APRNs in Chronic Illness Care
Ann Marie Hart
INTRODUCTION
Advanced practice registered nurses (APRNs) play an integral role in the care and well-being of individuals and families experiencing chronic illnesses. The complex nature of chronic illness, with care focused primarily on maximizing function and well-being as opposed to cure and recovery, is particularly suited to nursing’s holistic focus (Lupari, Coates, Adamson, & Crealey, 2011; Saxe et al., 2007). APRNs are involved in every facet of chronic illness care from making an initial diagnosis, providing early anticipatory guidance, and coordinating care to monitoring for disease progression, managing medications, and problem-solving complications (e.g., adverse treatment effects, caregiver fatigue, reimbursement issues). Truly, there is no aspect of chronic illness for which APRNs are not well suited to assist in and enhance the lives of those experiencing it.
APRN Defined
For almost 5 decades, APRNs have been involved in the health and care of patients, families, and communities. In 2008, more than 250,000 APRNs were licensed to practice in the United States—just over 8% of the entire population of licensed registered nurses (U.S. Department of Health and Human Services Health Resources and Service Administration, 2010). As the numbers of APRNs have increased, so too have their capabilities and specialties, making the need for a unified regulatory model paramount. In 2008, after 4 years of dialogue and collaboration among leaders from the APRN Consensus Work Group and the National Council of State Boards of Nursing (Stanley, Werner, & Apple, 2009), an important and visionary document was published: Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. In addition to establishing regulatory guidance for APRNs, the model also provides a legal definition of APRN that underscores the commonalities inherent in all APRN practice. Thus far, the model has been well received and has provided much needed clarification and direction for current and future APRN education and practice.
According to the Consensus Model (APRN Consensus Work Group & the National Council of State Boards of Nursing [APRN CWG & NCSBN], 2008, pp. 7-8), an APRN is defined as a registered nurse (RN) who:
has completed an accredited graduatelevel education program preparing him/her for one of the four recognized APRN roles: certified registered nurse anesthetist (CRNA), certified nursemidwife (CNM), clinical nurse
specialist (CNS), or certified nurse practitioner (CNP);
has passed a national certification examination that measures APRN, role, and population-focused competencies and who maintains continued competence as evidenced by recertification in the role and population through the national certification program;
has acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals;
(whose) practice builds on the competencies of RNs by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy;
is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions;
has clinical experience of sufficient depth and breadth to reflect the intended license; and
has obtained a license to practice as an APRN in one of the four APRN roles.
The Consensus Model provides detailed descriptions for each of the four APRN roles, and the reader is encouraged to review the model for specific role-related information. Although one might envision chronic illness care falling only under the purview of the CNS and CNP, chronic illness has no boundaries and frequently enters the realm of care provided by CNMs and CRNAs. For example, CNMs encounter chronic illness when they are providing prenatal care to women with comorbidities such as diabetes, mental illness, and inflammatory bowel disease, as well as when they are providing care to nonpregnant women with illnesses such as endometriosis, polycystic ovarian disease, and breast cancer. Similarly, CRNAs routinely provide anesthesia services to individuals experiencing chronic illness, as well as analgesia to individuals experiencing chronic pain conditions (see Figure 17-1 for the APRN Regulatory Model).
APRN Education
Similar to regulation, APRN education has also experienced a watershed event. In October 2004 after recognizing the additional knowledge and skill set required for advanced practice nursing, the American Association of Colleges of Nursing (AACN) published a landmark document, AACN Position Statement on the Practice Doctorate Nursing that called for the Doctor of Nursing Practice (DNP) to be the entry-level degree for all advanced practice nursing roles. Unlike the PhD degree, the DNP does not prepare graduates to conduct original research. Rather the DNP is a practice-focused doctorate that prepares nurse clinicians for the highest level of nursing practice. Since the AACN’s call for doctoral education for APRNs, more than 100 nursing programs in 37 states have developed DNP programs (AACN, 2011a) and many more DNP programs are under development. While most practicing APRNs were initially educated at the
master’s level, since 2004 many have either obtained or are now pursuing DNP education. The hope is that future generations of APRNs will all be doctorally prepared and competent in the eight essentials of DNP education (AACN, 2006). (See Table 17-1.)
master’s level, since 2004 many have either obtained or are now pursuing DNP education. The hope is that future generations of APRNs will all be doctorally prepared and competent in the eight essentials of DNP education (AACN, 2006). (See Table 17-1.)
 FIGURE 17-1 APRN Regulatory Model. |
Core Competencies of Advanced Practice Nursing
Although the consensus regulatory model (APRN CWG & NCSBN, 2008) and the AACN’s (2004) position statement were both watershed
events for APRNs, no similar consensus has been reached regarding the conceptual underpinnings of advanced practice nursing. However, lack of conceptual consensus should not be construed as a dearth of work or quality scholarship in this area. Indeed, numerous nursing scholars have provided us with a rich body of literature as they have struggled to identify and articulate the essence of advanced practice nursing—that is how advanced practice nursing builds upon, yet is uniquely different from, basic nursing practice. Although it is beyond the scope of this chapter to summarize and critique the entire conceptual body of literature related to advanced practice nursing, six core competencies have been identified that are particularly useful for discussing the practice role of the APRN, particularly when caring for patients and families experiencing chronic illness (Hamric, 2009):
events for APRNs, no similar consensus has been reached regarding the conceptual underpinnings of advanced practice nursing. However, lack of conceptual consensus should not be construed as a dearth of work or quality scholarship in this area. Indeed, numerous nursing scholars have provided us with a rich body of literature as they have struggled to identify and articulate the essence of advanced practice nursing—that is how advanced practice nursing builds upon, yet is uniquely different from, basic nursing practice. Although it is beyond the scope of this chapter to summarize and critique the entire conceptual body of literature related to advanced practice nursing, six core competencies have been identified that are particularly useful for discussing the practice role of the APRN, particularly when caring for patients and families experiencing chronic illness (Hamric, 2009):
Table 17-1 Essentials of Doctor of Nursing (Practice) Education for Advanced Practice Nursing | ||||||||||||||||||||
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Expert coaching and guidance
Consultation
Research
Clinical, professional, and systems leadership
Collaboration
Ethical decision making
These six competencies have been espoused by and/or reflected in the work of multiple scholars and organizations including but not limited to the AACN (2006), Hamric (2009), Mantzoukas & Watkinson (2006); the National Association of Clinical Nurse Specialists [NACNS] (2004, 2009); and the National Organization of Nurse Practitioner Faculties [NONPF] (2006) and are described as “core competencies” by Hamric (2009) in her conceptual definition of advanced practice nursing (see Figure 17-2).
APRN CORE COMPETENCIES IN CHRONIC ILLNESS CARE
Although the six aforementioned core competencies underlie all APRN practice, they are by no means unique to APRNs. Basic-prepared nurses may also demonstrate them. What distinguishes these competencies from basic-prepared nursing is that they are essential to (i.e., required for) APRN practice. In other words, if an APRN
is not proficient in or does not consistently strive to demonstrate all of these competencies in his or her practice, he or she is technically not providing advanced practice nursing care. The expectation is that these six competencies are consistently demonstrated in the APRN’s routine practice. As such, these competencies serve as an excellent framework for discussing the role of the APRN in chronic illness care.
is not proficient in or does not consistently strive to demonstrate all of these competencies in his or her practice, he or she is technically not providing advanced practice nursing care. The expectation is that these six competencies are consistently demonstrated in the APRN’s routine practice. As such, these competencies serve as an excellent framework for discussing the role of the APRN in chronic illness care.
 FIGURE 17-2 Hamric’s Model of Advanced Practice Nursing. |
Expert Coaching and Guidance
Coaching and guidance are essential to the provision of chronic illness care. On the surface, this competency seems straightforward and the experienced nurse may assume he or she does this well and with “expertise.” It is easy to assume proficiency with this competency; most nurses interact with and teach patients frequently during their daily patient care activities. Upon closer examination, there is more to coaching and guidance than meets the eye. Spross (2009) reminds us that the verb “coach” stems from the word’s origins as a carriage used to facilitate the safe transmission of individual(s) from one point to another. Transferring this to nursing practice, coaching is “interpersonal work that helps people who are facing personal transitions or
journeys” (p. 161), such as those associated with chronic illnesses.
journeys” (p. 161), such as those associated with chronic illnesses.
The phenomenon of expert coaching is complex. In addition to establishing rapport, actively listening, and expressing empathy, expert APRN coaching requires clinical competence, and creative problem solving, as well as knowledge and skill regarding how best to assist individuals who are experiencing crisis, desiring change, or even expressing apathy toward an illness or situation. For example, to assist a middleaged adult female with obesity and poorly controlled type II diabetes who desires to lose weight and bring her glycosolated hemoglobin level (HgbA1c) to goal range, the APRN must demonstrate expertise regarding the pathophysiology of diabetes and the complications associated with poor control. He or she must also be thoroughly familiar with current evidence regarding diabetes care parameters and treatments. In addition, the APRN should possess knowledge of and experience with efficacious diabetes education strategies, as well as the transtheoretical stages of change model (DiClemente & Prochaska, 1982; Norcross, Krebs, & Prochaska, 2011; Prochaska, 1979), motivational interviewing (Miller & Rollnick, 1992; Rollnick, Miller, & Butler, 2007), and other evidencebased behavioral change techniques.
Clinical Competence
To provide expert coaching and guidance in chronic illness care, APRNs must be knowledgeable regarding the illness(es) of interest and experienced enough to anticipate the informational and emotional needs of the patient and his or her family members. Going beyond asking the patient and family what they “want to know” and anticipating what they “need to know” is a critical aspect of the APRN’s coaching skills and requires that the APRN be intimately familiar with the illness of interest, its progression, and its management.
Creative Problem Solving
Just as no one asks to have a chronic illness, no one asks to have the myriad problems that are often associated with chronic illness. Expert coaching in chronic illness care often involves assisting patients and families who may be angry, despondent, anxious, confused, or desperate. Thus, it is critical that the APRN be willing to set aside his or her routine “script” or “protocol” and be able to create a revised plan that takes into consideration the unique needs, styles, and interests of the patient or family. Examples of creative educational and coaching strategies for chronic illness management that are gaining support in the research literature are group appointments for diabetes mellitus (Edelman et al., 2010); the use of lay-leaders for diabetes mellitus, hypertension, arthritis, and chronic pain (Foster, Taylor, Eldridge, Ramsay, & Griffiths, 2009); and the use of mobile phone technology for conditions such as diabetes and hypertension (Yoo et al., 2009).
Consultation
Although the APRN will often consult with other APRNs and members of the healthcare team, an essential feature of the role is that APRNs also serve as consultants to other professionals (e.g., nurses, physicians, mental health providers). There are a number of ways in which consultation may be categorized; however, in chronic illness care APRNs primarily provide consultations related to direct patient care. They either see a patient or make specific recommendations to the consultee (i.e., basic-prepared nurse, team of nurses, or
nonnursing provider) on how best to proceed with the patient’s care, or they assist the consultee with formulating an effective plan of care. Regardless of whether the APRN sees the actual patient or not, the aim of APRN-directed consultation is to assist the consultee in providing patient care.
nonnursing provider) on how best to proceed with the patient’s care, or they assist the consultee with formulating an effective plan of care. Regardless of whether the APRN sees the actual patient or not, the aim of APRN-directed consultation is to assist the consultee in providing patient care.
Acting as a consultant requires that the APRN have expertise in a particular area and be respected for this expertise. Barron and White (2009, p. 196) pose seven principles of professional APRN consultation that espouse the collaborative, professional, and transparent nature of APRN 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 rather makes recommendations.
The consultee is free to accept or reject the recommendations of the consultant.
The consultation should be documented.
Research
Gone are the days when APRNs can avoid “research” by choosing to work in clinical practice settings. For more than half a century, nurses have worked to base their care in research-based evidence. Now with the accessibility of current and comprehensive electronic research databases (e.g., Cummulative Index to Nursing and Allied Health Literature [CINAHL] and the National Library of Medicine [through PubMed]), the ability to truly bridge the research-practice gap is no longer an impossible dream.
In most healthcare settings since 2000, the term research has been replaced by the term evidence, and evidence-based practice (EBP) has become a priority goal of all allied health professionals, including APRNs. EBP is most commonly defined as the integration of three components: 1) best research evidence, 2) clinician expertise, and 3) patient preferences and values (Strauss, Richardson, Glasziou, & Haynes, 2005; Melnyk & Fineout-Overholt, 2010). To date, the EBP literature has primarily focused on how to develop compelling clinical questions, as well as how to search for and critique original research studies and systematic reviews. Very little has been published regarding how to best evaluate clinician expertise and patient values or how to “integrate” clinician expertise and values with research findings. Fortunately, APRNs have a long history of providing patient-centered care. Similarly, the development and recognition of nurse expertise has been well established and documented (e.g., Benner, 1984; De Jong et al., 2010; Foley, Kee, Minick, Harvey, & Jennings, 2002; Gorman & Morris, 1991).
By definition, EBP does not elevate or promote the status of research evidence above clinician expertise or patient values. However, EBP does require a moderate degree of competency in basic statistics, research terminology, and research design, which unlike clinician expertise and patient values, are areas that are not as easily gained or mastered from experiential practice. Thus it is critical that APRNs value research, master basic research skills, and utilize these skills on a routine basis.
Depalma (2009) describes three sub-components to the research competency for APRNs. These skills are also echoed in the AACN’s
Essentials of Doctoral Education for Advanced Nursing Practice (2006) and Essentials of Master’s Education in Nursing (2011):
Essentials of Doctoral Education for Advanced Nursing Practice (2006) and Essentials of Master’s Education in Nursing (2011):
Interpretation and use of research findings and other evidence in clinical decision making
Evaluation of practice
Participation in collaborative research
Interpretation and Use of Research Findings and Other Evidence in Clinical Decision Making
We live in exciting times, where a wealth of highquality research exists to help inform and guide ARPN practice. Although not every clinical scenario has been fully researched and a fresh set of unanswered questions arises from each new study, much of the work facing APRNs is supported by research. Indeed it is rare for the APRN, particularly the APRN working with individuals experiencing chronic illnesses, not to have relevant research to draw upon. Thus it is critical for APRNs to be able to competently search for and critically evaluate the research literature, especially as it applies to their own area of clinical expertise.
Having a mechanism to remain aware of current research findings is an all important first step toward competency in research. At present, a growing number of services exist to facilitate this. Some examples include daily electronic “Smart Briefs” from the American Nurses Association, the American Academy of Nurse Practitioners (AANP), and Physician’s First Watch. In addition, many other professional nursing organizations offer weekly or monthly electronic research updates to members.
Participation in professional journal clubs is another avenue for APRNs to remain current regarding the research literature and has the added benefit of being able to dialogue with others about research and how it applies to clinical practice. Professional journal clubs may be sponsored by a workplace organization or organized “off site” by a group of like-minded colleagues. They may occur in a variety of formats including face-to-face monthly meetings, email discussions, wikis, or blogs. Several professional organizations and journals are now hosting electronic journal clubs to subscribers, for example the AANP Virtual Journal Club and the Cochrane Journal Club. There are a number of excellent publications regarding the value of and how to initiate a professional journal club, and the interested reader is encouraged to review these (e.g., Deenadayalan, Grimmer-Somers, Prior, & Kumar, 2008; Dobrzanska & Cromack, 2005; Honey & Baker, 2011; Hughes, 2010; Lizarondo, Kumar, & Grimmer-Somers, 2010; Luby, Riley, & Towne, 2006).
In addition to having access to research findings related to chronic illness, APRNs must also be able to critically evaluate these findings and determine whether and/or how the findings apply to practice. Simply put, critically appraising the research literature requires the ability to evaluate the validity of a single study’s methodology and the meaningfulness of its findings, while simultaneously synthesizing findings from multiple studies across the literature. Obviously, there is nothing “simple” about this process, and similar to many clinical skills, research appraisal is an acquired process that requires adequate education and experience. A variety of excellent courses, workshops, and websites exist to assist APRNs with developing the skills to be able to critically evaluate research evidence (see Table 17-2). Having an EBP mentor or EBP team to consult
with and a supportive work environment are also invaluable to the successful acquisition of EBP skills (Aitken et al., 2011; Fineout-Overholt & Melnyk, 2010).
with and a supportive work environment are also invaluable to the successful acquisition of EBP skills (Aitken et al., 2011; Fineout-Overholt & Melnyk, 2010).
Table 17-2 Examples of Useful Resources for Evidence-Based Skill Development | |
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Similarly, APRNs’ practices should reflect an awareness of current research findings, which requires that they have and maintain mechanisms to remain current on the latest research literature. At present a variety of mechanisms exist to facilitate this, including daily or electronic research alerts from organizations such as the American Academy of Nurse Practitioners and Journal Watch (see Table 17-3). Fortunately, a variety of possibilities are available including APRNs being able to dialogue with other professionals, as well as patients, regarding research evidence.
Evaluation of Practice
In addition to basing care on research-based evidence, APRNs who work with individuals
experiencing chronic illnesses should be routinely evaluating their clinical practice and practicerelated outcomes. These types of evaluations not only ensure quality but also provide data that can be used by researchers and stakeholders (i.e., consumers, insurers, healthcare agencies) who are studying or evaluating care provided by APRNs. Evaluation of APRN practice may revolve around any number of professional aspects including but not limited to scope and standards of practice, role and job descriptions, and evidence-based guidelines and national quality indicators (Depalma, 2009). For example, APRNs who work with adults and children experiencing diabetes could evaluate their own practices to ensure that they are supported by (i.e., contained within) national and state scopes and standards for practice. Similarly, these APRNs could also evaluate specific aspects of diabetes management for adherence rates (e.g., influenza vaccination, microalbuminuria, and retinopathy screening) and attainment of goal disease indicators (e.g., HgbA1c, blood pressure, and lipids).
experiencing chronic illnesses should be routinely evaluating their clinical practice and practicerelated outcomes. These types of evaluations not only ensure quality but also provide data that can be used by researchers and stakeholders (i.e., consumers, insurers, healthcare agencies) who are studying or evaluating care provided by APRNs. Evaluation of APRN practice may revolve around any number of professional aspects including but not limited to scope and standards of practice, role and job descriptions, and evidence-based guidelines and national quality indicators (Depalma, 2009). For example, APRNs who work with adults and children experiencing diabetes could evaluate their own practices to ensure that they are supported by (i.e., contained within) national and state scopes and standards for practice. Similarly, these APRNs could also evaluate specific aspects of diabetes management for adherence rates (e.g., influenza vaccination, microalbuminuria, and retinopathy screening) and attainment of goal disease indicators (e.g., HgbA1c, blood pressure, and lipids).
Table 17-3 Evidence-Based Resources for APRNs | |
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Practice evaluations may occur using a variety of mechanisms. For example, checklists can be developed to compare national and state standards to a particular agency’s APRN job descriptions and evaluation criteria. Another example is conducting chart or electronic reviews of specific care practices (e.g., foot or retina evaluations in patients with diabetes) or patient outcomes (e.g., HgbA1c or lipid levels), which would need to be conducted in accordance with the Health Insurance Portability and Accountability Act (HIPAA, 1996).
Regardless of how or what practice parameters are evaluated, it is essential that APRNs utilize evaluative data to improve their practices. Thus it is critical that the evaluative process be understood and supported by all participating providers (e.g., APRNs, basic-prepared nurses, technicians, and care providers). Similarly, it is important that data are reported in a clear, standardized fashion and that an established process for quality improvement/harm reduction be followed (e.g., using the principles of Continuous Quality Improvement [McLaughlin & Kaluzny, 2005] or Total Quality Management [Kelly, 2006]; see also Carman et al., 2010).
Participation in Collaborative Research
In addition to being able to interpret and apply research findings and evaluate and improve care based on research-based evidence, APRNs should also be able to participate and collaborate in research activities related to their area of clinical expertise. Although APRNs do not need to design and oversee research studies, they should possess general knowledge about research paradigms and phases of the research process (Burns & Grove, 2010; Polit & Beck, 2006). Perhaps most importantly, APRNs need to be interested in research and earnestly desire to contribute to research knowledge by developing collaborative relationships with nurse scientists and others who are studying aspects of interest to APRN practice.
Evidence-Based Practice Box
How Low Should We Go? HgbA1c Goals in Adults with Type 2 Diabetes Mellitus
Early results from the U.K. Prospective Diabetes Study (UKPDS, 1998) demonstrated a significant association between lower HgbA1c values and reduction in the development of microvascular disease (i.e., nephropathy, neuropathy, retinopathy) but not macrovascular disease (i.e., coronary artery disease and cerebrovascular disease) in adults with type 2 diabetes. Because myocardial infarction (MI) is a
leading cause of death amongst individuals with type 2 diabetes, there has been much controversy and continued research regarding intensive glucose control and coronary artery disease. A 10-year followup study of the original UKPDS subjects found that individuals who had originally been assigned to tight glycemic control group (HgbA1c 7.0 vs. 7.9) had significantly reduced rates of both MI (15-33% depending on treatment, p < 0.01) and all cause mortality (13-27% depending on treatment, p < 0.007) (Holman, Paul, Bethel, Matthews, & Neil, 2008). In addition, the PROactive trial found a 28% reduced rate of fatal and nonfatal MI (p = 0.045) in the group randomized to intensive treatment (HgbA1c 7.0 vs. 7.6) (Erdmann et al., 2007). However, the ACCORD (2008, HgbA1c 6.4 vs. 7.5), ADVANCE (2008, HgbA1c 6.3 vs. 7.0), and VADT (2009, HgbA1c 6.9 vs. 8.4) trials found no relationship between intensive HgbA1c lowering and reduction in coronary artery disease. Furthermore, the ACCORD trial, which studied patients with type II diabetes, who had either preexisting coronary artery disease or other cardiovascular risk factors, found an increased risk for all cause mortality in patients who were in the intensive treatment arm (HR 1.22, 95% CI, 1.01-1.46, p = 0.04) with more cases of fatal MI and congestive heart failure.
leading cause of death amongst individuals with type 2 diabetes, there has been much controversy and continued research regarding intensive glucose control and coronary artery disease. A 10-year followup study of the original UKPDS subjects found that individuals who had originally been assigned to tight glycemic control group (HgbA1c 7.0 vs. 7.9) had significantly reduced rates of both MI (15-33% depending on treatment, p < 0.01) and all cause mortality (13-27% depending on treatment, p < 0.007) (Holman, Paul, Bethel, Matthews, & Neil, 2008). In addition, the PROactive trial found a 28% reduced rate of fatal and nonfatal MI (p = 0.045) in the group randomized to intensive treatment (HgbA1c 7.0 vs. 7.6) (Erdmann et al., 2007). However, the ACCORD (2008, HgbA1c 6.4 vs. 7.5), ADVANCE (2008, HgbA1c 6.3 vs. 7.0), and VADT (2009, HgbA1c 6.9 vs. 8.4) trials found no relationship between intensive HgbA1c lowering and reduction in coronary artery disease. Furthermore, the ACCORD trial, which studied patients with type II diabetes, who had either preexisting coronary artery disease or other cardiovascular risk factors, found an increased risk for all cause mortality in patients who were in the intensive treatment arm (HR 1.22, 95% CI, 1.01-1.46, p = 0.04) with more cases of fatal MI and congestive heart failure.
Despite these conflicting findings, results of two meta-analyses suggest that intensive HgbA1c lowering is associated with a modest reduction in nonfatal MI (Turnbull et al., 2009; Tkac, 2009). Additionally, researchers are exploring other potential causes between intensive glycemic lowering and increased coronary artery disease, including the relationship between severe hypoglycemia and vascular events (Riddle et al., 2010; Zoungas et al., 2010).
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