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A Conceptual Model for Frontier Nursing Practice

The purpose of this book is to explicate concepts related to frontier nurse practitioner (NP) practice and utilize those concepts to develop a conceptual model for frontier NP practice. The purpose of a conceptual model is to guide practice by bringing the characteristics of a relatively unknown phenomenon, such as frontier NP practice, to light (Risjord, 2010, p. 173). This chapter begins with a review of concepts related to nursing models in general and then applies these concepts to the conceptual model developed in this book.

  NURSING MODELS

Conceptual models provide a way of thinking about a phenomenon, a mental picture of how that phenomenon is put together and works (Rogers, 1973). When one thinks about frontier practice, certain ideas and notions come to mind. These ideas or notions become concepts that can be identified and defined. Furthermore, some of the concepts may be related to each other. These relationships are then clarified in relational statements indicating how the relationship informs the phenomenon in question. It is the relational statements that provide the foundation for a nursing model.

Nursing models are prescriptive, a guide for nursing action or intervention (Risjord, 2010, p. 180). Models for nursing guide practice in a manner that incorporates the ethics, values, and goals of nursing. This guidance may be related to practice, administration, research, or education. To take responsible action, one must consider all the ramifications and nuances of that action. This involves choices that may have ethical implications.

TABLE 12.1    Nurse of the Future: Metaparadigm Constructs

AACN, American Association of Critical-Care Nurses; ANA, American Nurses Association.

Source: Masters (2013, p. 77).

Nursing models are concerned with aspects of practice that are related to nursing’s sphere of influence or metaparadigm. Nursing’s metaparadigm includes the person, health, nursing, and the environment. These four metaparadigm constructs are very broad and have multiple definitions. Therefore, specific nursing models have different definitions of the constructs depending upon the nature of the model (Fawcett, 1992). The model in this book utilizes the metaparadigm definitions outlined in Table 12.1. These definitions were chosen to represent areas of core competencies for the Nurse of the Future (NOF) project (Massachusetts Department of Higher Education, 2010, as cited in Masters, 2013).

These construct definitions take into account both the broad scope of practice and the wide area of influence that frontier NPs have. For example, the nursing outcomes in the conceptual model for frontier NP practice are related to both individuals and the community. This is congruent with the NOF definition of person. In addition, the NOF definition of environment is wide enough to encompass both the physical and the psychosocial environment of frontier NP practice. Also, the NOF definition of health is congruent with the concept of health in the frontier, one that focuses on the ability to work and be productive rather than on the absence of disease. Furthermore, the NOF definition of nursing takes into account advocacy for individuals or groups, an intervention that was clearly described in the narratives.

The frame of reference for the model developed in this book is frontier NP practice, a specialized type of advanced practice nursing. Different frames of reference allow models to function as guidelines for specific areas of nursing specialization (Rogers, 1973). As noted in Chapter 1, frontier NPs practice in the borderlands between nursing and medicine (Boyd, 2000; Hanson & Hamric, 2003). However, NPs approach their practice with a nursing mindset and are guided by the principles and values of the nursing profession. Therefore, the model for NP practice prescribes a distinct type of practice, one that is rooted in nursing (Ruel & Motyka, 2009).

  RELATIONAL STATEMENTS

As previously noted, conceptual models illustrate how concepts are interrelated. These relationships are clarified through the use of relational statements. In the model for frontier NP practice, these statements include:

       •   Frontier NPs practice independently; they manage chronic and emergent patient problems without backup

       •   Emergency services are lacking in the frontier; frontier NPs manage emergency and trauma situations

       •   Frontier NPs may practice solo; they utilize triage skills to manage multiple patient situations simultaneously

       •   Frontier NPs experience role diffusion; frontier practice requires a broad skillset

       •   Frontier NPs practice in professional isolation; they build interdisciplinary teams to enhance patient care

       •   Frontier NPs practice in environments with limited educational resources; they continually seek learning opportunities

       •   Frontier NPs practice in environments with limited resources; they use innovative strategies to provide patient care

       •   Mental health services are lacking in the frontier; frontier NPs require knowledge regarding the diagnosis and treatment of mental health problems

       •   Public health is lacking in the frontier; frontier NPs require knowledge regarding communicable and emerging diseases

       •   Frontier communities are culturally diverse; frontier NPs are culturally sensitive and possess knowledge that is specific to the setting

       •   Political forces impact frontier health care; frontier NPs use knowledge of federal policies and programs to stabilize local health care access

       •   State and federal policies change over time, so frontier clinics may close or merge with larger organizations; frontier NPs advocate for access to local health care

       •   Frontier NPs face a wide variety of ethical dilemmas; they utilize the concepts of patient autonomy, confidentiality, duty, stewardship, and distributive justice to navigate through patient situations that require ethical comportment

       •   Social capital is lacking in the frontier; NPs add to the social capital in their communities through leadership roles and personal commitment

These statements include interventions that require four types of knowledge, as discussed in Chapter 11: (a) frontier skills and competencies, (b) contextual knowledge, (c) political knowledge, and (d) art and ethics.

  THE MODEL

Models are developed to guide nursing action toward a specified outcome or outcomes. In the model for frontier NP practice (see Figure 12.1), these outcomes include (a) stable access to local health care, (b) less reliance on hospital emergency departments for care, (c) an integrated approach to emergent patient situations, and (d) increased social capital.

These outcomes are the result of frontier NP praxis. Praxis constitutes nursing as a human caring practice and occurs when scientific competence, therapeutic use of self, moral–ethical comportment, and transformative art/acts occur in synchrony (Chinn & Kramer, 1999, p. 256). In the model, praxis is conceptualized as effective frontier NP practice. It is considered effective because all participants in this book demonstrated effectiveness, not only in practice, but also in leadership and program administration.

FIGURE 12.1 Conceptual model for frontier NP practice.

NP, nurse practitioner.

Effective frontier NP practice is at the center of the model (see Figure 12.1). This practice is supported by four types of knowledge, as indicated by one-directional arrows. The arrows between the types of knowledge are bidirectional, indicating reciprocal relationships between them. Each type of knowledge is supported by concepts and themes from the narratives.

Effective frontier NP practice leads to enhanced provision of frontier health care. One-directional arrows from practice to community outcomes indicate this relationship. The relationship between effective frontier NP practice and community outcomes may be stated in the form of propositional statements, such as:

       •   Effective frontier NP practice leads to an integrated response to emergent patient situations.

       •   Effective NP practice stabilizes local health care.

       •   Effective NP practice increases the social capital in frontier communities.

       •   Effective NP practice reduces avoidable emergency department visits.

The model also includes personal/professional outcomes. The relationships between effective frontier NP practice and these outcomes are symbolized with bidirectional arrows. The assumptions underlying these relationships are:

       •   A healthy work–life balance leads to effective NP practice.

       •   An effective NP maintains appropriate social boundaries.

       •   Community acceptance enhances frontier NP practice.

       •   Frontier NPs who successfully manage the personal and professional challenges of frontier practice are more likely to stay in the frontier.

       •   The maintenance of a current knowledge base leads to effective NP practice.

A reciprocal relationship between personal/professional outcomes and community outcomes was not demonstrated in the narratives. However, NPs who successfully manage the personal challenges of frontier practice are more likely to be retained in those settings. Therefore, there is a one-directional relationship between personal outcomes and community outcomes.

The theoretical constructs of independence/fear and isolation/intimacy are in the center of the model. The constructs of independence/fear are relational constructs that emerged from stories involving clinical practice; therefore, they are placed above competencies and contextual knowledge. The constructs of isolation/fear are relational constructs that emerged from stories involving interpersonal relationships; therefore, they are situated above the art and ethics of frontier practice.

  CONCLUSION

Concepts are ideas or notions that are specific to a certain phenomenon. Concepts may be related to one another. When these relationships bridge the gap between abstract notions and practical wisdom, they act as a guide for nursing practice. Relational statements form the basis for symbolic models that can be depicted visually as diagrams. The diagram of the model resulting from the participant interviews is depicted in Figure 12.1. Models that include measurable outcomes can be tested through research. Linking nursing interventions to positive patient or community outcomes informs nursing science. The community outcomes in this model can be tested using a variety of research designs.

The authority for the model lies in nursing’s metaparadigm, the components of which are evident in the model: person, health, environment, and nursing. The validity for the model lies within the narratives of NPs who live the experience of frontier practice. The participants were recruited from five different western states and represent a variety of frontier health care models. This participant criterion enhances the transferability of the model to other frontier practice settings.

The model is a guide for frontier NP practice. It is built on the knowledge of NPs who have demonstrated nursing praxis in their communities. The model is also an example of practice informing theory regarding the salient features of frontier nursing practice.

The theory underlying the research for the model is pragmatism. Therefore, the model is a pragmatic guide for frontier NP practice because it is based on concepts that are important to those who practice there. The model also informs nurse educators regarding the distinct nature of frontier NP practice and the specific educational preparation and prerequisite experience required for effective frontier practice.

  QUESTIONS FOR DISCUSSION

         •   Have you ever utilized a nursing model in practice?

         •   Can you remember a nursing situation where your interventions may have been enhanced through the use of a nursing model?

         •   Think of a research question that might stem from this model. How might you design a study to answer your question?

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