Evolving and Innovative Opportunities for Advanced Practice Nursing

Technologic advances and economic and sociocultural conditions have sustained a climate of change in the health care environment, and opportunities for advanced practice nursing continue to emerge in the wake of these changes. As specialties have emerged, many new roles have evolved from specialty nursing practice and have expanded to incorporate some or all of the core attributes of advanced practice nursing (see Chapters 2 and 3). Some of these roles have clearly evolved as advanced practice roles, whereas others are in various stages of evolution. Not all specialties, however, will evolve into advanced practice roles, for a variety of reasons. For example, some specialties evolve away from the core definition of advanced practice nursing, which encompasses direct clinical practice and clinical expertise as essential ingredients. Other specialties, such as informatics and nursing administration, arise as specialties and remain as specialties because direct clinical practice is not a requisite role component.

The purpose of this chapter is to examine some currently evolving specialties and characterize stages in their continuing evolution from specialty nursing practice to advanced practice nursing. Some of these specialties have not yet fully evolved to an advanced level; however, movement within the specialty toward advanced practice may be accelerated as Doctor of Nursing Practice (DNP) programs target these specialties for development. The focus of the discussion is on the various specialties—not on particular advanced practice nursing roles, such as clinical nurse specialist (CNS), nurse practitioner (NP), certified nurse-midwife (CNM), or certified registered nurse anesthetist (CRNA). Specialties selected for inclusion in this discussion were chosen for one or more of the following reasons:

• The specialty has the potential to transition (or is transitioning) to the DNP.

• The specialty has the potential to evolve to advanced practice nursing, given the complexity of care required by the patient population, and direct care is likely to be a defining factor.

• The specialty has arisen as a result of scientific and/or technologic advances and the influence of these advances on the delivery of health care.

• The specialty is growing because of the rising incidence of health problems in the population.

• The specialty’s patient population needs sophisticated care across settings in the complex health care environment.

Opportunities in these evolving specialties for advanced practice nurses (APNs) are discussed and a framework for evaluating progress toward advanced practice status is presented. Exemplars provided by APNs in the specialty were deliberately chosen to illuminate the added value of advanced practice competencies to these evolving specialties.

Patterns in the Evolution of Specialty to Advanced Practice Nursing

Before discussing the evolution of specialty nursing practice into advanced practice nursing, it is important to make a distinction between the two, as well as to clarify the use of the term subspecialty in this chapter. Specialization involves focusing on practice in a specific area derived from the field of professional nursing. Specialties can be further characterized as nursing practice that intersects with another body of knowledge, has a direct impact on nursing practice, and is supportive of the direct care provided to patients by other registered nurses (American Nurses Association [ANA], 2010a). As the profession of nursing has responded to changes in health care, the need for specialty knowledge has increased. For example, in the wake of the National Cancer Act of 1971, which was enacted as a consequence of the increasing incidence of cancer in the population and the need to advance national efforts in prevention and treatment, the oncology specialty became more widely recognized (Oncology Nursing Society [ONS], 2012). The ONS traces its origin to the first National Cancer Nursing Research Conference, supported by the ANA and American Cancer Society, in 1973, after which a small group met to discuss the need for a national organization to support their professional development. From these early efforts, this organization, which was incorporated in 1975, has become a leader in cancer care in the United States and around the world (ONS, 2012).

The classic specialties in nursing have been pediatric, psychiatric and mental health, obstetrics (now termed women’s health), community and public health, and medical-surgical nursing (now termed adult health). Specialties that have emerged include, for example, concentrations in critical care, emergency, and oncology nursing. As a given specialty coalesces, nurses often form specialty nursing organizations out of clinicians’ needs to share practice experiences and specialty knowledge. Some examples include the American Association of Critical-Care Nurses, Oncology Nursing Society, and Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). Scope and standards of practice statements legitimize specialty designation and prompt efforts to provide opportunities for specialty education and certification. The efforts of the International Transplant Nurses Society (ITNS) to develop and approve a scope of practice statement, a core curriculum, and specialty certification for registered nurses is just one example (ITNS, 2007).

Advanced practice nursing includes specialization but goes beyond it; it involves expansion, which legitimizes role autonomy, and advancement, characterized by the integration of a broad range of theoretical, research-based, and practical knowledge (ANA, 2010; see Chapter 2). Thus, advanced practice nursing reflects concentrated knowledge in a specialty that offers the opportunity for expanded and autonomous practice based on a broader practical and theoretical knowledge base.

The term specialty suggests that the focus of practice is limited to parts of the whole (ANA, 2010b). For example, family NPs, who typically see themselves as generalists, have in fact specialized in one of the many facets of health care—namely, primary care. Subspecialization further delineates the focus of practice. In subspecialty practice, knowledge and skill in a delimited clinical area is expanded further. With this expanded knowledge and skill, there is potentially further advancement of theoretical, evidence-based, and practical knowledge in caring for a specific patient population base. Examples of subspecialty practices within the specialty of adult health nursing include diabetes, transplant, and palliative care nursing. Notably, most of the practice opportunities chosen for discussion in this chapter are subspecialty practices. This distinction between specialty and subspecialty is important, particularly for certification and regulatory reasons, and was recently codified when the National Council of State Boards of Nursing (NCSBN) proposed the regulation of advanced practice nursing in terms of certification requirements at the broad population foci level (e.g., psychiatric and mental health, pediatrics, adult and gerontology), with specialty or subspecialty certification being voluntary (NCSBN, 2008). Regulatory considerations aside, the expansion of advanced practice nursing is increasingly occurring in specialty and subspecialty practice. Expanding these boundaries places APNs on the cutting edge of clinical care delivery in a complex, ever-changing, health care environment. However, for the sake of consistency with the Consensus Model for APRN Regulation (2008), in the remainder of this chapter, we refer to specialty and subspecialty practice as specialties.

The evolution of specialty nursing practice to advanced practice nursing follows a trajectory that has been described by several authors (Beitz, 2000; Bigbee & Amidii-Nouri, 2000; Hamric, 2000; Lewis, 2000; see Chapter 1). Hanson and Hamric (2003) synthesized these observations and characterized this evolution as having distinct stages (Table 5-1). Initially, in stage I, the specialty develops in response to changing patient needs, needs that are usually a result of new technology, new medical specialties, and/or changes in the health care workforce. For example, a lack of pediatric residents created an opportunity for the development of the neonatal NP role (DeNicola, Klied, & Brink, 1994).

TABLE 5-1

Four Stages in the Evolution of Advanced Practice Nursing

Stage	Description	Characteristics
I	Specialty begins	Specialty develops in practice settings; development driven by increasing complexity in care demands, new technology, changing workforce opportunities; on the job training, expansion of practice; not exclusively nursing
II	Specialty organizes	Organized training for specialty practice begins; institution-specific training develops; initially uses apprenticeship model; progresses to certificate training; specialty organization forms; certification examination develops but may not be nursing-specific; reports appear on role of nurse in specialty
III	Pressures mount for standardization	Knowledge base grows; pressures mount for standardization, graduate education; knowledge base keeps growing, scope of practice expands for practitioners in the specialty; expanded practice leads to expanded regulatory oversight; leaders call for transition to graduate education and differentiated practice to standardize practice in the specialty; APNs migrate to specialty or specialty nurses return to school; reports appear differentiating APN role in the specialty
IV	Maturity and growing interdisciplinarity	APN practice in the specialty is well articulated, recognized by other providers; APNs practice collaboratively with other practitioners in the specialty; APNs are experts in the specialty or subspecialty; shared knowledge base with other health care professionals recognized; interdisciplinary certification examinations developed

Adapted from Hanson, C.M., & Hamric, A.B. (2003). Reflections on the continuing evolution of advanced practice nursing. Nursing Outlook, 51, 203–211.

A second stage of development is characterized by progress to the point that organized training begins. This training is often institution-specific, on the job training that develops experts in the specialty. Some of these institution-specific programs develop into certificate programs; however, the content may not be standardized, and the quality of these specialty programs may vary. One example is the early transplant coordination role in major transplant centers (see later, “Clinical Transplant Coordination”).

In the third stage, the knowledge base required for specialty practice becomes more extensive and the scope of practice of the nurse with specialty training expands. There is growing recognition of the additional knowledge and skill needed for increasingly complex practice. It is not unusual at this stage to see APNs migrate into an evolving specialty and further expand practice by infusing it with advanced practice core competencies, making the specialty resemble advanced practice and creating new calls for evolution to this higher level. This transition is clearly evident in wound, ostomy, and continence nursing (see later, “Wound, Ostomy, and Continence Nursing”), as well as in palliative care nursing. Over time, pressure for the standardization of education and skills involved in the specialty arise from clinicians, the profession, and regulators. Certificate-level training programs move into graduate schools that assume responsibility for preparing nurses for these evolving specialties, improving standardization, elevating the status of the specialty, and fostering its emergence as an advanced practice role. In this third stage of the trajectory, graduate education becomes an expected level of preparation (Hanson & Hamric, 2003).

Stage IV, initially described by Salyer and Hamric (2009), is characterized by mature and recognized APN practice in the specialty, along with an emerging understanding of a shared interdisciplinary component. Nurse practitioners in human immunodeficiency virus (HIV) practice who have attained certification as an HIV specialist, awarded by the American Academy of HIV Medicine, are an example of mature expert practitioners who share an interdisciplinary clinical knowledge base with physicians in this specialty.

It is important to note that these stages are dynamic and not mutually exclusive. It is not unusual for specialties to show characteristics of more than one stage simultaneously (e.g., graduate programs began to develop at the same time that most practitioners in the specialty were prepared in certificate programs). In addition, the duration of each stage may vary significantly by specialty. We contend that the evolution from specialty to advanced practice nursing can represent a natural maturation that should result from deliberate logical planning to strengthen the education and broaden the scope of practice of specialty nurses. Some of these roles evolve to fulfill needs of specific patient populations or the needs of organizations. In some cases, changes in the legal recognition and regulation of practice also influence the movement toward advanced practice nursing. For example, nurse midwifery moved toward requiring graduate-level educational preparation for their specialty in response to the national movement among state boards of nursing to require this level of education for all APNs. Complex and often controversial issues must be addressed before and during this evolutionary process (Box 5-1). In the following sections, the evolution of particular specialties to advanced practice nursing is described and these issues are discussed. Some of these specialties are struggling to evolve and change is haphazard. Others are following a planned course of action and have emerged (or will soon do so) at the advanced practice level. All evolving specialties share two challenges—the need to gain support within and external to nursing for these roles, and the need to delineate their potential contributions clearly in the health care environment.

Box 5-1

Issues in the Evolution of Specialty to Advanced Practice Nursing

• Defining the attributes of advanced practice in the specialty

• Delineating the core competencies of the specialty as encompassing the core competencies of advanced practice

• Delineating a vision of advanced practice that may step outside of nursing’s traditional vision of what constitutes an advanced practice role and gaining support within the nursing and health care community for the role

• Standardizing curricula for achieving competency at the advanced practice level

• Clarifying certification and credentialing requirements

• Overcoming legal and regulatory issues that are barriers to patient and/or consumer access to APNs

• Promoting recognition of APNs and nursing as a profession

• Clarifying APN role titles to be consistent and decrease confusion

Adapted from Hanson, C.M., & Hamric, A.B. (2003). Reflections on the continuing evolution of advanced practice nursing, Nursing Outlook, 51, 203–211.

Innovative Practice Opportunities: Stage I

The initial stage of the evolution from specialty practice to advanced practice is characterized by the development of a specialty focus. Numerous examples are apparent in the history of nursing, which is replete with accounts of nursing’s response to unmet patient needs. As a consequence, definable specialties emerge as nurses expand their practice to include the knowledge and skills necessary to meet the needs of patients requiring specialty care. Examples from our history include the specialty of enterostomal therapy (ET) nursing, now known as wound, ostomy, and continence (WOC) nursing, and forensic nursing, which has historically encompassed care provision in correctional facilities, psychiatric settings, and emergency departments as nurse examiners care for sexual assault and child abuse victims (Burgess, Berger, & Boersma, 2004; Doyle, 2001; Hutson, 2002; Maeve & Vaughn, 2001; McCrone & Shelton, 2001). As specialties begin to coalesce, the practice may not be viewed as a nursing role. For example, early enterostomal therapists were laypersons with ostomies. However, as the specialty evolved, the valuable contributions of nurses began to distinguish them from other care providers.

Several evolving roles in nursing are characterized as being innovative. Some of these roles do not reflect the core competencies of advanced practice nursing and the role components differ significantly, in some cases, from those of an APN. For example, if the focus of practice in forensic nursing had remained on the gathering of legal evidence, not sustained clinical practice using advanced practice core competency elements, the role would not be evolving to an advanced practice level. Regardless, nurses functioning in these subspecialties, some of whom are APNs, make unique contributions to the health of specific populations of patients. One such role to be explored as a stage I specialty is that of the hospitalist.

Hospitalist Practice

The development of the hospitalist movement over the past 15 years represents a break in the tradition of primary care physicians (PCPs) managing patients in inpatient and outpatient settings. In this model, inpatients are cared for by what is termed a hospitalist physician—a term coined by Wachter and Goldman (1996)—whose primary professional focus is the general medical care of hospitalized patients (Coffman & Rundall, 2005). The hospitalist model is growing rapidly as a result of the role of managed care in organizations, increasing complexity of inpatient care, fragmentation of care, and pressures experienced by physicians in busy outpatient practices (Freed, 2004; Lee, 2008; Wachter, 2004). In this model, inpatient management is voluntarily transferred by the PCP to the hospitalist during the hospital admission and, on discharge, care is resumed by the PCP. More recently, an opportunity for APNs to practice in this relatively new innovative specialty has evolved out of the physician hospitalist model of care (Nyberg, 2006, Sullivan, 2009).

Exemplar 5-1 APN Hospitalist *

The Hospital Medicine Nurse Practitioner Service at Strong Memorial Hospital, University of Rochester Medical Center, was started in 1995 as an initiative to reduce length of stay. Four NPs were hired, along with a hospitalist, to start a short-stay unit. Patients included those with myocardial infarction rule-outs, new-onset atrial fibrillation, and simple cellulitis, as well as those needing observation after procedures. The NPs covered the unit 10 hours/day, 5 days/week, with fellows and other house staff covering the remaining hours (Terboss, 2007).

Since its inception, the service has grown exponentially, primarily in response to the reduced number of medical resident positions and tighter restrictions on resident work hours by the Accreditation Council on Graduate Medical Education (ACGME). In addition, the team’s census grew along with the hospital census when two hospitals in the city closed. Other changes included an increase in patients, the addition of physician assistants (PAs) to the team, and orthopedic surgery patients attended to by the Hospital Medicine Service. The service has expanded to cover patients on 15 patient care units, 24 hours/day, 7 days/week, including holidays.

The specialty of hospital medicine is relatively new, and therefore the role of the acute care nurse practitioner (ACNP) in a hospitalist role varies from hospital to hospital. At Strong Memorial, ACNPs have a variety of roles and responsibilities. They collaborate with the Hospital Medicine Division physicians and community-based primary care providers and share responsibility for examinations, documentation, order writing, and discharge planning. The ACNPs also follow patients admitted to subspecialty services, such as gastroenterology, nephrology, cardiology, and infectious diseases. Whereas the subspecialist attending physician or fellow may focus on the organ of interest, the ACNP independently manages comorbidities, updates families, and coordinates care, all of which provide a more holistic perspective to the patient’s hospital stay.

Concrete defined tasks include admitting histories, physical examinations, orders, discharge instructions and summaries, and a daily visit with a progress note. ACNPs order and interpret diagnostic and laboratory tests, participate in multidisciplinary unit rounds, and update an electronic sign-out system for safer handoffs. Procedures such as line placement are usually provided by residents as part of their educational experience.

Many of the ACNP’s responsibilities are less easily defined or measured. However, in these functions, the ACNP adds value to the care provided by the Hospital Medicine Service. They include coordination of care among the variety of consultants, other health professionals (e.g., physical therapists, nutritionists, social workers), and unit management. In addition, ACNPs update patients and families to maintain open communication and keep them informed of the care plan. They also orient new ACNPs to their role and mentor ACNP students. Most importantly, ACNPs collaborate with the bedside nurses and unit staff. Communication of updates, orders, and plans is essential to ensuring safe, timely, and quality care. The accessibility of the ACNP promotes collaboration and many opportunities for informal teaching. As APNs, ACNPs are often the most knowledgeable about medication information, technology management, or even basic nursing care and can serve as resources for newer, less experienced nurses. Teaching and mentoring are important to ensure staff development and retention as well as safe patient care. The importance of these activities has been difficult to quantify. It has been and continues to be a challenge to the Hospital Medicine Service to measure these contributions and illustrate their value.

The future for ACNPs on Hospital Medicine teams is promising. The specialty is growing, along with the acuity of inpatients and the complexities of discharge planning, both of which ACNPs are well-suited to manage. ACNP programs are incorporating hospital medicine into their curricula and into clinical rotations. The ACNPs on the Hospital Medicine Service have precepted many of these students, some of whom have gone on to join our team. Many challenges are ahead, including finding ways to quantify our contribution in terms of quality of care, length of stay, and patient and staff satisfaction. Orienting new ACNPs to handle the complexity of these inpatients and recruiting for 24-hour, 7-days/week positions is also a challenge.

I find my role as an ACNP on the Hospital Medicine Service to be highly satisfying because I care for patients with a wide variety of health problems. I also have the opportunity every day to teach, learn, and make a difference for a patient or another nurse. Finally, it is very rewarding to work on a team of APNs who are so dedicated to hospital medicine, providing excellent patient care and supporting and helping each other. I am proud to be an ACNP in hospitalist practice.

^*We gratefully acknowledge Elizabeth Palermo, MS, RN, APRN-BC, Rochester, NY, for assistance with this exemplar.

Although there are limited definitions of the APN hospitalist in the literature, Sullivan (2009) reported the following, which serves as a guide for the role description of the hospitalist APN in the state of Mississippi. This definition states that an APN hospitalist is a nationally certified nurse practitioner whose practice site is the hospital and who has no outside primary or tertiary practice site. As part of a hospitalist team, this APN does the following: (1) admits and discharges patients; (2) diagnoses and manages common health problems in hospitalized patients in collaboration with a physician hospitalist; (3) performs procedures that are within their scope of practice; (4) interprets laboratory and diagnostic tests; and (5) plans and coordinates the discharge, rehabilitation, home health care, and follow-up of patients with acute health problems. This definition, and the specific functions it delineates, illuminates the centrality of direct care practice of APNs in this specialty. As the APN hospitalist specialty continues to evolve, the added value of practice guided by acute care competencies has the potential to improve the quality of care received by hospitalized patients.

The Society of Hospital Medicine (SHM), with over 6000 members, is a multidisciplinary organization (physicians, PAs, NPs) with the following goals (SHM, 2010a):

• Promote high quality care for all hospitalized patients.

• Promote education and research in hospital medicine.

• Promote teamwork to achieve the best possible care for hospitalized patients.

• Advocate a career path that will attract and retain the highest quality hospitalists.

• Define the competencies, activities, and needs of the hospitalist community.

• Support, propose, and promote changes to the health care system that lead to higher quality and more efficient care for all hospitalized patients.

This organization recognizes the contributions of nonphysician providers and has a standing committee within the organizational structure to develop initiatives and programs to promote and define the role of NPs and PAs in hospital medicine (SHM, 2010b). As the role of nonphysician providers continues to evolve, hospitalist practice will become interdisciplinary, and APNs and PAs will continue to be members of collaborative hospitalist teams to provide differentiated levels of care in the inpatient setting.

Commentary: Stage I

Hospitalist practice is a quickly emerging specialty in medicine. Although NPs, particularly and most appropriately ACNPs, are beginning to practice in this specialty, we see this as a stage I specialty for two reasons. First, the specialty is not yet recognized as a nursing specialty, and, although hospitalist practice for nurse practitioners has been defined by at least one state (Sullivan, 2009), describing unique distinctions between an APN hospitalist and physician hospitalist has not yet been attempted. Second, APN preparation for hospitalist practice is continuing to evolve as programs develop competency-based curricula more fully, with practica aimed at the development and refinement of knowledge and skills required for acute care, inpatient practice. One challenge for this stage I specialty is to articulate clearly the unique contributions that APNs can bring to the care of hospitalized patients, which may decrease fragmentation of care and improve interdisciplinary collaboration and overall patient outcomes. In addition, graduate nursing programs offering acute care education can ensure that hospital practice, based on the identified competencies in hospital medicine (Dressler, Pistoria, Budnitz, et al., 2006) and acute care competencies (National Panel for Acute Care Nurse Practitioner Competencies, 2004), are incorporated into required clinical practica. The challenge to any APN moving into this specialty is to maintain APN competencies and avoid a practice that is strictly an extension of medical practice. This transition may be facilitated if acute care nursing organizations promote and support establishment of special interest groups in these organizations to facilitate these transitions.

Specialties in Transition: Stage II

Stage II roles are characterized by progress in the evolution of the specialty to the point that organized training in the specialty begins. This training is often institution-specific, on the job training that develops experts in the specialty. The two roles discussed as demonstrating predominantly stage II characteristics but may exhibit some characteristics of stage III are those of the clinical transplant coordinator (CTC) and forensic nurse. The CTC role is clearly a stage II specialty practice, whereas the forensic nursing role can best be characterized as having several attributes of a stage III specialty (see Box 5-1).

Clinical Transplant Coordination

There is mounting evidence that the role of the CTC is evolving to the level of advanced practice nursing in response to patient care requirements in the referral and evaluation phase for patients, their families, and living donors, and in the pretransplant and post-transplant management phases of candidates and recipients. Specialty nurses with expertise in transplant nursing recognize the complex needs of these patients and many obtain graduate education to prepare them better to deal with the realities of transplant nursing. To the benefit of their patients, these coordinators have expanded the specialty by incorporating advanced practice core competencies.

Two organizations provide opportunities for ongoing education and preparation for certification for nurses who provide care for transplant patients, the North Atlantic Transplant Coordinators Organization (NATCO) and the International Transplant Nurses Society (ITNS). NATCO provides organized education in the specialty in the form of an introductory course for new clinical and procurement transplant coordinators (NATCO, 2009) in preparation for certification by the American Board for Transplant Certification (ABTC, 2007). ITNS, an organization focusing on the professional growth and development of the transplant clinician (ITNS, 2012), provides education on advances in transplantation and transplant patient care. ITNS has published a core curriculum (Ohler & Cupples, 2007) and scope and standards of a practice statement (ANA & ITNS, 2009) for the specialty that incorporates core competencies. Unlike the NATCO core competencies for the advanced practice transplant professional (APTP), which define the APTP as a provider who is not a physician but is licensed to diagnose and treat patients in collaboration with a physician (NATCO, 2010), the scope and standards of practice document developed by ITNS (2012) clearly address the scope of practice for transplant nurses, clinical and procurement transplant coordinators, and advanced practice transplant nurses, both NPs and CNSs. Building on the practice of the registered nurse generalist in transplant care and transplant nurse coordinator by demonstrating a greater depth and breadth of knowledge, greater synthesis of data and interventions, and significant role autonomy, which may include medical diagnosis and prescriptive authority, APNs working in transplant centers integrate and apply a broad range of theoretical and evidence-based knowledge using specialized and expanded knowledge and skills (ITNS, 2007).

It can be argued that the complex needs of patients with end-stage organ disease require higher levels of clinical reasoning and analytic skills, such as those possessed by APNs; however, to advance the CTC role (not just individuals in the role) to this higher level, attention to several issues is necessary. First and foremost, leaders in this specialty must systematically determine whether advanced practice core competencies (see Chapter 3) are required to enact the role fully or whether two levels of differentiated practice-generalist professional and APN—should be defined. Second, the specialty’s leadership must agree that the role is a nursing role. Because some CTCs are not nurses, making these decisions may disenfranchise many committed and experienced transplant professionals who are essential care providers. Similar to the different certifications in place for diabetes educators and advanced diabetes managers, a similar method of differentiation, which would recognize the added value that advanced practice knowledge and skill brings to the CTC role, might serve to acknowledge the contributions of APNs and other transplant professionals. Both ITNS and NATCO are moving in this direction by doing the following: (1) delineating the core competencies required for clinical and procurement transplant coordinators (NATCO, 2009; ITNS, 2007), (2) developing a core curriculum for transplant nursing at the generalist level (Ohler & Cupples, 2007); and (3) as of 2004, initiating a certification examination for the clinical transplant nurse (certified clinical transplant nurse, CCTN; American Board for Transplant Certification [ABTC], 2007). Institution-specific, on the job education and experience, attributes that characterize a stage II specialty, continue to be widely embraced in the specialty; however, efforts to provide more formalized education are now the standard.

The issue of specialty certification is an issue for all evolving advanced practice nursing specialties. Educational institutions that prepare APNs must consider the certification requirements and ensure that their graduates are eligible to sit for APN certification examinations approved for legal recognition of an APN role. Specialty certification offered by specialty organizations, although optional, demonstrates a knowledge base shared among clinicians in the specialty and improves clinical credibility.

The evolution toward advanced practice nursing has been haphazard as a result of inattention to several issues. Most notably, the lack of recognition that the role requires advanced practice competencies and the lack of opportunities for advanced practice specialty certification may impede expansion into advanced practice nursing as an expectation of coordinator roles. The issue of specialty certification (at the generalist level) has been addressed, but no plans for advanced practice certification have been proposed, except for the APTP. Clearly, however, there is a commitment to advanced practice nursing in transplantation and, given that commitment, more attention to these issues will be necessary for the CTC role to evolve to stage III.

Exemplar 5-2 demonstrates the complexity of care required for transplant candidates, recipients, and their families. In addition to expertise in advanced practice core competencies, the exemplar also highlights the skill of the CNS in dealing with systems issues—in the hospital and community—and staff education and coaching, both of which are important components of providing care to this challenging patient population. As a member of a team of care providers, collaboration provides the opportunity to advocate for patients and their family members and influence quality of care. It is our view that the knowledge and expertise of advanced practice nurses could fully enable the potential of the CTC position.

Exemplar 5-2 Heart Transplant Coordinator *

Given the complexity of care associated with solid organ transplant patients, most transplant programs have multidisciplinary teams that care for candidates and recipients (Donaldson, 2003). The clinical transplant coordinator’s role is to facilitate the care of the patient, in collaboration with the multidisciplinary team, throughout the transplantation process. This process begins with the patient’s initial referral to the transplant program and often continues for the rest of the patient’s life.

As a CNS, my clinical transplant coordinator position affords me the opportunity to incorporate the core competencies of advanced practice nursing. My clinical practice role includes direct and indirect care activities. For example, key direct care activities involve coordinating detailed discharge planning, seeing patients in the transplant clinic, and triaging telephone calls from candidates, recipients, and family members. Indirect care activities include participating in interdisciplinary clinical rounds (e.g., transfer conferences as patients transition from the intensive care unit to the intermediate care unit), developing protocols and patient education materials, participating in performance evaluation and improvement activities, initiating referrals to other health care specialists, and facilitating staff support groups. One example of staff support involved a transplant candidate with biventricular mechanical support who remained hospitalized for over 12 months until a suitable donor organ became available.

Over the course of this prolonged hospitalization, the nursing staff encountered several challenging problems. Many of the patient-staff conflicts revolved around the patient’s desire for autonomy and the staff’s need to provide care in a timely manner (e.g., dressing changes, physical therapy). To provide support for the staff as they worked toward resolving these problems, I organized consultative sessions with the transplant team’s neuropsychologist and social worker that were held biweekly. The neuropsychologist enhanced the staff’s understanding of the patient’s cognitive status and the social worker helped the staff articulate their frustrations. Over time, in collaboration with the patient, mutually acceptable strategies were devised and implemented. For example, I coached the staff members in how to negotiate with the patient to develop a daily schedule that permitted him to sleep in on weekends when the census was typically low and the staff had more flexibility in providing care. In turn, the patient agreed to follow a more rigid schedule on weekdays.

My role affords many opportunities for staff and patient education. Staff education is formal (e.g., teaching in the critical care nurse internship program) and informal (e.g., answering staff nurses’ questions during rounds). I provide patient education, which involves extensive teaching sessions with prospective transplant candidates and their family members. The purpose of these sessions is to provide patients with information so they can make informed decisions about whether they wish to proceed with transplantation. Once a patient decides to proceed and is placed on the waiting list, additional education is provided during monthly support group meetings, which I lead. After the transplant procedure, recipients and family members attend comprehensive discharge education sessions. Post-discharge education is provided through newsletters, support group meetings, and individual counseling sessions during clinic visits.

One example of my role as collaborator is my participation with the interdisciplinary team that discusses, plans, implements, and evaluates the ongoing care of transplant candidates and recipients. One of our major responsibilities, as members of the transplant team, is to collaborate with other team members regarding whether a particular patient meets the heart transplant program’s physiological and psychosocial eligibility criteria for placement on the waiting list. A second example concerns technology transfer, more specifically, the transfer of scientific advances of mechanical assist device technology into clinical practice. When the heart transplant team was about to discharge our first patient with a left ventricular assist device (LVAD), I coordinated this process working with the heart transplant research nurse, social worker, NP, physicians, hospital administrators, MedStar flight crew members, and community resource providers (e.g., the local power companies). The purpose of this collaborative effort was to establish physiologic and psychosocial criteria for discharge and develop policies and procedures regarding emergent and routine follow-up care.

Last, I have had the opportunity to collaborate with an international, multidisciplinary task force in reviewing the literature pertaining to the biopsychosocial outcomes of cardiothoracic transplantation, evaluating the strength of the evidence, and developing specific recommendations for future research designed to improve psychosocial and clinical outcomes.

^*We gratefully acknowledge Sandra A. Cupples, DNSc, RN, Washington, DC, for assistance with this exemplar.

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