The Advanced Practice Nurse Role
An advanced practice nurse is a nurse with advanced didactic and clinical education. Whether they are nurse practitioners, clinical nurse specialists, nurse anesthetists, or nurse midwives, play a pivotal role in the future of health care. APNs are often primary care providers and are at the forefront of providing preventative care to the public. Because of different title they can have, their role can be very confusing; mostly in defining their role as practitioners or as researcher. The groundwork of nursing is evidence base practice; which open opportunities for APNs to be in research studies. Nurses tend to avoid research because of lack of knowledge or simply not aware about the fields. It is vital that nurses be more involved in research because it will help the profession to evolve better. Therefore training and educational opportunities should be available to enable nurses to progress in career like clinical, medical, or nursing research. As a result, experienced nurses as well as novice nurse researchers will play a more active role in educating and motivating others to not only apply research that was conducted by others, but to be involve in research which in turn will be incorporated in their daily practice.
Advanced practice nurses are taking their place in the forefront of the rapidly changing health care system, developing an innumerable of roles in organizations that aim to provide cost-effective, quality care. Due to the variety of specialty under the APN umbrella it becomes confusing to define APN and their role. The International Council of Nurses (ICN) defines Advance Practice Nurse (APN) as “a Registered Nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice; the characteristics of which are shaped by the context and/or country in which she is credentialed to practice.” http://icn-apnetwork.org/. Hamric, Spross, and Hanson( 2009) state that: the State Nursing Practice Act uses APNs to refer to Nurse Practitioners (NPs), Clinical Nurse Specialist (CNSs), nurse anesthesiologist (CRNAs), and Nurse Midwife (CNMs). In spite of the title or area of practice, it is obvious that research is important in healthcare practice nowadays. In this paper, a general overview of the role of research in healthcare will be presented, which then will follow by the different roles of the APN in research. Also, a look at some of the literatures that outlines the current trends in APN research activities will also be elaborated. The advantages and disadvantages of research will be presented.
According to Hamric, Spross, and Hanson (2009), research is one of the core competencies of advanced practice nursing, and research skills are imperative for the Advanced Practice Nurse (APN) to be able to fulfill their roles. The core APN research competency has three individual competencies: interpretation and use of research findings and other in clinical decision making, evaluation of practice, and participation in collaborative research (Hamric et al., 2009). There is different level of Core competency which shows exactly what APNs can be involved in during their practice. For example, Core competency I is demonstrated by the APNs when they make practical decision that is based on the best and most current evidence which helps them to develop and promote changes in practice based on evidence. According to Hamric et al. (2009) the Evidence Based Practice (EBP) process involves understanding the clinical issue and being able to state the problem, followed by finding, evaluating, and synthesizing the evidence in order to make a decision or recommendation based on the evidence. Secondly, there is Core competency II which is very important to the APN practice because it can provide evidence to support the care provided. Lastly, in the Core competency III the APN needs to be involved in nursing or interdisciplinary research studies in order to generate knowledge. Hamric et al. (2009) report that regardless of the APNs’ work setting or responsibilities, they must apply competency III because it has a fundamental and an expanded level needed for the profession. For example, in the fundamental level, the APN who has a master’s degree can function as a consultant or clinical expert to a study. Even after the completion of DNP program, the APN is still in the fundamental level. Furthermore, the expanded level is obtained after many years of practical experience in research or it can also be after graduating from a PhD program. Once the APN is at that level, he or she is the perfect candidate for the position of Principal Investigator (PI) or co-Investigator (Hamric et al., 2009). Therefore, APNs can be involved in a wide range of research activities, and they can be a good contribution by making valuable contributions to all the phases of the research process.
The APN can be a research nurse or a nurse researcher; these two terms can be very confusing and people may use one for the other. However, after exploring those two terms carefully, it will be evident that they are not at all the same. For instance, the research nurse can be research coordinators, data managers/collectors, research assistant who works under the supervision of a medical practitioner (Richardson, 2005). Moreover, the work of the research nurse does not necessarily contribute to the advancement of the nursing profession as the majority of the studies are non-nursing. On the other hand, the nurse researcher can be a Principal Investigator (PI) as well as an Assistant Investigator (AI). A PI is a credentialed member of the medical, nursing, pharmacy or psychology staff. This is the kind of nurse who is responsible for the design, conduct, and oversight of research protocols. The role is to ensure the protection of human subjects, the integrity of the informed consent process, and analysis of research data. Rosenzweig, Bender, and Brufsky (2005) report that doctorally prepared nurses are uniquely positioned for the role of PI in pharmaceutical trials. Nurses with appropriate preparation and partnership with a physician listed as a co-investigator are permitted to be principal investigators of clinical trials involving medications (Rosenzweig et al. 2005). In addition, an AI is a credentialed member of the medical, nursing, pharmacy staff who supports the conduct of protocols. http://oma.od.nih.gov/manualchapters/intramural/3014/. Gardner, Webster, and Geary (2010) reported that the role of a nurse researcher is to conduct and facilitate nursing-oriented research, rather than simply providing support for research conducted by others. They also state that nurse researchers need to have post graduate qualifications; however, knowledge and or experience of research is not necessarily a requirement for research nurses’ positions.
Graduate Education, Mentorship and access to funding according to Edwards, Webber, Mill, Kahwa, and Roelofs (2009) are enablers that can help strengthen nursing research capacity, as with other disciplines, graduate education prepares nurses to better use and conduct research. Unfortunately, a lack of graduate training contributes to inadequate requisite knowledge and skills to initiate research compete for funding knowledge (Edwards et al., 2009). Because of the tendency to undervalue nursing research, there is a perception that nursing research lacks importance resulting in underfunding by national granting (Edwards et al. 2009). The other issue is that the private research sponsors such as the pharmaceutical companies and the medical device manufactures tend to target physicians as their Principal Investigators for efficacy and effectiveness trials along with biomedical scientists. They tend to leave APNs out of a very profitable area of research.
Weyer and Werner (2010) present the concept of Practice Based Research Network (PBRN).
PRBNs enable research to be conducted in ambulatory primary care setting where most patients receive their healthcare. Historically, PRBNs have been led by physician; advanced practice led PRBNs have emerged within the past few years (Weyer and Werner 2010). As the role of the NP continues to evolve in response to the changing healthcare environment, Weyer and Werner propose that PBRNs offer NPs the opportunity to participate in the discovery of new knowledge (research) and the translation of the new knowledge into clinical practice.
Wallerstedt, Sangare, Bartlett, and Mahoney (2009) conducted a study with the purpose of the study was to characterize the role of APNs particularly Nurse Practitioners (NPs) in the practice setting of the NIH. NIH NPs combine clinical research responsibilities with the provision of comprehensive medical management to patients enrolled in NIH protocols, blending: clinical, research, educational, and administrative task into a unique multifaceted role. Many of the NPs served as AIs; the goal of the NIH NP group is to work toward developing collaborative relationships and to initiate research protocols with NPs as lead investigators ( Wallerstedt et al., 2009)
Chan, Gardner, Webster, and Geary (2010) conducted a study to examine the nurse researcher role of the nurse researcher in the Nurse Researcher Project (NRP). The nurse researcher project first started to support development of a nursing research and evidence based practice culture in cancer care services in a large tertiary hospital in Australia. The role of the nurse researcher was to conduct primary research and systematic reviews with the goal to address pertinent clinical issues, promote evidence base nursing and supervise clinical nurses in their research activities. It was found that: the nurse researchers were able a crucial role in the advancement of nursing knowledge. Also, it facilitate the evidence based practice because it was placed to support a specialized team of nursing at a service level.
Nowadays, The evolution of nursing services is evident, a new generation of nurse leaders are required to provide evidence to justify charges. Continual development and utilization of research knowledge in nursing practice is necessary to respond to the contemporary changes in the environment. Nursing research has historically been seen as the responsibility of nurse academics. Nurses wanting a career in research have been traditionally employed in the position of research nurses, assistants, trial coordinators or data collectors to conduct research under the supervision of a medical practitioner (Richardson, 2005); but this is all changing with the current trend of APN working as PI, or AI in multiple settings.
Research is crucial to the development of healthcare in general, particularly in nursing; the importance of research is recognized increasingly. For a novice RN, the role of the nurse researcher can be a good career choice. However, Advanced Practice nurses (APN) need to be more involved in research under the supervision of a nurse researcher. The nurse researcher is a more suitable role for an APN because it synchronizes with the roles of the APNs as clinicians, leaders and educators. From the review of diverse literatures, the evidence is clear that there are a lot of research opportunities for APNs to explore. Unfortunately, this information is known to only a few APN.
The Evident Base Practice (EBP) is a requirement to the current trend in healthcare. Research is important to the practice of the APNs because it provides the evidence that has been tested and can be used which then can be applied in patient care. Research is very important to the nursing profession, for it helps to set the standards, guidelines, policies and procedures. Applying Proven Outcomes (APO) means that a practitioner is using evidence based on interventions. According to McSherry at al. (2006), Evidence Based Practice (EBP) is done by the combination of social, political and professional factors. Politically, helps the practitioner to save time and money. Furthermore, The APN has access to protocols and treatment plan which enable them to prescribe or follow what have already been proven to be effective. The use of EBP can also facilitate the patients and 3rd party payers to save money which then can lead to good patient’s outcome. Being able to use Evidence Based Guidelines can influence the reimbursement positively because it will give the APN will have guidelines to justify their clinical decisions.
The application of research findings through Evidence Based Practice (EBP) is very crucial when it comes to the reimbursement of APNs for their services. In addition, There was a law passed by Congress about Medicare regarding reimbursement for Nurse Practitioner. This law was signed by the president on August 1997, it stated that regardless of the area of practice, “Nurse Practitioners are being reimbursed at the rate of 80% of the lesser of the actual charge or 85% of the fee schedule amount for physicians (Section 1848).” “Medicare reimbursement fact sheet”. It is in the APNs’ best interest to continue to be involved in research because it will show their importance in the healthcare system. In addition, more outcome studies are needed to support the already proven fact that shows that the APNs’ care is comparable or similar to the physicians’. Therefore, they can still continue to argue or to push for 100% reimbursement for APN services. Also, APNs’ involvements need to be more visible in pharmaceutical trials because pharmaceutical studies are very profitable; of course, it will be beneficial for the APNs as they gain the experience needed on medical trials. It will also help them to develop a relationship with the organizations that conduct those studies. As a result, it will open doors for other APNs to take on the role of PI in pharmaceutical trials which in turn will give APN more confidence.