Nursing Outcomes in Advanced Practice

Michelle Beauchesne, DNSc, RN,CPNP Fellow, National Academy of Practice

Fellow, American Academy of Nurse

Practitioners

Associate Professor & PNP Coordinator

Northeastern University, Boston, MA, USA

Engage Experience Excel

Boston February 6, 2009

What are outcomes?

End result of care

Measurable change in health status or behavior

A desired condition

A measurable patient goal

 Nursing Outcome 

The measure or status of a nursing 

diagnosis at points in time after a 

nursing intervention

ICNP® 2001

Why do we need outcome data?

Accountability

Regulatory bodies

Evidence Based Practice/ Guidelines

Consumer demand

Policy driven

Societal perspective

2 important questions

What is to be measured and why?

What result are you seeking and when?

What? Issues in Defining Nursing

Benchmark dataNot sensitive to nursing care

Team practice Whole vs individual

Bundling costs and resources All inclusive

Next : How do we define advanced practice?

Definition:Advanced Practice Nursing

Nurse Practitioner/Advanced Practice Nurse is 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 s/he is credentialed to practice. A master's degree is recommended for entry level.

International Council of Nursing Nurse Practitioner/Advanced Practice Network (ICNNP/APN)

The Problem

A recent survey among 18 countries, conducted by the International Nurse Practitioner/ Advanced Practice Nursing Network (INP/APNN) of the International Council of Nursing identified:

14 different titles existed for the APN role Majority (75%) had formal recognition of the APN role 58% had formal APN education programs 52% had licensure requirements, showcasing developing

acknowledgement of the APN as an official advanced role for nursing practice

Examples of Early Advance Practice Nursing

Outcome Research• Florence Nightingale: Modern Nursing

• First outcome data• First nurse managed

Hospitals• First environmentalist• First public health

nurse

Do No Harm

Cheaper to keep well than cure illness!

Early Nursing Outcome Research Informs

Policy• Lillian Wald (1867-1940)

• Visiting Nurses Service 1893• Henry Street Settlement House 1895• Nursing Insurance Partnership 1909• Federal Children’s Bureau 1912

• Esther Lucile Brown ( 1898-1990)• Social Anthropologist PhD Yale 1929• Russell Sage Foundation 1930• “The Brown Report”• 1948, ''Nursing for the Future''

Mary Adelaide Nutting1858-1948

World's First Professor of Nursing 1910 Teachers College at Columbia University in New York City

1918 Shared with the Rockefeller Foundation her dream of seeing basic education for nurses established in universities

Resulted in formation of the Committee for the Study of Nursing Education, which released the 500-page study Nursing and Nursing Education in the United States in 1922. (aka The Goldmark Report for its author, Josephine Goldmark)

Authored with Lavina Dock, 4 volume History of Nursing

All before the Vote!!!!!

American Nurses Association (ANA) Congress of Nursing

Practice, 1974

Definitions of Advanced Practice Roles:

• Nurse Anesthetist

• Nurse Midwife

• Clinical Nurse Specialist

• Nurse Practitioner

Historical Review• Sister Mary Bernard St.

Vincent’s Hospital Erie, PA 1st Nurse Anesthetist 1877

Agatha Hodgins1st NA program Ohio 1914

AANA 1931

• Mary Breckenridge British-Trained

Nurse-Midwife Frontier Nursing School and Service 1925

AANM 1929

Frances Reiter

• 1943• “Nurse-Clinician”• Designated a nurse with advanced

clinical competence

Clinical Nurse Specialist

• Adelaide A. Mayo, editor• American Journal of Nursing• 1944

1st Clinical Nurse Specialist Program

• Hildegard Peplau• Rutgers University, New Jersey• 1954• Psychiatric Nursing- Master’s Level• NACNS 1995

1st Nurse Practitioner Programs

• Pediatric Nurse Practitioner• Loretta Ford & Henry Silver• University of Colorado 1965• NAPNAP

• Adult/Family Nurse Practitioner 1971• AANP• ACNP

• Neonatal Nurse Practitioner 1977• Acute Care Nurse Practitioner

• 1995 Adult• 2005 Pediatric

APN Outcome Studies

CRNAs

Alice MaGaw 1899

1st outcome study Northwestern Lancet

CNMWs

UCSF PEW Health Professions 1998

14 recommendations to improve practice

CNS

Dayhoff & Lyon 2001 CNS defined by role

1st NP Outcome Study

• The University of Colorado PNP Demonstration Project 1965

• Purpose: To prepare professional nurses to provide comprehensive well-child care as well as manage common childhood health problems.

• Emphasis: Family dynamics and community cultural values.

• Focus: Shift from care of medical illness to a strong family oriented health promotive approach.

Factors Influencing US Nurse Practitioner Development

• Nurse Training Acts• Public Health Nursing• Primary Care Physician

Shortage• Trend Toward Medical

Specialization• Consumer Movement• Women’s Movement

• Needs within the population

• Nursing profession• Health-care delivery

system• Emphasis on primary

health care

Landmark Outcomes Study

Committee of the Secretary of Health, Education, and Welfare

Report, 1971Purpose:• to study extended roles for nurses• to evaluate feasibility of expanding

nursing practice

Significant Conclusions

• Extending the scope of the nurse’s role was essential to providing equal access to health care for all consumers.

• Need to establish innovative curricular designs in health science centers with increased financial support for nursing education.

• Need to advocate for commonality of nursing licensure and certification, including a model nursing practice law suitable for national application.

• Need for research related to cost-benefit analyses and attitudinal surveys to assess impact of new role.

Loretta Ford 1991

“The nurse practitioner movement is one of the finest demonstrations of how nurses exploited trends in the larger health care system to advance their own professional agenda and to realize their great potential to serve society.”

Challenges in Outcomes Research 40 years later

• Ambiguity over role definition still exists• Historically lack of unity in requirements for

entry into programs• Variations in degree received• Debate over setting for and length of program

• Certificate, MS, now DNP

• Scope of practice (State vs Federal in US)

Standardization of Educational Preparation for Nurse Practitioners

1979 - 124 certificate programs, 74 master’s

1990 - 11 certificate programs, 84 master’s programs

2005 - 2 certificate programs 400+ master’s

2007 - 11 DNP programs

2015 - DNP all NP programs

Standards & Guidelines

AACN Masters Essentials (1996)

` To establish a unifying framework for APN curricula through the identification of a “common educational core”

Advanced Nursing Practice:Building Curriculum

for Quality NP Education (2002)

Common Features of APN Graduate Education

• The Graduate Nursing Core: generic to all master’s nursing degrees

• The Advanced Practice Nursing Core: generic to all advanced nursing practice

• The specialty role core specific to each APN role

Graduate Core Curriculum Content

I. Research

II. Policy organization and financing of health care

a. Health care policy

b. Organization of the health care delivery system

c. Health care financing

III. Ethics

IV. Professional Role Development

V. Theoretical Foundations of Nursing Practice

VI. Human Diversity and Social Issues

VII. Health Promotion and Disease Prevention

APN Core Curriculum

• Advanced Health/Physical Assessment• Advanced Physiology/Pathophysiology• Advanced Pharmacology

Specialty Curriculum

• Process of Clinical Decision Making• Complex or Advanced Nursing

Interventions• Health Promotion/Disease Prevention• Epidemiology• Role Differentiation• Interpersonal and Family Theory

APN Curriculum Framework and Competencies

National Organization of Nurse Practitioner Faculties (NONPF) 2006

Seven Domains of Practice

1.* Management of Client Health/Illness Status

2. The Nurse-Client Relationship

3. The Teaching-Coaching Function

4. Professional Role

5.* Managing and Negotiating Health Care Delivery Systems

6. *Monitoring and Ensuring the Quality of Health Care Practice

7. Cultural and Spiritual competency

Sample NP Skills & Functions

• screening• physical and psychosocial assessment• management of common health problems• follow-up• continuity of care• health promotion• problem-centered services• identification and mobilization of resources• health education• client and group advocacy* All are aspects of Primary, Secondary, Tertiary Care

Avedis Donabedian’s Quality of Care Model

StructureProcessOutcomes

Supports federal government’s sponsorship of Professional Standards Review Organizations (PSRO's) & Continuing Quality Improvement (CQI)

Science, Vol 200, Issue 4344, 856-864Copyright © 1978 by American Association for the Advancement of Science

Quality of Care

The degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge

Institute of Medicine (IOM) 1990

Challenges to Nursing Outcome Research

Patient autonomyMultiplicity of individual’s health problemsNonclinical characteristicsMultiplicity of providersUnknown time between interventions and outcomesLack of baseline measurementsComplexity of variables

Additional Problems

Relative insensitivity of outcomesFinal outcomes not known until too lateOutcomes can be influenced by outside factorsInformation about outcomes not readily availableFew lists of valid effectiveness criteria and measurements

Nugent & Lambert 1997

Variance in OutcomesNot met at allMet later than expectedMet ahead of time

Variance Positive Negative

Classification of Variance System Provider Client

Murray & Anderson 2000, Murray & Lindgren 2001

Questions to guide outcome research

Which outcomes are most important?To whom are they important?How are they defined?How should they be measured?Who is accountable for achieving them?

Minnick 2001

Outcomes Measures(Indicators of Outcomes)

Observation

Description

Quantification

Types of Outcomes

Physiological Heart rate Weight

Perceptual Satisfaction Symptom control Quality of life Well being

Psychosocial Attitude Mood

Cognitive Knowledge Understanding

Functional ADLs ROM

Fiscal Cost

Behavioral Compliance Motivation

General Outcomes

Length of stay

Resource use

Costs

Patient satisfaction

Technical skills

 Inventory of Patient Outcomes

Symptom control and change in symptom severity.  Functional status.  Knowledge of condition and treatment.  Patient satisfaction with care.  Unplanned emergency department visits.  Unplanned hospital readmissions.  Strength of treatment alliance.

International Council of Nurses (2001) International Classification for Nursing Practice 

Clinical Outcomes

Need to adjust for risk factorsBaseline statusClinical statusTreatment SettingEnvironment

Variables affecting patient outcomes

Socio economic factors

 Family support

 Age and gender

Quality of care provided by other 

professionals and support workers

Continuum of Outcomes

Too global or general Difficult to measure

or link them to prior action

Too specific or specialized Limited meaning or

generalizability

Principles in Determining Outcomes

Must be measurableMust relate to care process/interventionMust be realisticMust be measured within accessible time spanMust describe riskMust consider costChosen parameters must be accurate and specific to care

Consider Cost

Minimization

Benefit analysis

Consequences

Utility

Underutilization

Direct

Indirect

Opportunity

Gold Standard in Early APN Outcome Research

Comparative outcomes

Measured against physician care Equivalent Superior

US Comparative Studies

Brooten et al 1986Mundinger 2000Health Resources and Service Administration (HRSA) Bureau of Health Professions (2000) CNS & NP workforce reportsUS Congress Office of Technology Assessment 1986

International Comparative Studies

AustraliaHorrocks, Anderson & Salisbury (2002)Chang et a (1999)

United KingdomKinnersley et al (2000)Sakr et al (1999)

NetherlandsLaurant et al (2004)

Reviews of categories of indicators for outcomes

Hegyvary 1991 Clinical Functional Financial Perceptual

Irvine et al 1998 Complication

Prevention Clinical outcomes Knowledge Functional health Cost of care Patient satisfaction

Classification of OutcomesLang & Marek 1990

Physiological

Psychological

Functional

Knowledge

Symptom control

Home maintenance

Pt satisfaction

SafetyNursing diagnosis resolutionFrequency of serviceCost & rehospitalizationWell beingGoal attainment

Sources of Measurement:Common Data Sets

Administrative dataMedical recordsDischarge summariesSurveysElectronic medical recordsPatient/family reportsClinical practice guidelines/critical pathwaysStandardized Data Sets JCAHO CONQUEST AHRQ HEDIS

APN Outcomes and Acute Care Setting

Large body of literature

>disease/medical based

> physiological measures

>skill/function based

Systematic Reviews of Nursing Outcome

Research

Bourbonniere & Evans 2002

Cunningham 2004

Kleinpell 2001

Limitations in APN Studies

Lack of methodological rigor

Use of variable measurement strategies

Lack of specific health related outcomes

Use of physician as comparative group

Heterogeneous outcomes

Lack of economic analysis

All Conclude: Need Nursing/APN Sensitive Outcomes 

Changes in health status upon 

which nursing/APN care 

has  had a direct influence

 

Nursing Outcome Goals

Often directed toward cost containment

>hospital based, < community based

Rarely directed toward understanding scientific basis for clinical practice

Rarely examine underlying relationship between outcomes and care

Beyond comparative value outcomes of APNs

Unique contributions of APNs

Income

“Value added” Mundinger 2000 Ryden et al 2000 Wong et al 2000

Example APN value added skills

Health education integral to careDisease prevention/health promotionTeaching/counselling/listeningCoordination of careCommunity resource accessPartnerships with patients/familiesHolistic care in a family social contextAdded ‘nursing ingredient’ to APN care

(Plager & Conger 2007)

Nurse Sensitive Outcomes of Practice

ANA 1996 Set of Nursing Indicators

Johnson & Maas 1997

Nursing Outcomes Classification

Generic Nursing

CNS Literature

Ingersoll et al (2000) Nurse Sensitive Outcomes of

APN Practice 10 indicators

Pt satisfaction Symptom

resolution/reduction Compliance/

adherence/ cooperation Knowledge of

patient/family Quality of life

Perception of being well cared forTrust in providerCollaboration among providersCare provider recommendationsFrequency/type procedures ordered

How do we capture both the art and the science of

high level caring at all levels of nursing?

The Blended Art & Science of APN

Cunnngham (2000) posits, “How to measure, as Benner (1984) suggests, the exquisite skill in clinical judgment that comes from ‘knowledge embedded in practice’ which may be a deciding variable in APN care

Bourbonniere & Evans (2002) use the term ‘contextual thinking’ to denote the APN’s high level of data synthesis

Conclusion:What is the importance of Nurse Sensitive Indicators &Outcomes? . 

Demonstrate that nurses at all levels provide safe, quality, and cost effective care.Provide strong support for appropriate 

allocation of health care resources.Continue to measure the Art of Nursing as well as the Science of Nursing.

Make Nursing Visible.

Future Challenges and Opportunities

APRN Regulatory Model2008

4 roles6 population fociEducation, certification, and licensure must be congruent in terms of role & population foci.Specialties can provide depth in one’s practice within the established population foci.

Doctorate in Nursing Practice (DNP)

Although the current masters and PhD programs in nursing are critical to the future of the profession and are evolving to keep pace with new demands, they do not fill the growing need for expert clinical teachers and clinicians.

Informational shifts, demographic changes, growing disparities in healthcare delivery and access, and stakeholder expectations are all creating new demands on the nursing profession.

The practice (also called clinical and professional) doctorate, with a focus on direct practice and healthcare leadership, offers nursing an exciting opportunity to meet these demands.

22 National Nursing Organizations Join Together to Commission a Study of the Impact of Advanced Practice Registered Nurseson Healthcare Quality, Safety, & Effectiveness since 1990

24/9/2008 The Tri-Council for Nursing

Robin Newhouse, PhD, RN, CNAA, BC, CNOR

University of Maryland & Johns Hopkins University.

“Nursing is not second class medicine but first-class health care”

Loretta Ford