Nurses in advanced roles apply “an expanded range of practical, theoretical, and research-based competencies to phenomena” (Barker, 2009, p.19) within specialized areas of nursing. Advanced roles include nurse practitioner, nurse educator, nurse informaticist, and nurse administrator. Each role is distinct yet all roles share similarities in the areas of clinical practice, primary care, education, administration, and research. This assumption is explored by comparing and contrasting the different roles. A good background on advanced nursing roles assists in situating this student’s own role as family nurse practitioner. Henceforth, it becomes easier to analyze this specific role in terms of regulatory and legal requirements, membership in professional organizations, competencies and certification, and career possibilities. As nurses are called to lead in health care reform, it is also important to become aware of one’s own leadership capabilities and areas that require improvement. The impact of leadership will be illustrated in a proposed policy change.
Advanced Practice Roles in Nursing
All advanced roles require higher levels of competency in critical thinking, decision-making, and leadership that allow greater professional autonomy in specialized clinical or non-clinical fields (Barker, 2009). These competencies are necessary because nurses in advanced roles are expected to assume responsibility for addressing more complex problems or issues. For this reason, their roles are also associated with greater accountability. Different curricula have been developed encompassing the required education and training for each advanced role. However, many of the competencies learned through the curricula, such as leadership and management, advanced clinical skills, provision of primary care, information technology, and education are common across the various roles but differ in application. At the same time, the application of competencies by nurses in different advanced roles has a single goal which is to improve nursing care.
The primary domain of nurse practitioners is direct clinical care employing a population focus. NPs assess, diagnose, treat, manage, and educate individuals across the lifespan as well as families in primary or acute care (NONPF, 2012). They have the privilege of conducting physical examinations, eliciting health histories, ordering and interpreting diagnostic tests, and prescribing treatments or therapies within their scope of practice. Besides curative care, they also render primary care through preventive and promotive interventions that improve health and wellbeing in a comprehensive manner (NONPF, 2012). For instance, NPs provide health screening and care for the well. They provide education and counseling to positively influence patients’ thinking and behavior leading to the maintenance of optimum health, prevention of disease, or management of existing conditions.
Moreover, they provide clinical education to staff nurses. Although they engage in research, this is typically in relation to generating or utilizing evidence to improve direct care. To a lesser extent, they also exercise administrative functions albeit in relation to the clinical practice environment. These functions include leading protocol evaluation or development, coordinating interdisciplinary care, leading clinical policy change, and advocating for better health care delivery systems (NONPF, 2012).
In contrast, the focus of nurse administrators is leadership and management with regard to people and processes within an organization (UC, 2014). Their role similarly relates to clinical practice, education, and research but within the context of fulfilling managerial functions. They are not involved in direct care but schedule and supervise the staff in the frontlines. They may interact with patients for the purpose of monitoring the quality of care, the work environment, and the performance of nurses as well as troubleshooting issues. Among other administrative tasks is ensuring the staff nurses’ adherence to clinical practice standards and guidelines (AONE, 2011).
Further, nurse administrators perform human resource functions in overseeing the professional development of the nursing staff through education, training, and counseling (UC, 2014). In addition, they are concerned with budgets, communication systems, collaboration, staff morale, and retention. Nurse administrators also focus on quality improvement, risk management, accreditation, and health care policy at all levels (AONE, 2011). The education they provide relate to these aspects of administration as do the research they conduct. For the reason that nurse administrators oversee the systems, processes, procedures, and policies that shape nursing practice within acute or primary care settings, they are held responsible for overall nursing care (UC, 2014). In governance, they deal with the economic side of health care, represent the nursing perspective during strategic planning, and assist in achieving strategic goals.
Meanwhile, nurse informaticists are concerned with the development, utilization, and management of communication and information technology systems that support health care (HIMSS, 2014). These include clinical decision support, research databases, resources that promote consumer health literacy, educational resources for patients, learning platforms for professional and student nurses, telehealth, and the electronic health record. Given their role, nurse informaticists are also not involved in direct patient care but provide technological support to facilitate communication and the use of information in acute and primary care settings. They apply research competencies in the development, evaluation, and dissemination of practices in their field (HIMSS, 2014). They assist with the retrieval of patient information for research purposes. Nurse informaticists also educate the nursing staff but with regard to the use of these technologies. Administration within this specialty entails troubleshooting and enhancing current systems and facilitating interaction between the different users of information and technology (HIMSS, 2014).
Nurse educators develop their expertise in the socialization of student nurses into the profession and meeting the knowledge and skill needs of professional nurses (NLN, 2011). They interact with patients in the course of supervising student nurses during clinical rotations but otherwise do not participate in frontline nursing care. They conduct research to enhance the assessment of learning needs and strategies used in teaching and learning (NLN, 2011). They are involved in the development, use, evaluation, and improvement of educational resources. Moreover, research is employed in administrative functions such as curriculum development and revision enabling professional nurses to adequately respond to the health care needs of specific groups of patients or the general population (NLN, 2011). Nurse educators also perform research to explore issues in the academe including faculty attrition and shortage. Similar to the nurse administrator role, nurse educators may perform additional administrative tasks in institutional governance such as determining the mission and goals of the nursing program and partnering with hospitals and other employers.
The Family Nurse Practitioner Role
The overview of advance nursing roles indicates that nurses in these roles often collaborate in the course of performing their unique and similar tasks. Specialization permits the roles to complement each other in addressing all aspects of patient care in the best ways possible. However, specialization goes beyond the four roles discussed above. In particular, nurse practitioners can choose to specialize in direct care for families, children and adolescents, adults, older adults, women, and neonates (Manheim, 2012). They can also specialize in setting such as acute care, occupational health, schools, and primary care. As such, there is a guarantee that advanced nursing care is appropriate to the patient.
This student chose the role of family nurse practitioner (FNP). This role entails providing care to individuals across the lifespan. As such, clinical competencies relate to caring for newborns to older adults within the context of the family as a social unit that provides care to its members. The core competencies of an FNP in general relate to scientific foundation, leadership, quality, practice inquiry, literacy in information and technology, policy, health care delivery, and ethics (NONPF, 2013). Family nurse practitioners need to develop these competencies and in addition, there are specific competencies for independent practice. These include obtaining a health history not only of the individual patient but of family life as well, and performing examinations on persons of varying ages.
The FNP must be capable of conducting physical examinations, behavioral and developmental screenings, and evaluations of mental health. Further, FNPs engage individuals and families in the management of risk factors throughout the life cycle through appropriate interventions (NONPF, 2013). In addition, acute and chronic conditions may have a negative effect on family units that also warrant intervention. FNPs must be prepared to address the complexity of care needs of persons and their families brought on by aging, co-morbid conditions, terminal illness, psychosocial functioning, and economic issues (NONPF, 2013). Among others, these needs are self-management, palliative care, decision-making support, and mental health that may require referral. FNPs employ theories on family and developmental stages to ensure individualized treatment and management.
Family nurse practitioners must be knowledgeable of normal and abnormal assessment findings throughout the lifespan. Following the appropriate use of diagnostic tools and a synthesis of all available patient information, FNPs make decisions about diagnosis, and treatment. Again, FNPs are expected to be capable of treating or managing non-complicated physiologic and mental health conditions, acute or chronic, across the lifespan. For example, medications, therapies, and devices must consider the age and developmental stage of patients.
Requirements for Certification
The American Nurses Credentialing Center (ANCC) lists the eligibility criteria for family nurse practitioner certification. First, an individual must hold an active registered nurse (RN) license in a U.S. state or territory. Second, the RN must have graduated from a postgraduate master’s or doctoral degree from an FNP program with accreditation from the Accreditation Commission for Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE) (ANCC, 2014). The program must have included at least 500 clinical hours with faculty supervision. Third, the nurse must have finished comprehensive and advanced post-graduate courses in physiology or pathophysiology applicable to different developmental stages, health assessment of all body systems, and pharmacology (ANCC, 2014). Fourth, courses must have included content in health promotion, differential diagnosis, and disease management.
Regulatory and Legal Requirements
In New York, a certificate that authorizes the use of “Nurse Practitioner” as professional title is given by the New York State Education Department (Office of the Professions, 2014). To qualify, the individual must have an active RN license in the state and should satisfy the educational requirements. A certificate is issued for each specialty area. The state recognizes 16 specialty areas including family health (Office of the Professions, 2014). There are legal requirements that apply to nurse practitioners and all licensed professionals. The regulations of the Office of the Professions that govern the practice of nursing apply to nurse practitioners as well. According to the Nurse Practitioner Modernization Act that will take effect in 2015, NPs with less than two years of experience are required to comply with practice protocols for the chosen specialization and to enter into a collaborative practice agreement with a physician who certifies the NP’s compliance (NPA NYS, 2014). These restrictions are removed when the NP’s experience exceeds two years.
The American Association of Nurse Practitioners (AANP) is the largest professional organization of full-time nurse practitioners regardless of specialty. It is active in policy advocacy for the independent practice of NPs in each state (AANP, 2014). In New York, the Nurse Practitioner Association New York State represents the state-wide interests of NPs. The association’s advocacy was instrumental in the successful enactment of the Nurse Practitioner Modernization Act.
I would like to work with family practice physicians for collaborative practice in accordance with New York legal and regulatory requirements. It would be best to experience working with a variety of clients – infants, children, adolescents, adults, and older adults and their families – to enhance my ability to truly provide care across the lifespan. As an NP, it would be necessary to collaborate also with mental health professionals, other physicians, physical therapists, dieticians, and other health and non-health professionals providing care to patients. After two years, I would like to transition into a nurse-managed health center as a primary health care provider. Working with fellow nurse practitioners with similar or different specialties preferably in a supportive and mentoring environment fosters full professional autonomy in caring for patients that will truly advance the profession.
Based on the quiz results, my leadership style is participative and delegative. I value the input of others especially in the event of conflict, practice and workplace issues, ethical dilemmas, and significant changes. I believe staff input and participation in these scenarios are important because there is a lot at stake for them. They enact the behaviors necessary for successful change. They are also affected by clinical and work environment issues as well as moral distress related to ethical predicaments. To elicit buy-in, commitment, high morale, and satisfaction, it is appropriate to let the staff have a voice and a hand in the decision-making and implementation processes (Borkowski, 2009). However, I make decisions in situations where I know there is little contention over my analysis and actions.
My leadership style is also delegative. It reflects my humility in admitting that sometimes, the nursing staff knows more than I do and I defer to them. In doing so, I communicate the message that it is acceptable to ask for assistance or guidance when needed because it is in the best interest of patients. Delegation further communicates trust in the nurse’s abilities that improves morale. When delegating, I make sure the task and expectations are clear and the nurse is qualified to assume the responsibility.
Good leadership entails the effective use of different strategies appropriate to the situation (Frankel, 2009). My major weakness is an aversion to using the authoritative leadership style. There are times when I need to take charge to achieve desired outcomes because of failures in systems and processes. It would take time to analyze the situation, determine the root cause, and implement corrective actions. However, I have negative feelings about the top-down concept of dictating what needs to be done and making decisions on my own.
Clearly, I need to use the authoritative style more effectively when necessary and prevent delays in decision-making. In addressing this weakness, I will engage in self-reflection to evaluate my personal values and experiences and ascertain why I have this attitude towards this leadership style. Reflection means sorting through prior situations and drawing learning insights to enhance future responses (Patterson & Chapman, 2013). Awareness helps me understand myself better and facilitates self-criticism leading to improvement. It is also necessary to seek feedback and advice from more experienced peers or peers who seem comfortable in switching between different leadership styles.
Proposed Health Care Policy
A pressing health issue is the persistence of health disparities. Unhealthy behaviors that increase the risks for serious and chronic non-infectious diseases are significantly higher among persons of low socioeconomic status and minority status. For instance, greater morbidity and mortality is noted among Black Americans with heart failure compared to Whites and more so among Black women (Sharma, 2014; Williams, 2009). Smoking and sedentary lifestyles are more prevalent among cultural minorities than Whites (Pampel, Krueger & Denney, 2010). There are many factors contributing to disparity. However, the most significant are patient-related level of health literacy and the nature of the encounters with health care providers (Misra-Hebert & Isaacson, 2012).
Patients who do not adequately understand their condition and the recommended treatment and management will more likely not comply or when given a less optimal choice will opt for it. On the other side of the coin, biases and prejudices among health care providers also perpetuate disparity (Misra-Hebert & Isaacson, 2012). When patients are judged as non-compliant, providers often fail to ascertain the underlying reasons that many times relate to the former’s lack of understanding. In turn, poor understanding may be brought about by low literacy levels versus information that is not simplified to suit this level (Pampel, Krueger & Denney, 2010). Thus, there is a breakdown in communication. At the same time, care for cultural minorities is often suboptimal because of incongruence between medical advice and the patient’s values, beliefs, and health practices. This situation is also often perceived as non-compliance. Where providers see the situation from their perspective instead of that of the patient and monopolize the decision-making process, they are prone to providing ineffective care and generating distrust.
The provider is in the best position to address disparity relating to health literacy because they educate the patient. He or she is also in a suitable role to address issues with communication and the decision-making process. As such, building the capacity of health care providers to improve the patient-provider relationship is of utmost importance. However, there is no systematic and concerted effort to include concepts of disparity and related interventions in education. In Texas, two bills pertaining to disparity were recently adjourned. One targeted the curricula of health professional education and the other intended to create a body that will coordinate research and project development and implementation for eliminating disparity (NCSL, 2014). A law that will mandate the inclusion of the concepts of culture and literacy and the relationship of communication, decision-making, and patient trust with these concepts is necessary. Having the knowledge and skills enables providers to effect changes in clinical practice and therefore improve health outcomes (Harris, 2010, Misra-Hebert & Isaacson, 2012).
Developing such a policy entails bringing together the stakeholders, namely leaders in educational institutions, educators, health care professionals including nurse practitioners, students, consumer representatives, and cultural minority groups. It will increase awareness of the issue, the need for change, and the steps toward resolution. Stakeholder participation also ensures that the proposed change is appropriate, acceptable, and cost-efficient (Mason, Leavitt & Chaffee, 2012). It is important for stakeholders to support the policy to ensure success. The policy must reinforce stakeholder commitment by providing technical assistance, information, tools, and other resources to learning institutions, educators, and health care providers who need such support to improve both education and practice. There must be specific, measurable, and attainable goals and performance measures that will spur change through monitoring (Mason, Leavitt & Chaffee, 2012).
As a nurse practitioner providing direct care, I can provide leadership over the research process needed to develop the policy. Having this knowledge, I can initiate awareness-building activities in various venues, including my workplace, sharing what I learned in policy development. Public awareness increases the chances of the issue making it to the legislative agenda (Mason, Leavitt & Chaffee, 2012). I can also approach legislators who have a track record in supporting or sponsoring proposed law relating to improving health care and the welfare of cultural minorities. A summative evaluation following policy implementation should show reductions in disparity measures as well as positive qualitative feedback from health care providers and patients. Previous studies on the impact of improving the cultural competence of providers in a smaller scale, namely clinical settings, have been successful (Harris, 2010). The evidence supporting the policy compounded with strong stakeholder support should bring about successful change.
Advance practice roles are essential in today’s health care environment. These roles represent specializations that permit unique professional expertise in the different aspects of patient care thus complementing each other to provide high quality care. However, the different roles have common competencies albeit applied in various practice settings. Exploring my future role against the backdrop of the general categories of advance roles provided a concrete picture of the laws and regulations that shape my role. Knowing the career possibilities and venues for professional development are helpful as well. The emphasis on leadership in health care policy development is timely given the challenge posed to nurses in helping lead reforms in the health care system. I feel that it is feasible for me to exercise such leadership in the arena of legislative advocacy.
American Association of Nurse Practitioners (2014). Membership/benefits. Retrieved from http://www.aanp.org/membership
American Nurses Credentialing Center (2014). Family nurse practitioner certification eligibility criteria. Retrieved from http://www.nursecredentialing.org/FamilyNP-Eligibility.aspx
American Organization of Nurse Executives (2014). Nurse executive competencies. Retrieved from http://www.aone.org/resources/leadership%20tools/nursecomp.shtml
Barker, A.M. (2009). Advanced practice nursing: Essential knowledge for the profession. Sudbury, MA: Jones and Bartlett Publishers.
Borkowski, N. (2009). Organizational behavior in healthcare (2nd ed.). Massachusetts, MA: Jones and Bartlett Publishers.
Frankel, A. (2009). What leadership styles should senior nurses develop? Nursing Times, 104(35), 23-24. Retrieved from http://www.nursingtimes.net/nursing-practice/leadership/what-leadership-styles-should-senior-nurses-develop/1811643.article
Harris, G.L.A. (2010). Cultural competence: Its promise for reducing healthcare disparities. Journal of Health and Human Services Administration, 33(1), 2-52. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20568583
Healthcare Information and Management Systems Society (2014). Nursing informatics competencies. Retrieved from http://www.himss.org/resourcelibrary/TopicList.aspx?MetaDataID=788
Manheim, J.K. (2012). Nurse practitioner (NP). Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001934.htm
Mason, D.J., Leavitt, J.K., & Chaffee, M.W. (2012). Policy and politics in nursing and health care. St. Louis, MO: Elsevier Saunders
Misra-Hebert, A.D., & Isaacson, J.H. (). Overcoming health care disparities via better cross-cultural communication and health literacy. Cleveland Clinic Journal of Medicine, 79(2), 127-133. doi:10.3949/ccjm.79a.11006.
National Conference of State Legislatures (2014). 2013 health disparities legislation. Retrieved from http://www.ncsl.org/research/health/2013-health-disparities-legislation.aspx
National League of Nursing (2011). Core competencies of nurse educators with task statements. Retrieved from http://www.nln.org/profdev/corecompetencies.pdf
National Organization of Nurse Practitioner Faculty (2012). Nurse practitioner core competencies. Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecompetenciesfinal2012.pdf
National Organization of Nurse Practitioner Faculty (2013). Population-focused nurse practitioner competencies. Retrieved from http://www.aacn.nche.edu/education-resources/PopulationFocusNPComps2013.pdf
Nurse Practitioner Association New York State (2014). New York’s Nurse Practitioner Modernization Act at a glance. Retrieved from http://www.thenpa.org/
Office of the Professions (2014). License requirements: Nurse practitioner. Retrieved from http://www.op.nysed.gov/prof/nurse/np.htm
Pampel, F.C., Krueger, P.M., & Denney, J.T. (2010). Socioeconomic disparities in health behaviors. Annual Reviews in Sociology, 36(1), 349-370. doi:10.1146/annurev.soc.012809.102529.
Patterson, C., & Chapman, J. (2013). Enhancing skills of critical reflection to evidence learning in professional practice. Physical Therapy in Sport, 14(2013), 133-138. Retrieved from http://dx.doi.org/10.1016/j.ptsp.2013.03.004
Sharma, A. (2014). Heart failure in African Americans: Disparities can be overcome. Cleveland Clinic Journal of Medicine, 81(5), 301-311. Retrieved from http://www.ccjm.org/content/81/5/301
Williams, R.A. (2009). Cardiovascular disease in African American women: A health care disparities issue. Journal of the National Medical Association, 101(6), 536-540. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19585921