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ConceptAnalysis.pptxAdvanced Practice Registered Nurses
The Concept of Scope of Practice in
Concept Analysis 101
Walker & Avant (2011)
Concepts are the blocks of nursing theory construction
Are made up of attributes that make them unique from other concepts
Examining the structure and function of a concept is the purpose of concept analysis
Theory
attribute
For a concept to be solid and strong
It must clearly name the thing to
which it refers
It must uphold the structure of the theory
Walker & Avant, 2011
Scope of Practice Definition
Definition of scope:
Range of operation
Definition of practice:
A professional business
Hybrid definition of scope of practice
The range of operation of a professional business
Webster’s Collegiate Dictionary, 2011
Walker & Avant steps
Select a concept
Determine the purpose of the analysis
Identify all uses of the concept you can discover
Determine the defining attributes
Identify a model case
Identify a borderline, related, contrary, invented, and illegitimate cases
Identify antecedents and consequences
Define empirical referents
1. Best way to discover all uses is to look up definitions
5
Step 1. Select a concept
Scope of practice of APRNs
Dissertation- relationship between APRN scope of practice and pt outcomes. Why? Facilities need to have a reason to expand sop in the institution- make it financial
6
Step 2. Purpose of the analysis
Concept analysis is a tool by which nurses bring clarity to abstract ideas
Scope of practice of APRNs is an abstract concept
Confusion surrounding the term
Standards of professional practice
Legal basis of the profession
Components of clinical duties
APRN Scope of Practice
Aim: Examine the concept of scope of practice in the context of APRNs in order to bring clarity to the concept and unity to the use of the term
Step 3. Identify uses of the concept
Law: used in connotation of the rules of the profession for discipline or description of when an attorney can use professional judgment
Clergy: Used to delineate counselling duties from those of medical professionals
Trade Occupations: Used by licensing boards to distinguish duties that require licensure or levels of expertise
Engineering: used to delineate areas of competence
American Bar Association, 2000; Veterans Health Administration Dept. of Veteran’s Affairs, 2008;New Jersey Board of Examiners of Master Plumbers;
2006; State of Maine Electrician’s Examining Board, 2011; The New York State Office of Professionals: Engineering, 2009
Scope of Practice Uses in Healthcare
Most common usage is in healthcare professions; nursing, OT, PT, pharmacy, optometry, family therapists, EMTs
Defines scope of practice within their own profession
Medicine
Defines scope of practice limitations of other healthcare professions
AMA- formulation of clearer definitions of physician-extenders to include direct appropriate physician supervision and recommended guidelines for physician supervision to ensure quality patient care.
AOMA- supports the limits on scope of practice of non-physicians professionals and the prohibition of non-physicians as identified providers of primary care.
10
Historical Context of Scope of Practice within Healthcare Professions
Medical Practice Acts
Claimed the entire human condition as their domain
Controlled the supply of the division of labor and restricted non-physicians by law from performing duties relegated to physicians
Had legal authority to supervise and limit what other professions could do within the entire human condition
Starr, 1982
Step 4: Identify defining attributes
Attribute
Defining characteristic that occurs most frequently in the discussion of a concept
Identify relationships between the attributes
Walker & Avant, 2013
Step 4. Identify defining attributes of APRN Scope of Practice
Profession Composition
Authority
Jurisdiction
Define and identify relationship between attributes
13
Defining Attributes of APRN Scope of Practice
Profession Composition
To be a member of a profession is to own a body of knowledge and act in ways denied to other members of society
Professional Associations are recognized as the bodies that are most closely associated with a profession’s practice
Devise scope of practice and standards of care statements
Devise standards for education and accreditation
It is the broadest in scope and represents the full range of practice possibilities an individual is educated to perform
McMurray, 2011; Kleinpell, et. al., 2011; Greenwood, et. al, 2002
Defining Attributes of APRN Scope of Practice
Authority
The permissive right to practice the duties associated with the knowledge possessed by the profession
License- specific right to practice the professional duties and is bestowed by
Society
Legal authority (legislation and regulation)
facility
Mandate- the rightful claim to expertise of the knowledge
Utilizes the Profession Composition as a guide to defining the authority granted to APRN practice, but is generally more restrictive based upon the needs of the state.
Dingwall, 2008; Hughes, 1984; McMurray, 2011
Defining Attributes of APRN Scope of Practice
Legal Authority
Written into state based Nurse Practice Acts
Broad language
Use professional association Profession Composition as a guideline but more restrictive
Cannot be less restrictive, as education, training, and certification not present
BON- composition, authority are contained in NPA
Education program standards
Nursing practice standards
Title recognition
License requirements
Rules surrounding disciplinary action
Buppert, 2005
Defining Attributes of APRN Scope of Practice
Legal Authority
Great variation in Nurse Practice Act APRN language
Not the case for other healthcare professionals (physicians, RNs, PAs) who have consistent legal authority across states
Variation usually relates to practice independence
Supervision and collaboration language
8 states support full practice independence
Kleinpell, et.al., 2011
Defining Attributes of APRN Scope of Practice
Legal Authority
Oversight by BOM can also be written into NPA
28 states- solely BON
22 states- joint BON/BOM
Pohl, et. al., 2010
Kalist, 2004
Nurse Practice Act variation
Board oversight variation
-Confusion
-Decreased APRN movement across state lines
-decreased enrollment in more restrictive states
-decreased access to care in more restrictive states
Defining Attributes of APRN Scope of Practice
Legal Authority
NCSBN Consensus Model for State Regulation for APRNs
Aim: alignment of education, accreditation, certification and licensure standards across nation
Released 5 years ago
Multiple states have seen legislative attempts to align with consensus model language
NCSBN, 2008
Defining Attributes of APRN Scope of Practice
Jurisdiction
The granting of a practice space in which a member of a profession can claim salary or fee for the application of the unique knowledge to a portion of society
The facility level of practice
More narrow and specific than Authority to practice or the Profession Composition
McMurray, 2011
Defining Attributes of APRN Scope of Practice
Jurisdiction
Job descriptions
Facility policies and procedures
Privileging
Accrediting agencies (Joint Commission)
E.g. the requirement that a dissociative medication be administered by a CRNA under physician supervision in ASC- AAAASF
Reimbursement
CMS conditions for participation/coverage
Kleinpell, 2011; AAAASF, 2011; CMS, 2013
American association of accreditation of ambulatory surgery facilities
22
Relationship of Attributes of Scope of Practice for ARPNs
Authority
Granted
By Society
Attribute Relationship
Not unidirectional
Authority
Profession
Composition
Jurisdiction
Jurisdiction
Authority
Profession
Composition
Step 7. Define Antecedents to APRN Scope of Practice
Societal Need
Trust in and acceptance of Nurses to fulfill the need
Willingness of Nurses to fulfill the role
Step 7: Original Antecedents of Societal Need for APRN
CNRA
Late 1800s
patient safety under anesthesia
CNM
1920’s
Obstetric care in underserved immigrant and rural populations
CNS
1940s
Meet the needs of patients in the high-tech, more complex hospital environment
CNP
1960s
Meet primary care and pediatric patient needs in time of physician shortage
Bankert, 1989; Scoggin, 1997; Holmes, 1998; Murphy, 1990
Contemporary need for APRN Scope of Practice
Primary care physician shortage
Increasing number of patients entering health care system
Unsustainable costs of the current healthcare system
Restrictions on medical resident hours
Increased complexity of patients
Trends toward specialization
Contemporary evidence of trust in nurses to fulfill the role
Gallup poll-
Nurses most trusted profession in America last 10 out of 11 years
Prina 2013
Majority of Californian’s support the expansion of CNP scope of practice to meet increased need for primary care
Dill, et al 2012
50% American’s would be willing to see an CNP or PA if it meant a decreased waiting time
People who had prior experience with the role were even more willing to accept care
Contemporary evidence of nurses willingness to fulfill the role
2001-2011 near doubling of APRN graduates from accredited schools
8842-15,112
HRSA, 2013
Step 7.Consequences (outcomes) of APRN scope of practice
Positive
Improved patient satisfaction
Decreased length of stay (acute care)
Decreased cost (acute care)
Increased access to care (primary care)
Decreased wait times (ER settings)
Neutral
No difference in quality of care compared to physicians
Negative
Confusion due to role blurring
Professional conflict
Newhouse, 2011; Carter, et. al., 2007; Dowling, 2013, Schuiling, et.al, 2000
Step 5. Model Case
Model Case- A CRNA sits on a Policies
and Procedures Committee within an institution
that is reviewing their current informed consent policy. The current policy states an informed consent can only be obtained by a physician. The CRNA points out that obtaining an informed consent from a patient is a function clearly within a CRNAs scope of practice: it is contained within CRNA education, is recognized within the AANA’s scope of practice documents, and authority is granted by state law.
The function is within Professional Composition
Authority has been granted by the state
Jurisdiction is being requested at the facility level
Profession composition
Authority granted by state
Jurisdiction: facility
Policies & Procedures,
Privileges
Step 6. Borderline Case
Borderline Case A CNP just graduated as a primary care adult NP, and has been hired at an institution near her home in which she previously worked as an ICU RN. Her new role officially has her assigned to work in a immunization clinic attached to the hospital. During slow periods her DON has asked the CNP to help out in the ICU as an NP, because, now that she is a CNP and was a prior expert RN in the ICU, it is within her scope of practice to do so.
Her role as the immunization CNP is within her education and certification, so is within her profession composition, and state authority and facility jurisdiction is granted for this role
Her role as the ICU NP is not within her education and certification, so is not within her profession composition, and state authority is not granted for this role, therefore, facility jurisdiction is not applicable.
Jurisdiction: Facility
Policies & Procedures, Privileges
Profession Composition
Authority grantedby
state
Jurisdiction: Facility
Policies & Procedures, Privileges
Step 6. Contrary Case
Contrary Case A peds NP
Is visiting her relative who c/o
Shortness of breath and dizziness. The PNP tells the relative to lie down and rest, there is no reason to call for additional help, as she (the PNP) has 15 years of experience with adults, therefore it is within her scope of practice to treat the problem.
The PNP is not an adult APRN as she has no adult APRN education, training, or certification, and therefore does not possess profession.
Not possessing profession composition, she cannot be granted authority or jurisdiction to function within the adult APRN scope of practice.
Profession Composition
Authority granted by state
Jurisdiction: Facility
Policies & Procedures,
Privileges
Step 8. Empirical Referents
Categories of actual phenomena that demonstrate the existence of the concept itself.
Empiric referents may be the same as the attributes, but not if the concept is broad or very abstract, as in the case of APRN scope of practice.
It is not a tool to measure the concept
Can measure the attributes of the concept
Many tools have been created that proclaim to measure scope of practice of APRNS, but in actuality, they are measuring one or more of the 3 attributes.
Walker & Avant, 2013
Observable properties for that concept
34
Step 8. Empirical Referents
Procedures or practices that an APRN performs in their particular facility, which really measures the jurisdiction not their full scope of practice.
example : a tool developed to measure the percentage of time spent each day by acute care nurse practitioners in various defined tasks such as taking a history and physical or discharge planning
Restrictions placed upon practice in various states across the nation. This compilation is actually measuring the authority granted to an APRN in that state
NCSBN’s report on APRN regulatory
barriers to practice at state level
Kilpatrick, 2011; Pearson, 2012
Conclusion
The concept of APRN scope of practice is complex and multi-faceted
Often when people discuss the concept they are actually referring to a single attribute of the concept
Rarely are they considering all of the facets of the concept, therefore, confusion may arise due to intermixing and misinterpretation of the different attributes of the concept.
Example: SOPP vs CPR
Conclusion
Discussions around scope of practice will only increase in the upcoming years
A continued focus on quality and cost containment will drive consumers and other stakeholders to investigate alternate methods of healthcare delivery
Continued focus on NCSBN APRN Consensus Model Language
These convergent factors make this an unprecedented time for APRN Scope of Practice, so it is imperative the concept is understood and utilized in a consistent manner
References
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References
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Lori Schirle, CRNA, MSN
PhD student
University of Miami School of Nursing and Health Sciences
