Perceptions of The Doctor of Nursing Practice Role in Care of Older Persons in the US

Transcription

1 Perceptions of The Doctor of Nursing Practice Role in Care of Older Persons in the US Pamella Stoeckel PhD, RN, Cheryl Kruschke EdD, RN Regis University, Denver, Colorado Royal College of Nursing 2012 International Nursing Research Conference April 24,

2 Presentation Objectives The Learner will review the background and proposed value added by the DNP degree. The Learner will examine the emerging role of the Doctor of Nursing Practice (DNP) to fill a gap in care of older persons in the US. 2

3 Background and Significance The DNP was developed in response to the call for increased preparation for healthcare professionals and the National Academy of Sciences (2005) call for a non research nursing doctorate. DNP curricula builds on traditional master s programs by providing education in evidence-based practice, quality improvement, and systems leadership. Nurses prepared at the DNP level with clinical, organizational, economic, and leadership skills are expected to significantly impact healthcare outcomes. 3

4 Nursing Rationale for the DNP Rapid changes and complexity in the healthcare system require an interdisciplinary approach to patient-centered evidencebased care The shortage of qualified clinical nursing faculty requires nurses with the DNP to admit and educate nurses. The increased need for mid-level providers to provide care in underserved areas. The need for parity with other disciplines requires the clinical doctorate for entry into advance practice (e.g. MD, DDS, PharmD, PsyD, DPT, AudD) Institute of Medicine,

5 Parity with Other Disciplines The tipping point for me was when I was at a team meeting and everyone there had a doctorate in their respective fields except the nurse (AACN, 2006) 5

6 Recommendations from AACN The DNP (Doctor of Nursing Practice) will be the only practice-focused degree to prepare graduates for the highest level of nursing practice preparation by 2015 including the four roles of: clinical nurse specialists nurse anesthetist nurse midwife nurse practitioner 6

7 Standardization of Educational Preparation for Advance Practice Nurses certificate programs, 74 master s certificate programs, 84 master s programs certificate programs 400+ master s DNP programs DNP graduates DNP programs 161 programs planned All APRN/NP programs= DNP 7

8 AACN Contrast Grid of the Key Differences between DNP and PhD/DNSc/DNS Programs DNP PhD/DNS/DNSc Program of Study Objectives Prepare nurse specialists at the highest level of advanced practice Competencies Objectives Prepare nurse researchers Students Commitment to practice career Oriented toward improving outcomes of care Commitment to research career Oriented toward developing new knowledge Program Faculty Leadership experience in area of specialty practice High level of expertise in specialty practice congruent with focus of academic program Research doctorate in nursing or related field Leadership experience in area of sustained research Resources Mentors and/or precepts in leadership positions across a variety of practice settings Access to diverse practice settings Mentors and/or precepts in research settings Access to research settings with appropriate resources 8

9 AACN Proposed Added Value of the DNP Advanced clinical skills and expertise in one area of advanced nursing practice Organizational and system leadership/management Quality improvement and systems thinking Application of evidence-based research Health policy development, implementation, and evaluation Utilization of technology and information systems Interdisciplinary collaboration of improving patient and population healthcare outcomes (AACN, 2006) 9

10 DNPs Working with the Elderly 36,790,000 aged 65 years and older in the US (U.S. Census Bureau, 2008) Aging population and increased client demand for new services, technologies, and drugs contribute to both the increase in health care expenditure and to the waste of resources (AACN, 2006b, p. 3) DNP provides leadership preparation for nurses desiring expertise in advanced nursing assessment and management for health promotion and disease prevention, management of complex health conditions, and working with interdisciplinary teams to provide care and services for older adults. 10

11 The DNP Internationally Nursing doctorates are offered world wide (INDEN, 2007) The professional doctorate is offered in the United Kingdom more than 23 programs in 2004 (Ellis et al., 2005) Australian DNP programs are also growing in numbers Debate over the DNP has begun in Canada (Acorn et al., 2009; Joachim, 2008) 11

12 DNP Program Tracks DNP Clinical track to become APRNs (NP, Midwives, CRNA, CNS) Leadership/Administrative track APRN Prepared MSN Education MSN Management BSN RN 12

13 Summary of Literature Review Nurses with the DNP are expected to demonstrate added service and abilities in providing quality patient care. While the impact of the role is not entirely clear the DNP degree meets the need for expanding clinical competencies to address the needs of the changing healthcare system. 13

14 Research Question: What do Practicing DNPs Perceive about the Role of the DNP in Care of Older Persons? 14

15 Methodology Key Informant approach was used as a means of gathering rich, varied, and textured data presented in local persons words from informants selected for their specialized knowledge and unique perspectives on the topic (Creswell, 1998) 15

16 Sample The participants were 12 practicing DNPS throughout the US. All participants agreed to be interviewed either in their offices at their facilities or by conference call. Consent forms obtained from all participants. IRB approval obtained through Regis University. Confidentiality was assured. 16

17 Demographics Number: 12 practicing DNP s in the US Gender: 10 females and 2 males Length of time with the Degree: 7 years - 2 participant 4 years - 3 participants 3 years - 1 participant 2 years 1 participant 1 year 2 participants All participants were NPs prior to entering DNP programs 17

18 Data Collection 40 minute phone interviews using open ended questions Setting: phone conference calls to DNPs Interviews were audiotaped and transcribed and reviewed by the participants 18

19 Data Analysis Creswell (1998, p. 150) describes the process for open coding as the process by which the researcher examines the text for salient categories of information Interviews were coded for themes using a content analysis approach 19

20 Trustworthiness of the Study Audit trail Reflective notes Member checking Peer Review 20

21 Research Findings Themes and Supportive Data 21

22 Perceptions of the DNP Themes Educational Preparation Practice Settings Role Impact Leadership Challenges 22

23 Educational Preparation Deliberate Design of Geriatric Learning Training I got in geriatrics came through my masters program whenever possible my assignments would be tailored to the geriatric population...so more self driven I did take electives through the gerontology program and completed a gerontology certificate I researched topics such as osteoporosis, certain specific topics that have been clinical questions or common [geriatric] themes that I wanted to tune up keeping myself current on common and uncommon geriatric issues A couple of classes I took were vey population focused and I focused them on the elderly 23

24 Practice Settings In-Patient I have a small nursing home practice we are just starting the Hospital Elder Life Program and a delirium prevention program for inpatient elders we help to train residents [in the School of Medicine] I am the founder and the current director of the Palliative Medicine Service I got a faculty appointment in nursing and in pharmacy My work is with a group of geriatricians my focus is more with the Geriatric Center of Behavior Issues The majority of my neurology patients were elderly primarily stroke 24

25 Practice Settings Community A nurse practitioner directed and run clinic...most of my patients are homeless, marginally housed, live in different facilities with no continuity of care The mission of this clinic is very much for the Medicaid population, the uninsured, the under-insured and the homeless We are planning a health fair right now that will impact older adults My team is planning a very large community event inside the grocery store that will focus on support for seniors and various health evaluations It s all home bound/bed bound so we do home visits exclusively...including assisted living facilities 25

26 Role Impact Expert Clinicians Outpatient Consultations for Geriatric Evaluations Have my own panel of primary care patients They ask me for my input on things that were heavily nursing weighted and even medically driven I do histories and physicals, create treatment plans and interventions for the older adults I am an expert in aging They see me as an expert in aging and gerontology I coordinate all the care We found that we are reducing emergency department utilization by about 50% for the people that we take into our panel 26

27 Role Impact Psychosocial Aspects of Care Help the resident to have a better quality of life especially in relation to behavior issues Attend behavioral management meetings and then family care conferences We can t change people s personalities but we can help them in specific situations in how to manage behaviors that might be bothersome especially to other residents My focus in more with the geriatric center of behavior issues helping the staff to really feel like they are important in the care of individuals I talk to the staff about ways in which they can help the residents to have a better quality of life especially in relation to behavior issues Help lead the practice of an entire mental health or nursing home whatever it would be and better care for folks 27

28 Role Impact Communicator Help them understand what I am able to do and what the staff (shoots for) Medicare do not allow me to do. So when they get out in practice they will know what the nurse practitioners are all about Talking with families Helping them [staff] to communicate in a way that may be, might be better It s also extremely important to be able to understand what s going on with the individual and be able to explain it to them and to their families in a way that they can understand 28

29 Role Impact Collaborator So we really establish some collaborative, collegial relationships with the elderly patients I work with a group of Geriatricians Behavior management team conferences We see them [older persons] quite a bit because they shop in the same places [retail settings-grocery stores] all the time. So we establish collaborative collegial relationships with the elderly patients Attend behavioral management meetings with interdisciplinary staff I also think about the physicians in a different way because my practice is definitely different than theirs from a medical model 29

30 Role Impact Advocate My vision of caring for the elderly is to be the expert in geriatric prescribing, gero-psych, something along those lines and a skill and knowledge set Advocacy [for older persons] I think is the number one thing especially in our setting Helping older individuals really to help themselves We are serving as advocates and taking time to refer those people to the appropriate medical entities 30

31 Role Impact Future Role Expansion They re going to need more clinicians to care for this boom of geriatric patients that s coming up Now they re saying we need nurse practitioners and physician assistants to help care for this population; to be their primary care provider I would like to see DNP s who are entrepreneurs in corporations or even that own long term care facilities or assisted living that really set a standard for excellence including evaluations and looking at outcomes I really hope that DNP s can really take the leadership role and really be involved in healthcare policy [The DNP] can be involved in some of the traditional physician run organizations like the American Medical Association A DNP could run an entire clinic 31

32 Role Impact Future Role Expansion I would like to see DNP s who have adult or gerontology nurse practitioner roles as well being medical directors or the health director of facilities I will say that it could evolve into the DNP taking on a greater role of responsibility in managing the care of the elderly I see the DNP as really truly the person in the future who takes the lead in managing the elderly The population is aging and I think the DNP, as nurse, is really educated in a much broader way or much better able to see the larger picture I believe that we will take the lead as the primary providers and management of the elderly both in the nursing home setting and in the community based setting I do see the DNP expanding into the geriatric palliative care component 32

33 Leadership Evolving Leader DNP preparation should include care of the older adults with both individual older adult and again the aggregate with mental health issues Really looking more at the organization I m also applying theory to the staff because in long term care most of the nurses are either LPN s or associate degree prepared I think to that my role is to empower the staff and make them feel that the things that they see on an everyday basis, because they re working with the residents all the time, but what they know and what they see is extremely valuable The staff and the administration look at me as a leader and ask me questions helping them problem solve 33

34 Challenges Laws and Regulations Medicare doesn t reimburse me anymore (DNP versus NP) Medicare requires currently that the comprehensive new patient visit be done by a physician But for now a DNP to do more, [it] is impossible until that [regulatory] language is changed We can t be medical directors unless laws change or regulations change I find also a frustration with the current home health regulations. Now I can be the attending of record for a hospice patient as a nurse practitioner but I cannot be the attending of record for a home health patient The home health laws and regulations are so obsolete that it has to be a physician and the physician can t delegate to a nurse practitioner 34

35 Challenges Role Perception: Nursing Peers [NPs see me] as a trusted colleague, but I am not sure it has changed since I got the doctorate [DNP] I m almost 60; my age peers are saying I m not going back to school, this is just too much Reassuring them that I don t think I m better than they are [In a large nursing audience] a bunch of people were very confrontational about it [the DNP] in public Until we re at a point where we have a critical mass, within the profession with the degree, it still points to kind of a curiosity 35

36 Challenges Lack of role understanding There aren t a tremendous number of NPs in leadership roles that would be appropriate for somebody at the doctoral level Most people don t have the degree Employers haven t recognized the expertise that the DNP brings to the work place they advertized for a PhD better suited to a DNP Future DNPs will not be prepared as leaders initially [novice] 36

37 Conclusions 37

38 Conclusions DNP students with a geriatric focus deliberately tailor learning experiences in DNP programs to address care of older persons DNPs work in a variety of in-patient and community settings; jobs are being created to address the strengths they bring to the workplace DNPs meet the role of expert clinician, collaborator, communicator and advocate. A particular strength was the psychosocial aspects of care that DNPs bring working with both older persons and staff 38

39 Conclusions Challenges for DNPs in working with older persons include policy decisions related to reimbursement and scope of practice Challenges faced by DNPs include lack of role understanding by physicians/staff and nursing peers due to the new role The DNP address a gap in nursing leadership in care of older persons in the practice setting 39

40 References Acorn S., Lamarche,K., & Edwards, M., (2009). Practice doctorates in nursing: Developing nursing leaders. Canadian Journal of Nursing Leadership, 22(2): American Association of Colleges of Nursing. (2010). The doctor of nursing practice fact sheet. Retrieved from Benner, p.,(1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo park, California: Addison-Wesley Creswell, J.W.(1998) Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Sage Publications Ellis, L.B., & Lee, N. (2005). The changing landscape of doctoral education: Introducing the professional doctorate for nurses. Nurse Education Today, 25, Retrieved from lltext 40

41 References Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. International Network for Doctoral Education in Nursing. (2007). Directory of international doctoral programs. Retrieved from Joachim, G. (2008). The Practice Doctorate: Where Do Canadian Nursing Leaders Stand? Nursing Leadership (CJNL), 21(4) 2008: Retrieved from ew&id=73&itemid=9 U.S. Census Bureau, Population Division. (2008). Age Data of the United States. Retrieved from 41

42 Discussion Questions and Comments 42

43 Thank You! 43