The Advanced Practice Nurse in the Community
administrator, p. 861
advanced public health nurse, p. 856
certification, p. 858
clinical nurse leader, p. 857
clinical nurse specialist, p. 856
clinician, p. 859
competencies, p. 857
consultant, p. 861
educator, p. 860
faith community nursing, p. 863
Healthy People 2020, p. 864
independent practice, p. 862
institutional privileges, p. 866
interprofessional collaborative practice, p. 867
liability, p. 866
nurse practitioner, p. 856
nursing centers, p. 863
parish nursing, p. 863
portfolios, p. 866
prescriptive authority, p. 865
primary health care, p. 857
professional isolation, p. 866
protocols, p. 860
researcher, p. 862
third-party reimbursement, p. 862
—See Glossary for definitions
Molly A. Rose, RN, PhD
Molly A. Rose is a professor at Thomas Jefferson University in Philadelphia, Pennsylvania, and previous coordinator of the graduate community health/public health nursing program entitled Community Systems Administration. She is Co-Director of the Jefferson InterProfessional Education Center. She is a clinical nurse specialist in community health nursing and a family nurse practitioner. She has completed research in the areas of HIV and women, caregivers of children with HIV, HIV and the older adult, and interprofessional education and health promotion and the older adult. Dr. Rose’s roles in community/public health nursing have included the areas of home health, camp, and parish nursing; she was president of the board of directors of a free clinic for older adults; she was a VISTA (Volunteers in Service to America) nurse in the rural South; and she has been involved in homeless shelters, program planning and evaluation, school health, clinics for the underserved, and academia.
Kellie A. Smith, RN, MSN
Kellie A. Smith is an instructor at Thomas Jefferson University in Philadelphia, Pennsylvania, and is the coordinator of the graduate community health/public health nursing program entitled Community Systems Administration. She is a clinical nurse specialist in community health nursing. She has been involved in NIH/NIDDK (National Institute of Health/National Institute of Diabetes and Digestive and Kidney Diseases) research for type 2 diabetes prevention, the Diabetes Prevention Program. Ms. Smith was also involved with the trial’s translational campaign, “Small Steps. Big Rewards,” directed by The National Diabetes Education Program (NDEP). Ms. Smith has participated in health care professions’ interprofessional education initiatives, including a chronic disease health mentor program. She has assisted students in community activism and philanthropy as the nursing student government faculty advisor.
This chapter explores the roles of the advanced practice nurse in the community. Why, one might ask, is this chapter in the text? For a few good reasons, since it is the intent to provide the BSN student with an understanding of the career opportunities that may be chosen for continuing one’s education to the graduate level. For the nurse in a graduate program, the chapter will provide an in-depth understanding of the role in the specialty area that has been chosen. The advanced practice nurse roles described in this chapter offer excellent choices for exciting careers, which will assure satisfaction that a major contribution can be made to making a difference in health outcomes and improved health status of clients at all levels.
The advanced practice nurse is a licensed professional nurse prepared at the master’s level or doctoral level to take leadership roles in applying the nursing process and public health sciences to achieve specific health outcomes for the community; this nurse is often referred to as an advanced public health nurse (APHN) or public health clinical nurse specialist (CNS). Since both the American Nurses Association (2007) and the Association of Community Health Nursing Educators (ACHNE, 2007) refer to this specialized role as APHN, this is the title that will be used in this chapter. On the other hand, the advanced practice nurse in the community may be a nurse practitioner (NP). A nurse practitioner is generally a master’s-prepared nurse who applies advanced practice nursing knowledge with physical, psychosocial, and environmental assessment skills to respond to common health and illness problems. Since about 2006, NPs were beginning to be prepared at the doctoral level through Doctorate of Nursing Practice Programs (AACN, 2006; NONPF, 2006). The APHN and NP often work in similar settings. However, their client focuses differ. The NP’s client is an individual or family, usually in a fixed setting, who has the opportunity to identify individual trends in their practices. The APHN’s clients may be individuals, families, groups at risk, or communities, but the ultimate goal is the health of the community as a whole (ANA/Quad Council, 2007; ACHNE, 2007). The APHN always has a population focus and obtains knowledge from nursing, social, and public health sciences to achieve goals of promoting and protecting the health of populations by creating conditions in which people can optimize their health (ACHNE, 2007; ANA, 2007). Table 39-1 compares the functions taught to the APHN and the NP in their educational programs.
|FUNCTION||NP PROGRAM||APHN PROGRAM|
|Physiology and pharmacology||Almost always||Often|
|Diagnosis and management||Always||Often|
|Systems||Individual/family focus||More systems focused|
|Program planning and evaluation||Less often||Always in community and public health|
This chapter provides a history of the educational preparation of the advanced practice nurse. Functions in advanced practice and arenas for practice are discussed. Issues and concerns, role negotiation, and areas of role stress relative to the APHN and the NP in the community are also discussed.
Changes in the health care system and nursing have occurred in the past few decades because of a shift in societal demands and needs. Trends that have influenced the roles of the APHN and NP include a shift from institution-based health care to population-focused health care, improvements in technology, self-care, cost-containment measures, accountability to the client, third-party reimbursement, and demands for making technology-related care more responsive to the client.
The CNS role began in the early 1960s and grew out of a need to improve client care. CNSs educate clients, communities, populations, families, and individuals; provide social and psychological support to clients; serve as role models to other nursing staff; consult with communities, nurses, and staff in other disciplines; and conduct clinical nursing research (Robertson and Baldwin, 2007).
In the United States during the 1960s, a shortage of physicians occurred, and there was an increasing tendency among physicians to specialize. The number of physicians who might have provided medical care to communities and families across the nation was reduced. As this trend continued, a serious gap in primary health care services developed. Primary health care includes both public health and primary care services.
The NP movement began in 1965 at the University of Colorado by Dr. Loretta Ford and Dr. Henry Silver. They determined that the morbidity among medically deprived children could be decreased by educating nurses to provide well-child care to children of all ages. Nursing practice for these pediatric nurse practitioners included the identification, assessment, and management of common acute and chronic health problems, with appropriate referral of more complex problems to physicians (Silver, Ford, and Stearly, 1967). The priorities of the nursing profession have traditionally been to care for and support the well, the worried well, and the ill, offering physical care services previously provided only by physicians. Preparing nurses as primary health care providers was not only consistent with traditional nursing, but also was responsive to society’s critical need for primary health care services, including health promotion and illness prevention (Hooker and McCaig, 2001).
In 1965, the physician assistant (PA) role was initiated at Duke University. This program was intended to attract former military corpsmen for training as medical extenders (Hooker and Berlin, 2002). Nurse practitioners are often combined into a single category with other non-physician providers and are mistakenly portrayed as physician extenders. This misinterpretation of the intended role is addressed by one of the founders, Dr. Loretta Ford:
As conceptualized, the nurse practitioner was always intended to be a nursing model focused on the promotion of health in daily living, on growth and development of children in families, and on the prevention of disease and disability. Nursing as a discipline and a profession evolved not because there was a shortage of physicians but because of societal needs. The early plans did not include preparing nurses to assume medical functions. The interests were in health promotion and disease prevention for aggregate populations in community settings, including underserved groups. These were the hallmarks of community-oriented nursing (Ford, 1986).
A report issued by the U.S. Department of Health, Education, and Welfare (now USDHHS), Extending the Scope of Nursing Practice (1971), helped convince Congress of the value of NPs as primary health care providers. The Nurse Training Act of 1971 (PL 92-150) and the comprehensive Health Manpower Act of 1971 (PL 92-157) provided education monies for many NP and PA programs through the 1970s and into the 1980s. Similarly, in the 1970s the concept of an expanded practice role for nurses was garnering interest in Canada. Canadian nurses saw the NP role as an opportunity to expand their scope of practice and perform the role in various settings largely outside tertiary care (Bajnok and Wright, 1993). The United Kingdom has increased their advanced practice nurse programs to educate and monitor the role that has been in place for about 20 years. They continue to define the role (RCN, 2010).
Graduate education for nursing is changing. AACN (2007) called for the creation of a new nursing role, clinical nurse leader (CNL). The clinical nurse leader is defined as a nurse who is a master’s prepared generalist who functions at the micro-system level and assumes accountability for health care outcomes for a specific group of clients within a unit or area (AACN, 2007). In 2010, there were approximately 100 CNL programs in the U.S. (AACN, 2010). In addition, the AACN has determined that the degree for nurses seeking advanced practice should be the Doctor of Nursing Practice (DNP) (AACN, 2006). (See the Cutting Edge box.)
The Quad Council of Public Health Nursing Organizations , in 2003, developed a set of national public health competencies specific for public health nursing practice that are based on the Core Competencies for Public Health Professionals authored by the Council on Linkages Between Academia and Public Health Practice (2001). The core competencies were designed to serve as a starting point for academic and practice organizations to understand, assess, and meet training and workforce needs for health professionals practicing in public health; they were updated in 2009 (Council on Linkages, 2009). The Quad Council competencies are more specific to public health nursing and were developed to assist agencies that employ public health nurses, as well as academic settings that prepare public health nurses, to facilitate education, orientation, training, and lifelong learning (Quad Council, 2003). The competencies are categorized into eight domains and are applied to two levels of public health nursing practice: the staff nurse/generalist role and the manager/consultant/CNS. The domains, which were updated, include core areas of analytic assessment, policy development/program planning, communication, cultural competency, community dimensions of practice, basic public health science, financial planning and management, and leadership and systems thinking skills (Quad Council, 2009). (See the Linking Content to Practice box.) The American Nurses Association (ANA, 2007) published Scope and Standards for Public Health Nursing Practice, which includes population-focused standards of care in the following areas: assessment, diagnosis, outcome identification, planning, assurance, evaluations and standards for professional performance in quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization. This document is a collaboration between the ANA and the American Public Health Association-Public Health Nursing section’s definition and role of Public Health Nursing Practice (1996).
Educational preparation for the APHN includes a minimum of a master’s degree and is based on a synthesis of current knowledge and research in nursing, public health, and other scientific disciplines. In addition to performing the functions of the generalist in population-focused nursing, the specialist possesses clinical experience in interprofessional planning, organizing, community empowerment, delivering and evaluating service, political and legislative activities, and assuming a leadership role in interventions that have a positive effect on the health of the community. ACHNE recommendations for graduate nursing education for the public health nurse specialty are guided by the IOM’s 2003 report Who Will Keep the Public Healthy? (2003), ANA’s Public Health Nursing Scope and Standards of Practice (2007), and AACN’s DNP Essentials (2006). They identified five role characteristics of APHNs: (1) population-level health care focus, (2) ecological view, (3) responsibility for health outcomes for populations, (4) partnership/collaboration using an interprofessional approach, and (5) leadership in practice. The curriculum areas for the APHN that were identified are population-centered nursing theory and practice, interprofessional practice, leadership, systems thinking, biostatistics, epidemiology, environmental health sciences, health policy and management, social and behavioral sciences, public health informatics, genomics, health communication, cultural competence, community-based participatory research, global health, policy and law and public health ethics (ACHNE, 2007). In addition to didactic content, graduate education for the APHN must include practicum experience that takes place at the population level, be grounded in the ecological perspective, and include the measurement of outcomes (ACHNE, 2007).
In contrast to the APHN, educational preparation of the NP has not always been at the graduate level. Early NP programs were continuing education certificate programs, and the baccalaureate degree was not always a requirement. At present, however, NPs are required to hold master’s degrees and encouraged to obtain a practice doctorate (AACN, 2006). The curriculum prepares NPs to perform a wide range of professional nursing functions including assessing and diagnosing, conducting physical examinations, ordering laboratory and other diagnostic tests, developing and implementing treatment plans for some acute and chronic illnesses, prescribing medications, monitoring client status, educating and counseling clients, and consulting and collaborating with and referring to other providers (AACN, 1996). Many institutions are offering combined CNS/NP programs. A 2006 AACN position statement calls for DNP education for advanced practice nurses and nurses seeking top systems/organizational roles. The eight foundational essentials for DNP programs are knowledge with a scientific underpinning; organizational and systems leadership; clinical scholarship; information systems; policy; collaboration; prevention and population health; and advanced nursing practice (AACN, 2006).
Certification examinations for advanced practice nurses are offered by the American Nurses Credentialing Center (ANCC). The purpose of professional certification is to confirm knowledge and expertise and provide recognition of professional achievement in a defined area of nursing. Certification is a means of assuring the public that nurses who claim to be competent at an advanced level have had their credentials verified through examination (ANCC, 2009). Although certification itself is not mandatory, many state boards of nursing require that nurses in advanced practice, particularly those in an NP role, be nationally certified to practice.
The American Nurses Association (ANA) began its certification program in 1973 and has offered NP certification examinations since 1976. The American Nurses Credentialing Center was opened in 1991 and offers certification in NP, Advanced Practice, and CNS specialty areas. Until 2009 a nurse could also be certified as a generalist or as a BSN-prepared specialist in community health. Since 1985, the basic qualifications for certification as an NP have been a baccalaureate degree in nursing and successful completion of a formal NP program. As of 1992, a master’s or higher degree in nursing is required for NP certification through the ANCC.
Examination topics for the NP certification examination include clinical management, professional role and policy, NP and client relationship, assessment, research, and health promotion and disease prevention (ANCC, 2010). The American Academy of Nurse Practitioners also has national competency-based certification examinations in three areas: family, adult, and gerontological nurse practitioners (AANP, 2010).
The certification examination for CNS in public/community health nursing was first offered in October 1990. Qualifications for this examination include a master’s or higher degree in nursing with a specialization in community/public health nursing practice. Effective in 1998, eligibility requirements included holding a master’s or higher degree in nursing with a specialization in community/public health nursing or holding a baccalaureate or higher degree in nursing and a master’s degree in public health with a specialization in community/public health nursing. In 2009, the ANCC Commission renamed the certification exam from Clinical Nurse Specialist in Public/Community Health to Advanced Public Health Nursing. Along with the name change, the eligibility criteria were expanded to accept a variety of graduate education preparation in public/community health. (See the Did You Know? box.) Those who complete a master’s degree in nursing in community/public health (which includes a minimum of 500 practicum hours), or a master’s in public health degree and successfully pass the certification examination will be eligible to use the credential of Advanced Public Health Nurse–Board Certified (APHN-BC) (ANCC, 2010). Nurses who complete a master’s degree in nursing in community/public health with additional courses in advanced pathophysiology, advanced pharmacology, and advanced health assessment, complete a minimum of 500 practicum hours and pass the examination, will be eligible to use the credential of Public Health Clinical Nurse Specialist–Board Certified (PHCNS-BC) (ANCC, 2010). Up until 2015, nurses who have a graduate degree in an area other than community/public health nursing and complete 2000 clinical hours of advanced practice public/community health nursing within the last 3 years are also eligible to sit for this examination and use the credential of APHN-BC. Examination topics for both distinctions include foundations of advanced public/community health; application of developmental theories; epidemiology; biostatistics; research evaluation; methods and utilization; public, community, and environmental health assessment; strategies to improve public/community health; health promotion; disease prevention; risk reduction; theories and concepts of health behaviors; health screening and counseling; populations and communities education; health systems; organization and networks; and leadership concepts and professionalism (ANCC, 2010).
Certification for the APHN and NP is for 5 years. To maintain certification, the nurse must submit documentation of current RN licensure and meet a practice and continuing education requirement within the specialty area.
Advanced Practice Roles
APNs holding a master’s degree in nursing and specializing in public health nursing, in community health nursing, or as a nurse practitioner have many roles, some of which will be described here. It should be noted that the “nursing role in the APHN is not distinguished by the sites in which the nurses practice, but rather by the perspective, knowledge base, and principles that focus on care of populations” (ACHNE, 2007, p 16). The APHN’s role characteristics include a focus on population health such as population and community assessment; advocacy and policy-setting at the organizational, community, and state levels; ecological view for large-scale program planning, project management; and leadership and partnership building. APHNs deliver population-focused services, programs, and research (ACHNE, 2007; Robertson and Baldwin, 2007).
Most of the differences between the roles of the APHN and the NP are seen in clinical practice. Although the APHN’s practice includes nursing directed at individuals, families, and groups, the primary responsibility is to take a leadership role in the overall assessment, planning, development, coordination, and evaluation of innovative programs to meet identified community health needs. The APHN provides the direction for population-focused health care by identifying and documenting health needs and resources in a particular community and in collaborating with population-focused nurse generalists, other health professionals, and consumers (ACHNE, 2007). Practicing within the role of clinician, the APHN is involved in conducting community assessments; identifying needs of populations at risk; and planning, implementing, and evaluating population-focused programs to achieve health goals, including health promotion and disease prevention activities. The APHN ultimately works toward the goals of promoting and protecting the health of populations by creating conditions in which people can optimize their health (ANA, 2007).
The NP applies advanced practice nursing knowledge and physical, psychosocial, and environmental assessment skills to manage common health and illness problems of clients of all ages and both sexes. The NP’s primary client is the individual and family. In the direct role of clinician, the NP assesses health risks and health and illness status, as well as the response to illness of individuals and families. The NP also diagnoses actual or potential health problems; decides on treatment plans jointly with clients; intervenes to promote health, to protect against disease, to treat illness, to manage chronic disease, and to limit disability; and evaluates with the client and other primary care team members about how effective and comprehensive the nursing intervention may be in providing continuity of care (AACN, 1996; NONPF, 2006). Despite the setting of the practice nurse practitioner, the practice can be population focused. These interventions often include community assessment and analysis, case finding, an emphasis on prevention, and participation in public policy. An advanced practice nurse in the community may work in an agency or setting where the caseload consists of individuals who present themselves for services. The APHN goal would be to identify others in the community who may be at risk and in need of the services. Outreach activities can accomplish this while also trying to accomplish the goals and objectives of Healthy People 2020 (Box 39-1).