services to which they have a right (Sorrell, 2012).
Ethics of Care in Today’s Healthcare Environment
There are several factors in the healthcare environment at present that can compel the incorporation of ethics of care into practice. Lachman (2012) argues that one of these factors is institutional policies aimed at entrenching the ethics of care into practice. The hospital administrator, nurses in charge, and other leaders in healthcare need to institute policy frameworks to encourage the ethics of care in practice. This is recognition of the impact that this perspective has on the quality of care and patient outcomes. Lachman (2012) illustrates these policies using some examples from practice. Some facilities have made policies that require hourly rounding by nurses. Hourly rounding allows the nurses more time with the patients. This time is spent determining the needs of the patients and taking appropriate actions to meet these needs.
Another factor as argued by LaSala, Bjarnason (2010) is mission, vision, and values of healthcare organizations. These factors are influential in the actions of a healthcare organization to entrench the ethics of care in practice. If this perspective is reflected in their mission, vision, and values, it will be prioritized as an element of practice in the organization. These factors are also enabling factors for the formulation of the policies alluded to above. From a holistic perspective, if the mission, vision, and values of a healthcare organization reflect the importance of ethics of care in practice, there is trickledown effect in the form of training, of its personnel, the creation of an enabling environment, policy formulation, and the monitoring and evaluation approaches.
Nursing leadership is yet another factor that can compel ethics of care into practice. Entrenching ethics of care into practice requires moral courage. In agreeing with this assertion, Lachman (2012) argues that the leadership environment in healthcare institutions should encourage moral courage. Moral courage entails the use of critical thinking in examining the context, particular problem and the individual situation devoid of impersonal principles. Nursing leadership has an influential role to play in capacity building the nurses to employ this perspective in practice. This is more the case in the context of expanded practice of advance nurse practice.
The expanded roles in advance nursing practice have been a subject for discussion for a while. While progress is desired in this front, it is impeded by structural and political challenges. The variability in scope of practice from one state to another underscores the need for leadership in advance nursing practice. The expanded roles are internationally recognized as has been shown in the paper. Healthcare organizations domestically also recognize the appropriateness of the expanded roles and the competence of advance practice nurses to practice independently. With regard to ethics of nursing, the ethics of justice and care and two of the competing approaches to ethics in practice. The ethics of justice are concerned with the just, fair and equitable allotment of healthcare resources. The impact of this perspective is the increase in coverage and access to healthcare services. The ethics of care is more concerned with empathy, compassion, concern for others, sympathy, and caring from others in the delivery of care. The impact of this approach is improved quality of care and patient outcomes as has been illustrated using evidence from practice.
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