A Nurse Practitioner’s View
This is my blog that will highlight current issues, trends and policies affecting Nurse Practitioners and the health care system today.
Tuesday, April 20, 2010
- Nurse Practitioner practice is not brand new. The profession has been around since the mid 1960’s. Therefore, all of these intimations that we are doing something (or looking to do something) new is inaccurate. There is a 40-year history of NP practice.
- NPs are not individuals who one day arbitrarily started writing prescriptions. There is a standardized education, training, licensure, and certification process that allows us to perform in that capacity. There are differences in each State practice act that sets the standard for what we can (and can’t) do in each state. Note that the majority of State acts have these regulations that haven’t been updated to reflect current education and training.
- The Doctor of Nursing Practice (DNP) degree is often linked to these conversations but this is really a separate issue. Yes, this is a relatively new terminal clinical degree for the profession. There used to be to be the Doctor of Nursing Science (DNS) that has pretty much fallen out of favor to the DNP. Why in the world would this be a bad thing? (Oh right, because we are trying to confuse everyone into thinking we are really a «doctor» which I guess is some how synonymous only with a «physician» these days.) Now, this educational degree in and of itself does not change existing practice. There are many opinions about the DNP degree out there (of which I will share mine soon) but the bottom line is that the degree does not change the requirements of current state licensure/certification and to the already existing 140,000+ NPs.
- Our approach to patient care is not the allopathic model. We utilize a synthesis of both nursing and medical knowledge to care for patients. I as an NP, generally feel that lifestyle modifications, health education and communication, disease prevention/treatment, wellness preservation and a partnership approach are driving principles of my philosophy to practice. NP education has largely adopted the evidence-based practice (EBP) model of care. That is, using proven interventions in the provision of care rather than doing something the way it’s been done forever. Does this allow us to spend more time with patients? Perhaps. But maybe the evidence suggests that spending more time with patients produces better outcomes.
- NPs face the same reimbursement issues that primary care physicians face (albeit at an even more reduced rate — Medicare reimburses NPs at 85%) yet the majority of NPs choose primary care or closely related field to work in. This, of course, assumes that every NP wants to own their own practice. I will go out on a limb and say that most want no part of this. The push for autonomous practice stems from out-dated and arbitrary barriers that negatively affect patient care. For example, the NP working for a physician in Florida with no intention of starting their own practice but with their own panel of established patients. The NP sees one of their patients determines that the patient needs some pharmacological pain medication intervention yet cannot prescribe this to their patient since there is no physician in the office that day (Florida NPs cannot prescribe controlled substances). The patient is ultimately out of luck here and suffers since they cannot have their pain managed. It also puts the NP at an unfair disadvantage since patients knowing this regulatory issue may choose another provider based on this.
- NPs are filling a void in primary, not «taking over.» I’ve said time and time again in this blog, let the patients decide if they want care from an NP. If not, we would surely have little to argue against. However, if patients want to choose care from an NP, they should be able to without prejudice or barrier.
I continue to have tremendous respect for my physician colleagues. I appreciate their time commitment to the education/training process and vast knowledge base. I cannot perform surgery or many other procedures nor would ever want to. But I am confident in identifying when a patient does need surgery for example. I just don’t necessarily think that physicians can be the only providers and captains of health care. I don’t buy into the argument that we don’t know what we don’t know. We all collaborate and refer to colleagues when something falls outside of our comfort zone or specialty. The one who thinks they know it all and can cure all is the one I would be especially leery of.
Hey I’m a FNP student and I agree with what you had to say in this blog well said. Now another issue is, male nurse practitioners are nursing is still a female dominated profession. We must break barriers and tell the public that men can be nurses and nurse practitioners as well and not only physicians.
Wow, Stephen VERY well said! You really captured the issues!
All mainstream health providers are trained in evidence based practice, especially physicians. It is certainly not exclusive to NPs, as your post suggests.
Nurse practitioners have championed the evidence-based practice movement. I would hardly say that «all mainstream health providers» are trained. When you talk about systematic reviews and PICO questions, people’s eyes start glazing over.
I found it interesting. Its very valuable you shared your experiences. Give us the closest point of view.
Reflective Nursing Essay
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Case Study One
In this case study I will use Gibbs (1988) model of reflection to write a personal account of an abdominal examination carried out in general practice under the supervision of my mentor, utilising the skills taught during the module thus far.
During morning routine sick parade I was presented with a 21 year old male soldier experiencing severe acute, non specific, abdominal pain. Under the supervision of the medical officer (MO) I proceeded to carry out a full assessment and abdominal examination, using Byrne and Long’s (1976) model to structure the consultation. I requested the patients’ consent before conducting the examination, as is essential before commencement of any medical procedure, be it a physical examination or a critical surgical procedure (Seidal et al, 2006).
The patient was quite agitated on arrival and appeared to be in a great deal of pain, and so before continuing with the physical examination I reassured him and made him comfortable in the treatment room. On examination his abdomen was soft, palpable with no tenderness, on auscultation bowel sounds where normal, vital signs normal, with cramping centralised pain.
I was feeling confident in my ability to deal with the patient and perform the examination effectively as I had practiced this several times previously using the university resources and mock OSCE with my facilitator. As I am often solely responsible for the care and management of patients during out of hours (OOH) I felt comfortable assessing and triaging the patient. However, under normal circumstances I would assess the patient and refer them to the MO if I was concerned about their condition, in order for a decision to be made. I was also being closely monitored throughout which did increase the pressure to deliver the correct diagnosis and make appropriate decisions. However, by utilising the consultation model I feel I managed to keep a focused approach and ensure the correct questions where asked.
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I feel I gained a good history from the patient by using the SOLER principles (Egan, 1990) taught in the history taking presentation. Thus allowing me to form a differential diagnosis and rule out certain causes, such as; constipation, and indigestion. Subsequently, the physical examination enabled me to confirm a diagnosis of acute abdomen. As the patient was not experiencing any worrying (red flag) symptoms associated with abdominal emergencies, such as; appendicitis or pancreatitis. However, I did forget certain aspects of the physical examination and had to be prompted by the MO. Although with more practice such incidence would be reduced.
I was happy that I managed to rule out any distinct causes of the abdominal pain by performing the examination to collect data, analyse it, and use the results to make an appropriate decision (Schon, 1984). However, had I performed the examination without assistance I may not have gained all the information required to confirm diagnosis, as I did forget some aspects.
The MO seemed happy with my diagnosis and care plan, though he did highlight the importance of practicing the physical examination skills in order to become a more competent practitioner. Overall I feel gaining knowledge and skills in translating a patients’ history and physical examination results, has enabled me to become more confident in making a diagnosis and has improved my decision making skills.
In order to become a more capable and effective practitioner I must continue to perform physical examinations under the guidance of a more senior practitioner, and utilise their expertise during the decision making process.
Additionally, I will continue to develop my consultation and history taking skills by using Byrne and Long’s (1976) consultation model to assist my practice and aid future development.
BYRNE, P, S., LONG, B, E, L. (1976) Doctors talking to patients. London: HMSO EGAN, G. (1998) The Skilled Helper: A problem-management approach to helping. 6th edn. Pacific Grove, London: Brooks/Cole. GIBBS, G. (1988) Learning by doing: a guide to teaching and learning methods. Oxford: further education unit, oxford polytechnic SEIDAL, H, M., BALL, J, W., DAINS, J, E., BENEDICT, G, W. (2006) Mosby’s Guide to Physical Examination. 6th edn. Philadelphia: Elsevier. SCHON, D. (1984) The Reflective Practitioner: how professionals think in action. New York: Basic Books.
Going back through previous experiences and tracing back the footsteps we have made allows us to reminisce about the good things that have happened in our lives. Somehow the undesirable memories would also seep in as they are part and parcel of our existence that we cannot do away with. This process gives us an opportunity to encounter past events that can necessarily aid us in the future. In the Nursing practice, reflection is a retrospective approach that evaluates historical processing of experiences that takes place in a structured form and is deemed highly essential (Eliis, Kenworthy and Gates, 2003, 156).
In the clinical practice, this retrospective activity facilitates in the promotion of quality care. The art of reflection however in the nursing practice focus on self rather than on the situation as the care provider (Quinn, 2000, 252). The process is a reflective practice that is a cognitive act by which we are allowed to make sense of our thoughts and memories (Taylor, 2000, 43).
This method therefore allows a practitioner to generate a complementary or alternative form of knowledge and a set of choices in the evaluation of the best course of action. It is a “deep learning” experience that reflects on our knowledge and theories and go beyond merely thinking about what we do but involves recalling what had occurred and analyzing the situation by interpreting important information recalled (Taylor, 2000, 4).
In Nursing, the reflective process is aimed about our own practice (Taylor, 20000, 3); that nursing education and research cannot do without as a common practice in the learning mechanism in which we all engage in a regular basis (Slevin and Basford, 2000, 483). With a main purpose of enabling the practitioner to learn from experiences and increase clinical effectiveness, reflection is highly essential to the nursing practice.
For this process to be effective, Johns has provided a guided reflection which employs different models of self-inquiry to enable a practitioner to realize desirable and effective practice (2002:3). Considering that this involves a cognitive and emotional component that is expressed through analysis, different models would aid us feel comfortable about the activity. John’s model can be used in preparation for or during clinical supervision and applicable to specific incidents rather than more general day to day issues and particularly applicable to those who prefer a structure approach (Ellis, Kenworthy and Gates, 155).
Gibbs Model use term description rather than “a return to the entire experience” as a form of reflection is considered as a simpler method but one where a mentor or facilitator is likely needed(Davies, Bullman and Finlay, 2000, 84). Both models however in supervision practice can be used to facilitate clinical governance through the promotion of quality care where an exchange between two professionals employing this technique seeks to improve their practice (Watkins, Edwards and Gastrell, 2003, 266).
To maximize the potential benefits of clinical supervision, nurses have to learn to be comfortable with this retrospective activity with the aid of Gibbs or John’s models depending on where one feels most comfortable working with (Ellis, Kenworthy and Gates, 156).
Gibbs Model for reflection
As a simple and easily attainable method, Gibbs model uses term description rather than a return to a previous experience (Davies, Bullman and Finlay, 84). In psychology and teaching, reflection facilitates as purposeful change and competencies such as psychological-mindedness and self-regulation (Clutterback and Lane, 2004, 196). Usually this process involves a mentor, teacher or supervisor working with a student at different stage while allowing for individuality.
Although less specific than re-evaluating an experience; Gibbs in his cycle or reflection makes the action planning a more overt component of reflection (Davies, Bullman and Finlay, 84). Gibbs provides that in one’s own practice, an essential aspect of working as an autonomous practitioner involves a critical analysis of one’s role and responsibilities from a personal perspective (Gibbs, 1998,13). It is a process that requires others to become involved that encourages feedback and constructive comment to recognize your role and value in a health team (Humphris and Masterson, 2000, 77).
John’s Model for reflection
John’s model uses the concept of guided reflection to describe a structure supportive approach that helps the practitioner learn from their reflections and experiences (Quinn, 2000, 572). The approach involves the use of a model of structure reflection, one-on-one group supervision and the keeping of a reflective diary (Quinn, 572). The practice would aid the practitioner in learning from a reflection of their experiences. John’s model is more detailed as it provides a checklist of specific points necessary for reflection (Davies, Bullman and Finlay, 85).
The only problem cited with John’s model if it imposes on a framework that is external to the practitioner leaving little scope for inclusion as cite by other theories. John’s model can be used in preparation and during clinical supervision consisting of 6 steps that is applicable t specific incidents rather than more generalized day to day issues facing the supervisee (Ellis, Kenworthy and Gates, 155). This model is highly attractive to those who prefer a structured approach but others may find this type more restricting (Ellis, Kenworthy and Gates, 156).
Criticisms against the reflective process
Reflection involves cognitive and emotional components that are expressed through analysis and to maximize the potential benefits of the clinical supervisor nurses have to learn to feel comfortable with this retrospective activity both during and in preparation for supervision sessions (Ellis, Kenworth and Gates, 157). This could be deemed time–consuming in an institution where time is often an important element in the delivery of care. A time for reflection can be done positively only when a situation or a need arises. This is probably why reflection method is considered a radical approach to nursing education and practice given the ample time training can afford (Slevin and Basford, 483).
Yet reflection is valuable if done in partnership with someone else which led Davies et al to believe that the approach is quasi-therapeutic (Davies, Bullman and Finlay, 86). The principles have been transferred directly from client-centered psychotherapy and may trigger more powerful responses such as guilt and anxiety. Practitioners are therefore evaluated before they are given a chance to try this one out according to conservative studies. However with practice, it is assumed that a reflective process may not hold as much negative impact for the learned practitioner in an answer to the demands for a continuous review of a practice in a critical and analytical manner that support the reflective concept.
The Value of Reflection for the Student Nurse
As an essential component of scholarly practice, reflection, reflection is a method for generating a complementary alternative form of knowledge and theory (Humphris and Masterson, 2000:78). Regardless of any negative criticism a reflective method may elicit from critics, I consider this to be a valuable tool. For the student, this is a process were one internally examines and explores an issue of concern triggered by an experience that clarifies the meaning of perspectives (Canham and Bennett, 2001, 185). The nursing practice has been surrounded by a world of silence and reflection is a way for nurses to reflect that is enhanced and introduced in the nursing curriculum (Guzzetta, 1998, 102).
Often in the professional practice, nurses have encouraged silence among themselves in their health environment and setting while usually developing a shared professional voice with her team. Oftentimes, her relationship with the rest of the health team and other professionals faced difficult efforts because of the autonomy. The process of reflection allows one to air out her sentiments and ideas within her group or to a mentor or a supervisor during moments of reflection that could be produced as a shared voice for the team.
Developing a habit of reflection is therefore a must for nursing education in order to uncover dimensions of experiences such as hidden and explicit meanings of behavior that can aid a student nurse in identifying her own perspective of the nursing practice that is highly useful in her entry to the profession (Guzzetta, 1998, 103).
For a student in nursing, one must therefore develop a habit of reflection in order to uncover experiences and the meaning of behavior, values and thoughts that could readily prepare one for professional practice. It should be noted that the reflective process can helpfully aid in teamwork where one has the chance to relay sentiments after reflection of her past experience. Nursing education must therefore develop and evaluate innovative strategies to prepare nurses to meet the challenges of the rapidly changing health care system and for lifelong learning (Johns and Freshwater, 1998, 149).
Reflection and reflective practice are currently receiving attention as a strategy yet little is known about the process of becoming a reflective thinker, how to teach skills needed for reflection, or the barriers and facilitators to becoming a reflective practitioner (Clutterback and Lane, 2004, 198). However a reflection process is worthy of study and practice that should initially be started and adapted as a core training for everyone wishing to professionally practice nursing as a positive way to analyze the development of reflective practice abilities.
Canham, Judith and Bennett, JoAnne, 2001, Mentoring in Community Nursing: Challenges and Opportunities, Blackwell, London, 2001.
Clutterback, David and Lane, Gill, 2004, The Situational Mentor: An International Review of Competencies and Capabilities in Mentoring, GowerHouse, London.
Davies, Celia, Bullman, Anne and Finlay, Linda, 2000, Changing Practice in Health and Social Care, Sage, London.
Ellis, Roger, Kenworthy, Neil and Gates, Bob, 2003, Interpersonal Communication in Nursing: Theory and Practice, Elsevier Sciences, Orlando.
Gibbs, Graham, 1998, Learning by Doing: A Guide to Teaching and Learning Methods, Oxford, London.
Guzzetta, Cathie, 1998,Essential Readings in Holistic Nursing, Jones Bartlett, Maryland.
Humphris, Debra and Masterson, Abigail Masterson, 2000, Developing New Clinical Roles: A Guide for Health Professionals, Elsevier, Florida.
Johns, Christopher, 2002, Guided Reflection: Research in Practice, Blackwell Publishing, Perth.
Johns, Christopher and Freshwater, Dawn, 1998, Transforming Nursing Through Reflective Practice. Blackwell, Perth.
Quinn, Francis M. 2000, The Principles and Practice of Nurse Education, 4rth ed., Nelson Thorne, London.
Slevin, Oliver and Basford, Lynn, 2003, Theory and Practice of Nursing: An Integrated Approach to Caring Practice, Nelson Thomas, London.
Taylor Beverly, 2000, Reflective Practice: A guide for Nurses and Midwives, Allen and Unwin, St. Leonard.
Watkins, Dianne, Edwards, Judy and Gastrell, Pam, 2003, Community Health Nursing: Frameworks for Practice, Elsevier Sciences, Orlando.