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Picture yourself on a sled being pulled
along a snowy countryside by a team of Alaskan huskies
rushing toward an igloo, where a seriously ill child
awaits the care that only you can provide. Sound unrealistic?
This scenario may be a bit dated, because both housing
and transportation in Alaska now are similar to that
found in the lower 48, and propeller airplanes are the
preferred mode of transport these days. But if you're
considering a career as an advanced practice nurse,
chances are that a similar vision may have influenced
your thinking about a move into this evolving field.
Whether you become a nurse practitioner or an advanced
clinician in one of several specialties, you will find
your role as an advanced practice nurse different from
that of the traditional registered nurse.
The advanced practice nurse belongs to a growing segment
of registered nurses who have satisfied clinical and
educational requirements beyond the two to four years
of basic nursing education required of all RNs. They
fall into four major categories: nurse practitioner,
certified nurse-midwife, clinical nurse specialist and
certified registered nurse anesthetist.
Nearly 140,000 nurses are in advanced practice positions
in the United States, according to the American Nurses
Association, many filling a need created by "chronically
underserved populations"-the elderly, poor and
those living in isolated areas, where access to adequate
health care services is difficult or nonexistent.
As APNs step out of the physicians' shadow and into
increasingly responsible roles as health care providers,
there is a heightened awareness of their value and skills,
with some patients beginning to prefer their hands-on,
unhurried care to that of their primary care physicians.
Moreover, a great percentage of primary and preventive
care can be done by a nurse at a lower cost.
Educational qualifications for an APN vary from state
to state, but national accreditation is possible in
some areas of practice through professional associations.
Increasingly, legislation favoring the expansion of
practice is being proposed and passed, moving the profession
toward a national standard.
The nurse practitioner
Nurse practitioners are registered nurses with advanced
practice preparation and specialized training licensed
to provide health care services either independently
or in collaboration with physicians and other health
care professionals. Working in clinics, nursing homes,
hospitals or their own offices, they perform physical
exams, diagnose and treat common illnesses or injuries,
and order and interpret diagnostic, laboratory and radiology
studies.
Even though NPs, who number more than 71,000 in the
United States, have been around for more than 30 years,
most people are only vaguely aware of their roles as
health care providers. Additionally, health plans largely
have overlooked the potential of NPs and other advanced
care practice nurses as primary care providers. But
this is changing, as a broad-based coalition of NPs
push for visibility through national and regional associations,
as well as in legislative halls.
"Nurse practitioners can practice more independently
than most areas of advanced practice," said Melanie
Goodman, JD, MN, CPNP, president of the California Coalition
of Nurse Practitioners, an organization that keeps its
members abreast of legislative and health insurance
issues affecting them. "They follow their patients'
problems and decide where treatment should occur-the
physician or specialist's office or the hospital."
Goodman observes that many nurses choose independent
practice because it gives them a sense of ownership
and investment return. She is quick to stress that the
return is usually more in self-accomplishment than in
money.
Julie Worley, MS, FNP, RN, agrees. After exploring
many possibilities in nursing, the Chicago native, who
now lives in rural Tennessee, settled on advanced practice.
Worley is moderator of the nurse practitioner reference
section and forum for nursingnet.org,
a Web site dedicated to nursing practice of all disciplines.
She also is president of her local APN and physician
assistant association, as well as a contributing editor
to the Internet magazine The Practicing Nurse. She works
part time with a family practice physician.
"I do think many nurses go into advanced practice
nursing so that they can be more independent and make
more medical and treatment-related decisions for patients,"
she said. "I am so glad I became an NP. I love
my job."
Worley tells aspiring nurses that they must have a
strong desire to care for people. "To me, nursing
needs to be almost like a calling," she said.
Veronica Thrasher, Ph.D., M.Ed., PNP, became an NP
because she saw a need for more minority nurse practitioners.
As a school nurse in Massillon, Ohio, Thrasher approaches
nursing from a holistic viewpoint and advocates for
care that focuses on the whole being, not just the illness.
"I think nurses should be sensitive to what their
patients are not saying, their environment and diet.
Being a nurse practitioner also allows me a better vantage
point from which to advocate for improved health care
for minorities," she said.
Marilyn Hockenberry, Ph.D., RN, PNP, FAAN, combines
her interest in research to improve patient outcomes
with her profession as a clinician and educator. As
director of the pediatric nurse practitioner program
at Texas Children's Hospital in Houston, the largest
children's hospital in the world, Hockenberry oversees
90 pediatric and clinical NPs in all areas of specialties.
Hockenberry trained at the University of Texas M.D.
Anderson Cancer Center, specializing in pediatric oncology
because of the "deficiency of physicians"
practicing oncology. Physicians who chose oncology,
she observed, had greater time constraints and could
not spend adequate time with their young patients.
"I discovered that NPs were able to spend more
time with patients and provide continuity of care and
nursing from a holistic approach," she said. "We
were able to look at growth and development of the sick
child and to work with the family. There are research
areas for us as nurses to improve patient outcomes.
Our philosophy is to improve both the continuity and
quality of patient care from a nursing role, while working
with staff and fulfilling responsibilities to academics
and research."
A researcher with five funded grants, Hockenberry is
looking for ways to improve the care of children with
cancer through research. The hospital supports a nursing
scholarship program through which 18 nurses are given
one day a week for a year to develop research projects
that directly affect patient care.
For example, one nurse is monitoring vital signs during
sedation for echocardiograms to assess safe limits,
while another is developing a support group for parents
of children with liver disease. Hockenberry sees much
potential for growth in the research scholarship area
and envisions "centers of excellence" throughout
the hospital as a result.
Hockenberry is recognized as a full professor by the
hospital medical staff, many of whom are faculty at
the Baylor College of Medicine, a rare honor for someone
who is not a physician.
"I chose pediatric oncology because of the children,"
she said. "All children are special, but children
with chronic illnesses are extra special. They give
back so much. They teach us so much about respecting
and cherishing life. The future is endless as far as
opportunities for advanced practice."
The certified nurse-midwife
About 7,400 certified nurse-midwife professionals work
in the United States. Most have a year and a half of
specialized education beyond nursing school, either
in accredited certificate programs or increasingly at
the master's level.
CNMs provide care not only at delivery, but also give
well-woman gynecological and low-risk obstetrical care,
including prenatal, labor and delivery and postpartum.
Their services have proved invaluable, both economically
and from a quality, utilization and risk-management
perspective.
A 1993 ANA meta-analysis of CNM care disclosed that
nurse-midwives performed fewer fetal monitors, episiotomies
and forceps deliveries, gave fewer IVs, delivered fewer
low-birthweight and premature babies, and had shorter
patient hospital stays.
Seattle-based Wendy Wheeler, MSN, RN, was drawn to
midwifery because it presented an opportunity to take
care of women. Wheeler, who is board certified by the
American College of Nurse-Midwives, is a full-time NP
for King County Women's Health, providing care and education
on family planning.
"One of the advantages of being a CNM is caring
for healthy people." She views childbirth as a
life event and one that she does not have to "fix."
Wheeler's advice to nurses considering advanced practice
careers:
"Go for it. You have choices not available to
you as a staff nurse. In Washington state, NPs can be
completely independent of doctors. More patients are
requesting NPs because we take the time to listen to
patients and provide a lot more education."
A strong indication that NPs are being taken seriously
in Washington state is the recently passed legislation
permitting them to dispense narcotics. "Prescriptive
authority of narcotics will save a lot of time and bolster
our credibility as health care providers," Wheeler
said.
The clinical nurse specialist
A CNS is a registered nurse with an advanced nursing
degree, master's or doctoral who is an expert in a specialized
area of clinical practice such as mental health, gerontology,
cardiac or cancer care and community or neonatal health.
The ANA reports that more than 58,000 clinical nurse
specialists work in a variety of settings, including
hospitals, clinics, nursing homes, their own offices
and other community-based settings such as industry
home care and HMOs. CNSs provide primary care and psychotherapy
in a wide range of disciplines. They conduct health
assessments, diagnose, treat, consult, conduct research,
are educators and hold administrative positions in a
variety of health care settings. Services provided by
CNSs are reimbursable by Medicare, Medicaid, CHAMPUS
and private insurers.
Gennifer Newton, MSN, RN, uses her clinical practice
skills to help students at Seattle's Shoreline Community
College through their maternal child nursing rotation.
Newton's present occupation is a natural offshoot of
her early days as a staff nurse in a labor and delivery
unit. She continues to work part time as a labor and
delivery nurse to maintain her clinical skills.
"I love teaching and interacting with students,"
she said.
The certified registered nurse anesthetist
The ANA reports that 25,238 registered nurses are CRNAs.
These nurses complete two to three years of education
beyond the four-year bachelor's degree and must meet
national certification standards. The oldest of the
advanced practice specialities, CRNAs administer more
than 65 percent of all anesthetics given to patients
annually and provide all of the anesthetics given in
85 percent of rural hospitals.
While CRNAs sometimes work under the supervision of
anesthesiologists, the majority of their services are
performed independently in the operating room, dentist
offices and ambulatory surgical centers.
"There are many attractions to the specialty of
anesthesia. I believe there are two main motivators.
The first is the overall challenge-we are held to the
same standards and practice as physician anesthesiologists,"
said Air Force Maj. Thomas Evans, MS, CRNA, of Elmendorf
Air Force Base in Alaska.
While the training is "long and difficult,"
Evans said it's worth it in the end. "You stand
out among your peers as a highly trained nurse specialist.
You gain respect from nurses, surgeons and friends,"
he said.
"The second motivator is that financial rewards
are great."
Contact Alicia Hugg at rosewind09@earthlink.net.
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