My Scope of Practice: New Year’s Resolution: Become an Advanced Practice Nurse
Advanced Practice Nurses (APNs) can diagnose and treat a range of health problems. They are educated at the Master’s level in one of four specific clinical areas: Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Nurse Anesthetist (CRNA), and Nurse Midwife (CNM). The first APN program educated NPs at the University of Colorado in 1965; programs now are available at more than 325 colleges and universities throughout the US. According to the American Academy of Nurse Practitioners (https://www.aanp.org) there are currently approximately 115,000 practicing NPs, with about 6,000 new NPs being prepared each year.
Advanced Practice Nurse responsibility is subject to the rules and regulations of the licensing state (APNs are licensed in all states and the District of Columbia) and can include ordering, performing, and interpreting diagnostic tests; diagnosing and treating acute and chronic conditions; prescribing medications and other treatments; managing overall patient care; and counseling and educating patients. Specialty areas include acute care, adult health, family health, neonatal health, pediatric/child health, gerontology health, oncology, psychiatric/mental health, and women’s health. Despite the fact that the APNs’ hands often are tied by state-generated restrictions, they report almost 600 million patient visits each year. An article in the Bucks County (Pennsylvania) Courier Times (December 12, 2006) says APNs can perform 70% of what a primary care practitioner can at 50% of the cost. Several studies have shown care equal or greater in quality to physician colleagues.
Advanced Practice Nurse (and OWM Editorial Review Board member) Catherine T. (“Cathy”) Milne, APRN, MSN, BC, CWOCN is an APN specializing in adult health. Cathy, and colleague Lisa Corbett, CNS, opened one of the first advanced private practice nursing businesses in Connecticut. They contract with acute and long-term care facilities and home care companies to provide direct patient care, education, and outcomes-oriented research. Underscoring her determination to help establish a scientific, clinical base for practice, Cathy was integral to the development of the Association for the Advancement of Wound Care Conceptual Framework of Quality Systems for Wound Care, a project of the AAWC’ s Quality of Care Task Force. Her willingness to collaborate for ostomy and wound practitioners such as physicians and physical therapists celebrates her desire to “help everybody achieve good patient outcomes.”
Cathy earned her bachelor’s degree in nursing at American University, Washington, DC. Her Clinical Master’s degree from Western Connecticut State University expanded her abilities as a researcher, change agent, and clinical practitioner, but she believed she needed more. She pursued a post-Master’s degree at the University of Connecticut, becoming an Adult Nurse Practitioner. She worked as a med/surg Clinical Nurse Specialist at a Connecticut hospital and when the ET nurse retired, Cathy was handed the wound/skin/ostomy component. “I kept taking courses, reading, attending conferences, and soliciting the help of my mentors,” Cathy says. “Then I incorporated what I learned into my practice. My goal was and is to use a systematic, scientific approach with patients to improve outcomes.”
In 1995, Cathy – following what she sees as a trend of nurses going into private practice – partnered with Lisa Corbett, going out into the community (nursing homes and home health). Their mission was to reduce the need for wound care patients to return to the hospital for inpatient treatment.
Practicing across the care continuum can be daunting. “Each setting has its challenges based on the patients, regulatory and financial burdens, and staffing,” Cathy says. “APNs are equipped to understand the chronic care involved in wound and ostomy management and well-suited to managing these patients over long periods. Our knowledge of the pathophysiology – the cellular and molecular dysfunction that sometimes cannot be reversed – and our recognition of patient needs make APNs a good fit in palliative care.”
The reimbursement conundrum is not as easily addressed. “Third-party payors expect to see a direct supervisory link to a physician,” Cathy says. “Medicare requires a collaborative agreement. Insurance companies want all APNs to work in the physician office setting and to use the physician’s number, even though the APN can document better outcomes. This creates barriers to patient care.” In addition, regulatory pressures in a number of settings have changed practice. States now are increasing enforcement and people are becoming more proactive, resulting in greater emphasis on prevention.
Another unintended challenge is that to the casual observer, APNs can make wound care look easy. The visual stimulus of a quickly healing wound gives positive reinforcement to all involved. Subsequently, non-wound specialists and others without the appropriate education, training, or certification think, I, too, can do this. “I guess that’s the hallmark of a true professional, like an athlete or actor,” Cathy says. “Others don’t appreciate everything that goes into what you do.
Cathy’s participation on the AAWC Quality of Care Task Force involves a commitment to defining “quality,” particularly in wound care. She is grateful that her work on the Task Force has given her the opportunity to meet people from all over the US and exchange wound care information. She says valuable lessons can be learned from podiatry, physical therapy, and industry perspectives of quality. Because achieving quality outcomes involves everyone speaking the same language, Cathy is helping create a wound care glossary to standardize nomenclature for providers and publishers of the research she so heartily champions. Cathy hopes these endeavors will help define what is meant by a “quality care center” – a concept that should help consumers in their healthcare choices. She also encourages increased give-and-take between wound care organizations like the AAWC and the WOCN (she is a member of both). “In this healthcare climate, we shouldn’t be territorial,” she says. “There are enough wounds for all of us.”
Cathy also thrives on the ability to navigate patients through the healthcare system. Patient advocacy is one of the more rewarding aspects of her job; it requires teamwork among the patient, family, and healthcare providers. The wife of a recent patient with quadriplegia was so encouraged by her experience that she intends to become a nurse.
“When I first came to nursing, Maalox (Novartis) and heat lamps were part of the wound healing regimen,” Cathy says. “Now, wound care is becoming a true science. Not practicing according to tradition is a fabulous trend. The shift to a pharmaceutical/technological approach to care is yielding better outcomes. My practice and my push to secure clinical-based data are certainly fulfilling for me. Historically, I would change jobs every 3 years. Now, I plan to stay where I am in my scope of practice.”
My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.
