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Advanced Practice Nursing Interview- Week 4

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Jill Castro

on 22 April 2014

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Transcript of Advanced Practice Nursing Interview- Week 4

Advanced Practice Nursing Interviews
Introduction
INTERVIEW QUESTIONS

Progression from Novice to Expert
INTERVIEW QUESTIONS

Direct & Indirect Clinical Practice
Common Themes Discovered Among APRN's
Stephanie Albers
Sommer Mattingly
Morgan Montez
Becca Newberry
Jill Castro

NPR/505
May 31, 2013
Gwen Wodiuk

INTERVIEW QUESTIONS

Role of the APRN
1.) Compare/Contrast your definition of an APRN to your current work setting roles and responsibilities.

2.) Do you believe your current position/organization utilizes your full potential as an APRN?

3.) Describe any necessary changes that could assist in enhancing your relationship between members of the interdisciplinary team, particularly APRN and physicians.
INTERVIEW QUESTIONS

Professional Background and
Experience
1.) Describe your work experience prior to pursuing an advanced practice degree.

2.) Describe how your previous nursing experience prepared you for your new role as an APRN.
Pre-Interview Research
1.) Compare the confidence you felt in your last nursing role to that of your first six months as an APRN.

2.) How long before you felt confident in your new role and what milestones marked this achievement?

3.) Did you have a mentor to help guide you in your role transition? If not, do you believe a mentor would have been beneficial to your professional development as a novice APRN?
1.) Describe your clinical practice setting and direct patient care responsibilities.

2.) What are some example of indirect patient care that you provide on a daily basis? How do these influence your patient outcomes?
APRN scope and role is under utilized.
References
Differences Discovered Among APRNs
Conclusion
Pre-Interview Research
Pre-Interview Research
Rationale for Questions
New grad NPs commonly experience:
Anxiety related to time management and utilization of new skills
Insecurity
Role ambiguity (RN vs NP vs MD)

Suggestions for practice:
Mentorship
System/Organization support
http://search.proquest.com/docview/203975982?accountid=35812

Cahill, M., & Hysong, A. (2012, October). Moving forward with role
recognition for Clinical Nurse Specialists. Journal of Nursing
Regulation, 3(3), 47-50.

Kelly, N., PhD. & Mathews, M. (2001). The transition to first position as
nurse practitioner. Journal of Nursing Education, 40(4), 156-62.
Retrieved from
http://search.proquest.com/docview/203975982?accountid=35812

Jones, T.S., & Fitzpatrick, J.J. (2009, December).
CRNA-physician collaboration in anesthesia. AANA Journal, 77(6), 431-436.

Latham, C. L. & Fahey, L. J. (2006). Novice to expert advanced practice
nurse role transition: Guided student self-reflection. Journal of Nursing Education, 45(1), 46-48.

Quaal, S.J. (1999, February). Clinical nurse specialist: Role restructuring
to advanced practice registered nurse. Critical Care Nursing Quarterly, 21(4), 37-41.
APRN Interviewees
Adult Nurse Practitioner (ANP)
Mayo Clinic Hospital - Organ Transplant

Clinical Nurse Specialist (CNS)
Mayo Clinic Hospital - Transplant/Intermediate Care Unit
Adult Nurse Practitioner
Hospice of Arizona - Hospice and Palliative

Certified Registered Nurse Anesthetist (CRNA)
Baylor All Saints- Fort Worth, TX
Family Nurse Practitioner (FNP)
Red Mountain Med Spa, Glendale, AZ

Clinical Nurse Specialist
Banner Good Samaritan Hospital-
Women Infant Service (WIS)
"APN Novice to Expert Paper"
Used "Benner’s (1984) concepts of novice to expert nursing practice and eight advanced practice roles purported by Hamric, Spross, and Hanson, (2000)"
Method to encourage positive role development
Identify their competencies, professional self-efficacy and feelings, and future educational needs
Self Evaluation Tool
Novice Advance Practice Nurses
Experience a lack of self confidence and hesitation
(Latham & Faherty, 2006, p. 46)
FNP:
Red Mountain Med Spa
CNS:
Women Infant Services
Banner Good Samaritan
Intern
St. Joe's neuro 3yrs
BSN: ASU
St. Joe's neuro 5yrs
FNP: UofP
St. Joe's neuro 2yrs
10 yrs experience prior to achieving FNP
Experience:
CRNA:
Baylor All Saints: Fort Worth, TX
Experience:
11 yrs as a Paramedic with 3 of those yrs being a flight medic.
1 yr. ICU
2 yrs. of ER
2.5 yrs. Flight Nurse
Preparation for New Role:
Understanding of hospital system and the different agencies within it to provide care on multiple levels.
Exposure to communicating
with different agencies.
FNP:
Red Mountain Med Spa
CNS:
Women Infant Services
Banner Good Samaritan
First 6 months:
Confidence decreased
Nervous to be responsible for patient care/life
Time Frame for Confidence in
New Role as APN:
3 years: didn't have to review resources consistently
Seen as a resource for other NP's
Utilizes CEU's to maintain competencies
Received scholarship IOMSN organization
Certified in specialty: Multiple Sclerosis
Spoke at conferences
Educated community
FNP:
Red Mountain Med Spa
CNS:
Women Infant Services
Banner Good Samaritan
CRNA: Baylor All Saints:
Fort Worth, TX
First 6 months:
Time Frame for Confidence in New Role as APN:
Felt more confident in new role than as a RN.
Enjoyed the autonomy.
Ability to practice within new scope using experience and training as a guide.
Few months to transition.
Excelled in new role
Approached to be a leader to others.
FNP:
Red Mountain Med Spa
CNS:
Women Infant Services
Banner Good Samaritan
Mentor:
Did not have mentor
Feels some could benefit from one
Allows for transition at a steadier pace.
CRNA: Baylor All Saints:
Fort Worth, TX
CRNA:
Baylor All Saints:
Fort Worth, TX
Direct Clinical Practices:
Indirect Clinical Practices
Overall patient safety
Antibiotics prior to surgical incision
Safe airway
Hemodynamic management
Postoperative pain management
Aid in reversing, limiting, and correcting any adverse occurrence while providing safe and effective anesthesia
Include family and ensure full understanding of procedure prior to being done.
Explain what to expect, length of time, patient state in recovery, what their role will be, where patient will be going after recovery (ex. ICU).
Patient Outcomes
Alleviate family and patient stress: providing knowledge in order to gain a sense of control.
Promoting a happier family in order to support patient: leads to better outcomes.
Compare/Contrast APRN Definition to Current Role/Responsibilities:
Current Utilization of APRN Potential:
Necessary Changes/
Area for Improvement:
Does NOT use CRNA's to full potential
Sufficient experience in multiple fields of healthcare before obtaining education and training within a specialty.
Hold's APRN's to a higher degree
Scope of practice is larger
More responsibility and autonomy than an RN.
Communication & Teaching (scope, skills, and training)
Adult Nurse Practitioner
Hospice of AZ
Worked as a critical care nurse for 22 yrs.
Some experience as a flight RN.
Some experience as OR RN.
Past experience provided a solid foundation to assess, treat, and teach patients.
Adult Nurse Practitioner
Hospice of AZ
Had more confidence as RN than NP.
Most positions held where in specialty areas with limited scope.
Experience:
RN: Banner Good Samaritan Medical Center (BGSMC)
8 yrs Gyn, Oncology & Med Surg
6 yrs L&D, Antepartum, Postpartum
7 yrs Hospital Registry
Educator: BGSMC
4 yrs Women Infant Service
Case Management: BGSMC
5 yrs Women Infant Service
Clinical Nurse Specialist: BGSMC
9 yrs Women Infant Service
Preparation for New Role:
Work/School experience
Professional Memberships
Conferences
Novice for 2 yrs
High risk obstetrical physicians mentoring
Preparation for New Role:
School/Work experience
Big fish in small pond vs.
small fish in big pond
Cheat sheets & Epocrates
Novice for 2-3 yrs
Worked at Indian health services
Excellent Physician, NP and PA mentors/
teachers.
Hospice of AZ NP
Direct Clinical Practices & Responsibilities:
Direct Clinical Practices:
Performs face to face evaluations for hospice patients, initial histories and physicals.
Participates in interdisciplinary team meetings
Acts as a resource for case managers, admit RN's when they need guidance or advice.
Work with NP's, MD, & DO at a Medical Spa
Focus: Bariatric/weight loss; provides bioidentical hormone
Evaluate, counsel, educate, manage, & administer medications
Collaborate with pt's PCP's
Refer patients to specialist r/t screening results
Laser tx's, botox, fillers, & fat/cellulite reduction procedures
Hospice of Arizona NP
Utilizes assessment skills
Limited management opportunities
Limited billing capabilities
Indirect Clinical Practices:
Necessary changes/Areas for Improvement:
Oversee/manage 5-6 medical assistants in the office
Sees approx 40-70 pt's in 8-11hr/day
Protocols/Policies to ensure 5 sites are practicing universally
Has access to 2 physicians at all times
Can manage pt.'s within scope but cannot bill for it.
Medical director is the only one who can bill for service. Due to state not allowing NP's to be
medical directors and HOA not willing to
restructure the billing process.
CEU's, conferences, biannual company
provider meetings
CNS: Mayo Clinic Transplant/Intermediate Unit
Experience:
Preparation for New Role:
Current Utilization of APRN Potential:
I do believe that I am utilized to my full potential as an APRN
Current Utilization of APRN Potential:
Necessary Changes/Areas of Improvement:
Having more frequent meetings
Enhance relationships among team members
Compare/Contrast APRN Definition to
Current Role/Responsibilities:
Compare/Contrast APRN Definition to Current Role/Responsibilities:
Graduated in 2002 and worked in ortho for 2 years
Earned a Master's degree in nursing and then became a nurse educator in 2005.
In 2010 she accepted the role as a CNS position and then earned the certificate while being mentored by other CNS's in the institution.
Role as nurse educator was very valuable to prepare her for the CNS role
Learned the ins and outs of nursing competency, adult learning theory, and evidence-based practice.
Had the opportunity to meet other people in the institution and gave her a bigger picture image of what nursing roles existed within the organization
CNS: Mayo Clinic Transplant/Intermediate Unit
First 6 months:
Role as a bedside nurse is much more well-defined than that of a CNS.
Time Frame for Confidence in New Role as APRN:
Received frequent feedback from other mentors and when she started to have ideas similar to her mentors she gained confidence.
Becoming confident in her recommendations was a significant milestone.
CNS: Mayo Clinic Transplant/Intermediate Unit
Direct Clinical Practice:
Supports intermediate and med-surg nursing unit
Attends transplant rounds regularly and consults with physicians and nurses on the treatment plans of individual patients
Assists Transplant Nurse Coordinators with work flows to enhance the discharge and outpatient management of transplant recipients
Indirect Clinical Practices:
Standardized patient education
Variety of organizational practices
Pharmacy interventions to represent nursing in the medication administration procedure
Makes sure we are up to date with regulatory bodies
Chair of the Nursing Research and Evidence Based Practice Subcommittee
CNS: Mayo Clinic Intermediate/Transplant Unit
Compare/Contrast APRN Definition to Current Role/Responsibilities:
She believes the CNS role could be better utilized in driving care for patients
The CNS role at the Mayo Clinic is less about direct patient care and more about driving practice changes and guidelines, which is very different from other APRN roles.
Technically, she operates in three spheres such as: patient, nurse, and organization, but feels the organizational sphere is the most time consuming and the others are only utilized when other areas have been exhausted
(J. Pearson, personal communication, May 28, 2013)
(J. Pearson, personal communication, May 28, 2013)
Necessary Changes/Areas for Improvement:
Believes the CNS role could be more widely used to include more direct patient care
The CNS role is not well-understood by physicians, therefore, they cannot utilized them to their full potential; having more opportunities for work partnerships would help build this relationship
First 6 months:
Difficulty transitioning into new role
Had to educate staff and physicians regarding the role of a CNS.
Time Frame for Confidence in New Role as APN:
1 year: felt comfortable in new role due to past work experience as staff nurse and educator in specialty area.
Developed/Published research projects.
Presented at national & state level conferences.
Mentored numerous evidence based projects
Certified in specialty: high risk obstetrics
Involved within the community
Primarily clinical resource in the facilitation of a patient centered nursing care in women and infant services (WIS).
Coaching, education, consultation, research, collaboration,and leadership to optimize the care of the obstetrical population.
Utilize research, process improvement,and interdisciplinary collaboration to promote quality care.
Policy & Procedures: Update according to current literature and research.
Indirect Clinical Practices:
Mentors staff
Attends & presents at conferences
Networks with colleagues across the institution and community to bring best practices to the bedside
At the beginning I was not utilized to my full potential; misunderstanding of role.
Currently I am utilized to my full potential.
The CNS is an RN with a Master’s Degree in clinical nursing and an expert in a specific specialty.
The CNS role is to improve patient care and influence others.
Specialty-focused clinical expertise
Educating healthcare workers, providers,& community the role
Necessary Changes/Areas for Improvement:
An APRN is a nurse who is master's prepared in clinical nursing and provide patient care with the ultimate goal of creating the best possible outcome.
Direct Clinical Practices:
Indirect Clinical Practices:
Compare/Contrast APRN Definition
to Current Role/Responsibilities:
CRNA-Physician Collaboration in Anesthesia
Respect for, and recognition of, each group member's knowledge and judgment is a prerequisite to collaboration (Jones & Fitzpatrick, 2009, p. 431).
Stress linked with occupational stress, scope of practice, and collaboration with anesthesia practice types.
Satisfying job demands with unclear expectations, lack of autonomy, and limited scope of practice.
Need for mutual respect for each member's knowledge base.
Most CRNA's working in ACT models, the need to
address issues of collaboration from conflicting expectations and poor communication.
(Jones & Fitzpatrick, 2009, p. 431-435).
Moving Forward with Role Recognition for Clinical Nurse Specialists:
(Cahill & Hysong, 2012, p. 47-49.)
Pre-Interview Research
Consensus Model for APRN Regulation: 5 states have adopted all the major elements for full implementation.

Model hinges on all boards of nursing recognizing the four distinct roles.

CNP and CNM recognized in all US jurisdictions; CRNA recognized in all but four; CNS not recognized in 10.

Challenges for CNS role: varied regulatory requirements, APRN preparation/requirements, inconsistent scope of practice.

Board of Nursing vs. state legislation

"Variety in practice focus and settings as well as regional variation in recognition and licensure have created a considerable spread in
the diversity of roles occupied by those education as CNS's"
(Cahill & Hysong, 2012, p. 49).
According to Quaal (1999), CNS role has blended with the NP role to:
increase public and political acceptance of the APRN
enhance educational credibility
present a unified group of nurses
expand roles
The questions we asked dove into the role of each APRN and his or her perception of how the role functions in their current workplace.

Quaal (1999) describes the traditional role of the APRN as:
"providing primary health care to patients in diverse settings, focusing on health promotion, disease prevention, health maintenance, illness and disability minimization" (p.39).
Increased public awareness is needed regarding APRN role.
APRN's are highly involved with patient and family education.
Need for National Standards and scope of practice for each individual APRN role.
Increased education within the healthcare system regarding APRN's different roles and scope of practice.
Need for increased communication and collaboration with physicians.
APRNs interviewed all work in a variety of capacities.
APRN utilizes the core competencies differently within each of their roles.
Level of comfort transitioning from role of
RN to APRN varied depending on prior experience and mentoring.
Different levels of direct and indirect patient care.
Majority of APRN felt they were not
utilized to the full capacity of their scope,
with the exception of one NP.
(J. Pearson, personal communication, May 28, 2013)
"APRNs provide primary healthcare to patients in diverse settings, focusing on health promotion, disease prevention,
health maintenance, illness, and disability minimization" (Quaal, 1999, p. 39).
Appropriate utilization of the APRN within the healthcare system is essential for the future expansion of the APRN role.
Making the APRN role all encompassing will help
to unify the role, establish political power and
public awareness.
The success of The Consensus Model hinges on
the ability for national legislation as well as
individual states to agree on the elements
for each role.
Adult NP:
Mayo Clinic Transplant Service
RN Mayo Clinic Hospital:
3 years Adult ICU
3 years PACU
Experience:
Preparation for New Role:
Mayo Clinic Hospital: Second largest transplant center in SW
Mayo ICU and PACU provided opportunity to care for pre and post transplant patients in varying stages of illness
Familiarity with members of transplant service eased role transition
(S. Perez, personal communication, May 28, 2013)
Adult NP:
Mayo Clinic Transplant Service
First 6 months:
Loss of confidence
Self-doubt
Many questions, less comfortable making independent decisions
Time Frame for Confidence in New Role as APRN:
Approximately 1 year: Confident in clinical decisions, rarely needed to consult with Attending MD
Mentor:
No formal mentor
Did not work independently until comfortable
Always had senior leadership to consult
(S. Perez, personal communication, May 28, 2013)
Adult NP:
Mayo Clinic Transplant Service
Direct Clinical Practices:
Manage patients hospitalized because of complications related to organ failure and post transplant (non-ICU)
Daily rounding/assessing progress
Treating complications
Ordering medications, lab work, and other diagnostics
Indirect Clinical Practice
Consultation with other clinicians to ensure patients receive necessary clinical intervention
Collaboration with pharmacists, bedside nurses, physical therapy, radiologists, and several other services within the hospital setting to ensure holistic approach
Family/community education
Participation in transplant candidacy evaluations
Adult NP:
Mayo Clinic Transplant Service
Compare/Contrast APRN Definition to Current Role/Responsibilities:
Works independently and autonomously
Given freedom to treat patients in a medical setting, incorporating nursing values
Hospital setting vs. outpatient: orders must be signed off by attending MD
Not “primary” provider for patients
Hospital setting creates pyramid with MD at the top: Source of frustration,“comes with the territory”
Necessary Changes/Areas for Improvement:
MDs should be more familiar with NP role/scope of practice; NPs can and should be utilized to greater capacity
S. Perez, personal communication, May 28, 2013
Mentor:
Mentor: MD Consulted: other NP's
First 6 months:
Time Frame for Confidence in New Role as APRN:
Mentor:
Having a mentor(s) at beginning of APRN
role would have helped with confidence.
Mentor:
Mentoring from other CNS's in the organization helped her confidence
grow (3 years)
Mentor:
Experience:
Preparation for New Role:
Current Utilization of APRN Potential:
NP's not used to full potential of role.
Current Utilization of APRN Potential:
She believes the APRN role is not utilized to its full potential.
(P. Leguizamon personal communication, May 25th, 2013)
(P. Leguizamon, personal communication, May 25th, 2013).
(P.Leguizamon, personal communication, May 25th, 2013)
(P. Leguizamon, personal communication, May 25, 2013)
(A. Pena personal communication, May 24, 2013)
(A. Pena personal communication, May 26, 2013)
(A. Pena personal communication, May 26, 2013)
(C. Tussey personal communication, May 28,2013)
(A. Pena personal communication, May 26, 2013)
(C. Tussey personal communication, May 28,2013)
Current Utilization of APRN Potential
Current work setting embodies what it is to be a nurse practitioner; although not utilized to full potential
Did not have a specific mentor
Consulted CNS's in other departments
Consulted with administrators, physicians, & management team
(C. tussey personal communication, May 28, 2013)
(C. Tussey personal communication, May 28, 2013)
(W. Crane, personal communication, May 27, 2013)
(W. Crane, personal communication, May 27, 2013)
(W. Crane, personal communication, May 27, 2013)
(W. Crane, personal communication, May 27, 2013)
(W. Crane, personal communication, May 27, 2013)
S. Perez, personal communication, May 28, 2013
(J. Pearson, personal communication, May 28, 2013)
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