(NP, PA): ( )
(1)
(2) /
: : 2013-2015 800 (, 3100 ) 2013 350 2014 250 2015 200-4 : 80 ( 88 ), 3, 14 - : 36, 10, 4 1 (24 ), 12 -, 1 :
License vs Certificate Licensure: Authority to practice., Certification:,,
(Generalist, RN, BC RN,C) : 1000-2 (competent) ANA : 2-3 (B enner, 1984) : Pediatric RN-C, Pediatric RN-BC, CCRN(certified cardiac RN) CORN(certified operating RN), CNN(certified nephrology nurse), CFRN, OCN
Generalist Certifications Psychiatric and Mental Health Nurse (RN,C) Medical-Surgical Nurse (RN,C) Pediatric Nurse (RN,C) Gerontological Nurse (RN,C) Community Health Nurse General Nursing Practice School Nurse Perinatal Nurse College Health Nurse Home Health Nurse Cardiac Rehabilitation Nurse Ambulatory Care Nurse (RN,C) Informatics Nurse Nurse Case Management (RN,C) Nursing Administration (RN, CNA) Continuing Education & Staff Development
Physician Assistant(PA) : : : 26, 2008 : National Commission of Physician Assistants (PA-C)
: (self-initiated treatment regimen) (expert) : Nurse Practitioner(NP) Clinical Nurse Specialist(CNS) Nurse Anesthetist (CRNA: Certified Registered Nurse Anesthetist) Nurse midwife(cnm: Certified Nurse Midwife) : APRN,BC(Advanced Practice RN, Board Certified)
Core concepts for Advanced Practice N urse(apn) Autonomy in clinical practice Professional and clinical leadership Expert practitioner and researcher Furlong & Smith(2005)
Direct clinical practice Expert coaching and guidance Consultation Research Clinical & professional leadership Ethical decision making * Preventive & behavioral aspects Hamric & Hanson(2003)
Process of Care(1) (American Academy of Nurse Practitioners: AANP) * Framework: National standard of care scientific proc ess 1. health and medical history,
Process of Care(2) 2.,,, 3.,, - -, - -
Process of Care(3) 4. :,, :,,, 5.,
Other Standards of Practice(AANP) 1. / 2. 3. 4. guidelines 5. NP Mentor, educator, researcher, manager, consultant 6.,
Graduate Core Advanced Practice Core NP/CNS Role,,,, /,, /,,,,, / Specialty Theory( ) Clinical Practicum (500 ) Specialty Role
Doctorate of Nursing Practice(DNP) : Advanced Generalist : Advanced Specialist : (translational research), /,,,,,, 1000
Nurse Practice Act( ) Nursing Practic e Act( ) Joint publication of the standard and scope of pr actice(, / )
Role and Scope of Advanced Practice Nurses(Texas Board of Nursing+ ) Nurse Midwives:,,, /,,, STD Clinical Nurse Specialist:,,,,,,,, EBP Nurse Anesthetist:,,, NP:,,, /, /
Endocrinology Competency Framework for Adult Endocrine Nursing( ) High standard of care career plan,
Competency Areas Acromegaly Benign adrenal tumors Cushing s syndrome Endocrine dynamic function testing Hypo-hyperparathyroidism Hypogonadism Hypopituitarism Osteoporosis Polycystic ovary syndrome Steroid replacement therapy for disorders of the pituitary and adrenal glands Thyroid disease Transition( )
Competency Framework (Thyro id disease) Competent ( 6 ) / / /, Proficient (+Competent) s enior staff,, / Junior staff Expert (+Competent/Proficient),, cyst CP Junior staff,, /,,,
APN scope of practice :,,, hypoglycemic therapy :,,,, : /,,, support calls - /,, (coordination)-,,
Chronic Care Model(CCM) Delivery system design - Inpatients-Planned visits(am), Acute visits(pm) - Outpatients-Annual, Quarterly visits Self-management support-,, Decision support- EBP( ) Clinical information system-,,,, Community resources and policies Health care organization-
2006 7 7 : 2 :,
: 2004 2, : :, / /,,,,
3 + 33 + - (2), (2), (2), (2+1), (2), (2) 13-10 -10 ( 300 )
- - :, - : - :, /,,,,,,,, - (, ) (, )
PA / / / (, ) standing order /
( ) ( 12 10 ) ( ) NP(52 ) PA(26 ) CNS (67 ) (Clinical Nurse Specialist) SA (35 ) (Surgical Assistant) PA(20,, ) (Physician Assistant) SA(36 ) (Surgical Assistant) PA(86 ) - 38, - / 48 78 102 56 86 / ( ) ( ) ( ) ( ) CNS : SA : ( ) ( )
( ) ( ) CNS : SA : ( ) ( ) CNS :, SA : ( ) 1 (, ) CNS 5, 3,, SA : * SA 3 *
NP (1) n=94, On call,,, EMR Memo,,,, /Push /,,, stich out, (,, ), /, -,
NP (2) (follow-up call) ( -,, DB/Registry,, ),,,, / CP
PA (, ) :, Foley insertion, skin prep : 1st 2nd assistant : specimen,,, ICU : - - Specimen,
RNFA (RN First Assistant) (collaboration),,. RNFA
RNFA 1983 American College of Surgeons 1983 (AORN) 1984 AORN RNFA,,, 1993 AORN
RNFA : (State Nurse Practice Act) 50,, Medicaid 13.6-16%
RNFA Certified RN in OR 2000 (1400 ), 500 2 : 70%, 30 /
RNFA - -, - -,, -, /,,, - - -, * RNFA,,,, /
AORN APN
APNs Clinical Educator : /,,, Sales Professional, (theater) Staff Developer,,,,
( / ),,,, NP, CNS, PA /,, -
(1) 1) / (,, ) 13 2) ( / / / ) 3) PA(Physician Assistant) 4) /, 5),,
(2) 6) ( ) ( ) 7), 8) (,,,,, /,, / / ) 9)
(, ) EMR -,,,,,,,, / Clinical Track career ladder system NP, PA
DON NE NM APN CN IV CN III CN II CN I
:,,, (Byers & Brunell, 1998) :,, ( / ), (Davis et al, 1994)
Classification of the outcomes.rm.2009 ) (Kleinpell Care-related outcomes: Patient-related outcomes:,, Performance-related outcomes:
Care-related outcomes : Lab values, Clinical symptoms ( :dyspnea, pain), Physical function & mobility,,,,,,,,,,,,,, TPN,,, ICU: /reintubations, ventilator-associated pneumonia, ABG,, ICU,,, tube feeding, ER: Stroke/ MI response time, tpa,,
Patient-related outcomes,, / ( : foot care), /,,,,,,,,, caregiver-related outcomes
Performance-related outcomes / Finding of new health problems Best practice guideline Night calls options / / Thoracotomy tube insertion /
Performance-related outcomes APN / OT
Service by /volume(productivity) by core competencies(role functions) by role performance(duties) Retro/Prospective Independent or team approach (indicators)
Team approach shared decision making Shared ideas and knowledge Consistent interaction Better collaboration Improved quality of care Patient satisfaction
/,,
Outcome indicators sources Joint Commission on Accreditation of Healthcare Organiza tion(icaho)-medicare certification & state licensure National Committee for Quality Assurance(NCQA) Specialty organizations Soft ware programs Internet Clinical guidelines, protocols, critical pathways Flow chart, check list, guideline-bases performance measur es
(1): Specialization Professionalism Advancement Financial reimbursem ent ANA(2003)
(2): Comprehensive Consistent Coordinated Collaborative Cost-effective