Advanced Practice Nursing: Constraints to Role Fulfillment

摘要

This paper reports on a secondary analysis of data from an outcomes study of advanced practice nurse (APN) graduates from a university in the southwest United States. These authors describe the theme–constraints to role fulfillment–that emerged from data analysis. Interpretive phenomenology was the methodology used. All nursing masters graduates in practice for at least one year were invited to participate in the study either through a focus group or individual interview. Four themes related to constraints to role fulfillment for APNs were uncovered, including issues related to the practice setting, health care systems, legal systems, and environmental constraints. Implications for education, practice, and policy are discussed. Further research is indicated to explore the effect of various environments on APNs' ability to provide access to health care for all people in this country. Outcomes studies of APN programs can reveal helpful insights for program evaluation and continued improvement of educational programs. Support: Northern Arizona University Intramural Grant Disclaimer:An earlier version of this paper was presented at Western Institute of Nursing Conference, Albuquerque, NM, April 7, 2006 Introduction Constraints to APN practice, also referred to as barriers to practice, have been described in the literature for nearly as long as advance practice nursing roles have existed. In Stanley's text (1), the author details two primary categories of barriers to practice: internal disputes related especially to the role of nurse practitioners (NPs) versus clinical nurse specialists (CNSs) and external obstacles that are primarily related to public policy. The importance in identifying these constraints is that educational programs can prepare graduates proactively for the realities of practice and enable graduates to practice to the full extent of their preparation.This paper contains a report on a secondary analysis of data from an outcomes study of advanced practice nurse (APN) graduates from a university in the southwest United States. The authors refer to APNs as both NPs and CNSs; however, at points where differentiation is needed these roles are addressed as NP or CNS. The original study aimed to determine how graduates actualized our program terminal competencies in practice and examined APN role differentiation. The terminal competencies are based on domains of practice as established by the National Organization of Nurse Practitioner Faculties (2, 3), the National Association of Clinical Nurse Specialists (4), and American Academy of Colleges of Nursing (5). The theme, constraints to role fulfillment, emerged from our data analysis and is described in this paper. Literature Review Constraints to practice identified in the literature include conflict between nursing versus the medical role, public policy issues, and health care system concerns. Each of these constraints are discussed.Nursing versus Medical RoleThe tension between the nurse and physician role for the nurse practitioner is a constant source of concern. Bryant-Lukosius, DiCenso, Browne, and Pinelli (6) described important nursing values that must be maintained in the advanced practice role. These values include practice that is patient-centered, health-focused, and holistic. Jones (7) described the nursing role as a partnership between the patient and nurse in which the focus is to assist the patient “in living and coping with circumstances and environment in such a way that illnesses may be prevented or recovery may be facilitated” (p. 2). Miller, Snyder, and Lindeke (8) state that “few studies have examined the added ingredient NPs bring to the care setting: they are nurses and use this knowledge and experience in providing care” (p. 167). The authors proposed that a possible reason for positive outcomes of NP practice related to patient satisfaction and teaching is the knowledge and expertise they bring from their nursing background. In many managed ca