An advanced practice nurse (APN) can be described as a registered nurse possessing
highly specialized and advanced clinical knowledge and skills with the purpose of providing care
to diverse populations and ultimately increasing the access to quality and cost-effective
healthcare services (DiFazio & Vessey, 2014). There are four recognized categories of APNs,
including nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse anesthetists
(CRNA), and certified nurse-midwives (CNM). Several studies have substantiated the
significant contribution of APNs towards the improvement of patient care and outcomes.
According to Parker and Hill (2017), the effectiveness of APNS as change agents in the clinical
setting and the recognition of their clinical expertise and leadership have led to the increasing
demands for APNs worldwide. Mason, Gardner, Outlaw, and O’Grady (2016) also emphasized
that health care in the United States has consistently been challenged by fragmentation, concerns
about patient safety, workforce shortages, healthcare disparities, and inequality in access to
services that APNs are in the forefront to address and mitigate some of these issues to improve
the health of individuals and communities.
In the hospital where I am currently employed, I am an active member of the
Comprehensive Unit-based Safety Program (CUSP) which is actively led by an APN, our clinical
nurse specialist. CUSP utilizes the experience of clinical teams and frontline nurses for the
achievement of a safer patient care environment through the combination of improved teamwork,
enhanced communication, clinical best practices, and the application of the science of safety
(Slade & Hata, 2016). The clinical leadership of our CNS in the intensive care unit has led to
several quality improvement initiatives in our unit. One prime example of this initiative is the
significant decrease of catheter-associated urinary tract infection (CAUTI) in our unit, with the
last reported CAUTI incidence in the ICU being in 2017. This was made possible by the
significant reduction of indwelling urinary catheter (IUC) insertion, with the utilization of
external urinary catheter alternatives for both male and female patients; two-person policy on
indwelling catheter insertion; and strict implementation of perineal care for patients with IUC.
According to McEwen and Wills (2014), quality improvement refers to the analysis of methods
to decreases costs of hospitalization related to nurse-sensitive adverse patient outcomes. By
eliminating the occurrences of hospital-related infections, patient outcome is not only improved
but it also leads to decreased costs of hospitalization.
There are several other quality improvement initiatives spearheaded by the CUSP team in
the ICU with the effective leadership of our CNS which are worth mentioning. First is the
ultrasound-guided insertion of a peripheral intravenous cannula for nurses, which significantly
decreased the number of IV insertion attempts for patients with thin and fragile veins. This led
to enhancement of patient experience, leading to lesser painful experiences associated with IV
insertions and is cost-effective as well, as it lessens the expenses associated with repeated IV
attempts. Another is the modification of the practice guidelines to be followed during the
insertion of the Dobhoff tube (nasogastric tube). There were incidences of pneumothorax
associated with the insertion of the Dobhoff tube and this was addressed through the use of end-
tidal CO2 detection during the tube insertion to ensure proper placement of the tube and to avoid
inadvertent insertion of the Dobhoff in the patient’s lungs leading to serious complications.
Lastly, the issue of safe patient handling and transfer has also been addressed by a QI initiative
spearheaded by the ICU CNS. Through her leadership, the ICU was able to acquire Prevalon™
air taps that not only facilitated safe patient transfer, made patient turning easier, minimized the
issue of friction and shear in bedridden patients, and most importantly, helped decrease incidence
of back pain and work-related injury of nurses associated with the frequent lifting and
transferring of bedridden or immobile patients admitted in the intensive care unit. It is important
to highlight the central role of APNs in being the forerunner of changes for the creation of
innovative health care system solution changes for acute and critically-ill hospitalized patients as
they develop and adhere to best practice clinical guidelines (Tracy, 2014).
APNs also have a significant role in the expansion of clinical knowledge through nursing
research. Evidence-based practice (EBP) can be defined as the provision of the highest quality
of care to patients and families through the utilization of a problem-solving approach in the
clinical setting with the integration of the most recent and relevant research, incorporation of the
clinician’s own clinical expertise and assimilation of the preferences and values of patients
(McEwen & Wills, 2014). In the ICU where I work, APNs occupy various leadership positions
such as the Department Head (DH), Clinical Nurse Educator (CNE), charge nurse and team lead
for various nursing teams and I believe every one of them plays a great part in contributing to
evidence-based practice taking root in our organization. EBP has universally been defined as the
integration of best research evidence with clinical expertise and patient values, with the notable
benefits of cost-savings, improvement in patient outcomes, and translation of research findings to
the bedside (Tracy, 2014). One of the significant EBP activities that are currently ongoing in our
unit is a collaborative effort of the department head, CNE, CNS, team leads and the CUSP team
to implement an EBP change to address disparities regarding the current Massive Transfusion
Protocol being utilized in the hospital. Another EBP activity is being initiated at the hospital
level and is being spearheaded by the ICU leadership and CUSP team is the redesign of the
Rapid Response Team parameters being currently implemented in the inpatient units. The goal
of this EBP initiative is to structure the parameters so that the clinical alarms will be sensitive
and specific enough to identify patients manifesting signs of clinical deterioration but not too
restrictive that hinders nurses in the inpatient units to implement nursing interventions at the
bedside before necessitating the activation of the Rapid Response Team.
According to Mick (2017), the common barriers to evidence-based practice include lack
of knowledge or awareness, negative perception of evidence-based practice as requiring
extra/additional work, considerable amounts of information in professional journals coupled with
the lack of time and resource to search for and scrutinize evidence, and pressure to continue with
practices steeped in tradition. As healthcare leaders, APNs have a key role in translating research
evidence through evidence-based nursing practice to improve health outcomes for patients
(Mick, 2017). I believe that APNs in my hospital and in various hospitals across the country are
in the ideal position to bring expert knowledge, clinical expertise, interaction with the patient
population, and central role as a consistent point of contact in the multidisciplinary team to assist
in the initiation of various quality improvement projects and evidence-based practice initiatives
in the clinical setting. APNs can be in the forefront to determine what is clinically beneficial for
patients and can promote adherence to best-practice guidelines. As James 3:17 (English
Standard Version) states, “But the wisdom from above is first pure, then peaceable, gentle, open
to reason, full of mercy and good fruits, impartial and sincere.”
References
DiFazio, R. L., & Vessey, J. (2014, March). Advanced practice registered nurses: Addressing
emerging needs in emergency care. African Journal of Emergency Medicine, 4(1), 43-49.
https://doi.org/https://doi.org/10.1016/j.afjem.2013.04.008
Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy and politics in
nursing and health care (7th ed.). St. Louis, MO: Elsevier.
McEwen, M., & Wills, E. M. (2014). Theoretical basis of nursing (4th ed.). Philadelphia, PA:
Wolters Kluwer Health.
Mick, J. (2017, April). Call to action: How to implement evidence-based nursing practice.
Nursing 2017, 47(4), 37-43. https://doi.org/10.1097/01.NURSE.0000513603.03034.5c
Parker, J. M., & Hill, M. N. (2017, April 10). A review of advanced practice nursing in the
United States, Canada, Australia and Hong Kong Special Administrative Region (SAR),
China. International Journal of Nursing Sciences, 4(2), 196-204.
https://doi.org/https://doi.org/10.1016/j.ijnss.2017.01.002
Slade, J., & Hata, R. (2016, December). Building a safe unit culture with CUSP. Nursing
Management, 47(12), 8-12. https://doi.org/10.1097/01.NUMA.0000508266.49722.7d
Tracy, M. F. (2014, September-October). American Academy of Nursing: Improving health and
health care systems with advanced practice registered nurse practice in acute and critical
care settings. Nursing Outlook: The Offical Journal of the American Academy of Nursing,
62(5), 366-370. https://doi.org/https://doi.org/10.1016/j.outlook.2014.07.003
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