Tag Archives: advanced practice nurses

WHNPs in specialty positions: My experience in breast surgical oncology

When I, Caitlyn E. Hull, sought to become a women’s health nurse practitioner (WHNP), I had not considered the variety of roles that might be available. I had imagined myself working as a generalist in an obstetrics/gynecology (Ob/Gyn) private practice or federally funded clinic like many of my professors and preceptors, and I was thrilled with the possibilities that lay ahead of me in this field. When I was offered a position as a WHNP in surgical oncology at the Stefanie Spielman Comprehensive Breast Center (Photograph), which is affiliated with The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital (The James) and Richard J. Solove Research Institute, I had several questions and hesitations. I was curious about how my education and training would be utilized in breast oncology, particularly as a new NP. Continue reading »

The consensus model: What current and future NPs need to know

Editor’s Note: This article originally appeared in American Nurse Today, January 2018.

Acute care vs. chronic care is the key.

By Caroline Lloyd Doherty, AGACNP-BC; Patricia Pawlow, ACNP-BC; and Deborah Becker, PhD, ACNP-BC, CHSE, FAAN

As a current or future advanced practice nurse (APRN), you must understand the Consensus Model and its career implications to practice. The model was developed in 2008 by the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. It was endorsed by more than 40 nursing organizations, including the American Association of Colleges of Nursing, National Organization of Nurse Practitioner Faculties, American Association of Nurse Anesthetists, American College  of Nurse-Midwives, and the American Association of Nurse Practitioners. Continue reading »

Four APN students’ narratives on abortion training in Mexico City

Nurse practitioners and certified nurse midwives play an integral role in all facets of reproductive healthcare. They provide full-spectrum pregnancy care, contraception care, and counseling about pregnancy options, including abortion care. Advanced practice nurses (APNs) are first-line practitioners in the prevention and management of unintended pregnancy—a major public health issue. This commentary presents narratives from four APNs who sought and obtained clinical training in abortion care while they were APN students, training that is not currently integrated into APN educational programs.

Throughout the world, 40% of all pregnancies are unintended.1 In the United States, nearly half of pregnancies are unplanned; 40% of these pregnancies are terminated legally by abortion.2 The percentage of women seeking to terminate an unintended pregnancy in countries where abortion is illegal is similar to that in the U.S.; what varies is the rate of complications from illegal and unsanctioned abortions.3 In 2008, the incidence of unsafe abortion was 1/1,000 women aged 15-44 years in developed countries versus 16/1,000 women of the same age in developing countries.Women die as a result of illegal abortions; the number of abortion-related deaths due to unsafe abortion in 2008 was 90 in developed regions versus 47,000 in developing regions.4 Although abortion is a legal option in the U.S., access varies from state to state and region to region. Eighty-nine percent of all counties in this country have no abortion provider, and the number of abortion clinics declined from 851 to 839 from 2008 to 2011.2

Early aspiration abortion is an in-clinic procedure that involves dilating the cervix, inserting a sterile cannula into the uterus, and applying gentle suction to remove pregnancy tissue. Medication abortion can be done through various regimens; in the U.S., it involves sequential administration of two drugs, mifepristone and misoprostol, to halt embryonic development and induce uterine contractions so the patient may pass the pregnancy at home. Numerous recent studies have shown that advanced practice nurses (APNs) can provide both aspiration and medication abortion procedures with the same safety and quality outcomes as their physician colleagues.5 Despite the evidence, only a dozen states permit APNs to provide medication abortion and fewer than half of these states allow APNs to perform aspiration abortion.5,6

Although evidence shows that APNs can safely provide aspiration and medication abortions, obtaining training to perform these procedures presents a challenge. Foster et alinvestigated the status of abortion education in accredited nurse practitioner (NP), certified nurse midwife (CNM), and physician assistant programs, and found educational opportunities to be deficient. These authors concluded that didactic and clinical training in abortion care should be included in routine curricula. Unfortunately, not much has changed since the publication of their report 10 years ago.

In this commentary, we present narratives from three NPs and one CNM who sought abortion training as APN students. All four of them completed the same program in Mexico City and learned the essential skills to perform an aspiration abortion: bimanual examination for gestational age assessment, basic ultrasonographic evaluation, paracervical block administration, cervical dilation, uterine aspiration, and identification of the products of conception. Their experience differs from those of medical residents who have in-country access to training in abortion procedures through their academic institutions.8 APN students lack access to such training in this country. The objective of this commentary is to describe why four APN students sought training to become abortion providers, how they achieved their goal, and how they are using their abortion training experience to best serve patients in their current clinical practice.

Narrative One

My post-college plan was to become a midwife. I moved to Texas to train as an apprentice and interned in Mexico with traditional midwives. I learned about pregnancy care and experienced the joy of birth. What left a lasting impression, though, was when a woman presented with an unintended pregnancy and was sent away to a whispered location. I decided to become a nurse practitioner and enrolled in a program that I hoped would prepare me to offer full-scope reproductive care within the context of primary care. As an NP student, I sought abortion training in the U.S., but the opportunity fell through.

I reached out to a midwife I met in Mexico to discuss my dilemma. She told me about an organization that trained physicians and midwives in manual vacuum aspiration (MVA). After some persistence, I was invited to participate in their 6-week Integrated Medical Model of Aspiration Procedures for Unintended Pregnancies training. The program entailed long days and many hours of studying. I learned more hands-on skills in 6 weeks than in a year of clinical rotations at school. I performed 30 MVA procedures, including 16 solo procedures, and several post-procedure intrauterine device (IUD) insertions, all while expanding my Spanish-speaking and gynecologic skills.

Today, I work at a community clinic in the South Bronx—a marginalized area with a long list of health challenges, including unplanned pregnancy. Although I do not perform abortions here, my training experience in Mexico shaped me as a provider. The patient-centered care model and the hands-on skills I acquired there prepared me for performing procedures such as endometrial biopsy and IUD insertion. The experience equipped me with counseling tools that I use to discuss all pregnancy options with patients who present with an unintended pregnancy. I hope that abortion training will be offered to all interested APN students here in the U.S. so that safe abortion will be easily accessible to anyone who needs it.

Narrative Two

When I began my NP program, I knew I wanted to focus on sexual and reproductive healthcare; I liked the idea of caring for patients’ most sensitive needs and helping them understand their bodies in a nonjudgmental space. I had always supported a person’s right to choose, but I hadn’t felt strongly about becoming an abortion provider myself. When I started my graduate studies, I wasn’t even aware that NPs could provide abortions. That all changed when I attended my first National Abortion Federation (NAF) conference.

Prior to the conference, I had learned nothing about abortion in my NP program. At NAF, I learned that NPs could legally provide abortions in some states. I attended a lecture by another APN student who had trained in Mexico City. She spoke about the complexities of working in a country where abortion is legal only up to 12 weeks’ gestation and only in the capital city. She discussed how these restrictions forced women to carry undesired pregnancies to term, undergo unsafe abortions, or travel long distances to receive care. She addressed the fact that when abortion access is restricted or denied—as is increasingly the case in the U.S.—patients suffer. These realizations made the proverbial light bulb go off in my head: I needed to become an abortion provider in order to fully meet the needs of my patients by providing all reproductive care options.

There was nowhere in the U.S. for me to train. In the summer before my final year of APN school, I traveled to Mexico City to become an abortion provider. Over an intensive 6 weeks, I studied, trained, and completed 28 MVA abortion procedures.

In my current clinical work in California, I provide comprehensive reproductive healthcare, including medication abortion. I will soon offer MVA because I live in a state where APNs can legally provide aspiration procedures. My training in Mexico City laid the groundwork for me to become a full-scope abortion provider.

Narrative Three

Abortion care has always been a passion of mine, so I decided to pursue a career in midwifery and women’s healthcare. A classmate once commented that I care about contraception and abortion in “the same way other midwives feel about birth.” Prior to nursing school, I worked as a family planning and abortion counselor. I became aware that the experience of ending a pregnancy can be as transformative as giving birth, and that supporting a woman through this experience is a privilege. To me, abortion care is a natural extension of midwifery care; if the meaning of the word midwife is “with woman,” then midwives should provide the same holistic care for women undergoing abortion they do for those undergoing pregnancy and childbirth.

Having exhausted all options for training in the U.S., I attended the program in Mexico City as a nurse midwife student. I am so grateful for the unique learning opportunity it afforded me. The doctors in the clinic were excellent teachers. After 5 weeks of training, I felt confident in my MVA skills and in my ability to manage abortion complications. I improved in my physical assessment techniques and I felt more selfassured with IUD insertions. I finished the program better able to counsel patients in either English or Spanish regarding all pregnancy options.

I now work as a CNM in Massachusetts. NPs and CNMs are restricted from providing aspiration abortion in this state, but I am involved with advocacy groups to advance efforts to include all aspects of abortion care as part of our scope of practice. My patients know they can come to me for patient-centered midwifery, including abortion care.

Narrative Four

When I began nursing school, I had a strong desire to make meaningful change in the world. In pursuit of this goal, I planned to become an NP and provide individualized care. After meeting abortion providers during clinical rotations, I learned how common abortion is and saw first-hand the value of a provider who offers whole-hearted support while discussing all the options that a pregnant patient has. I learned that abortion is simple and safe. It became important to me that abortion care be a part of my future practice as a clinician. The experience of providing abortion care is summed up well in Virginia Henderson’s definition of nursing: “It is a service, which, at its best, is emotionally and intellectually rewarding to those who give it, and highly-prized by those who receive it.”9

After unsuccessful attempts to find training in the U.S., I heard about the program in Mexico City. I was mentored and strategically trained in aspiration abortion by doctors to whom I am forever grateful. As a clinician, I support my patients to become their most complete and healthy selves. If becoming a parent, carrying a pregnancy to term, or choosing adoption does not make sense for a given patient, I am honored to support her in her decision to have an abortion. Working in outpatient healthcare settings does not often allow a provider to see patients “cured” in one visit. Seeing a woman enter the clinic with an unwanted pregnancy and leave feeling cared for and respected is extremely satisfying for both patient and clinician.

Today, I work in California, a state that recognizes my ability to provide effective and safe aspiration and medication abortions. At my place of employment, I am receiving continued aspiration abortion training by a physician and performing the procedure independently.

Conclusion

In her treatise on the concept of nursing, Virginia Henderson stated, “The most successful preparation of nurses will always include whatever gives them the broadest possible understanding of humanity and the world in which they live.”Henderson proposed that all nursing students have an opportunity to participate in learning in a variety of healthcare settings in order to gain broad knowledge of the world, humanity, and the multifaceted needs of the patients they serve.

These narratives demonstrate how abortion training helped prepare four APNs for clinical practice. They also reveal the lack of access to abortion training for APN students in this country. With motivation and resourcefulness, these students were able to receive the education they desired. These narratives validate the favorable impact that abortion training has on the development of both clinical skills and confidence as an APN.

Advanced practice nursing students should not need to leave the U.S. to acquire clinical skills that they are legally permitted to apply in several states. Expansion of training opportunities in full-scope reproductive care, including abortion care, via both didactic and clinical experience, should be included in nursing curricula in this country. This training will be essential in preparing the next generation of APNs to meet the needs of all our patients by providing fullscope, patient-centered reproductive care.

Annelle Taylor is a women’s health and adult primary care NP at a family-centered community health clinic in the South Bronx, New York. Alison Hathaway is a women’s health and adult NP at Planned Parenthood Mar Monte in San Jose, California. Michelle Luneau is a women’s health and adult NP in clinical practice at Planned Parenthood of the Pacific Southwest in San Diego, California. Fedelma McKenna is a CNM working in full-spectrum women’s health in a community hospital and birth center in Cambridge, Massachusetts. Joyce D. Cappiello is Assistant Professor of Nursing at the University of New Hampshire in Durham. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Sedgh G, Singh S, Hussain R. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plann. 2014;54(3):301-314.

2. Guttmacher Institute. Induced Abortion in the United States. May 2016.

3. Guttmacher Institute. Induced Abortion Worldwide. Global Incidence and Trends. May 2016.

4. World Health Organization. Unsafe Abortion Incidence and Mortality. Global and Regional Levels in 2008 and Trends During 1990-2008.

5. Guttmacher Institute. State Laws and Policies: Medication Abortion. August 2016.

6. Weitz TA, Taylor D, Desai S, et al. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. Am J Public Health. 2013;103(3):454-461.

7. Foster AM, Polis C, Allee MK, et al. Abortion education in nurse practitioner, physician assistant and certified nurse-midwifery programs: a national survey. Contraception. 2006;73(4):408-414.

8. Singer J, Fiascone S, Huber WJ 3rd, et al. Four residents’ narratives on abortion training: a residency climate of reflection, support, and mutual respect. Obstet Gynecol. 2015;126(1):56-60.

9. Henderson V. The concept of nursing. J Adv Nurs. 2006;53(1):21-31.

Formation of a peer review group for advanced practice nurses

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By Simone J. van der Linden, MANP, BEd, RN; Leni van Doorn, MSc, MANP, RN; Judith P. van Eck, MANP, RN; Wanda Geilvoet, MANP, RN; and Greta Mulders, MANP, RN

A group of Dutch advanced practice nurses (APNs) describe their process of forming a peer review group (PRG) to share cases and provide feedback to one another. The purpose of the PRG is to help APNs expand their knowledge base and hone their clinical skills, with the ultimate goal of improving patient care.

In 1996, Dr. Els Borst, former Minister of Health of the Netherlands, proposed that specially trained master’s-prepared nurses assume certain tasks of physicians in order to help meet the growing need for healthcare in the midst of a physician shortage. In light of the increased number of elderly and chronically ill patients today, this need is even more pressing.1 The consequence of Dr. Borst’s proposal was the inauguration of the first Master’s in Advanced Nursing Practice (MANP) program in Groningen, the Netherlands, at the Hanze University of Applied Sciences in 1997.

Since that time, the training and the work accountability of advanced practice nurses (APNs) in the Netherlands have been extended. A major change occurred in March 2009, when Dutch APNs were granted official registration numbers and legal title protection. Nurses can be registered as APNs only after earning a master’s degree from a certified university and undergoing training on the job at a certified healthcare institute with a certified medical and nursing trainer.

Dutch APNs can be registered in one of five nursing specialties: (1) acute care in somatic disorders, (2) intensive care in somatic disorders, (3) chronic care in somatic disorders, (4) preventive care in somatic disorders and (5) mental health. Like physicians, APNs must attend conferences offering staff development workshops and be actively employed for at least 24 hours a week. In 2014, more than 2,500 APNs were registered in the Netherlands.2

After initial registration, APNs must re-register every 5 years to maintain an active license. Since 2010, one of the requisites for re-registration has been participation in peer review (PR). Guidelines of the Dutch Nursing Specialty Registration Board (DNSRB) require APNs to participate in a PR group (PRG) for at least 40 hours per 5-year period.3 In addition, to ensure competence and continuous professional development, periodic self-appraisal and peer feedback must be in place for all levels of nursing.4

Defining peer review

Peer review is a systematic process by which one assesses, monitors, and makes judgments about the quality of care provided to patients by others, as measured against established standards of practice.5,6 Nursing PR is an evaluation of one’s professional nursing practice, including identification of opportunities to improve care, by persons with the appropriate expertise to perform the evaluation.7 Because they undergo PR, APNs are a group of healthcare providers (HCPs) whose personal competencies in various nursing specialties are compared—with those of other APNs and with objective criteria—with the aim of improving daily practice.3 PR, recognized as a measure of accountability and a means to evaluate and improve practice,4 enhances development of the APN profession and improves the quality of patient care.

Peer review has multiple benefits for APNs. It facilitates an open and safe learning environment. It provides APNs with an opportunity to reflect on questions and problems together. Because of the interactive setting, APNs invariably learn something new.8 PR even offers APNs a break in an otherwise hectic workday. PR can help APNs evaluate the quality of care they have delivered, and gain insight into their greatest strengths and weaknesses as HCPs. With feedback and recommendations from the group, APNs can gain new knowledge and improve their skills.

Creating and working as a PRG

Because the APN profession is relatively new in the Netherlands, the nursing education department of the Erasmus Medical Center Rotterdam had no experience in starting or structuring a PRG. Five years ago, five pioneering APNs working on an internal medicine unit decided to create such a PRG. These APNs found several examples of PRGs in the literature and took the initiative in creating a framework, based on non-empirical research, that took into account the criteria requisites of the DNSRB.

To initiate an effective PRG, some basic steps are essential. The first step is to form a group of 3-5 APNs in the same specialty who have similar interests within their specialty. The next step is to elect a chair to serve a 1-year term. The chair then makes a yearly schedule so that members can plan to attend all PRG meetings. To meet the criterion of spending 40 hours in the PRG over 5 years, the group must meet for about 2 hours every 3 months.

At each meeting, members take turns serving as the contributor, who presents a case related to her work field. One week before the meeting, the contributor sends a recap of the case—along with corresponding literature, protocols, and guidelines—to PRG members so that they can read background material and analyze the case. Each case submitted for PR must have these elements:

  • The patient’s presenting complaint, personal and family health history, and physical examination findings;
  • An analysis of the case, with corresponding literature or guidelines to clarify or substantiate the diagnosis or the problem;
  • A list of dilemmas that can occur or that did occur with the presented case, as well as learning points, and
  • Learning objectives extracted from the presented case for discussion.

At the meeting, the contributor uses PowerPoint to present the case and then leads the discussion regarding dilemmas and learning goals. A member who is appointed secretary for each meeting takes notes and creates a report of the thoughts and views exchanged during the meeting. The report includes a summary of the case, the learning goals of the contributor, and feedback/recommendations from the group. After the meeting, the report is sent to the PRG members. Reports of PRG meetings are saved in a digital portfolio.

At the next PRG meeting, notes of the previous meeting are discussed. The chair asks the previous contributor whether she used feedback from the last PRG meeting and applied it to her practice. The process gives the contributor an opportunity to reflect on her own goals and improve the quality of her work.

Choosing the best method to present a case

Within the first year of the PRG’s existence, all five members had submitted a case. The group then met to determine the best format for presenting a case. The PRG considered three options: the testing method, the Balint method, and the research method. These methods were evaluated in terms of whether they enhanced the professionalism of the APN through the sharing of knowledge, expertise, and thoughts. The group was most satisfied with the testing method, which is particularly suitable for case study discussion and for evaluation of clinical guidelines and protocols. With this method, the group works together, sharing ideas and coming to an agreement on how practice can be improved. One downside of the testing method is that the personal learning goals of the APN are not included.

Gaining competencies

In the Netherlands, the focus of learning is to gain competencies. A framework used for the competency-based approach is that of the Canadian Medical Education Directives for Specialists (CanMEDS) (Figure).9 The CanMEDS framework describes seven different roles of an HCP: professional, communicator, collaborator, manager, health advocate, scholar, and, in the center, medical expert. APNs who have gained the first six competencies can become medical experts (the center of the honeycomb), but they cannot become medical experts if they fail to gain one of the six competencies surrounding the central competency. APNs need to enhance themselves in all seven competencies in order to become better HCPs.

Figure

Achieving the best practice

A combined framework using both the testing method and the CanMEDS framework was determined to be the best practice. This combined framework was deemed to be the best way to prepare a case for discussion and to give the PRG and the contributor the clearest insight into the questions and learning issues provided by the case. The testing method is an ideal way to discuss problems or questions regarding certain procedures and guidelines within the safe confines of a group. In addition, each group member can impart information and share expertise via the group discussions, which can then be absorbed by the other members and translated into their own practices.

Discussion

The PRG found that, over a 4-year period, a combined approach—the testing method and the CanMEDS framework—constituted the best practice for structuring a case for discussion and determining the contributor’s own learning issues. The DNSRB also recommends use of CanMEDS competencies in this regard. If the combined framework does not work well for a given PRG, it may be related to poor group dynamics, lack of a safe environment, or a tendency for members discussing a case to highlight their feelings rather than their own practice. Some PRG members indicated that they sometimes felt vulnerable. It takes courage to learn from colleagues. According to Karas-Irwin and Hoffmann,4 a caring environment imbued with genuine respect enhances PRG interactions. By participating in a PRG, APNs in the Netherlands not only meet the needs and criteria of the DNSRB, but also enhance their professional skills and build their knowledge base.

Implications for APNs in the United States

Although there is no specific requirement to participate in PR as part of APN licensure in the United States, PR is recognized as an important component of practice and professional responsibility.10,11 The opportunity to come together as a small group of APNs with similar clinical practices and interests on a regular basis to review challenging cases provides a collegial environment for learning from each other. Peer assessments can play an important role in enhancing quality of care for complex patients with multiple interrelated chronic conditions, especially as seen in the U.S. with its aging population and the increasing prevalence of obesity and its co-morbidities.

Simone J. van der Linden is an APN in the Department of Hematology, Cancer Institute; Leni van Doorn is an APN in the Department of Medical Oncology, Cancer Institute; Judith P. van Eck is an APN in the Department of Medicine, Section of Endo­crinology; Wanda Geilvoet is an APN in the Department of Medicine, Section of Endocrinology; and Greta Mulders is an APN in the Department of Hematology, all at Erasmus Medical Centre, Rotterdam, The Netherlands. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

Acknowledgment
The authors thank L. Maas, RN, MS, Rotterdam University, Master’s in Advanced Nursing Practice Program, Rotterdam, the Netherlands.

References
1. Statistics Netherlands. Dutch population expected to reach 17.5 million in 2038. cbs.nl/en-GB/menu/themas/
bevolking/publicaties/artikelen/archief/2008/2008-085-pb.htm

2. Dutch Nursing Association. 2013. venvnvs.nl/files/2014/09/Jaarverslag-VVN-VS-okt13-okt14-def.pdf

3. Dutch Nursing Specialty Registration Board. Intercollegiale Toetsing Verpleegkundig Specialisten. 2010.
verpleegkundigspecialismen.nl/Portals/45/20100203%20Intercollegiale%20Toetsing%20Verpleegkundig%20
Specialisten%20_3.pdf

4. Karas-Irwin BS, Hoffmann RL. Facing the facts: in-person peer review. Nurs Manage. 2014;45(11):14-17.

5. Sherwood GD, Brown M, Fay V, Wardell D. Defining nurse practitioner scope of practice: expanding primary care services. Internet J Adv Nurs Pract. 1997;1(2). geide.org/uploads/6/4/8/8/6488798/definingscope.pdf

6. Smith MA, Atherly AJ, Kane RL, Pacala JT. Peer review of the quality of care. Reliability and sources of variability for outcome and process assessments. JAMA. 1997;278(19):1573-1578.

7. Spiva LA, Jarrell N, Baio P. The power of nursing peer review. J Nurs Adm. 2014;44(11):586-590.

8. de Haan E. Leren met Collega’s. Uitgeverij Van Gorcum; 2009.

9. Frank JR, Jabbour M, Fréchette D, et al. Report of the CanMEDS Phase IV Working Groups. Ottawa, Canada: The Royal College of Physicians and Surgeons of Canada; 2005.

10. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Core Competencies. 2012. c.ymcdn.com/
sites/www.nonpf.org/resource/resmgr/competencies/npcorecompetenciesfinal2012.pdf

11. National Association of Nurse Practitioners in Women’s Health/Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th Edition. Washington, DC: NPWH/AWHONN; 2014.

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