Direct Clinical Practice

Chapter 7


Direct Clinical Practice




Chapter Contents



Direct Care Activities, 148



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



Diverse Approaches to Health and Illness Management



Management of Complex Situations



Conclusion


Direct care is the central competency of advanced practice nursing. This competency informs and shapes the execution of the other six competencies. Direct care is essential for a number of reasons. To consult, collaborate, and lead clinical staff and programs effectively, an advanced practice nurse (APN) must have clinical credibility. With the deep clinical and systems understanding that APNs possess, they facilitate the care processes that ensure achievement of outcomes for individuals and groups of patients. Advanced practice occurs within a health care system that is constantly changing—changing delivery models, reimbursement structures, regulatory requirements, population-based management, and even proposed changes in the basic educational requirements for advanced practice nurses through the Doctor of Nursing Practice (DNP) degree. The challenge that many APNs face is how to maintain the characteristics of care that have helped patients achieve positive health outcomes and afforded APN care a unique niche in the health care marketplace. Characteristics such as the use of a holistic perspective and formation of therapeutic partnerships with patients to coproduce individualized health care are challenged by cost containment strategies that emphasize standardization of care to achieve population-based outcome targets. Conversely, characteristics of APN care such as health promotion, fostering self-care, and patient education are valued by practices offering care to patients because they result in an appropriate use of health care resources and sustain quality.


This chapter describes the direct clinical practice of APNs and helps readers understand how it differs from the practice of experts by experience, describes strategies for balancing direct care with other competencies, and describes strategies for retaining a direct care focus. The six characteristics of APN practice are identified.



Direct Care Activities



Direct Care and Indirect Care


Direct care is the central APN competency (see Chapter 3). The APN is using advanced clinical judgment, systems thinking, and accountability in providing evidence-based care at a more advanced level than the care provided by the expert registered nurse. The APN is prepared to assist individuals through complex health care situations by the use of education, counseling, and coordination of care (American Association of Colleges of Nursing [AACN], 2006). Although an expert registered nurse may, at times, demonstrate components of care that are at an advanced level, it is care that is gained through experience and is exemplary (not expected) at that level. Essentials I and II of practice doctorate education for APNs delineate that APN-level care is demonstrated through advanced, refined assessment skills and implementation and evaluation of practice interventions based on integrated knowledge from a number of sciences, such as biophysical, psychosocial, behavioral, cultural, economic, and nursing science (AACN, 2006). Graduate-level APN education provides a foundation for the evolution of practice over time as necessitated by health care and patients. This advanced level of practice is an expected competency of all APNs, not an exemplary skill that is intermittently or inconsistently displayed by staff or expert nurses.


For the purposes of this chapter, the terms direct care and direct clinical practice refer to the activities and functions that APNs perform within the patient-nurse interface. Depending on the focus of an APN’s practice, the patient may, and often does, include family members and significant others. The activities that occur in this interface or as direct follow-up are unique because they are interpersonally and physically coenacted with a particular patient for the purpose of promoting that patient’s health or well-being. Many important processes transpire at this point of care, including the following:



Advanced practice nursing activities occurring before and adjacent to the patient-nurse interface have a great influence on the direct care that occurs; however, they are not performed with an individual patient or their main purpose is tangential to the direct care of the patient. Activities such as collaboration, consultation, and mentoring of staff may all be occurring in relation to the direct care interface. It is often difficult to separate out these indirect care interventions, which are equally necessary for adequate fulfillment of the APN role and care of the patient (Box 7-1). For example, when an APN consults with another provider regarding the nature of a patient’s condition or the care that should be recommended to a patient, the APN is engaging in advanced clinical practice, but it is not direct care. Even though the APN is accountable for the consultation, the primary purpose of that contact is to acquire information and understanding to use in formulating recommendations for the patient’s direct care provider (see Chapter 9). Thus, according to the definition of direct care used in this chapter, the APN is engaged in clinical practice but he or she is not providing direct care to the patient. The direct care role of the clinical nurse specialist (CNS) may not be as apparent to observers as it is for a nurse practitioner (NP), certified registered nurse anesthetist (CRNA), and certified nurse-midwife (CNM) because the CNS frequently shifts from direct to indirect activities depending on the situation and the providers involved. See Exemplar 7-1. For the CNS, these shifts may occur during one patient encounter, and certainly across a day. Most APNs will have a role in ensuring that others are providing quality and safe care through indirect practice.



imageBox 7-1   Examples of Advanced Practice Nurse Indirect Care Activities





imageExemplar 7-1   Examples of Direct and Indirect Care Provided by Advanced Practice Nurses



Direct Care


The medical intensive care unit (MICU) acute care nurse practitioner (ACNP) was called into a patient’s room by a novice staff nurse. On quick visual assessment of the patient and room, and a verbal update by the nurse, the ACNP ascertained that this was a 65-year-old man with acute respiratory distress syndrome who was intubated and on a ventilator, with an Fio2 at 60%. His current Sao2 reading was 84%, blood pressure was 88/60 mm Hg and dropping, and heart rate was 110 beats/min. The patient was sedated and his skin was pale. The alarm on the ventilator was sounding with high peak inspiratory pressures. The staff nurse appeared anxious and stated that she had been unable to determine why the alarm was sounding. When the nurse noticed that that the patient’s status was deteriorating, she called for the ACNP to help.


Recognizing that it was not an appropriate time to talk the staff nurse through troubleshooting the ventilator, the ACNP assumed responsibility for the nursing interventions by increasing the Fio2 on the ventilator and hyperventilating the patient. However, she explained each action she was taking to the staff nurse. The ACNP suctioned the patient and removed a large mucus plug. The patient’s color slowly returned to pink, blood pressure started to increase, heart rate started to decrease, and Sao2 rose to 92%.


After ensuring that the patient was stable, the ventilator was functioning, and returning the ventilator to the original settings, the ACNP reviewed the situation with the staff nurse. She reviewed each step, describing indicators and appropriate actions to take, and answered the staff nurse’s questions. In this case, the ACNP assumed direct care activities for the patient to address an urgent situation.



Indirect Care


The MICU clinical nurse specialist (CNS) was approached by an experienced staff nurse who was struggling to develop an interpersonal relationship with the family of a complex critically ill patient. The family was very anxious and was having difficulty synthesizing the information that the staff nurse was trying to provide to them.


Rather than intervene directly with the family, the CNS recognized that this would be a good opportunity for the staff nurse to develop and expand her skills at interpersonal relationship building. The CNS explored the interventions she had already attempted with the nurse and reviewed with her the literature regarding family stressors in critical care, family needs, and the goal of assessing and addressing what the family perceives as their educational and care needs. Armed with this information, the nurse felt comfortable in working with the family to assess their priority educational and psychosocial needs to obtain the resources and information they needed.


The CNS could have intervened by establishing a direct relationship with the family, which would have been providing direct care. In this case, however, she determined that it was more important to assist the staff nurse in the development of the relationship as a growth opportunity and to help the nurse form an ongoing partnership with the family, with whom she would be interacting on a continuing basis.


APN roles tend to diverge when comparing the amount of time spent in each of the direct care activities (Becker et al., 2006; Verger, Marcoux, Madden, et al., 2005). A research study by Oddsdottir and Sveinsdottir (2011) has demonstrated that CNSs spend most of their time in education and expert practice in the institutional domain; the authors recommended that the focus for CNSs needs to be spent on direct practice in the client-family domain. Critical care CNSs reported spending 36% of their time with nursing personnel, 21% with patient population work, and 17% on organizational and system work. Only 26% of their time was spent with individual patients, whereas ACNPs spent 74% of their time with individual patients (Becker et al., 2006). This finding is consistent with other studies reporting that NPs spend more time on individual patient care and less time on indirect and service-related care (ANCC, 2004; Gardner et al., 2010). Other studies have supported the finding that NPs and CNMs are spending most of their time in direct care with patients (Holland & Holland, 2007; McCloskey, Grey, Deshefy-Longhi, et al., 2003; Rosenfeld, McEvoy, & Glassman 2003; Swartz et al., 2003).


This delineation of direct and indirect practice is not intended to denigrate clinical activities that occur outside the patient-nurse interface—quite the contrary. These clinical activities and functions should be recognized as influencing what happens in the interface and as having a significant impact on patient outcomes. Because these other clinical activities significantly affect patient outcomes, they must be valued by the nursing community and health care systems. In the current environment of cost containment and technologic development, all activities that enhance patients’ health, recovery, and adjustment are critical components of care delivered by APNs. Ball and Cox (2003), based on a study of CNSs and NPs, found that APNs engage in a range of strategic activities, an excellent characterization of the direct and indirect but adjacent actions that make up the clinical practice of APNs as depicted in exemplars below.


Researchers are beginning to understand the specific activities that constitute the direct care component of various advanced practice nursing roles. However, it is difficult to make generalizations about these activities because the APNs studied had different roles and worked in different settings, with different populations. Different classification schemas were used to categorize APN actions. For example, in some studies, investigators used the term activities to classify APN actions; in others, the term interventions was used. The variability in terminology and definitions makes it difficult to compare results across APN roles, settings, and populations. Nevertheless, a review of these studies yields some insights into the extent and nature of direct care activities in APN roles.


Many direct care activities performed are similar across APN roles, and preparation of all APNs must include the 3 Ps—pathophysiology, advanced physical assessment, and pharmacology (AACN, 2011). Additional direct care activities that are similar across roles include patient and family education and counseling, ordering laboratory tests and medications, and performing procedures (Becker et al., 2006; Verger et al., 2005). Verger and colleagues (2005) surveyed pediatric critical care NPs regarding their direct care activities, which included physical assessments, patient and family teaching, and performing procedures such as venipuncture, IV insertions, lumbar punctures, feeding tube placements, endotracheal intubations, and central line placements. CNMs reported expansion of their direct care procedures to include first assisting during cesarean sections and performing endometrial biopsies (Holland & Holland, 2007). CNSs and administrators need to have ongoing monitoring of the direct care components of the CNS role. With increasing complexity and diversity of the role, there is a propensity to have CNSs perform less and less expert direct care of patients, which is the main characteristic of APN practice (Lewandowski & Adamle, 2009).


Regardless of the population being cared for, surveillance was a key direct care activity of APNs identified in studies (Brooten, Youngblut, Deatrick, et al., 2003; Brooten, Youngblut, Donahue, et al., 2007; Hughes et al., 2002). Surveillance is described as watching for physical and emotional signs and symptoms and monitoring dressing and wound care, laboratory results, medications, nutrition, response to treatment, and caretaking and parenting. Thus, surveillance refers to an APN’s vigilant assessment of patient status, the rapid diagnosis of subtle or emergent conditions, and quick intervention to prevent or reverse a potentially negative outcome. APNs in these studies also used extensive teaching, guidance, and counseling in many of the same areas in which they were using surveillance. The extent of surveillance and teaching may fluctuate depending on the phase of care and the particular population being cared for. Nursing surveillance can have a particularly important impact on the patient safety indicator of failure to rescue—situations in which providers fail to notice symptoms or respond adequately or swiftly to clinical signs, resulting in patient death from preventable complications. Failure to rescue has been linked to nursing surveillance; for example, the higher the nursing surveillance, as defined by staffing ratios, the lower the number of cases of failure to rescue (Aiken et al., 2002; Clarke & Aiken, 2003). A study by Shever (2011) has also supported the concept that patients who receive higher surveillance, as documented by nursing in the electronic health record, are less likely to be involved in a failure to rescue situation.


In summary, direct care activities make up a large part of what most APNs do, although there is considerable variation in which activities are performed and how much time is devoted to the direct care function across roles, settings, and patient populations.



Six Characteristics of Direct Clinical Care Provided by Advanced Practice Nurses


APNs function in many roles and settings, and with different populations. Despite such variability in role implementation, there is a similarity in the components of direct care provided. Characteristics of advanced practice nursing care extend across advanced practice roles, health care settings, and populations of patients. These characteristics include the following:



Accumulating evidence supports these features of APN practice as having positive influences on patient outcomes. Throughout this chapter, the empirical evidence cited regarding claims about APN practice is illustrative and not based on a systematic review of research. The research regarding outcomes of APN practice is addressed comprehensively in Chapter 24.


The six characteristics of advanced direct care practice have their roots in the traditional values of the nursing profession. These values are defined in nursing’s social contract with society, as outlined by the American Nurses Association (ANA; 2010, p. 6):



Nurses in advanced practice roles often have a deep commitment to the values on which these characteristics rest and are able to advocate persuasively and incorporate these values in daily practice. The expanded scope of practice of APN roles often enables APNs to fully enact these characteristics in their daily interactions with patients. An overview of strategies for enacting these characteristics is provided in Box 7-2.



imageBox 7-2   Characteristics of Advanced Direct Care Practice and Strategies for Enacting Them





Expert Clinical Performance



• 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 computer-related skills for accessing and managing patient data and practice information.






Use of a Holistic Perspective



Holism Described


Holism has a variety of meanings. A broad view is that holism involves a deep understanding of each patient as a complex and unique person who is embedded in a temporally unfolding life. The holistic perspective recognizes the multiple dimensions of each person—physiologic, social, emotional, cognitive, and spiritual—and that the relationships among these dimensions result in a whole that is greater than the sum of the parts. The broad perspective also recognizes that the individual is “a unitary whole in mutual process with the environment”(American Holistic Nurses Association, 2007). People are in constant interaction with themselves, others, and the environment and universe and exhibit maximum well-being when all parts are balanced and in harmony (Erickson, 2007); this state of well-being can exist whether there are physical disorders or not. This comprehensive and integrated view of human life and health is considered in the health care encounter in context of the full range of factors influencing patients’ experiences (Box 7-3) Clearly, high-tech care environments with many health care providers, each focused on a particular aspect of a patient’s condition and treatment, require designated coordinators who have a comprehensive and integrated appreciation of the patient and his or her experience of care as a whole. APNs’ capacity to keep the pieces together and promote continuity of care in a way that focuses care on the unique individual is undoubtedly why many clinical programs have an APN member or coordinator (see later, “Management of Complex Situations” on p. 172). The Shuler nurse practitioner practice model is based on a holistic understanding of human health and illness in older adults that integrates medical and nursing perspectives (Shuler, Huebscher, & Hallock, 2001; see Chapter 2).



imageBox 7-3   Factors to Consider When Helping the Patient Holistically




• Patient’s view of his or her health or illness


• Patterns of physical symptoms and amount of distress they cause


• The effect of physical symptoms on the patient’s daily functioning and quality of life


• Symptom management approaches that are acceptable to the patient


• Life changes that could affect the patient’s physical or psychological well-being (e.g., relationship break-up, job change, intrafamily conflict, retirement, death of a loved one)


• Context of the patient’s life, including the nuclear family unit, social support, job responsibilities, financial situation, health insurance coverage, responsibilities for the care of others (e.g., children, chronically ill spouse or partner, older parents)


• Spiritual and life values (e.g., independence, religion, beliefs about life, acceptance of fate)



Holism and Health Assessment


When working with a relatively healthy person, the APN seeks to understand the person’s life goals, functional interests, and health risks to preserve quality of life in the future. In contrast, when working with an ill patient, the APN is interested in what the person views as problems, how he or she is responding to problems, and what the problems and responses mean to the individual in terms of daily living and life goals. In a study of 199 primary care clinical situations (Burman, Stepans, Jansa, et al., 2002), NPs were found to engage in holistic assessment and ground their decision making within the context of the patient’s life.


The ability to function in daily activities and relationships is an important consideration for patients when they evaluate their health, so it is an appropriate and essential focus for holistic, person-centered assessment. Most functional assessment formats focus on the following: (1) how patients view their health or quality of life; (2) how they accomplish self-care and household or job responsibilities; (3) the social, physical, financial, environmental, and spiritual factors that augment or tax their functioning; and (4) the strategies that they and their families use to cope with the stresses and problems in their lives.


In pediatrics, measures of functional status such as one for children with asthma (Centers for Disease Control and Prevention [CDC], 2012) have been developed. In adults, APNs may choose to use a disease- or problem-focused tool such as measurement of functional status in heart failure patients (Rector, Anand, & Cohn, 2006), of symptom distress in cancer patients (Cleeland et al., 2000; Chen & Lin, 2007), or of function and disability in geriatric patients (Denkinger et al., 2009), or a widely used general measure such as the Short Form-36 Health Survey (SF-36), which measures overall health, functional status, and well-being in adults and is available in several languages (Ware & Sherbourne, 1992).



Nursing Model or Medical Model


As APNs have taken on responsibilities that were formerly in the purview of physicians, some have expressed concern that APNs are being asked to function within a medical model of practice rather than within a holistic nursing model. This concern is raised when APNs substitute for physicians. However, there is evidence that a nursing orientation is an enduring component of APN practice, even when medical management is part of the role (Blasdell, Klunick, & Purseglove, 2002; Hoffman, Tasota, Scharfenberg, et al., 2003; Hoffman, Happ, Scharfenberg, et al., 2004; Lambing, Adams, Fox, et al., 2004; Sidani et al., 2006; Watts et al., 2009; Box 7-4). Activities described in these studies clearly reflect a nursing-focused practice.



imageBox 7-4   Nursing-Focused Advanced Practice Interventions




Statements from professional organizations indicate that APNs value their nursing orientation and their medical functions. For example, the description of APNs in the ANA’s nursing social policy statement includes strong endorsement of specialized and expanded knowledge and skills within the context of holistic values (ANA, 2010). On the theoretical front, several models of advanced practice blend nursing and medical orientations (see the Shuler nurse practitioner practice model and the Dunphy-Winland models in Chapter 2).



Formation of Therapeutic Partnerships with Patients


The Institute of Medicine (IOM) has recommended patient-centered care as the foundation of safe, effective, and efficient health care (IOM, 2001). The person-centered, holistic perspective of APNs serves as the foundation for the types of relationships that they cocreate with patients. APNs are well prepared to develop therapeutic relationships as the cornerstone of patient-centered care (Badger & McArthur, 2003; Coddington & Sands, 2008). The Gallup Poll has consistently reported that the public views nurses as the most trusted professionals (ANA, 2011). The skill of APNs to develop therapeutic relationships with individual patients can influence broader public perceptions.


The development and maintenance of therapeutic relationships with patients and families is one of the key criteria in The Essentials of Doctoral Education for Advanced Nursing Practice, which is specific and foundational to advanced practice nursing (AACN, 2006). Studies have shown that APNs form collaborative relationships with patients. Dontje and colleagues (2004) have described the primary care environment as particularly conducive to developing sustained partnerships with patients. In a synthesis of the literature, a review of qualitative data, and reflection on their own clinical experiences, the authors identified the following as goals of therapeutic partnerships in primary care: self-management of care, promotion of shared decision making, and a holistic approach to care that promotes continuity. The authors posited that these characteristics of APN partnerships may contribute to high-quality care through the adoption of preventive care practices, improved patient satisfaction, appropriate use of resources, and overall better patient outcomes, although more research is needed in this area. In addition, Drennan and colleagues (2011) found that patients were satisfied with their relationships with nurses and midwives, including the consultation process, patient education, medication advice, and the patient’s intent to comply with provider advice.


APNs’ therapeutic use of self contributes to the optimization of a therapeutic relationship with patient and family. Therapeutic use of self involves APN awareness of personal feelings, attitudes, and values and how that awareness influences the patient-provider relationship (Warner, 2006). This increased awareness on the part of the APN helps increase empathy, allowing the APN to engage more deeply with patients while maintaining appropriate boundaries to maintain objectivity (Warner, 2006).



Shared Decision Making


In addition to eliciting information that increases understanding of the patient’s illness experience, APNs, in the studies cited, encourage patients to participate in decisions regarding how their diseases and illnesses should be managed. There is a continuum of patient involvement in making decisions for her or his own health care. At one end of the continuum are patients who want to be fully engaged in a partnership with providers in making decisions, whereas at the other end of the continuum are patients who want to rely on family members or care providers to make all treatment decisions. This may include patients who are older, sicker, or cognitively impaired, or who have cultural beliefs that lead them to defer decisions to others. Regardless of where the patient falls on this continuum, it is still incumbent on the provider to establish a collaborative partnership to ensure that regardless of whom the patient wants to make decisions, it is done in congruence with the patient’s beliefs and values.


APNs should individually determine each patient’s preference for participation in decision making and be sensitive to the fact that patients’ preferences may change over time as they get to know the provider better and as different types of health problems arise. Once the patient’s preference has been elicited, the provider should tailor his or her communication and decision making style to the patient’s preference. Many patients have not had prior health care experiences in which shared decision making was even a possibility but, when offered the opportunity, many choose it—tentatively in some cases, enthusiastically in others. Trying on a more active role may require some help from the provider, such as explaining how it would work and which responsibilities are the patient’s and which are the provider’s. Providers can encourage patients to bring up issues by asking open-ended questions such as “So, how have you been?” and focused but open questions such as “So, how are things going at home?” Patients can be encouraged to participate in decision making by offering them explicit opportunities in the form of questions such as “Does one of those approaches sound better to you than the other?” Gradually, patients approached in this way will learn that health care encounters will be organized around their concerns, not around a series of questions asked by the provider, and that they should feel safe to express their concerns and preferences.


Open and honest communication is foundational to a shared decision making philosophy. APNs have reported more advanced communication skills than those reported by basic RNs (Sivesind et al., 2003). The ability to adapt communication styles is a needed skill of APNs (Lawson, 2002; McCourt, 2006) and can result in patients who report that they have more knowledge and control of their own care. It is a skill that is necessary for an APN to maintain a therapeutic relationship with a patient while also supporting her or him in effective decision making . The APN needs to use an approach that incorporates verbal and nonverbal behaviors exhibited by the patient while being careful to maintain professional boundaries (Elliott, 2010).


APNs must be cognizant of their own personal beliefs and value systems in a partnership in which they are coaching patients in decision making (see Chapter 8). Although they are uniquely prepared to facilitate the holistic management of the physical, psychosocial, and spiritual aspects of care in these particular situations, APNs may be involved in interactions in which it is difficult for them to help patients make decisions. If the APN is unaware or has unresolved issues of his or her own, he or she may risk exercising undue or unintentional influence on a patient’s decision in emotionally charged situations (Bialk, 2004). Bringing one’s own beliefs and values to consciousness prior to a discussion focused on patient decision making, reflecting on one’s own cognitive and affective responses to such discussions, and debriefing with a colleague can help APNs maintain a therapeutic approach (or determine when it is appropriate for another clinician to become involved).



Cultural Influences on Partnerships


Another important factor affecting whether and how persons want to participate in health care decision making is their cultural background. It is easy to forget that not all cultures value individual autonomy as much as North Americans of Anglo-Saxon ancestry. Increasingly, recognizing and respecting the cultural identification of patients is being viewed as essential to building meaningful partnerships. Cultural groups form along lines of racial, national origin, religious, professional, organizational, sexual orientation, or age group identification. Some cultural groups are easier to identify than others. Physical differences in appearance often indicate to the provider that he or she is dealing with a person of a different cultural orientation. Other cultural identifications are less obvious—for example, people with religious beliefs about fate, God as healer, or treatment taboos. However, it is important to avoid making assumptions about cultural beliefs simply based on physical appearance or dress. In today’s increasingly diverse society, many families have blended traditional beliefs and practices from a number of cultures. These beliefs are learned by asking the patient open-ended questions and responding in a way that makes the patient feel understood.


The DNP Essentials identifies the need for APNs to synthesize and incorporate principles of cultural diversity into preventive and therapeutic interventions for individuals and populations (AACN, 2006). The preparation of APNs in the area of cultural competence and culturally appropriate care is key, because the demographics of nurses and APNs do not match the overall demographics of the United States population (McNeal & Walker, 2006; Ndiwane et al., 2004). Interactions that are complicated by cultural misunderstandings can result in incomplete or inaccurate assessments and even in misdiagnoses and suboptimal outcomes (Barakzai, Gregory, & Fraser, 2007; Sobralske & Katz, 2005). The APN needs to individualize care based on an assessment of the cultural influences on the perception of illness and reporting of symptoms. Otherwise, differences in perceptions can cause confusion, misunderstandings, and even conflicts that disrupt the patient-provider relationship and discourse. Moreover, they often complicate attempts to resolve misunderstandings because different cultural groups approach conflict negotiation differently. Studies have shown that NPs can engender trust in a population such as African Americans to a greater extent than physicians (Benkert, Peters, Tate, et al., 2008). In every encounter, the provider should expect that the patient may have values that are different in some ways from his or her own and must make a special effort to ensure that the care being given meets the patient’s needs and is acceptable to him or her (Escallier & Fullerton, 2009). APNs must always remain nonjudgmental and not impose their own beliefs or biases onto the patient.



Communication with Patients


A foundation of good communication with patients is essential to developing a therapeutic relationship. Research has shown that good communication between the APN and patient can increase patient satisfaction, establish trust, increase adherence to a treatment plan, and improve patient outcomes (Burley, 2011; Charlton, Dearing, Berry, et al., 2008; Gilbert & Hayes, 2009; Persson, Hornsten, Wirkvist, et al., 2011; Sandhu, Dale, Stallard, et al., 2009). Learning good communication skills takes ongoing practice throughout the APN’s career. Simulation laboratories have been shown to be helpful in assisting APN students to learn communication techniques in situations such as working with angry patients, delivering bad news to patients and families, providing empathy, and optimal motivational interviewing (Rosenzweig, Hravnak, Magdic, et al., 2008).


One aspect of optimal communication is listening. Listening has been described as being fully present with the patient to garner patient details, increase the level of trust in the relationship, and improve patient compliance (Browning & Waite, 2010). Listening takes as much concerted effort to perform optimally as verbal communication. Key to good listening is the ability on the APN’s part to avoid being distracted by personal thoughts, forming instant judgments, and formulating a reply while the patient is still speaking and telling her or his story. In addition, the APN must become aware of how individual expectations, experiences, and cultural paradigms can result in biases and misperceptions when working with patients (Browning & Waite, 2010). Reflective listening techniques can be useful when APNs convey to patients that they have been heard and understood without judgment and can assist patients to explore their personal situations more fully (Resnicow & McMaster, 2012). These techniques include taking patient statements and restating, rephrasing, reframing, and reflecting thoughts, feelings, and emotional undertones back to the patient (Miller, 2010). APN use of reflective listening has been shown to assist in behavioral change and self-care decision making in heart failure patients (Riegel et al., 2006).



Therapeutic Partnerships with Noncommunicative Patients


Some patients are not able to enter fully into partnership with APNs because they are too young, have compromised cognitive capacity, or are unconscious. Clinical populations who may be unable to participate fully in shared decision making are listed in Box 7-5. Unfortunately, staff nurses working with noncommunicative patients can become so focused on providing care that they forget about having meaningful interactions with the patient (Alasad & Ahmad, 2005). APNs can role-model alternative forms of communication so that noncommunicative patients can receive optimal care.



imageBox 7-5   Patient Populations Unable to Participate Fully in Partnership




Although these patients may have limited ability to speak for themselves, they are not entirely without opinion or voice. Situations in which patients will experience temporary alterations in cognition or verbal ability can often be anticipated. For example, in planned perioperative situations in which general anesthesia and intubation will be used, the CRNA has the opportunity to dialogue with the patient prior to the procedure. This creates a shared relationship in which the patient can feel comforted and confident about the upcoming procedure (Rudolfsson, von Post, & Eriksson, 2007). The CRNA can prepare patients for the period when communication will be a challenge and propose alternative methods for communication. In addition, the CRNA can discuss patients’ preferences for handling possible events beforehand to elicit their wishes.


In the absence of this type of prior dialogue, experts who work with patients who cannot verbalize their concerns and preferences learn to pay close attention to how patients are responding to what happens to them; facial expressions, body movement, and physiologic parameters are used to ascertain what causes the patient discomfort and what helps alleviate it. In a study of persons who had experienced and recovered from unconsciousness (Lawrence, 1995), 27% of the patients reported being able to hear, understand, and respond emotionally while they were unconscious. These findings suggest that nurses should communicate with unconscious patients by providing them with interventions such as reassurance, bodily care, pain relief, explanations, and comforting touch. APNs should view these interactions as not merely one-way imparting of information but also as providing key emotional support (Alasad & Ahmad, 2005; Geraghty, 2005).


There are tools that can be used for patients who are conscious but unable to communicate. Unfortunately, many nurses are not adequately educated in using alternative methods of communication and, if they are, may not be familiar or comfortable with the particular method required for an individual patient (Finke, Light, & Kitko, 2008). Other barriers include not having access to communication devices and time pressures that may not allow providers to engage adequately in a process that could take more time.


Other sources of information about patients who are unable to respond physically or to communicate should also be identified. For example, siblings visiting an adolescent male with a major head injury would be able to tell you what type of music he likes to listen to and would probably even bring you a CD to play for the patient. His mother would know what has caused him to have skin reactions in the past. Responding to his father’s offhand comment that he cannot stand to be without his glasses when he is not wearing his contact lenses would most likely help father and son. All these are ways of building a partnership with an unconscious teenager in an intensive care unit (ICU). In adults and adolescents, advance directives, heath care proxy documents, and organ donation cards are other sources of information regarding patients’ wishes. Thus, noncommunicative patients are not without voices, but hearing their voices does require presence and attentiveness, and establishing a relationship. Box 7-6 summarizes options for the APN when engaging with noncommunicative patients.



imageBox 7-6   Techniques for Communicating with Noncommunicative Patients





Expert Clinical Performance


Few studies have clearly differentiated between the expert skills of the APN and the practice of the basic RN. The expert performance of an APN encompasses clinical thinking and skills. An expert’s clinical judgment is characterized by the ability to make fine distinctions among features of a particular condition that were not possible during beginning practice. Benner’s studies of expert clinical judgment, although not with APN participants, inform this discussion of APNs’ clinical expertise (1984). Tanner (2006) has reviewed the literature regarding clinical judgment and found that it requires three main categories of knowledge. The first is scientific and theoretical knowledge that is widely applicable. The second is knowledge based on experience that fills in gaps and assists in the prompt identification of clinical issues. The final category is knowledge that is individualized to the patient, based on an interpersonal connection.



Clinical Thinking


APNs’ specialized knowledge accrues from a variety of sources, including graduate and continuing education, clinical experience, professional reading, reflection, mentoring, and exchange of information and ideas with colleagues within and outside nursing. The integration of knowledge from these sources provides a foundation for the expert clinical thinking that is associated with advanced direct care practice. Once an APN has been in practice for a while, formalized knowledge and experiential knowledge become so mixed together that they may not be distinguishable to the outside observer. Illness trajectories and presentations of prior patients make an impression and come to mind when a patient with a similar problem is seen later (Benner, 1984). The expert also remembers which interventions worked and did not work in certain situations. Eventually, the expert’s clinical knowledge consists of a complex network of memorable cases, prototypic images, research findings, thinking strategies, moral values, maxims, probabilities, behavioral responses, associations, illness trajectories and timetables, and therapeutic information. Thus, experts have extensive, varied, and complex knowledge networks that can be activated to help them understand clinical situations and events. These networks are comprised of internal and external resources. The APN may mentally review internal resources such as educational knowledge, typical cases, and previously experienced cases when confronted with a complex or challenging case. However, the APN is also cognizant of when internal resources are no longer adequate and knows when to refer to external resources for consultation, more data, or guidance.


Clinical reasoning brings together the clinical knowledge of the provider with specific observations, perceptions, events, and facts from the situation at hand to produce an understanding of what is occurring (O’Neill, 1995). Sometimes, the understanding is arrived at by using cognitive processes to consider evidence and alternative explanations logically. At other times, the insight or understanding arrives intuitively—that is, through direct apprehension without recourse to deliberate reasoning (Benner et al., 1996; Tanner, 2006). In these situations, APNs can use reflective practice to sort through the intuition to understand the components better and identify new insights. With experience, they can then repackage these insights and incorporate them into their experiential learning to use the information in the next relevant case prospectively and deliberately.


APN experts have the ability to scan a situation rapidly (e.g., past records, patient’s appearance, the patient’s unexpressed concern or discomfort) and identify salient and relevant information. The APN is able to suspend judgment purposefully about personal strongly held beliefs that may be proposed by others, such as “he’s a difficult patient” or “she’s just drug seeking.” The ability to do this ensures as much objectivity as possible when caring for patients. For example, research has shown that expert CNSs are able to transcend the labeling of a “difficult patient” to problem resolution through the use of patient respect, communication skills, and increased self-efficacy (Wolf & Robinson-Smith, 2007). Relying heavily on their perceptions, observations, and assessment skills, APNs quickly activate one or several lines of reasoning regarding what might be occurring. They then conduct a more focused assessment to determine which one best explains the situation at hand. These lines of reasoning can be informal personal theories about the specific patient situation; this formulation draws from personal knowledge of the particular patient, personal knowledge acquired from previous experiences, and formalized domain-specific knowledge (Tanner, 2006). In implementing the solutions, these lines of reasoning can be tested by performing a clinical intervention and noting how the patient responds. Throughout this process, the APN may be teaching and role modeling with staff to assist in staff nurse self-awareness and reflection. A novice APN may need to work through the situation in a formal logical way and be more deliberate about the use of formal educational knowledge, enriching it over time with experiential knowledge (Tanner, 2006).


It has been shown that the values and underlying knowledge a nurse brings to a situation also has a profound influence on his or her assessment of the patient. Results of one study demonstrated that a nurse’s beliefs about older adults can affect how a nurse assesses the older confused patient and can affect prioritization of that patient’s needs (Dahlke & Phinney, 2008). Another example is when a nurse’s moral opinion of drug addiction and the interpretation of behavior as drug seeking may have more influence on the treatment of a patient’s pain, rather than the actual assessment of the pain.


Most patient accounts unfold in a fairly predictable way and the APN arrives at a diagnosis and/or intervention with considerable confidence in her or his clinical inferences. At other times, however, there is uncertainty and lack of understanding regarding the situation. The uncertainty may pertain to information the patient provides, the diagnosis, the best approach to management, or to how the patient is responding (Brykczynski, 1991). When there is ambiguity, experts often break into conscious problem solving or “detective-like thinking and questioning” (Benner et al., 1996; Benner, Hooper-Kyriakidis, & Stannard, 1999) to try to determine what is going on.


Knowing the patient may be critical to perceptive and accurate clinical reasoning. Knowing the patient as an individual with certain patterns of responses enables experienced nurses to detect subtle changes in a patient’s condition over time (Tanner, 2006; Tanner, Benner, Chesla, et al., 1993). The extent to which any nurse knows a patient may be associated with that nurse’s ability to do the following:



Nonfitting data suggest to experts that they need to generate new or additional hypotheses because the current observations and parameters do not fully explain the clinical picture as it has been or as it should be. For example, when faced with a nonfitting sign or symptom, the nurse may generate alternative hypotheses pertaining to the onset of a complication or worsening of the disease process (Burman et al., 2002).



Thinking Errors

The clinical acumen of APNs and the inferences, hypotheses, and lines of reasoning that they generate are highly dependable. However, as practice becomes repetitive, APNs may develop routine responses and then run the risk of making certain types of thinking errors (Schön, 1992). Errors of expectancy occur when the correct diagnosis is not generated as a hypothesis because a set of circumstances, in the clinician’s experience or patient’s circumstances, predisposes the clinician to disregard it. For example, the NP who over several years has seen an older woman for problems associated with chronic pulmonary disease may fail to consider that the most recent onset of shortness of breath and fatigue could be related to worsening aortic stenosis; the NP has come to expect pulmonary disease, not cardiac disease.


Erroneous conclusions are also more likely when the situation is ambiguous—that is, when the meaning or reliability of the data is unclear, the interpretation of the data is not clear-cut, the best approach to treatment is debatable, or one cannot say for sure whether the patient is responding well to treatment (Brykczynski, 1991). To avoid errors in these types of situations, experts often revert to the use of maxims (a succinct metaphor for a general truth) to guide their thinking (Brykczynski, 1989). One of the maxims that NPs use to deal with uncertain diagnoses is “When you hear hoof beats in Kansas, think horses, not zebras.” This reminds clinicians who are about to make a diagnosis that occurs infrequently to consider the incidence of the condition in the population. Thus, an older adult with respiratory problems seen in a suburban office is unlikely to have tuberculosis; pneumonia is a more likely diagnosis. Because tuberculosis is rare in the older adult population, the clinical data for tuberculosis should be convincing if that diagnosis is proposed.


Poor judgment can also result from the following: tunnel vision; overgeneralization; influence by a recent dramatic experience; premature closure (Croskerry, 2003); and fixation on certain problems to the exclusion of others (Benner et al., 1999). Faulty thinking is not the only source of error in clinical decision making. Others include inaccurate observations, misinterpretation of the meaning of data, a sketchy knowledge of the particular situation, and a faulty or outdated model of the disease, condition, or response.


It is important that APNs recognize the potential for and avoid leaping to conclusions and making snap judgments. It can become easy to allow biases to lead to premature diagnoses without fully listening to or assessing patients. The expert APN has learned to scan data constantly and look for deviations. The ability to differentiate effectively between significant and insignificant data is needed to have safe practice. See Box 7-7 for actions that APNs can take to prevent thinking errors.



imageBox 7-7   Actions to Use to Avoid Thinking Errors





Time Pressures

Regardless of setting, practitioners worry about the effect that time pressures have on the accuracy and completeness of their clinical thinking and decision making. The IOM’s galvanizing report on errors and patient safety cited studies in which between 3% and 46% of hospitalized patients in the United States were harmed by error or negligence (IOM, 2000). It is estimated that more than 100,000 patients die from medical errors and a more recent study, in 2009, suggested that little progress has been made in the decade since it was published (see http://content.healthaffairs.org/content/29/1/165.abstract). The committee called for transformation and redesign of the health care system. The wide variation is the result of varying definitions of what constitutes adverse events and various methods of detecting their occurrence. A heavy workload is associated with feelings of pressure, being rushed, cognitive overload, and fatigue adding to already burdened clinicians; these feelings clearly contribute to unsafe acts and omissions in care (IOM, 2000). Evidence in support of this inference comes from studies of nurse staffing in hospitals in which fewer hours of nursing care per patient per day and less care provided by registered nurses were associated with poorer patient outcomes (Aiken, Cimiotti, Sloane, et al., 2011; Blegen, Goode, Spetz, et al., 2011; Kaen, Shamliyan, Mueller, et al., 2007; Needleman, Beurhaus, Pankratz, et al., 2011; Van den Heede, Lesaffre, Diya, et al., 2009). Effectively addressing the issues of time pressures and insufficient hours of nursing care requires culture change, process redesign, and appropriate use of technology. The patient safety movement has led to a variety of efforts aimed at preventing errors—root cause analysis of sentinel events, improved work processes, redesign of delivery systems, use of technologic aids, communication training, human factors analysis, and team building. All these factors can have significant direct and indirect effects on workload, fatigue, and time available for direct patient care.


The effects of a heavy workload on patient outcomes in nonhospital settings are less well understood; thus, actions to address this issue have received less attention. However, as lengths of visits or contact times are decreased or the number of patients whom practitioners are expected to see in a day is increased, it is logical to assume that the number of errors in clinical thinking will increase. Each contact requires the practitioner to reset his or her clinical reasoning process by closing out one thinking project and starting on an entirely new one. This resetting, which is done back to back often during a day, is cognitively and physically demanding. How these performance expectations affect clinical reasoning accuracy is unknown.


Moreover, time pressures often get compounded by hassles, which come in the form of interruptions, noise in the environment, missing supplies, and system glitches that make clinical data or even whole charts unavailable to providers. These hassles likely interfere with providers’ ability to concentrate on what the patient is saying and disrupt their efforts to make clinical sense of a patient’s account. In many settings, providers are required to multitask. They start a task but must attend to another before completing the original one. This clearly increases the risks of failure to obtain needed information, broken lines of thought, technologic missteps, omissions in care, and failure to respond to patients’ requests for service (Cornell, Riordan, Townsend-Gervis, et al., 2011; Ebright, Patterson, Chalko, et al., 2003).


Studies of emergency physicians and emergency NPs have demonstrated that their workflow patterns have frequent interruptions, which can result in short cuts, failure to return to the original task, increased perceptions of stress, and a potential for commission of errors (Burley, 2011; Chisholm, Weaver, Whenmouth, et al., 2011; Westbrook, Woods, Rob, et al., 2010). Emergency physicians are what is referred to as interrupt-driven. Admittedly, the emergency department may be an extreme example of a multitasking environment, but other settings also impose interruptions at a very high rate. An experienced APN may be more skilled at focusing on and prioritizing tasks and quickly dismissing interruptions and extraneous information. The novice APN, conversely, may take longer to perform tasks (allowing for more interruptions) and may need more assistance with consultations or accessing resources (Phillips, 2005). As time pressures for clinicians increase, organizational efforts to monitor for errors and potential errors and seek correction when there are system weaknesses are actions that APNs owe patients and themselves as providers functioning in busy environments.


Many patients are sensitive to the pace with which staff and providers greet them, talk with them, and do things, particularly those activities that involve verbal interaction and physical contact. Some patients respond to the fast-paced talk and hurried movements of providers by not bringing up some of the questions that they had intended to ask. Others may just get flustered and forget to mention important information; still others may become hostile and withhold information. Thus, errors in the form of information omission by the patient enter the clinical reasoning and decision making process.


In summary, clinical thinking is a complex task. It involves drawing on knowledge in memory and attending to multiple sources of situational input, some of which are difficult to interpret. Often, multiple clinical issues must be addressed during a patient encounter. These complexities make clinical thinking a challenging task, even under the best of circumstances. Situational awareness—perceptions of the current environment in which the APN is functioning—can make the APN more cognizant of the potential for error and improve diligence to the thought process at critical junctures, such as when writing orders or performing procedures, or during handoffs (Phillips, 2005).

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Oct 19, 2016 | Posted by in NURSING | Comments Off on Direct Clinical Practice

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