Extended role of nursing as advance and alternative career

1. 1
By:
Isha Thapa Magar
MN 1st Year

2. 
At the end of the session the participants
will be able to explain about “extended
role of nurse”
2
Objective

3. Extended role of nurse
 Introduction
 Direction
 Need of extended role
 Types of extended role of nurse
- Advance practice registered nurse
- Alternative nurse role
 Issues
 Way to improve nursing skill 3
Table of content

4. 
The extended and expanded role of nurse is
described as a role, which goes beyond
traditional nursing roles to include additional
responsibilities and a wide range functions in
community and clinical care setting.
4
Introduction

5. 
 In traditional role, qualified nurses were
concentrated in curative sector of health care
system providing general nursing services.
In expanded role trained nurses are urged to
move to community, institutional setting,
research etc. Hence extending their services
to people.
5

6. 
Directions for expanded role of nurses
Outward
 Nurses are moving from
curative sector into
community for supporting
primary health care.
 School health nursing
services.
 Maternal and child health
nursing services.
 Occupational health nursing
services etc.
Inward
Nurses are utilizing their
expertise for direct care
of client.
Client may be individual
or the family.
6

7. 
Health is now recognized as fundamental right of
individual.
Transition of health care system from disease
oriented model to a health oriented model is an
emerging trend.
Specialization in nursing practice.
Need of nursing experts to utilize their expertise
for care of client. 7
Need of extended role

8. Patient may seek health care facilities at home, at place
of work or in any type of health care agency.
Expansion of scientific knowledge and application of this
knowledge to diagnosis and treatment has lead to much
advancement.
 Patients can lead a productive life with artificial
parameters, organ transplant and radio therapy.
Search for increased status for nursing
Economic up gradation.
8
Need of contd…

9. 
Advanced Practice
Registered Nurse (APRN)
Alternative Nurse Role
9
Types of Extended role of
Nurses

10. 
10
Advanced Practice Registered Nursing
(APRN)

11. 
According to the American Nurse Association
(ANA), advanced practice requires a high
level expertise in assessment, diagnosis, and
treatment of complex responses to actual or
potential health problems.
11

12. 
12
Advanced Practice Registered Nursing
(APRN)
1. Certified Registered
Nurse Anesthetists
(CRNAs)
2. Certified Nurse-
Midwives (CNMs)
3. Clinical Nurse
Specialists(CNSs)
4.Nurse
Practitioner(NPs)

13. 13

14. The nurse anesthetist is the oldest advanced
practice nursing role.
A Certified Registered Nurse Anesthetist
(CRNA), is APRN who has acquired graduate level
education and specialized in administration of
anesthesia.
CRNA carries out pre-operative visits, assessments,
and administers general anesthetics for surgery
under the supervision of a physician prepared in
anesthesiology.
14
1. Certified Registered Nurse Anesthetist

15. CRNA also assesses postoperative of clients
In United States, Nurse anesthetists have been
providing quality anesthesia services for
nearly 150 years.
The discipline of nurse anesthesia developed
in response to requests of surgeons seeking a
solution to the high morbidity and mortality
attributed to anesthesia at that time.
15
Contd..

16. Surgeons saw nurses as a cadre of professionals
who could give their undivided attention to
patient care during surgical procedures.
Serving as pioneers in anesthesia, nurse
anesthetists became involved in the full range of
specialty surgical procedures, as well as in the
refinement of anesthesia techniques and
equipment. 16

17. 
17
In 1877, Sister Mary
Bernard, at St.
Vincent's Hospital in
Erie, Pennsylvania,
become first nurse to
specialize in anesthesia.

18. 
18
In 1893, Alice Magaw
begins working as nurse
anesthetist at St. Mary’s
Hospital (1889), in
Rochester, Minn. for Dr.
Charles.

19. 
In 1909, the first formal educational programs
in nurse anesthesia education was established.
 In 1931, establishment of the professional
association of nurse anesthetists as American
Association of Nurse Anesthetists (AANA) in
U.S.
19

20. 
The American Association of Nurse
Anesthetists (AANA) implemented a
certification program in 1945.
The first certification examination was
administered in 1945 to 92 candidates.
20

21. 
In 1952, the AANA established a mechanism for
accreditation of nurse anesthesia educational
programs that has been recognized by the U.S.
Department of Education since 1955.
The CRNA (Certified Registered Nurse
Anesthetist) credential came into existence in
1956.
21
Contd..

22. 
Certified Registered Nurse Anesthetists (CRNA)
practice in every healthcare setting in the United
States and administer anesthesia to more than 43
million patients a year. (AANA, 2016 )
22

23. • As of August 2019, there were;
- 121 accredited nurse anesthesia programs in the
United States,
- using more than 1,870 active clinical sites;
- 91 nurse anesthesia programs are approved to award
doctoral degrees for entry into practice.
• Nurse anesthesia programs range from 24-51
months, depending on university requirements.
23

24. A baccalaureate or graduate degree in nursing or
other appropriate major..
A minimum of one year full-time work
experience, or its part-time equivalent, as a
registered nurse in a critical care setting.
Graduation with a minimum of a master’s degree
from a nurse anesthesia educational program
accredited by the Council on Accreditation of
Nurse Anesthesia Educational Programs. 24
Education Requirements

25. 
In 2011, National Academy of Medical
Sciences (NAMS) started one-year Anesthesia
Assistant Course.
Minimum criteria:
 Proficiency Certificate Level in Nursing or
Health Assistant, or Ophthalmic Assistant.
 Two years work experience.
25
Nepal

26. Nurse practitioners (NPs) are the newest group of
APNs to emerge in America.
They are also the fastest growing group of APNs.
A nurse practitioner (NP) is an advanced
practice registered nurse and a type of mid-level
practitioner.
NPs are trained to assess patient needs, order and
interpret diagnostic and laboratory tests, diagnose
disease, formulate and prescribe treatment plans.
26
2. Nurse practitioner (NP)

27. 
NP training covers basic disease
prevention, coordination of care, and health
promotion, but does not provide the depth
of expertise needed to recognize more
complex conditions.
27

28. 
The present day concept of Nurse Practitioners
as a primary care provider was created in the
mid-1960s, due to the national shortage of
physicians.
28

29. In mid-1960s, Loretta
Ford, a nurse
discovered that,
because of a shortage
of primary care
physicians community,
health care for children
and families was
severely lacking.
3/18/2020 29

30. In 1965, she partnered with Henry K. Silver,
a pediatrician at the University of Colorado
Medical Center, to create and implement the
first pediatric nurse practitioner model and
training program.3/18/2020 30

31. Since 1965, the NP profession has grown
exponentially.
In 2018, there are more than 350 academic
institutions with NP programs, and
over 270,000 NPs practicing in the United
States while many similar programs have
emerged worldwide.
3/18/2020 31

32. 
These professionals typically need at least a
master’s degree to practice, and a doctor of
nursing practice (DNP) is quickly becoming
the preferred level of preparation in this field.
32

33. A clinical nurse specialist (CNS) is a graduate-
level registered nurse who is certified in a
specialty of choice. Obtaining specialty
certification demonstrates an advanced level of
knowledge as well as advanced clinical skills in a
niche area of nursing.
33
3. Clinical Nurse Specialist(CNS)

34. 
According to the International Council of
Nurses (ICN), an Advanced Practice Nurse
is a registered nurse who has acquired the
expert knowledge base, complex decision-
making skills and clinical competencies for
expanded practice, the characteristics of
which are shaped by the context and/or
country in which s/he is credentialed to
practice. 34

35. There are differences between a nurse practitioner
(NP) and CNS. While both are advanced-practice
registered nurses, their roles are different.
Nurse Practitioners:
Take comprehensive health histories
Diagnose, treat, and manage chronic and acute
illnesses
Often act a primary care provider
Prescribe medications 35

36. 
Clinical nurse specialists have a different
scope of practice. They can prescribe
medications if they apply for authority to do
so, but this is not always required in their
practice. They usually focus on education,
research, and consulting
36

37. 
The first graduate curriculum designed solely
for preparing clinical nurse specialists for
advanced practice was established in 1954 at
Rutgers University. This program prepared
clinical nurse specialists in psychiatric nursing
Acceptance of clinical nurse specialists in the
practice setting grew rapidly during the 1960s to
early 1980s. 37
Contd..

38. 
However by the late1980s, concerns over
health care costs led to a reduction in the
number in clinical nurse specialists
positions and many of these specialists
sought other positions in administration or
education
38

39. 
Currently clinical nurse specialists comprise largest
number of single group of advance practice nurse.
The CNSs functions as an expert clinician, educator,
consultant, researcher and administrator.
The CNS monitors the care of patients and
collaborates with physicians, nurses and other
member of the trans disciplinary healthcare team.
The emphasis of this advanced nursing practice is to
provide clinical support that improves patient care
and patient outcomes.
39

40. Clinical nurse specialists are advanced-practice registered
nurses who have completed a master's program in nursing
(MSN) or doctoral degree program (DNP). A DNP is
necessary for those who wish to focus on research.
To advance to a master's degree or doctoral in nursing, a
student must complete an accredited nursing program and
obtain a bachelor's degree in nursing (BSN). Students
should be sure the school is accredited by the Commission
on Collegiate Nursing Education (CCNE) or the
Accreditation Commission for Education in Nursing
(ACEN).
40
Educational Requirements

41. Successful completion of the NCLEX-RN is needed
for licensure. The length of time it takes to obtain an
MSN depends on the nurse's starting point:
Nursing students enrolled in a BSN program
complete in about four years
RN to BSN takes about two years
BSN to MSN takes about two years
BSN to DNP takes three to four years
MSN to DNP takes one to two years
41

42. 
According to the American College of Nurse-
Midwives (ACNM,1995), Nurse midwifery
practice is the independent management of
women’s health care, focusing particularly on
pregnancy, childbirth, postpartum period, care of
newborn and family planning and gynecologic
needs of women.
42
4. Certified Nurse Midwife

43. 
Prior to 1700s, the lay midwife was treated
as a respected member of the community.
This role fell from favor during the 1800s
however, owing to replacement by
physicians, by religious views and by
inadequate training- when growing
knowledge base of physician obstetrician.
43

44. 
During the early part of the 20th century
midwives were accused unfairly of poor
outcomes with regard to maternal and infant
mortality in US.
In 1918 Maternity Center Association was
established to advocate improved parental care
including midwife education and training.
44

45. 
Nurse-midwives attended only home births
until the mid-1950s, when obstetric leaders
of several inner-city teaching hospitals
developed midwifery services within their
departments to help them deal with the
post-war and to improve the quality of care
in those hospitals.
45

46. 
Nurse-midwives did not venture from care of
the poor for almost 50 years. By the early
1960s—nearly 40 years after fewer than 70
nurse-midwives were in practice in the U.S.
The American College of Nurse-Midwives
(ACNM) is the professional organization for
certified nurse-midwives and certified
midwives incorporated in 1955.
46

47. 
This practice occurs within a healthcare
system that provides for consultation,
collaborative management or referral as
indicated by the health status of the client.
47

48. 
A CNM is educated in the two disciplines of
nursing and midwifery.
A CNM has successfully completed prescribed
studies in midwifery and has met the requisite
qualifications to be certified.
A CNM is legally qualified to practice
48

49. 
 In 1922, ICM was established to support the
ongoing development of the midwives
profession.
 During the 20th Century, professional midwifery
was introduced to various countries in Africa and
Asia.
 Nursing and midwifery acts were passed and
councils of nursing were established. 49
ICM

50.  These provided registration for midwives, and
separate licensure for midwifery practice,
allowing midwives to be distinctly recognized
and protected to practice.
 Currently, ICM is representing over 1 million
midwives globally, with 140
Members Associations, in 121 countries across
6 regions of the world. 50

51. 
In 1977 (2033) Bachelor of Nursing in midwifery
was introduced.
In 1995 post graduate (Master in women Health
and Women Development) was introduced.
51
Milestone of Midwifery Profession
In Nepal

52. 
Midwifery Society of Nepal (MIDSON) is the
national professional forum for midwives in
Nepal, established under the Society
Registration Act 1978 (2034) on February
2010 and registered under Social Welfare Act
1993 (2049) on March 2010.
52

53. 
 National Academy of Medical Science, Bir
hospital has launched
Bachelor in Midwifery Sciences
(BMS) program from the academic year
2073/74 with ten (10) only.
 In 2016 AD, KU started 4 years Bachelor of
Midwifery (B.MID)programme.
53

54. 
 Bachelor in Midwifery has been started in
Karnali Academy of Health Sciences
(KAHS) from the academic year 2075/76.
 National Licensure Examination for
Bachelor in Midwifery Science (BMS)
started in 2076 BS.
54

55. 
55
Alternative Nurse Role
• Nurse Advocate
• Nurse Researcher
• Public Health
Nurse
• Home Health Nurse
• Forensic Nurse
• Hospice Nurse
• Telephone Triage
Nurse
• Flight Nurse
• School health
Nurse
• Occupational Nurse

56. Nurse Advocates
• Nurse advocate is defined as being a patient representative,
defending the patient’s rights and universal rights,
protecting the interests of the patient, contributing to
decision-making and supporting the patient’s decisions,
ethical-centered skills for the ‘professional self’, and ‘being
a voice for the vulnerable.
• Nurse Advocates are the liaison between patients and
doctors. They help patients understand their diagnosis and
make the best decisions about their health.
56

57. Nurse advocate..
• A nurse advocate is a nurse who works on
behalf of patients to maintain quality of care
and protect patients' rights. They intervene
when there is a care concern, and following the
proper channels, work to resolve any patient
care issues. Realistically, every nurse is an
advocate. There are, however, certain positions
which allow nurses to specialize in patient
advocacy.
57

58. Education Requirements for a Nurse
Advocate
• Those interested in nurse advocacy should first
pursue a nursing degree through a two- or four-
year university. Obtaining an associate's degree
(ADN) or bachelor's degree (BSN) in nursing is
required.
• After completion of an accredited nursing
program, successful completion of the NCLEX-
RN is required for licensure.
58

59. Working area
Nurse advocates can work in hospitals, outpatient
clinics, specialty departments, long-term care facilities,
non-profit organizations, or as independent healthcare
consultants. In the inpatient setting, nurse advocates can
work in:
• Patient care coordination
• Discharge planning
• Med/legal
• Risk management
• Management
• Patient services
59

60. Roles & Duties of a Nurse Advocate
The roles and duties of a nurse advocate is multi-faceted,
but the cornerstone is patient education. Roles and duties
may include:
• Assessing patient care needs during hospitalization and
discharge
• Reaching out to community resources as needed
• Educating patients about diagnoses and referring to
specialties
• Advocating for treatments/procedures/tests that are
appropriate for patient care/diagnoses
60

61. Roles contd…
• Reviewing patient care concerns or grievances
• Providing education on insurance benefits
• Educating patients on current standards of
practice in healthcare
• Demonstrating compassion and empathy with
patients and families with regards to their
healthcare wishes
• Educating patients on necessary healthcare
decisions without bias or coercion
61

62. Nurse Researcher
• Nursing research began when Florence
Nightingale accumulated and analyzed
complex information about conditions during
the Crimean War (1854-56). Although her
work illustrated the power of statistics to
reform nursing, her insistence that nurses
undertake systematic inquiry was ignored by
late 19th century training school
administrators.
3/18/2020 62

63. • 1902 Lavinia Dock reported a school nurse
“experiment” that was begun by Lillian Wald.
• 1906 Adelaide Nutting conducted a survey of the
educational status of nursing.
• 1923 A well-known study of nursing and nursing
education was conducted by the Committee for the
Study of Nursing Education and funded by the
Rockefeller Foundation.
• 1924 The first doctoral program for nurses was
established in 1924 at Teachers College, Columbia
University.
3/18/2020 63

64. • 1927 Jean Broadhurst and her colleagues reported a
research investigation on handwashing procedures.
• 1952 The first issue of Nursing Research was
published.
• 1953 The Institute of Research and Service in
Nursing Education was founded at Teachers
College, Columbia University.
• 1955 The American Nurses Foundation was
established with the goal of promoting high-level
wellness and the improvement of patient care.
3/18/2020 64

65. • 1972 The ANA established a Department of
Nursing Research.
• 1974 At its national convention, the ANA
delineated nursing practice as the area to
which nursing research should be directed in
the next decade.
• 1976 The Commission on Nursing Research of
the ANA recommended that research
preparation be included in undergraduate,
graduate, and continuing education programs.
3/18/2020 65

66. Issues
• Physician leaders fear that expanding the range
of services nurses can provide may threaten
patient safety.
• The current regulatory barriers for APNs are
prescriptive authority, reimbursement schemes,
nursing education, and scope of practice and
titling. The variance in board regulations from
state to state is a problem facing APNs who
highly mobile 66

67. • Policies and political influences
• Poorly developed monitoring and evaluation
system
• Scarce resources
• Lack of advocacy
• Social stigma
67

68. Ways to improve nursing skills
Nursing skills can be improved and maintained
through:
• Training,
• Continuing education,
• Professional conferences,
• Work experience and
mentors.
68

69. This provides high quality and effective health
care for patients and is necessary to improve
nursing skills in order to keep up with new
technologies and procedures.
69

70. 77