Family Nurse Practitioner Review and Resource Manual PDF

EDITION EDITION 6 CERTIFICATION REVIEW SERIES 6 Find more certification exam prep resources here: ANA’s Essentials of Nursing Practice package contains the authoritative texts on Family Nurse Practitioner nursing that provide essential information on the foundation of the profession: Family Nurse Practitioner REVIEW AND RESOURCE MANUAL More books in the Certification Review Series: Edited by: Courtney Reinisch, DNP, RN, FNP-BC, DCC Mary Elizabeth Duffy, DNP, RN, FNP-BC, ACNP-BC, DCC www.nursingworld.org Completion of this or any other course(s)/material(s) does not imply eligibility for certification or successful performance on any certification examination, nor is it a requirement to qualify for certification. The American Nurses Credentialing Center (ANCC) does not endorse any products or services. American Nurses Association 8403 Colesville Road Silver Spring, MD 20910-3492 [email protected] ©2024 American Nurses Association. All rights reserved. Review and Resource Manual amily Nurse F Practitioner 6th Edition Volumes 1 and 2 Edited by Courtney Reinisch, DNP, RN, FNP-BC, DCC Mary Elizabeth Duffy, DNP, RN, FNP-BC, ACNP-BC, DCC The ANA is the only full-service professional organization representing the interests of the nation’s 4.2 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public. American Nurses Association 8403 Colesville Road, Silver Spring, MD 20910 Library of Congress Control Number: 2024940653 Copyright © 2024 American Nurses Association. All rights reserved. No part of this book may be reproduced or used in any form or any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system, without permission in writing from the publisher. ISBNs Print Volume 1: 978-1-953985-43-9 Print Volume 2: 978-1-953985-44-6 ePDF: 978-1-953985-45-3 ePub: 978-1-953985-46-0 Mobi: 978-1-953985-47-7 SAN: 851-3481 CONTENTS VOLUME 1 Chapter 1. Preparing for The Certification Examination.................. 3 Before You Begin Studying.................................................................... 3 Tips for Preparing for the Exam............................................................. 4 The Night Before the Exam................................................................... 6 The Day of the Exam............................................................................. 7 Tips for Dealing with Anxiety................................................................ 7 Chapter 2. Important Factors Influencing The Nurse Practitioner Role...... 11 Legal Dimensions of the Role..............................................................11 Current Trends and Topics in Nurse Practitioner Education and Practice......................................................................................... 22 Practice Environment, Policy, and Advocacy....................................... 24 Theory and Principles of Family-Focused Care.................................... 46 Case Studies....................................................................................... 52 Case Studies Discussion..................................................................... 53 References.......................................................................................... 55 Chapter 3. Health Care Issues...................................... 61 General Approach................................................................................ 61 Model Epidemiologic Principles.......................................................... 63 Human Development.......................................................................... 71 Health Maintenance............................................................................ 79 Health Maintenance Practice.............................................................. 81 Safety.................................................................................................. 95 Health Maintenance...........................................................................101 iii iv FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 Other Health Care Considerations...................................................... 111 Case Studies......................................................................................113 Case Studies Discussion....................................................................116 References.........................................................................................119 Chapter 4. Infectious Diseases..................................... 121 General Approach.............................................................................. 121 Viral Infections................................................................................... 130 Bacterial And Other Infections.......................................................... 175 Illnesses of Unknown Origin............................................................. 196 Tropical/Global Diseases.................................................................... 216 Case Studies..................................................................................... 221 Case Studies Discussion................................................................... 223 References........................................................................................ 225 Chapter 5. Common Problems of The Skin........................... 227 General Approach.............................................................................. 227 Allergy............................................................................................... 231 Eczematous Conditions..................................................................... 239 Acne.................................................................................................. 248 Papulosquamous Eruptions............................................................... 260 Fungal and Yeast Infections............................................................... 263 Bacterial Infections of the Skin...........................................................274 Viral Skin Infections........................................................................... 286 Parasitic Infestations and Bites......................................................... 299 Tumors................................................................................................311 Other Integumentary Conditions....................................................... 321 Case Studies..................................................................................... 333 Case Studies Discussion................................................................... 335 References........................................................................................ 337 Contents v Chapter 6. EYE, EAR, NOSE, AND THROAT DISORDERS................ 339 General Approach.............................................................................. 339 Disorders of the Eyes........................................................................ 342 Ocular Trauma.................................................................................... 386 Problems of the Ears......................................................................... 405 Problems of Nose/Sinuses................................................................ 429 Problems of the Pharynx................................................................... 444 Problems of the Mouth..................................................................... 456 Problems of the Neck........................................................................ 466 Case Studies..................................................................................... 472 Case Studies Discussion....................................................................474 References........................................................................................ 476 Chapter 7. RESPIRATORY DISORDERS.............................. 479 General Approach.............................................................................. 479 Acute Conditions............................................................................... 481 Chronic Conditions............................................................................ 528 Case Studies..................................................................................... 556 Case Studies Discussion................................................................... 559 References........................................................................................ 563 Chapter 8. CARDIOVASCULAR DISORDERS.......................... 567 General Approach.............................................................................. 567 Red Flags........................................................................................... 568 Common Cardiovascular Disorders................................................... 571 Cardiovascular Disease/Coronary Artery Disease (Cad).................... 610 Congenital Heart Defects.................................................................. 666 Cyanotic Congenital Heart Defects................................................... 684 Peripheral Vascular Disorders............................................................ 688 Case Studies..................................................................................... 706 vi FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 Case Studies Discussion................................................................... 708 References........................................................................................ 710 Chapter 9. Gastrointestinal Disorders............................... 717 General Approach.............................................................................. 717 Gastrointestinal Signs and Symptoms.............................................. 718 Common Gastrointestinal Conditions.................................................741 Conditions that May Warrant Surgery............................................... 771 Conditions of the Rectum and Anus.................................................. 795 Conditions of the Liver...................................................................... 802 GI Conditions Found in Infants and Children..................................... 810 Case Studies..................................................................................... 820 Case Studies Discussion................................................................... 822 References........................................................................................ 824 VOLUME 1 CHAPTER 1 PREPARING FOR THE CERTIFICATION EXAMINATION Before You Begin Studying Confirm the eligibility criteria. The eligibility criteria will vary for each exam, but may include things like clinical practice hours, degree and license required, etc. Please check the American Nurses Credentialing Center (ANCC) website for details on the particular eligibility criteria for your exam. Review the general testing handbook. The general testing handbook can be found on ANCC’s website under “Additional Information and Resources (https://www.nursingworld.org/certification /certification-policies/). It provides information on how the exam is scored, policies, etc. TAKE ADVANTAGE OF ALL OF ANCC’S RESOURCES 1. Test Content Outline. The test content outline includes the number of questions for each domain of practice and identifies the areas that are included on the examination. 2. Test Reference List. Review the test reference list for review resources. While the list is not all-inclusive, it will act as a guide to help you prepare. 3. Sample Questions. In addition to the review questions at the back of this book, you can find sample questions that are similar to those on the actual examination on ANCC’s website. For many exams there are also banks of practice questions available from the American Nurses Association’s website: https://www.nursingworld.org /continuing-education/ce-subcategories/certification-review/. Make sure to look at practice tests designed for the exam. 4. Readiness Tests: Take a practice test in a simulated test environment either at a Prometric Testing Center or via Live Remote Proctoring to increase your comfort with the test environment and procedures. Find more details about Readiness Tests on ANCC’s website: https://www.nursingworld.org/certification/readiness-tests/ Develop a personal study plan approximately 3 months before you plan to take your exam. This could include self-study, finding a study buddy or group, taking a review course, taking an online narrated review course, reviewing current textbooks and articles, or other methods. The key is to have a study plan that works for you and follow through on it. 3 4 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 Arrange for special testing accommodations. The American Nurses Credentialing Center and its testing vendor make every effort to reasonably accommodate candidates with documented disabilities as defined by the Americans with Disabilities Act (ADA). If you have a disability as defined under the ADA, you must notify ANCC by submitting a report regarding your request from your physician or a qualified healthcare professional. The information must be on the physician’s or other qualified healthcare professional’s letterhead, typed, dated, and signed by the healthcare professional. Refer to the General Test Handbook for more details. Tips for Preparing for the Exam STEP 1: ASSESS CURRENT KNOWLEDGE General Content Examine the table of contents of this book and the test content outline, available at [insert website] t What content do you need to know? t How well do you know these subjects? Take a Review Course t Taking a review course is an excellent way to assess your knowledge of the content that will be included in the exam. t If you plan to take a review course, take it well before the exam so you will have plenty of time to master any areas of weakness the course uncovers. t If some topics in the review course are new to you, concentrate on these in your studies. STEP 2: DEVELOP YOUR STUDY PLAN t Write up a formal plan of study. ¸ Include topics for study, timetable, resources, and methods of study that work for you. ¸ Decide whether you want to organize a study group or work alone. ¸ Schedule regular times to study. Preparing for The Certification Examination 5 ¸ Avoid cramming; it is counterproductive. Try to schedule your study periods in 1-hour increments. ¸ Gather your study resources (general test handbook, Test Content Outline, Test Reference List, Review Manual, sample questions, etc.) t You will need to know facts and be able to interpret and analyze this information utilizing critical thinking. Personalize Your Study Plan t How do you learn best? Choose study methods that fit your learning style. t Have a specific place with good lighting set aside for studying. Find a place with no distractions. Assemble your study materials. t Make sure to focus on the areas you are weakest and reassess periodically STEP 3: IMPLEMENT YOUR STUDY PLAN t Refer to your study plan regularly. Write it up or type it out and put it someplace you will see it regularly. Post it at your desk or even put it into your calendar. t Stick to your schedule. t Take breaks when you get tired. t If you start procrastinating, get help from a friend or reorganize your study plan. t It is not necessary to follow your plan rigidly. Adjust as you learn where you need to spend more time. t Make sure you reference the Test Reference List and Test Content Outline on ANCC’s website for the latest updates and information about the exam. Pace Your Studying t Stop studying for the examination when you start to feel overwhelmed and take a break. If you need to, adjust your study plan: ¸ Break overwhelming tasks into smaller tasks that you know you can do. ¸ Try a new study method. 6 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 Work With Others t Put together a study group. ¸ Study groups can provide practice in analyzing cases, interpreting questions, and critical thinking. ¸ You can discuss a topic and take turns presenting cases for the group to analyze. ¸ Study groups can also provide moral support and help you stay on track. STEP 4: FINAL PREPARATION Use practice exams when studying to get accustomed to the exam format and time restrictions. The American Nurses Association has a bank of sample questions available online in many specialty areas. Practice tests can help you learn to judge the time it should take you to complete the exam and are useful for gaining experience in analyzing questions. However, keep in mind that books of questions may not uncover the gaps in your knowledge that a more systematic content review text like this manual will reveal. If you feel that you don’t know enough about a topic, refer to a text from the reference list to learn more. After you feel that you have learned the topic, practice questions are a wonderful tool to help improve your test-taking skills. Know your test-taking style and be aware of your potential pitfalls. Do you rush through the exam without reading the questions thoroughly? Practice reading the question completely, including all four choices. Choice “a” may sound good at first glance, but “d” is actually correct. Do you get stuck and dwell on a question for a long time? Remember that computer-based exams allow you to mark questions you are unsure about and go back to them later. You should spend about 45 to 60 seconds per question and finish with time to review the questions you marked. There is also no penalty for guessing; you are encouraged to respond to every examina- tion question. The Night Before the Exam t Be prepared to get to the exam on time. ¸ Know the test site location and how long it takes to get there. ¸ Take a “dry run” beforehand to make sure you know how to get to the testing site, if necessary. t Get a good night’s sleep. t Eat sensibly. Preparing for The Certification Examination 7 t Avoid alcohol the night before. t Assemble the required material to be admitted to the exam. Make sure you have the required form of ID. Reference the general test handbook for information about what you’ll need. t Read over the exam room rules. Know what you can and cannot bring with you. The Day of the Exam t Get there early. You must arrive to the test center at least 15 minutes before your scheduled appointment time. If you are late, you may not be admitted. t You will be given a dry erase board, which will be collected at the end of the exam. t Nothing else is allowed in the exam room. You will be required to put all personal items in a designated area such as a locker. t Items such as eye-wear, jewelry, etc. are subject to visual inspection t No water or food will be allowed. You may leave the testing room to use the restroom or get a drink of water, but you will need to sign out according to the instructions that will be explained at the test site. Your testing time will not be increased to accommo- date a break. t Think positively. You have studied hard and are well-prepared. t Remember your anxiety reduction strategies. Tips for Dealing with Anxiety LEADING UP TO THE EXAM: Everyone experiences anxiety when faced with taking the certification exam. t Taking a review course or setting up your own study plan will help you feel more confident about taking the exam. There is no substitute for being well-prepared. t Take practice tests and time yourself to get used to feeling of working on a timer. Remember that the total time for each test is usually 4 hours. Time is not meant to be a factor in the examination. t Brush up on test-taking skills. t Practice relaxation techniques. A few minutes of deep breathing, meditation, or even just listening to soothing music can help you calm down and focus. 8 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 t on’t put too much stock in what others tell you about their exam experience. D Remember that everything they can tell you is based on their memory of a stressful situation; it may not be very accurate. People tend to remember those items with which they are less comfortable; for instance, those with a limited background in women’s health may say that the exam was “all women’s health.” In fact, the test content outline ensures that the exam covers multiple content areas without overem- phasizing any one topic. EXAM DAY ANXIETY: Test anxiety is a specific type of anxiety. Symptoms include upset stomach, sweaty palms, tachycardia, trouble concentrating, and a feeling of dread. But there are ways to cope with test anxiety. t Avoid alcohol, excess coffee, caffeine, and any new medications that might sedate you, dull your senses, or make you feel agitated. t Take a few deep breaths and concentrate on the task at hand. t Use relaxation techniques such as breathing exercises, progressive muscle relaxation, or imagery and visualization. t Go into the exam with a strategy in mind. Plan to take water and bathroom breaks at specific intervals and take that opportunity to stretch. Mark questions you’re unsure of to come back to them later rather than spending too much time on one question. INTERNET RESOURCES: t ANCC website: [insert website] ¸ Test Content Outline ¸ Test Reference List ¸ Sample Questions ¸ Readiness Tests t General Testing and Renewal Handbook: https://www.nursingworld.org/~4aae16/global assets/certification/certification-policies/ancc-generaltestingrenewalrequirements4-1 -2017_final.pdf t ANA Bookstore: https://www.nursingworld.org/education-events/Books/. ¸ ANA Nursing: Scope and Standards of Practice ¸ ANA specialty scope and standards Preparing for The Certification Examination 9 ¸ Code of Ethics for Nurses ¸ Other titles that may be listed on your Test Reference List t American Nurses Association certification review resources: https://www.nursingworld.org/continuing-education/ce-subcategories/certification-review/ ¸ Practice questions ¸ Webinars and review courses ¸ Certification Exam Test-Taking Strategies Web Course CHAPTER 2 IMPORTANT FACTORS INFLUENCING THE NURSE PRACTITIONER ROLE Angela Richard-Eaglin, DNP, MSN, FAANP-BC, CNE, FAANP, CDE® Legal Dimensions of the Role LEGAL AUTHORITY FOR PRACTICE State Nurse Practice Acts—Rules and Regulations Authority for nurse practitioner (NP) practice is found in state legislative statutes and in rules and regulations. The Nurse Practice Act of every state customarily authorizes a board of nursing to establish statutory authority to define who may be called an NP (title protection), what they may do (scope of practice), restrictions on their practice, the requirements an NP must meet to be credentialed within the state as an NP (education, certification, etc.), and disciplinary grounds for infractions. See National Council of State Boards of Nursing’s (NCSBN’s) website (www. ncsbn.org) for a listing of state nursing board requirements. In many states, legislative acts may specifically require that an NP develop a collaborative practice agreement with a physician that defines general supervision and delegation of authority. Collaborative agreements describe what types of drugs, devices, or diagnostics might be ordered, and define limits related to NP practice. Statutory law is implemented in regulatory language. The rules and regulations for each state may further define scope of practice, practice requirements, and/or restrictions. In 1999, the National Council of State Boards of Nursing (NCSBN) began the implementation of an interstate compact for nursing practice to reduce state-to-state discrepancies in nursing requirements for practice. The Advanced Practice Registered Nurse (APRN) Compact addresses the need to promote consistent access to quality advanced practice nursing care within states and across state lines. The Uniform APRN Licensure/Authority to Practice Requirements, devel- oped by NCSBN with APRN stakeholders in 2000, establishes the foundation for this APRN Compact. Like the existing Nurse Licensure Compact for recognition of registered nurse (RN) and licensed practical nurse (LPN) licenses, the APRN Compact gives states the mechanism for mutually recognizing APRN licenses/authority to practice. To be eligible for the APRN Compact, a state must either be a member of the current nurse licensure compact for RNs and LPNs or 11 12 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION choose to enter both compacts simultaneously. To see which states participate view the state compact map at www.ncsbn.org/public-files/NLC_Map.pdf. NURSE PRACTITIONER PROFESSIONAL PRACTICE STANDARDS Licensure t Licensure is “[a] process by which an agency of government grants permission to individuals accountable for the practice of a profession to engage in the practice of that profession and prohibits all others from legally doing so” (Committee for the Study of Credentialing in Nursing, 1979; U.S. Department of Health, Education, and Welfare [DHEW], 1971). t The purpose of licensure is to protect the public by ensuring a minimum level of professional competence. Licensure benefits both the public and the individual nurse because essential qualifications for nursing practice are identified; a determination is made as to whether an individual meets those qualifications; and an objective forum is provided for review of concerns regarding a nurse’s practice when needed. Licensure benefits nurses because clear legal authorization for the scope of practice of the profession is established. Licensure also protects the use of titles. Only a licensed nurse is authorized to use certain titles (i.e., registered nurses [RNs], licensed practical/ vocational nurses [LPN/VNs], advanced practice registered nurses [APRNs], etc.) or to represent themself as a licensed nurse (NCSBN, 2011). Certification t Certification is “[a] process by which a non-governmental agency or association certifies that an individual licensed to practice as a professional has met certain pre-determined standards specified by that profession for specialty practice” (DHEW, 1971). t The purpose of certification is to assure the public that a person has mastery of a body of knowledge and has acquired the skills necessary to function in a particular specialty. Some certifications are required for entry into practice (e.g., for licensure within a state) and thus have a regulatory function; some certifications denote professional competence and recognize excellence. Accreditation t Accreditation is “[t]he process by which a voluntary, non-governmental agency or organization appraises and grants accreditation status to institutions and/or programs Important Factors Influencing The Nurse Practitioner Role 13 or services [that] meet predetermined structure, process and outcome criteria” (DHEW, 1971). The purpose is to ensure that the organization has met specific standards. Scope of Practice t Scope of practice defines a specific legal scope determined by state statutes, boards of nursing, educational preparation, and common practice within a community. ¸ For example, adult nurse practitioners (ANPs) are not legally authorized to care for children. The state might require an NP to have formal educational preparation in pediatrics. There is broad variation from state to state. t General scope of practice is specified in many published professional documents (e.g., Scope and Standards of Advanced Practice Registered Nursing, ANA, 1996). Many organizations have completed role delineation studies that attempt to qualify the core behaviors that all advanced practice nurses (APNs) must possess, as well as the core knowledge and behaviors required of persons in a particular specialty. ¸ For example, core knowledge for a pediatric nurse practitioner (PNP) is inherently different from that for a geriatric nurse practitioner (GNP). It is critical that these statements about specific scope and standards exist so that everyone—including nurses—will have access to materials to which they can refer when there are specific questions related to role. This is especially important when the traditional role of nurses is changing or “advancing” at an uneven rate through changes in state law. ¸ ecause the NP role has expanded into new practice settings, including hospice, B acute care hospitals, and home care, it is important that core knowledge and state law protecting NPs in these practice settings also expand, providing the legal authorization and title protection necessary for these practice settings. t Prescriptive authority is recognized as within the scope of practice for nurse practition ers in all 50 states, although there is major variability from state to state. This variabil- ity has created inherent difficulty in collecting data related to NP prescribing practices. The Nurse Practitioner Journal publishes a comprehensive update of legislative requirements and recent changes in its January issue each year. Data collected by Nurse Practitioner Alternatives, Inc., since 1996 has documented stability within prescribing patterns by NPs. Data from 2004 documents indicate that the majority of NPs possess their own Drug Enforcement Administration (DEA) numbers (72%), write between 6 and 25 prescriptions in an average clinical day (79%), recommend between 1 and 20 over-the-counter (OTC) preparations in an average clinical day (90%), and manage between 25% and 100% of their patient encounters independently (97%; Nurse Practitioner Alternatives, Inc., 2004). 14 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 Standards of Practice t Standards of practice are authoritative statements by which the quality of practice, service, or education can be judged (e.g., Scope of Practice for Nurse Practitioners, American Association of Nurse Practitioners, 2019; Code of Ethics for Nurses, ANA, 2015). t Professional standards focus on the minimum levels of acceptable performance as a way of providing consumers with a means of measuring the quality of care they receive. These standards may be written at the generic level to apply to all nurses (e.g., following standard precautions) as well as to define practice by each specialty. t The presence of accepted standards of practice may be used to legally describe the standard of care that a provider must meet. These standards may be precise proto cols that must be followed or recommendations for more general guidelines. The Future of Nurse Practitioner Education and Practice t In 2020, the National Organization of Nurse Practitioner Faculties (NONPF) released the new and revised Post-baccalaureate Doctor of Nursing Practice (DNP) Program Curriculum and Competency Mapping Templates. As documented by the NONPF, the intent of these documents is to support NONPF’s goal to transition all NP programs to the DNP by 2025. These documents can be viewed at https://www.nonpf.org/page /DNPResources?&hhsearchterms=%22practice+and+doctorate+and+entry+and+level+a nd+competencies%22 t In 2022, as part of a multi-organization collaboration, NONPF (www.nonpf.org), released the Standards for Quality Nurse Practitioner Education (NTFS), 6th edition, A Report of the National Task Force on Quality Nurse Practitioner Education. This consensus-based document provides new standards and revised criteria that facilitate program development, quality, and continuous improvement through assessment, sustainability, and planning. This document can be viewed at https://cdn.ymaws.com /www.nonpf.org/resource/resmgr/2022/ntfs_/ntfs_final.pdf THE NP ROLE IN UNDERSTANDING AND ADVOCATING FOR PATIENT RIGHTS Confidentiality t The patient and family have a right to assume that information given to the health care team will not be disclosed; that is, their information will be kept confidential. This has several dimensions. Important Factors Influencing The Nurse Practitioner Role 15 t Verbal information: Health care providers shall not discuss any information given to them during the health care encounter with anyone not directly involved in a patient’s care without the patient’s or family’s permission (when the family has decision-making permission). t Written information: Confidentiality of the health care encounter is protected under federal statute through the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Administrative Simplification provisions of HIPAA require the U.S. Department of Health and Human Services to establish national standards for elec- tronic health care transactions and national identifiers for providers, health plans, and employers. The provisions also address the security and privacy of health data. Information may be accessed at http://www.cms.gov/regulations-and-guidance/ hipaa -administrative-simplification/hipaageninfo/thehipaalawandrelated-information.html. The person’s right to privacy is to be respected when requesting or responding to a request for a patient’s medical record. t The statute requires that the provider discuss confidentiality issues with patients (parents in the case of a minor), establish consent, and clarify any questions about disclosure of information. t The provider is required to obtain a signed medical authorization and consent form to release medical records and information. t Exceptions to guaranteed confidentiality occur when the need for information out- weighs the principle of confidentiality. Examples include the following: ¸ Release of records to insurance companies ¸ Release of records to attorneys involved in litigation ¸ Court orders, subpoenas, or summonses ¸ Meeting state requirements for mandatory reporting of diseases or conditions ¸ In cases of suspected or actual child abuse ¸ If a person reveals an intent to harm someone Informed Consent t Informed consent is the right of all competent adults (age 18 or older) and emancipated minors (age 17 or younger who are married, a parent, or self-sufficiently living away from the family domicile) to accept or reject treatment by a health care provider. (Some states have laws concerning birth control or abortions that apply to patients younger than 18.) t The clinician has the duty to explain relevant information to patients to assist them in making informed decisions. This information usually includes diagnosis, nature and purpose of proposed treatment or procedure, risks and benefits, prognosis, availability 16 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 of alternative methods of treatment and their risks and benefits, and all possibilities of serious harm. t It must be documented in the medical records that this information has been provided. t Informed consent does not absolve the NP of allegations of malpractice. Care of Minors t In most jurisdictions, persons under the age of 18 cannot receive health care services without permission of a competent parent or legal guardian. t Exceptions to this rule may be made in some jurisdictions in the case of an emanci- pated minor, a pregnant minor, or in matters pertaining to sexually transmitted dis- eases and birth control. Advance Directives t When a patient is incapable of making decisions, the person’s preferences may be expressed in a written living will or a health care durable power of attorney created when the patient was still competent. Such documents are called advance directives. t Living wills are written documents prepared in advance in case of terminal illness or nonreversible loss of consciousness. t Their provisions go into effect when: ¸ The patient has become incompetent, ¸ The patient is declared terminally ill, and ¸ No further interventions will alter the patient’s course to a reasonable degree of medical certainty. Durable Power of Attorney for Health Care t eople can identify in writing an agent to act on their behalf, should they become P mentally incapacitated. The decisions of the designated agent are: ¸ Binding, ¸ Not limited to the circumstances of terminal illness, ¸ Flexible enough to carry out the patient’s wishes throughout the course of an illness, and ¸ Often accompanied by a durable power of attorney over financial issues. Important Factors Influencing The Nurse Practitioner Role 17 Ethical Decision-making t Moral concepts such as advocacy, accountability, loyalty, caring, compassion, and human dignity are the foundations of ethical behavior. t The ethical behavior of nurses has been defined for professional nursing in an American Nurses Association policy statement (ANA, 2015). t Ethical behavior incorporates respect for a person’s autonomy. Ethical behavior means that a patient must be allowed to make decisions regarding their care to the full extent of their personal capacity to do so. t Duty to help others (beneficence), avoidance of harmful behavior (nonmaleficence), and fairness are also foundational components of ethical behavior. Quality Assurance t Quality assurance (QA) is a system designed to evaluate and monitor the quality of patient care and facility management. t Formal programs provide a framework for systematic, deliberate, and continuous evaluation and monitoring of individual clinical practice. t Programs promote responsibility and accountability to deliver high-quality care, assist in the evaluation and improvement of the patient’s care, and provide for an organized means of problem-solving. t A good program identifies educational needs, improves the documentation of care, and reduces the clinician’s overall exposure to liability. t Programs identify components of structure, process, and outcomes of care. They also look at organizational effectiveness, efficiency, and client and provider interactions. ¸ QA may be implemented through audits, utilization review, peer review, outcome studies, and measurements of patient satisfaction. Quality & Safety Education for Nurses (QSEN) t Quality & Safety Education for Nurses (QSEN) was funded by the Robert Wood Johnson Foundation to address the knowledge, skills, and attitudes necessary to ensure the quality and safety of the health care systems in the United States. t The National Academy of Medicine (NAM), along with numerous professional organizations representing nursing, identified competencies to be used in the educa- tion, certification, and continuing education of advanced practice nurses. 18 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 t Areas identified that affect advanced practice include: ¸ Patient-centered care focus, ¸ Teamwork and collaboration, ¸ Use of evidence-based practice, ¸ Continuous quality improvement, ¸ Safety to minimize harm to patients and providers, and ¸ Use of informatics and technology. NURSE PRACTITIONER LEGAL AND FINANCIAL ISSUES Liability t NPs should be aware of liability issues or exposure to legal risk, which include ¸ Patients, ¸ procedures, and ¸ Quality of medical records. t There are methods of risk reduction or management: ¸ Activities or systems have been designed to recognize and intervene to reduce the risk of injury to patients and subsequent claims against health care providers. ¸ Malpractice insurance does not protect clinicians from charges of practicing outside their legal scope of practice. All clinicians carry their own liability insurance cover- age to ensure their own legal representation by an attorney to advocate for them. Malpractice t Malpractice involves negligent professional acts of persons engaged in professions requiring highly technical or professional skills. t The plaintiff has the burden of proving the four elements of malpractice. ¸ Duty: The clinician does not exercise reasonable care when undertaking and providing treatment to the patient when a patient–clinician relationship exists. ¸ Breach of duty: The clinician violates the applicable standard of care in treating the patient’s condition. ¸ Proximate cause: There is a causal relationship between the breach in the standard of care and the patient’s injuries. ¸ Damages: There are permanent and substantial damages to the patient because of the malpractice. Important Factors Influencing The Nurse Practitioner Role 19 t Types of malpractice insurance ¸ Claims-made policy: Covers a claim only as long as both the incident and the claim take place while the policy is in force. ¸ Occurrence-based policy: Covers any claim that results from an incident that occurs during the term of the policy, regardless of how long it takes before the claim is made. ¸ Tail coverage: Additional or supplemental insurance that covers the provider for incidents that occurred during the term of a claims-made policy but are not brought forward until after the policy has expired. National Practitioner Data Bank (NPDB) t The Health Care Quality Improvement Act of 1986 established a databank to scrutinize members of the health care profession and list those practitioners who have had malpractice claims asserted against them. t Currently few NPs are listed in the NPDB, but the number of NPs who have malpractice claims filed against them is increasing as the number of NPs in practice increases. Reimbursement t NPs are reimbursed for their services as primary care providers under Medicare, Medicaid, the yes Federal Employees Health Benefits Program, TRICARE (formerly known as CHAMPUS), veterans’ and military programs, and federally funded school- based clinics. t Medicare: People age 65 and over, some disabled people under the age of 65, and people with kidney disease treated with dialysis or transplant are eligible for Medicare. ¸ Medicare A: Hospital insurance that requires no premium. Part A covers inpatient care, including hospitals, skilled nursing facilities (not custodial or long-term care), hospice, and eligible home health care services. ¸ Medicare B: Outpatient insurance that requires a premium. Patients may decline coverage. Part B covers outpatient services, durable medical equipment, physical and occupational health services, home health care, and eligible preventive care services. ¸ Medicare C: Combines Part A and Part B of Medicare. ¸ Medicare D: Covers prescription drugs; usually requires a premium. The patient may decline coverage. ¸ Medicare E: Offers incentive/reimbursement for providers participating in elec- tronic prescribing. 20 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 t Incident to billing: Medicare regulation. Pays 100% of the physician charge to an NP who provides care to patients under specific guidelines (see the Centers for Medicare & Medicaid Services [CMS] website for full guidelines): ¸ ervices are furnished as an integral, although incidental, part of the physician’s S care. ¸ Physicians must provide the initial service and regular subsequent visits. ¸ A physician must be present in the office but not necessarily in the exam room. ¸ ervices are billed under the physician’s provider number at 100% of the physi- S cian rate. t Medicaid ¸ Individual states administer and make the rules for Medicaid. ¸ States must adhere to CMS rules and regulations when directing the Medicaid program. ¸ By federal law, Medicaid will cover services of family and pediatric NPs. ¸ If a state has applied to CMS for a Medicaid waiver, it is important that NPs are allowed to be primary care providers. ¸ NPs must apply to state Medicaid for Medicaid provider numbers. ¸ Full CMS guidelines are available at www.cms.gov t Private insurance plans may elect to reimburse for NP services even if not mandated to do so by state law. In some states, however, the insurance code may be interpreted rigidly to exclude the reimbursement of NPs. t Managed care organizations (MCOs) have frequently excluded NPs from being desig- nated as primary care providers carrying their own caseloads. Thus, in many MCOs, the only option for NPs is to be salaried employees. As salaried employees, the NP contributions are often not visible and may be credited to their collaborating physician, giving them a “ghost” provider status. Without a legitimate method to document services provided and revenue generated, the NP can find that job security is often at risk. Many state NP organizations have recently focused legislative activity on enacting state laws allowing NPs to function as primary care providers in both health mainte- nance organizations (HMOs) and preferred provider organizations (PPOs). These efforts have led to opposition from state medical organizations. ¸ here is considerable flux in state and national policy on what services and proce- T dures NPs may bill for and whether they will be paid directly. Incorrect billing places health care providers at risk of fraud and abuse charges, regardless of whether they knowingly violate the law or are simply ignorant of the regulations. ¸ NPs must be aware of specific regulations and policies for patient care services. Resources include CMS bulletins, among others (www.cms.hhs.gov/). Important Factors Influencing The Nurse Practitioner Role 21 ¸ Coding and billing practices are the responsibility of the NP provider, and knowl- edge of the regulations for payors is a requisite competency. ¸ Specific rules and regulations for Medicare and Medicaid can be found at www.cms.hhs.gov Performance Assessment t The NPDB and Health Integrity and Protection Data Bank (HIPDB) are maintained by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Practitioner Data Banks. Developed because of the Health Care Quality Improvement Act of 1986, the NPDB and HIPDB are flagging systems intended to facilitate a comprehensive review of the professional credentials of health care practitioners, with a goal of improving the quality of health care. The information contained in the NPDB includes a practitioner’s licensure, professional society memberships, malpractice payment history, and record of clinical privileges. An NP may perform a self-query by visiting the site at www.npdb -hipdb.com/ t Other programs monitoring and comparing health quality include the Healthcare Effectiveness Data and Information Set (HEDIS), developed by the National Committee on Quality Assurance (NCQA). HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans (www.ncqa. org). Health Records Electronic health record (EHR) systems readily allow access to medical records at a national level for more definitive monitoring of the effectiveness and outcomes of interventions. The data collected assists in determining the most effective clinical interventions and establishing effec- tive guidelines for health care providers. Centers for Medicare & Medicaid Services and Electronic Health Records t CMS is promoting the use of EHRs to assist in attaining national health care accuracy and efficiency and better meet established goals. t The term “meaningfully” is being used for the EHR to assess the efficiency of an elec- tronic system. The 2009 American Recovery and Reinvestment Act delineates three essential components for meaningful use of EHRs for electronic prescribing, exchange of information, and measurement of clinical quality. In 2011, the first of the three stages 22 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 was implemented, with the final stage implemented in 2015. The program is voluntary and requires application according to established guidelines. Reimbursement for program participation is based on specific criteria, such as benchmarks for recording accurate vital signs, height, body mass index (BMI), immunizations, and other health care interventions. t Benefits for the patient include receiving reminders for appointments by email, access- ing portions of the medical record to review lab work, and leaving messages for providers. Specifics may be found on the CMS website at https://www.cms.gov/ regulations-and-guidance/legislation/ehrincentiveprograms. t E-scribe: Electronic submission of prescriptions is now common practice, and specific laws regarding e-scribing vary slightly from state to state. Refer to specific state laws for accurate rules regarding the use of e-scribing by means of certified EHR. Current Trends and Topics in Nurse Practitioner Education and Practice CONSENSUS MODEL FOR APRN REGULATION: LICENSURE, ACCREDITATION, CERTIFICATION, AND EDUCATION t Consensus document from more than 40 nursing and advanced practice organizations and the NCSBN APRN Advisory Committee t Published July 2008 t Provides a national baseline for APRN licensure, accreditation, certification, and education (LACE) t Defines APRN practice, describes APRN regulatory model, identifies titles to be used, defines specialty, describes emergence of new roles and population foci, and presents strategies for implementation t Key issues: ¸ Goal is standardization of APRN education, licensure, and practice across all states and territories ¸ Limits APRN title to four roles: nurse practitioner, nurse anesthetist, nurse midwife, and clinical nurse specialist ¸ Identifies six population foci, with potential for more as practice changes ¸ Provided for elimination of separate geriatric and adult NP role and certification; replaced with combined ANP-GNP role, education, and certification Important Factors Influencing The Nurse Practitioner Role 23 FIGURE 2–1. APRN REGULATORY MODEL Reprinted from Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education (p. 10), by the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee, 2008. Retrieved from https://www.ncsbn.org/ Consensus_ Model_for_APRN_Regulation_July_2008.pdf DOCTOR OF NURSING PRACTICE (DNP) t 2004: American Association of Colleges of Nursing (AACN) members approved DNP Position Statement and 2015 target implementation date. t 2006: The Essentials of Doctoral Education for Advanced Nursing Practice was published. t DNP is the degree associated with practice-focused doctoral nursing education. t The goal is to prepare graduates for the highest level of nursing practice beyond the initial preparation in the discipline. 24 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 t It includes the four current APN roles: clinical nurse specialist, nurse anesthetist, nurse midwife, and nurse practitioner. t The degree may be entry into practice or post-master’s degree. t It includes eight essentials of doctoral education for advanced nursing practice: ¸ Scientific Underpinnings for Practice ¸ rganizational and Systems Leadership for Quality Improvement and Systems O Thinking ¸ Clinical Scholarship and Analytical Methods for Evidence-Based Practice ¸ Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care ¸ Health Care Policy for Advocacy in Health Care ¸ Inter-Professional Collaboration for Improving Patient and Population Health Outcomes ¸ Clinical Prevention and Population Health for Improving the Nation’s Health ¸ Advanced Nursing Practice t It is endorsed by APRN organizations but has no required entry-into-practice date established for NPs. ***NONPF committed to moving all entry-level nurse practitioner (NP) education to the DNP degree by 2025 (NONPF, 2018). NONPF developed new and revised the post-baccalaureate DNP Program curriculum and competency mapping templates (NONPF, 2020). More information can be found at the following link: https://www.nonpf.org/page/DNPResources Practice Environment, Policy, and Advocacy NAM’S FUTURE OF NURSING 2020–2030 At the request of the Robert Wood Johnson foundation and on behalf of the national academy of medicine, an ad hoc committee conducted a study to develop strategies that improve opportuni- ties for nurses to leverage their expertise to advance health equity and optimize health outcomes for all people. uture of nursing 2020–2030: charting a path to achieve health equity explores nursing’s role in F reducing health disparities, promoting equity, keeping costs at a minimum, utilizing technology, and maintaining patient-and family-focused care into 2030. Although the goal is to keep costs at bay, NPS must not do so at the expense of assisting patients to achieve optimal health out- comes. The goal of achieving health equity by eliminating health disparities requires that NPS prioritize the service aspect of health care. Using technology requires advocacy for equitable access to and assistance with literacy. Therefore, the np must promote and develop innovations Important Factors Influencing The Nurse Practitioner Role 25 that support persons and families with ease of access, effective and efficient communication, and high-quality telehealth to monitor health conditions. The report also outlines the critical areas that the nursing professions must bolster to have an impact on the goals of decreasing dispari- ties and advancing health equity. These areas include the nursing workforce, nursing leadership, nursing education, well-being, emergency preparedness and response, and nursing’s responsi- bility regarding individual and structural determinants of health. Nurses work in a broad array of settings, which provide opportunities to improve health through multiple intervention strategies, including the following: t Advocacy t Securing resources and making appropriate referrals t Patient, family, community, and population-focused education t Team-based/integrative care models t Active involvement in health policy t Participation in patient-centered outcomes research For more information on the Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, visit https://nam.edu/publications/the-future-of-nursing-2020-2030/ NONPF CALLS FOR GREATER RACIAL AND ETHNIC DIVERSITY IN NURSE PRACTITIONER EDUCATION (2018) In alignment with the mission and vision of NONPF, the organization strives to champion a culture of diversity and inclusivity across all NP education programs and calls upon NP faculty to consider increases in racially and ethnically diverse patient populations, persistence of racial and ethnic disparities in health care delivery, and disparate representation of racially and ethnically diverse groups among NP faculty and within the professional workforce. ANA POSITION STATEMENT The Nurse’s Role in Addressing Discrimination: Protecting and Promoting Inclusive Strategies in Practice Settings, Policy, and Advocacy states that the ANA seeks to eliminate all forms of dis- crimination, improving access to and attainment of quality health care, providing inclusive and impartial health care that is devoid of bias, and actively seeking and engaging in opportunities to eradicate disparities. The full ANA statement can be viewed at https://ojin.nursingworld.org /MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/ANA-Position-Statements /Nurses-Role-in-Addressing-Discrimination.html 26 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 AMERICAN ACADEMY OF NURSING (AAN) EQUITY, DIVERSITY, AND INCLUSIVITY STATEMENT The Academy envisions “Healthy Lives for All People” and their mission is to “Improve health and achieve health equity by impacting policy through nursing leadership, innovation, and science.” The Academy is committed to integrating its core values of equity, diversity, and inclu- sivity as the foundation for developing an anti-racist agenda and the ongoing goal of eliminating all forms of discrimination. “To the Academy, equity is assuring the right conditions for all people to thrive and achieve their full potential. The Academy defines diversity as affirming all the ways in which people differ. Inclusivity, as defined by the Academy, refers to the welcoming and active engagement of all voices within every aspect of the organization and with an intentional empha- sis on acknowledging those who experience or have experienced marginalization or disenfran- chisement.” The full statement can be viewed at https://www.aannet.org/about/about-the -academy/edi HEALTHY PEOPLE 2030 The Healthy People 2030 mission is “Building a Healthier Future for All.” The 10-year goals focus on improving health and well-being through data-driven objectives in three categories: (1) 10 core objectives, (2) developmental objectives, and (3) research objectives. The core objectives focus on evidence-based interventions to impact high-priority public health issues. The role of the NP in achieving the Healthy People goals is to apply the data to surveillance, implement strategic interventions, engage in research, and collaborate in the development of population-and issue- specific intervention strategies. The Healthy People 2030 goals initiative and Social Determinants of Health (SDOH) can be viewed at https://health.gov/healthypeople NOTABLE CONSIDERATIONS FOR ADVANCING HEALTH EQUITY Acquisition and Application of Cultural Intelligence Nurse practitioners across roles have the responsibility of caring for individuals and communi- ties that represent a vast array cultural backgrounds and must be prepared to provide culturally responsible individual-and population-centric care to advance health equity and eliminate health disparities and health care disparities. Critical to achieving these goals, the Healthy People 2030 goals, and the goals associated with the SDOH is the development of cultural intelligence (CQ). CQ is the skill and ability to function effectively in multicultural situations and environments. CQ can significantly improve cultural literacy and fluency, thereby eliminating barriers, such as personal and institutional biases, that impede the provision of culturally sensitive health care. Important Factors Influencing The Nurse Practitioner Role 27 The NP has an integral role in promoting and advancing health equity through practice, policy, and advocacy for all people Diversity, equity, inclusion, anti-discrimination, and anti-racism are central to the elimination of health disparities and optimizing health outcomes for all people. There is consensus among professional nursing organizations that supports the responsibility of nurses at all levels of practice to function professionally in concert with the humanitarian ethos, which is predicated on providing care to all humans from the lens of impartiality. The humanitar- ian principles undergird the code of ethics for nurses, highlighting the values of compassion, service, sympathy, mercy, trust, and respect for human life and dignity. Providing culturally responsible care requires that the NP be aware that clinical guidelines are meant to guide heath care practices and treatment plans, but that to achieve best practices, plans of care must be adapted to meet the individual needs of each person with whom they engage. The NP must engage in culturally responsible and inclusive care, regardless of personal prefer- ences and biases. Consideration and integration of the cultural preferences and practices of each individual and community are crucial in holistically addressing heath care needs, thus creating opportunities to shift the determinants of health toward equitable health care and optimal health outcomes for all individuals and communities. Bias Bias is a preference for or aversion to someone that may advantage or disadvantage those at whom the bias is aimed. Bias is a personal, and oftentimes, unsubstantiated judgement, label- ing, or stereotyping of someone or something. In health care, bias is a leading cause of health inequity and the subsequent health disparities and adverse health outcomes. Much of the litera ture addresses the impact of implicit bias on health inequities; however, both implicit and explicit bias may equally negatively impact morbidity and mortality among the most impacted popula- tions. Bias often impacts patient–provider interactions, clinical decision-making, and ultimately, patient and population health. From a geopolitical perspective, bias also affects the distribution of resources, many of which affect the overall health and well-being of individuals on the receiv- ing end of bias and discrimination. Nurse practitioners have the responsibility to be aware of their own personal biases and to recognize and stand against the biased-influenced decisions of others. All NPs must be willing to consistently participate in trainings that facilitate bias- reduction strategies to positively influence health outcomes for all human beings. Health Disparities It is important to note that there are two types of disparities that impact health outcomes: health care disparities and health disparities. Health care disparities are systems-based disparities that impact individuals and populations, and health disparities refer to the actual health of people. According to the U.S. Department of Health and Human Services Agency for Healthcare Research 28 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 and Quality, health care disparities refer to variances in the availability of and access to health care resources, including facilities and services. For more information, visit https://www.ahrq.gov /topics/disparities.html. The Centers for Disease Control and Prevention (CDC) refers to health disparities as preventable variances in disease burden, injury, violence, and/or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. The CDC acknowledges that “health inequities are directly related to the historical and current unequal distribution of social, political, economic, and environmental resources.” Factors such as race/ethnicity, gender, sexual orienta- tion, sex, ability, social and economic status, education level, and geographical location heavily influence health disparities and health care disparities. As determined by the NAM Future of Nursing 2020–2030 Report and the Healthy People 2030 initiative, intentionally and adequately addressing the SDOH can improve health outcomes through targeted efforts to decrease and eliminate social, economic, and health care disparities. Nurse practitioners have the power and unique opportunities to influence change in these areas. More information can be accessed at https://www.cdc.gov/healthyyouth/disparities/index.htm Health Literacy The Health Resources and Services Administration (HRSA) defines health literacy as the ability of an individual to obtain, process, and understand basic health information necessary for making decisions about their health care. It is critical for the NP to know that low health literacy is most prevalent among specific populations, such as older adults, historically underrepresented popu- lations, financially disadvantaged populations, and people from medically underserved popula- tions. However, NPs must not generalize, stereotype, or make assumptions about all individuals or communities who fall within these groups. Cultural intelligence and individualized care must be applied to all people. It is the responsibility of the NP to interview and assess each person to determine individual needs and provide appropriate education. More information on health literacy can be found at https://www.hrsa.gov/about/organization/bureaus/ohe/health-literacy /index.html Social Determinants of Health The CDC defines SDOH as “factors that contribute to a person’s current state of health.” These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature. Holistic FNP practice incorporates all components into patient care (https://www.cdc.gov/social -determinants/index.htm). Important Factors Influencing The Nurse Practitioner Role 29 Economic Stability Goal: Help people earn steady incomes that allow them to meet their health needs. One in 10 people in the United States live in poverty, making it difficult for many people to afford healthy foods, health care, and adequate housing. One of the foci of Healthy People 2030 is to help people achieve economic stability. Steady employment decreases the likelihood of living in poverty and increases the likelihood of being healthy. Living with certain disabilities, injuries, and health conditions often limits employment opportunities. NPs play a pivotal role in identifying financial burdens, barriers to access to health care, and barriers to acquisition of health-promoting foods and other resources. It is also within the role of the NP to serve as a liaison and assist in building relationships with social service entities that provide people and communities with needed resources. Other ways that NPs can help to advance the Heathy People 2030 goals is to be aware of and promote existing employment programs, career counseling, and high-quality childcare opportunities, all of which can help more people with job attainment and job security. In addition, many NPs are active in policy engagement, which provides prime opportunities to impact the revision of and/or development of policies aimed at subsidies to help people buy healthy foods, obtain safe housing, increase access to affordable health care, and quality educa- tion. Each of these initiatives can reduce poverty and improve health and well-being. More information on the Economic Stability SDOH can be viewed at https://health.gov/healthypeople /objectives-and-data/browse-objectives/economic-stability Education Access and Quality Goal: Increase educational opportunities and help children and adolescents do well in school. Higher educational levels increase the likelihood of people being healthier and life expectancy growth. Healthy People 2030 focuses on ensuring high-quality educational opportunities for children and adolescents and on helping them perform well in school. Stress associated with living in poverty can adversely affect brain development in children and make it more difficult for them to perform well in school. Of note for NPs is that children from low-income families, children with disabilities, and children who routinely experience forms of social discrimination are more likely to struggle with certain academic subjects, especially math and reading. They are also less likely to graduate from high school or pursue college education. This directly affects their ability to obtain safe jobs with decent wages, and consequently contributes to the development of health problems such as heart dis- ease, diabetes, and depression. In caring for children and adolescents, the NP should be vigilant in screening for and identifying indicators and risk factors related to low-quality education. Beyond identification, the NP serves as an advocate for families experiencing inadequate child and adolescent education and should engage in seeking ways to connect these families with appro- priate resources. Interventions that aid children and adolescents with school performance and providing financial resources for college may have long-term health benefits. More information 30 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 can be found at https://health.gov/healthypeople/objectives-and-data/browse-objectives/education -access-and-quality Health Care Access and Quality Goal: Increase access to comprehensive, high-quality health care services. Many people in the United States do not have health insurance, making it less likely to have a primary care provider, less likely to have consistent health care, and less likely to participate in wellness promotion, all of which adversely impact morbidity and mortality among these indi- viduals. The overall health and well-being of individuals cannot improve without adequate health care, including access (i.e., locations, transportation, health insurance, timeliness, and adequate employment to cover co-pays and prescriptions) and high-quality health care services. The number of individuals who cannot get access to health care as needed and those who are unable to obtain prescription medications when needed has increased over the past several years and is continuing to worsen, according to the Healthy People 2030 overview on the SDOH. NPs have a moral and professional responsibility to engage in policy and advocacy initiatives aimed at increasing access for affected individuals for significant change in the direction of comprehen- sive and high-quality health care to occur. Developing innovative interventions that facilitate increased access to health care is essential, and NPs can play a vital role in that. More informa- tion on health care access and quality can be found at https://health.gov/healthypeople/objectives -and-data/browse-objectives/health-care-access-and-quality Neighborhoods and Built Environments Goal: Create neighborhoods and environments that promote health and safety. The environment has a major influence on the health and well-being of people and communities. Air and water quality, physical safety (violent vs. non-violent; sidewalks and places to safely access physical activity), number of people interacting within a space (over-or under-populated). Historically underrepresented racial and ethnic minorities and financially disenfranchised people are more likely to live in high-risk places. These factors are key components of a holistic assess- ment and cannot be overlooked. It is within the purview of the NP to be an active participant in health promotion and safety. Healthy People 2030 recognizes that improving neighborhoods and built environments can impact health and safety in all the places where people live and interact. Nurse practitioners should engage in interventions and policy changes at every level of govern- ment to aid in health and safety risk reduction, health promotion, and improved quality of life and overall health outcomes. Additional information may be found at https://health.gov /healthypeople/objectives-and-data/browse-objectives/neighborhood-and-built-environment Important Factors Influencing The Nurse Practitioner Role 31 Social and Community Context Goal: Increase social and community support. Opportunities for interpersonal interactions in a variety of places may significantly affect overall health and well-being. In alignment with the focus of Healthy People 2030 on assisting people with social support needs, NPs should also identify and support this effort through advocacy and active engagement in interventions and innovations, and through interprofessional collaboration with other relevant health care advocates, including other professionals and organizations. More information can be accessed at https://health.gov/healthypeople/objectives-and-data/browse -objectives/social-and-community-context RESEARCH t Nurse Practitioners should understand research methods, advocate for ethical and culturally responsible research methods and practices and be able to translate research into practice. t Research Ethics: The ANA and other organizations provide codes of ethics related to research activities. t Quantitative vs. Qualitative Research ¸ Quantitative research: Research that uses objective measurements to provide numerical and statistical information and data in the form of numbers, percent- ages, and ratios; may include interventions and treatments ¸ Qualitative research: Investigation of a problem using inquiry methods and devel- oping conclusions based on observations, quotes, and themes t Translational Research ¸ Understanding research methodology and bio-statistical data to evaluate, interpret, and implement research findings ¸ Identification of evidence-based research and use of critical thinking to implement new research findings and ideas into practice t FNPs must be prepared to be ¸ Lifelong learners: identifying research problems, participating in research affects, and applying research findings ¸ Scholars: Providing outcomes research data through various dissemination modes such as publications, speaking engagements, and professional presentations t Assurance of Safe Practice t A system to evaluate and monitor the quality of patients’ care and facility management. 32 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 t Formal programs that provide a framework for continuous, consistent monitoring and evaluation: ¸ Structure, process, and outcomes of care ¸ Client interactions ¸ Clinical competence ¸ Performance assessment t Knowledge of standards of care and clinical guidelines t Minimizing clinical errors and complications by using risk-reducing tools such as smart phones and tablets, flow sheets, and electronic resources t Promoting a safe work environment using principles of QSEN t Evaluation of clinical outcomes using ¸ Continuous Quality Improvement (CQI) ¸ Peer review ¸ Audit DISASTER AND EMERGENCY CARE AND PLANNING Attention is increasingly being paid to preparing RNs to assume emergency roles during a time of mass casualties from either natural disasters or terrorist attacks. The International Nursing Coalition for Mass Casualty Education was established to help nurses to identify the educational competencies for RNs responding to mass casualty incidents. The coalition aspires to improve the ability of all nurses to respond safely and effectively to mass casualty incidents through the identification of existing and emerging roles and responsibilities of nurses, ensuring robustness of education for mass casualty incidents, helping to understand response frameworks, and ensuring collaborative efforts. As outlined in the NAM Future of Nursing 2020–2030 Report, nurses are expected to be prepared to respond to emergencies. Information on the objectives and work that has been done toward a uniform curriculum in this area may be obtained at http://www.nursing.vanderbilt. edu/advantage/emergency.html In addition, the Emergency Nurses Association, with endorsement from NONPF, published specialty competencies for the NP who practices in emergency care (Emergency Nurses Association {ENA}, 2008). The 2021 updated competencies from the American Academy of Emergency Nurse Practitioners and the ENA can be found at https://www.ena.org/docs/default-source/education-document-library /enpcompetencies_final.pdf?sfvrsn=f75b4634_0. The Centers for Disease Control and Prevention also maintains emergency preparedness resources for health care providers. These can be found at http://emergency.cdc.gov/ Important Factors Influencing The Nurse Practitioner Role 33 COMPLEMENTARY AND INTEGRATIVE HEALTH here is greater recognition of the use of complementary and integrative modalities. The T National Center for Complementary and Integrative Health (NCCIH) is the federal government’s lead agency for scientific research on complementary and integrative health (https://nccih.nih.gov). Delivery of holistic, patient-centered, and culturally intelligent care requires NPs to fully engage persons seeking wellness care and those who access care during times of illness in the development and management of treatment plans. The role of the NP in complementary and integrative health is to assess individual levels of health literacy and provide education accord- ingly. The focus of the plan of care should be on optimal health and well-being, as defined by each individual. Resources for health care providers can be found at https://www.nccih.nih.gov /health/providers. Definitions (NCCIH) t NCCIH uses the following terms: ¸ “Complementary health approaches” is used when discussing practices and products of nonmainstream origin. ¸ “Integrative health” is used when discussing practices that incorporate comple- mentary approaches into mainstream health care. ¸ If a practice is nonmainstream and used together with conventional medicine, it is referred to as “complementary.” ¸ If a practice is nonmainstream and used in place of conventional medicine, it is considered “alternative.” Demographics t More than 30% of adults and 12% of children use complementary or alternative approaches to health care. t Many drug–herb interactions have been identified. t Sixty-eight percent of clinically significant drug–herb reactions are related to five herbs: ¸ Kava ¸ Garlic ¸ Ginkgo biloba ¸ St. John’s wort ¸ Valerian 34 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 t The prescription medications most frequently affected: ¸ Warfarin ¸ Sedative/hypnotics ¸ Antidepressants ¸ Insulin ¸ Oral antidiabetic agents ¸ Hepatotoxic medications ¸ Oral contraceptives Role of Nurse Practitioner Nurse practitioners should be aware of current evidence and resources regarding Complementary and Alternative Medicine (CAM) interventions. t Maintain objectivity and be supportive about patients’ choice to use CAM. t Proactively ask all patients about the use of and response to CAM: ¸ Request that patients bring their supplements (bottles, tubes, containers, packag- ing, etc.) to visits. ¸ Ask about alternative therapies. ¸ Document all CAM information and referrals in patient’s record. ¸ Use caution with women of childbearing age—many herbals are category C. ABLE 2–1. T NCCIH TYPES OF COMPLEMENTARY HEALTH APPROACHES APPROACH EXAMPLES Natural Products* Vitamins and minerals, probiotics, herbs (also known as botanicals) Mind and Body Practices Acupuncture, relaxation techniques, guided imagery, tai chi, qigong, healing touch, hypnotherapy, movement therapies, yoga, chiropractic, meditation, massage therapy Other Complementary Homeopathy, traditional healers, Ayurvedic medicine, naturopathy, Health Approaches traditional Chinese medicine *Herbal products, probiotics, and vitamins are not approved by the U.S. Food and Drug Administration (FDA) and are considered food supplements. Source: National Center for Complementary and Integrative Health (NCCIH). Retrieved from https://nccih.nih.gov/health/integrative-health#term ABLE 2–2. T SELECT DRUG–HERB INTERACTIONS HERB DRUG(S) EFFECT Garlic Warfarin Decreased blood concentrations Ginkgo biloba Anticoagulants, aspirin, NSAIDs Increased risk of bleeding with warfarin Thiazide diuretic Increased blood pressure Trazodone Coma Anticonvulsants, TCAs Decreased seizure threshold Kava Benzodiazepines Additive CNS depression Levodopa Increased “off” periods in patients with Parkinson’s Disease St. John’s wort Warfarin and related anticoagulants, Decreased blood concentrations cyclosporin, amitriptyline, digoxin Piroxicam, tetracyclines Increased phototoxicity Antidepressants, CNS stimulants Additive effects Theophylline Decreased xanthine levels Valerian CNS depressants Additive CNS depression Note. NSAIDs = nonsteroidal anti-inflammatory drugs; TCAs = tricyclic antidepressants; CNS = central nervous system. ABLE 2–3. T COMMON TYPES OF COMPLEMENTARY HEALTH APPROACHES TEN MOST COMMON COMPLEMENTARY HEALTH APPROACHES IN USE BY ADULTS IN THE UNITED STATES 17.7% Natural products 10.9% Deep breathing 10.1% Yoga, tai chi, or qi gong 8.4% Chiropractic or osteopathic manipulation 8.0% Meditation 6.9% Massage 3.0% Special diets 2.2% Homeopathy 2.1% Progressive relaxation 1.7% Guided imagery Source: Trends in the use of complementary approaches among adults: United States, 2002–2012. National health statistics report no. 79, by T. C. Clarke, L. I. Black, B. J. Stussman, P. M. Barnes, and R. L. Nahin, 2015, Hyattsville, MD: National Center for Health Statistics. 36 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 CARING FOR PEOPLE WITH DISABILITIES Definitions The Americans with Disabilities Act (ADA) is a civil rights law that was enacted in 1990. It prohibits discrimination against individuals with disabilities in all areas of public life, including employ- ment, schools, transportation, and all public and private places that are open to the public. The law ensures that people with disabilities have equal and equitable rights and opportunities as compared to everyone else. The civil rights protections for individuals with disabilities are like those provided to individuals based on race, color, sex, national origin, age, and religion. It guarantees that individuals with disabilities have equal opportunities in public accommodations, employment, transportation, state and local government services, and telecommunications. A person with a disability has a physical or mental impairment that substantially limits one or more major life activities, or a record or history of such an impairment, or is regarded/perceived by others as having such an impairment. When used in reference to the ADA, the term “disability” is used in a legal rather than medical context. Nurse practitioners should be aware of this distinc- tion. More information about the ADA may be obtained at: https://adata.org/learn-about-ada t Characteristics of disabilities vary in severity: ¸ Very mild (inconvenience) ¸ Moderate (interfere with some activities) ¸ Severe (need assistance for activities of daily living [ADL] and instrumental ADL) ¸ Very severe (need technology for survival) t Disabilities vary in type: ¸ Physical ¸ Sensory (vision and hearing) ¸ Psychiatric or mental health ¸ Cognitive or intellectual ¸ Communication t Disabilities vary in visibility: ¸ Not at all visible to others ¸ Visible to informed others ¸ Visible to all t Issues for providers ¸ Access and care eople with disabilities encounter serious barriers to receiving quality health P care, preventive care, screening, and reproductive care. Important Factors Influencing The Nurse Practitioner Role 37 eople with disabilities have received lower quality of care, less aggressive P treatment, and are offered few choices. Health care providers are often under- prepared for addressing sexuality, pregnancy, childbearing, and common health problems in people with disabilities. This increases the risk for health inequities, health disparities, and sentinel events. ¸ Barriers to optimal care in people with disabilities include: Lack of awareness and knowledge about specific disabilities and of disability in general, Lack of CQ regarding interacting with and caring for people living with disabilities, Lack of accountability of health care providers for providing culturally respon- sible and inclusive care for all people, Lack of knowledge about the law or disregard for the legal mandates, An erroneous assumption is that people with disabilities are dependent on others and incapable of making their own decisions. ¸ Consequences of lack of substandard and non-inclusive care Negative encounters, often resulting in people with disabilities avoiding health care providers unless and until necessary Inadequate health care, including preventive screening Delay in treatment or lack of treatment Low level of participation in health-promotion activities Poor health status, isolation, and psychological issues Preventing health disparities using an inclusive excellence approach Inclusive excellence embodies the principles of cultural intelligence, the humanitarian ethos and principles, and ethical principles as defined in the ANA Code of Ethics for nurses. It embraces diversity, equity, equality, inclusion, belonging, and all the characteristics that make individuals and populations unique. The role of the NP is to adopt and employ supportive strategies that assist in the provision of care in ways that deter discriminatory practices and bias-influenced care, to increase opportunities to advance health equity, and improve population health. Some of those strategies include: t Self-awareness, bias acknowledgement, and mitigation and/or de-activation of bias- influenced decisions 38 FAMILY NURSE PRACTITIONER: REVIEW AND RESOURCE MANUAL 6TH EDITION, VOLUME 1 t Cultural intelligence application: ¸ Discuss culture and cultural preferences with each patient. ¸ Do not generalize, stereotype, or make assumptions about people from specific affinity groups, including race, gender identification, sex, nationality, ethnicity, disability, body composition, families, or communities. t Adopt inclusive language: ¸ Ask about pronouns and use appropriate pronouns. ¸ Ask about gender identification. t Approach the care of all persons as a partnership, not a dictatorship. People have the right to be active participants in and make the ultimate decisions regarding health care. t Attend trainings and other educational opportunities related to caring for people from underrepresented, marginalized, and stigmatized populations. t Provide appropriate and relevant accommodations for all persons who are consumers within the health care system. t Practice the concept of “nothing about us without us” and the conce

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