ESSAY NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings ESSAY

NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Primary Care

Everyone needs a primary care doctor—the one who conducts your physicals, the one you call when you twist your ankle, get stung by a bee, or eat something funny. Some doctors treat entire families; others see only children or only adults. Here are some details to help you find the best primary care doctor for you.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Family Medicine – Care for all individuals

At the heart of this specialty is the patient-physician relationship. Our family medicine physicians cover all areas of a family’s health and wellness, including care for children, women, and men, plus gynecology and aging issues. These specialists provide a medical home to their patients and look out for the overall health of the entire family by knowing them as a whole. They are also responsible for the coordination of any specialty care the patient may need.
More information on our Family Medicine doctors

ORDER A PLAGIARISM-FREE PAPER HERE

Internal Medicine – Care for adults

Internal medicine physicians have had extensive training in the prevention, diagnosis, and treatment of adult diseases, both chronic and acute, and provide care for individuals ages 18 and older. Our internal medicine physicians are equipped to deal with whatever problem a patient brings—no matter how common or rare, simple or complex—from preventive care to chronic disease. If additional medical specialists are needed, our internists will coordinate their patient’s care.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper
More information on our Internal Medicine doctors

Pediatrics – Care for children

When it comes to the health and well-being of children, our pediatricians combine warm, compassionate care with the knowledge that comes from advanced training and experience. Pediatric patients are rapidly growing and changing, and these specialists care for them in a thoughtful and concerted way to meet the child’s ever-changing needs. Our pediatricians can perform well-child checkups, sports physicals, back-to-school checkups and vaccines, and treat sports injuries. From infancy to any stage of childhood, our pediatricians will follow the development of your child and work with you to ensure the optimal health and well-being of your family.
More information on our Pediatricians

Geriatric Medicine – Care for aging

Our geriatricians recognize that aging is not an illness. Rather, your senior years are a time when the quality of life and functional ability can be maintained with proper care, and health and happiness are encouraged. The specialized care geriatricians provide can help manage the unique and often multiple health concerns of older adults, who may not react to illness and disease the same way younger adults do.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper
More information on our Geriatric Medicine doctors

Fifty-eight million Americans have no insurance coverage,1 with as much as 25% of the population uninsured. As the U. S. Congress continues the debate over universal health coverage, the dynamics of health care have forced numbers of people to seek primary care services. With only one-fourth of medical school graduates selecting residencies in the primary care specialties e.g., family medicine, pediatrics, general internal medicine, and obstetrics/gynecology, significant gaps in services compound the urgency. Nurse Practitioners (NPs) are uniquely qualified with advanced practice skills to meet the increased demand for primary care services.

Nurse Practitioners have demonstrated the ability to provide care to many under served groups, such as children, women, migrant workers, the homeless, and the elderly in nontraditional settings, such as schools, work sites, and health departments. Although multiple studies have documented the high quality of care and cost-effectiveness of APNs, these nurses remain an under-utilized resource.2

Schools of Nursing are investing significant resources for preparation of NPs and NPs are graduating in record numbers. Globally, there are increasing opportunities for nurses with advanced practice skills. It becomes imperative to resolve the scope of practice issues for NPs to gain the needed public support to expand their role to meet much needed primary care services.3 Yet restrictive practice environments continue to limit their efficient use both nationally and internationally.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

The degree of legal authority for APNs to practice varies by state. The Nurse Practice Act legislated in each state of the U.S. specifically delineates requirements for registered nurses in advanced practice roles. While registered nurses are now legally authorized to provide services for primary health promotion, disease prevention, and assessment of health status, questions remain as to the degree of independence, prescriptive authority, and reimbursement for APN for services. A broader definition of the scope of NP practice would enable expansion of primary care services to better serve the health care needs of the nation.4 To promote the role of the NP as a major player in health care reform, this paper will describe the current scope of practice, clinical competencies, and practice settings while tracing the historical development of this type of APN.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Advanced Practice Overview

Advanced Practice Nurse (APNs) include registered professional nurses, with a current license to practice, who is prepared for advanced nursing practice by virtue of knowledge and skills obtained through a post-basic or advanced education program of study acceptable to the State Board of Nurse Examiners. The APN is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings including, but not limited to, homes, hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice. The APN acts independently and/or in collaboration with other health care professionals to deliver health care services (Texas Nurse Practice Act, Section 221).5 APNs conduct comprehensive health assessments aimed at health promotion and disease prevention. They also diagnose and manage common acute illnesses, with referral as appropriate, and manage stable chronic conditions in a variety of settings. APNs titles include Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, and Certified Nurse Anesthetist. Independent practitioners are capable of solo practice with clinically competent skills and are legally approved to provide a defined set of services without assistance or supervision of another professional.6NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

APNs are uniquely qualified to resolve unmet needs in primary health care by serving as an individual’s point of first contact with the health care system. This contact provides a personalized, client-oriented, comprehensive continuum of care and integrates all other aspects of health care over a period of time. Care should be provided as much as possible by the same health care professional, with referrals coordinated as appropriate. The focus of care is on health surveillance (promotion and maintenance of wellness), but it also provides for management of acute and stable chronic illness in order to maintain continuity.7 8NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

NP Development

The NP role originated as one strategy to increase access to primary care 9 in response to a shortage of primary care physicians. The first successful program to prepare NPs was developed at the University of Colorado in 1965 under the co-direction of a nurse, Loretta Ford, and a physician, Henry Silver to prepare pediatric NPs with a focus on health and wellness. Working collaboratively with physicians, NPs with this advanced education from non-degree, certificate programs, were able to identify symptoms and to diagnose and manage health problems in children.

Federal legislation in the mid 1960’s provided funding to support the development of
primary care providers. In 1971, the Secretary of Health, Education and Welfare issued primary
care intervention recommendations for which nurses and physicians could share responsibility, thus
implying support for nurses as primary care providers.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

With the support of federal monies, nursing programs for NPs multiplied.10 By the mid-1970’s, there were more than 500, mostly certificate, programs across the country that were preparing nurses to deliver primary care.11 Programs gradually shifted from certificate to master’s degree preparation as accrediting bodies increasingly required a master’s degree. By the 1980’s, master’s degree programs far outweighed certificate programs. In response to health care reform in the 1990’s, NP programs are proliferating at an astonishing rate to meet increasing demands for primary care services. As of 1995, 248 programs in the U.S. offer a master’s degree with preparation as a NP.12 In 1994, 49,000 nurses were employed as NPs.13NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

A nurse practitioner (NP) is an advanced practice registered nurse (APRN) classified as a mid-level practitioner. A nurse practitioner is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose illness and disease, prescribe medication and formulate treatment plans. 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 cases in which multiple symptoms suggest more serious conditions.[1][2] According to the American Association of Nurse Practitioners, a nurse practitioner is educated at the masters or doctoral level to provide “primary, acute, chronic, and specialty care to patients of all ages and all walks of life”.[3] The scope of practice for a nurse practitioner is defined by jurisdiction.[4][5] Depending on jurisdiction, nurse practitioners may or may not be required to practice under the supervision of a physician. In United States, nurse practitioners have been lobbying for independent practice.[6]NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper The opponents of independent practice have argued that nurse practitioner education is “flimsy,” because it can consist of online coursework with few hours of actual patient contact.[7] The number of patient contact hours in nurse practitioner training is less than or equal to 3% of physician training.[1] Increased utilization of nurse practitioners is leading to increased cost of care through increased use of resources and unnecessary referrals.[8][9][10]

ORDER A PLAGIARISM-FREE PAPER HERE

The adult-gerontology nurse practitioner – primary care (AGNP-primary care) major in our MSN Program focuses on developing the knowledge and skills necessary to deliver nursing care to individuals from adolescence to older adulthood across primary care settings, including those in rural and under-served areas. Our AGNP-primary care major prepares advanced practice nurses as generalists in adult primary care in a wide variety of settings, including private practices, public clinics, hospital-based outpatient clinics, and specialty practices.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

As a graduate from our adult-gerontology nurse practitioner major you are well-prepared to provide culturally competent, evidence-based, state-of-the-art primary medical care to patients from adolescence through senescence. Our graduates practice in a wide variety of outpatient settings ranging from small community health centers to retail clinics to large academic medical centers.

PEOPLE who have chronic life-limiting conditions have complex and multifaceted needs that arise at different points during their illness trajectory. Many receive care over time from health care professionals within various health care sectors, including hospital, residential, and home care. Good care for people who have life-limiting conditions requires that principles of palliative care are adapted and integrated into contexts of care that do not provide specialized palliative care services, regardless of the health care sector in which the care is provided.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper This is often referred to as a “palliative approach” to care.1–3 Broadly conceptualized, a palliative approach involves adapting and integrating principles from palliative care (eg, patient- and family-centered care focused on quality of life of the person and not just on the disease) into the care received by persons who have life-limiting conditions as they encounter various health care sectors throughout their illness trajectory.4,5 This blending of chronic disease management and palliative care requires an “upstream” orientation to care delivery that addresses the needs of patients and their families related to the advancing nature of their illness and necessitates the integration of care delivery systems and partnerships among service providers to address these needs across all sectors of care.6
Primary Care

In defining primary care, it is necessary to describe the nature of services provided to patients, as well as to identify who are the primary care providers. The domain of primary care includes the primary care physician, other physicians who include some primary care services in their practices, and some non-physician providers. However, central to the concept of primary care is the patient. Therefore, such definitions are incomplete without including a description of the primary care practice.

The following five definitions relating to primary care should be taken together. They describe the care provided to the patient, the system of providing such care, the types of physicians whose role in the system is to provide primary care, and the role of other physicians, and non-physicians, in providing such care. Taken together they form a framework within which patients will have access to efficient and effective primary care services of the highest quality.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper
Definition #1 – Primary Care

Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any diagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.

Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.Primary care provides patient advocacy in the health care system to accomplish cost-effective care by coordination of health care services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in health care.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper
Definition #2 – Primary Care Practice

A primary care practice serves as the patient’s first point of entry into the health care system and as the continuing focal point for all needed health care services. Primary care practices provide patients with ready access to their own personal physician, or to an established back-up physician when the primary physician is not available.

Primary care practices provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.).

Primary care practices are organized to meet the needs of patients with undifferentiated problems, with the vast majority of patient concerns and needs being cared for in the primary care practice itself. Primary care practices are generally located in the community of the patients, thereby facilitating access to health care while maintaining a wide variety of specialty and institutional consultative and referral relationships for specific care needs. The structure of the primary care practice may include a team of physicians and non-physician health professionals.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper
Definition #3 – Primary Care Physician

A primary care physician is a specialist in Family Medicine, Internal Medicine or Pediatrics who provides definitive care to the undifferentiated patient at the point of first contact, and takes continuing responsibility for providing the patient’s comprehensive care. This care may include chronic, preventive and acute care in both inpatient and outpatient settings. Such a physician must be specifically trained to provide comprehensive primary care services through residency or fellowship training in acute and chronic care settings.

Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient’s medical and health care needs – not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.
Definition #4 – Non-Primary Care Physicians Providing Primary Care Services

Physicians who are not trained in the primary care specialties of family medicine, general internal medicine, or general pediatrics may sometimes provide patient care services that are usually delivered by primary care physicians. These physicians may focus on specific patient care needs related to prevention, health maintenance, acute care, chronic care or rehabilitation. These physicians, however, do not offer these services within the context of comprehensive, first contact and continuing care.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

The contributions of physicians who deliver some services usually found within the scope of primary care practice may be important to specific patient needs. However, the absence of a full scope of training in primary care requires that these individuals work in close consultation with fully-trained, primary care physicians. An effective system of primary care may utilize these physicians as members of the health care team with a primary care physician maintaining responsibility for the function of the health care team and the comprehensive, ongoing health care of the patient.
Definition #5 – Non-Physician Primary Care Providers

There are providers of health care other than physicians who render some primary care services. Such providers may include nurse practitioners, physician assistants and some other health care providers.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

These providers of primary care may meet the needs of specific patients. They should provide these services in collaborative teams in which the ultimate responsibility for the patient resides with the primary care physician. (1975) (2006)

Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care that the patient may need.[1][2][3] Patients commonly receive primary care from professionals such as a primary care physician (general practitioner or family physician), a nurse practitioner (adult-gerontology nurse practitioner, family nurse practitioner, or pediatric nurse practitioner), or a physician assistant. In some localities, such a professional may be a registered nurse, a pharmacist, a clinical officer (as in parts of Africa), or a Ayurvedic or other traditional medicine professional (as in parts of Asia). Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care. NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

ORDER A PLAGIARISM-FREE PAPER HERE

Types of Primary Care Physicians

Your primary care physician serves as the entry point for substantially all of your medical and health care needs. He or she is your advocate in coordinating the use of the entire health care system to benefit you and takes continuing responsibility for providing your care. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses. By regularly seeing a primary care practitioner, you can identify and control health risk factors before they become problems. Your primary care practitioner encourages you to take charge of your health and is a trusted partner in an environment where you can feel comfortable and known.

All doctors are not alike. Many different health care professionals with different types of education can provide health care. Adults in your family could see an internist. Children could go to a pediatrician. Or the whole family could see a family medicine doctor. You could have a family medicine doctor and an obstetrician/gynecologist, or an internist and a geriatrician. If it’s right for you, it’s the right choice. Here’s a guide to the five kinds of primary care doctors available at Lehigh Valley Health Network.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

If a physician on your care team is board-certified, he or she chose to obtain an additional credential after medical school and residency training. Board-certified physicians have completed additional education and passed an examination to earn this credential. If one of your caregivers is fellowship-trained, the physician has had additional training in a particular area of interest.

Family medicine doctors: Also called family practice doctors, they see people of all ages, including infants, children, teens and seniors. They are educated and board-certified in their knowledge of the body at all ages.

Internal medicine doctors: Also called internists, they generally care for people age 14 and up (the starting age can vary by practice). They are educated and board-certified in the understanding of the internal organs of the adult body. Some internal medicine and family medicine physicians also can provide care that you might not expect, like routine gynecologic care, dermatology and sports medicine.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Gynecologist or obstetrician: For many women, this physician is a key health resource. Through the reproductive years and afterward, your obstetrician or gynecologist has the knowledge and experience to promote your well-being. They recommend tests and exams necessary at different stages of your life.

Geriatricians: They have special education to address the specific needs of adults over age 60. They provide routine primary care, as well as medication management, physical and mental assessments related to falls, memory issues and other aspects of aging.

Pediatricians: Every child needs to see a doctor – in fact, more often than adults. Pediatricians are specially educated to care for children, ranging from newborns through age 21. If your child needs special care, our pediatricians work closely with our specialists so your child can receive the best care.
The Importance and Benefits of Primary Health Care

Primary health care refers to the essential health care made accessible to individuals in a community at costs that they can afford. The World Health Organization (WHO) put forward the concept of primary health care that focuses more on the importance of community participation by identifying some of the social, economic, and environmental determinants. It includes the basic services required for meeting one’s everyday health care needs like conducting a regular checkup with the family doctor or visiting low income health clinics.

Primary health care centers offer professional medical care for individuals based on a locality or community before shifting them to more advanced hospital-based care like the general specialist and super specialist. In fact, primary health care forms the vital aspect of a country’s health system while immensely assisting in the sociology-economic development of the community. All primary health care clinics tend to focus more on the quality of the service offered while maintaining cost effectiveness.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

The clinics that offer primary health care services usually include a team approach that facilitates appropriate care to an individual. It has also incorporated some of the latest aspects like the sharing of information among health care providers while focusing on promoting the health, preventing illness, and other chronic conditions. Moreover, primary health care also forges a new connection and participation within the members of a community.

Role and Benefits of Primary Health Care

The main role of primary health care is to provide continuous and comprehensive care to the patients. It also helps in making the patient available with the various social welfare and public health services initiated by the concerned governing bodies and other organizations. The other major role of a primary health care center is to offer quality health and social services to the underprivileged sections of the society.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

As for the benefits of primary health care to the members of a community, it offers the first set of professional care to the patients by incorporating a proactive approach that utilizes several preventive measures, management of chronic disease, and promoting self-care. Along with that, primary health care provides increased accessibility to advanced health care system for the community, which results in excellent health outcomes and prevention of delay.

All primary health care clinics contain a dedicated team of healthcare professionals offering the best medical services. They provide a coordinated approach to the delivery of health care that ensures that the beneficiaries receive the best care from the right health provider.

Sustainability of collaborative care interventions in primary care settings

Summary: We assessed patient and provider barriers and facilitators to sustainability of a collaborative depression care model for depression treatment in predominantly Hispanic diabetes patients in safety net care clinics.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

• Findings: Semi-structured interviews and focus groups were conducted with patients and providers at two community clinics participating in a randomized controlled effectiveness trial of the Multi-faceted Depression and Diabetes Program (MDDP), a socioculturally adapted collaborative care model. Analysis identified eight themes grouped into three categories: barriers, facilitators, and recommendations for program sustainability. Barriers included patient concerns about use of medication and provider concerns about use of psychotherapy, increased workload for clinic staff, delay in receiving outcomes data, and lack of resources to sustain the program. Facilitators included patient benefits such as improved clinical outcomes, quality of care received, access, and satisfaction; provider benefits such as increased awareness and reduced anxiety; and clinic benefits in the form of reduced costs of care. Recommendations included changes in communication patterns among providers, specific changes in procedures, changes in resources, and changes in clinic organizational culture.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

• Applications: Sustainable adoption of collaborative depression care for underserved populations in safety net care systems by organizational decision-makers and providers requires: stable funding and qualified staff; technologies to facilitate provider access to easily applied treatment guidelines, information exchange between primary care physicians and depression care providers, and routine monitoring of patient depression symptoms and treatment adherence and satisfaction; and treatment consistent with patient preferences.

Nurse practitioners are the principal group of advanced-practice nurses delivering primary care in the United States. We reviewed the current and projected nurse practitioner workforce, and we summarize the available evidence of their contributions to improving primary care and reducing more costly health resource use. We recommend that nurse practice acts—the state laws governing how nurses may practice—be standardized, that equivalent reimbursement be paid for comparable services regardless of practitioner, and that performance results be publicly reported to maximize the high-quality care that nurse practitioners provide.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Challenges To Primary Care

The U.S. health care system is plagued by a confluence of problems that challenge the core of its primary care system.

The growth in chronically ill 7 and elderly 8 populations, for example, compounds concerns about the adequacy of the workforce and persistent lags in quality. Questions regarding the value of the primary care system, as evidenced by performance on numerous economic indicators, health outcomes, and multiple dimensions of patients’ experiences, have been raised, especially in comparison to other developed countries. 9,10
Workforce

Gaps in quality are accompanied by workforce shortages that threaten the provision of services. 11 The number of medical students and residents entering primary care or pursuing careers in general internal medicine or family practice is steadily decreasing. 12–14 However, the nation is benefiting from the relative growth among NPs, whose per capita supply is projected to increase annually by an average of 9 percent. 15NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

There are similar trends in the education and training “pipeline.” Between 1995 and 2006, primary care medicine residency programs declined 3 percent, while primary care training programs for nurse practitioners grew 61 percent. 11 However, faculty shortages, inadequate supply of clinical preceptors and placements, and limited funding for students challenge this continued growth. More than 2,700 qualified applicants to master’s degree programs preparing NPs were turned away in 2008. 16

ORDER A PLAGIARISM-FREE PAPER HERE

Seeking Solutions

To better understand and quantify nurse practitioners’ roles in primary health care, we examined the literature on their participation in the health care workforce. We looked for current evidence of NPs’ contributions to high-value primary health care (that is, care that is safe, effective, patient-centered, timely, equitable, and efficient). We also sought to identify barriers to maximizing NPs’ contributions and policy solutions to enable their rapid and efficient use in primary care.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper
Advanced practitioners improve efficiency and patient satisfaction

There is a need for the role of advanced nursing practice in primary care. The King’s Fund has highlighted the current pressures within the NHS in relation to patient access and the fact that many services are running at overcapacity.1 The Department of Health (DH)2 encourages advanced skills of nurses to meet the growing demands of services and the NHS Plan3 advocates nurses being at the forefront of primary health care.

Within the author’s primary care practice patients were dissatisfied with the amount of time they waited for a routine GP appointment. The practice was facing increasing demands from patients who required or requested urgent appointments and it needed to be able to provide an efficient and effective service for them.

The introduction of an advanced nurse practitioner (ANP) role aimed to increase access to urgent on-the-day appointments and improve patient satisfaction with waiting times. Patients requesting an urgent appointment on the day would be mainly seen by an advanced nurse practitioner rather than a GP.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Defining advanced practice

There have been many definitions of the ANP role and patients have described confusion over the role.4 There is no statutory regulation under the Nursing and Midwifery Council (NMC), which means that anyone can call themselves an advanced practitioner.5

The advanced role has developed from that of the nurse practitioner. However, there are lots of variations and it can be difficult to distinguish between specialties.6 Many authors have discussed the need for clarification of the ANP role and the need for standards to define its scope and competences, as well as making people aware of what the role entails.4,7,8 At present, the role is not regulated, although this is under consideration.9

The Royal College of Nursing (RCN) recommends competencies that an ANP should meet.10NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

The DH defines an ANP as a registered nurse working at a level well beyond their initial registration, using additional skills and knowledge to inform and further develop their practice.11 ANPs work at an advanced level using critical thinking, reflection and analysis to inform assessments, clinical judgement, complex reasoning and decisions.12

Need for ANPs in primary care

Within the NHS, there are increasing pressures on A&E and out-of-hours services1 and nationally people are being encouraged to seek advice from the most appropriate person or place for their healthcare needs.13

The patient population is increasing, people are living longer and more people are living with long-term conditions.13 The situation is compounded in primary care by the shortage of GPs and because many GPs are taking early retirement.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

There is an increasing need to manage this rise in demand and the introduction of the role of the ANP is one way to do this. Patients also need to be made aware of other resources and other health professionals who can provide them with advice or treatment.

For example, the internet enables patients to access NHS websites that provide advice for the self-management of some illnesses. Patients can also receive advice and some treatments from a pharmacist, or they can have a consultation with an ANP.

To alleviate some of the pressures on A&E and out-of-hours services the NHS Plan set targets that patients should be able to get an appointment with their GPs within 48 hours.3 However, despite this, people continue to find it difficult to access their GP.14

Benefits of the role

Advanced practice roles can help fill some of the gaps caused by healthcare shortages.7 For example, the introduction of an ANP in general practice can alleviate some of the access issues.

In primary care, ANPs can deal with most patients requesting acute, same-day appointments that do not require GP contact.15,16 This more effective use of primary care services allows GPs to see patients with more complex health needs.17

A systematic review by Horrocks et al found that patients were equally satisfied with the consultation times, diagnosis, examination skills, time spent explaining treatment plans, and prescribing practices in consultations with an ANP as they were with a GP.18 There were also no differences in health outcomes, quality of life, or rate of return. The researchers did find that consultations with ANPs took longer, because they spent more time communicating and providing explanations.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

However, Richards and Tawfik found did not find an overall increase in consultation time with the ANP role.19

ANPs take time to discuss the treatments and potential side effects and negotiate care with patients – and this is different to the medical model of GP care. The consultation may, therefore, take longer but this is extra time spent giving patients the information they need to self‑manage their condition in the short term, and in the longer term this may reduce inappropriate attendance.

Potential challenges

It is important that patients have confidence in the role of the ANP. There may, of course, still be individuals who will always want to see a GP and not an ANP.20 Acceptability of the service has been found to increase if the patient has previous experience of consulting a nurse for a problem for which they would have normally seen a GP on a previous visit.21

A Scottish study showed that patients have a positive attitude to nurse practitioners, because the role has been part of practice for a long time and patients are more familiar and more confident with nurse-led care as a result.22 If patients are made more aware of a nurse’s capabilities and qualifications, they are more accepting.22

GPs also need to be accepting and have confidence in the ANP role. There have been instances of some GPs perceiving ANPs as a threat to their role and expressing concern about the nurse’s capabilities.23

Change in the practice

Patients were dissatisfied about the time they had to wait to get an appointment with a GP, which was evident in comments received on the friends and family questionnaire. This mode of feedback was launched in 2013 and provides a mechanism to highlight good and poor patient experiences.24NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Many patients have been unhappy with the waiting times for appointments or waiting times to see their GP of choice Patient satisfaction is at the forefront of the practice aims and a change had to be implemented to improve matters. General practices must ensure that they provide an accessible service so patients with an acute healthcare need do not present inappropriately to out-of-hours services or A&E departments.

The higher level of education of ANPs , who are accredited at master’s level, means they are expected to apply more complex and critical thinking in their practice.7 Before the master’s accreditation, the ANP role already had the non-medical prescribing qualification. This is crucial to the role and, without it, ANPs would find it difficult to deliver effective and holistic patient care.25

In addition to patients with minor illnesses, ANPs see those with more complex needs. However, individuals with an acute medical need, those who have a long-standing illness or complaint, children aged under six years or patients presenting with mental health issues are given a GP appointment, rather than one with an ANP. Advanced practitioner appointments are booked via telephone receptionists. Patients are asked to provide a brief description of the problem that needs addressing via an on-the-day appointment. A summary of patients who are suitable to be seen by the ANP was developed by the advanced practitioner and is available to receptionists for reference.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Patients who decline to have an appointment with the ANP are instead given an appointment with a GP. Patients can also request to see an ANP instead of a GP, if their problem is suitable. Patients are seen by ANPs for 15-minute consultations, the same amount of time allocated to GP consultations.

Importance of referral and supervision

Because patients may present to ANPs with acute care needs, some may require admission or referral to secondary care. ANPs should be able to assess individuals using a range of methods, not all of which will be within the remit of nurses without ANP accreditation.11

One of the competences set out for an advanced practitioner by the RCN is that the nurse should be able to provide treatment and care through referral to other agencies.10 One issue that has previously been raised is refusal of secondary care services to accept referral or investigations, such as a chest X-ray, from a nurse.26

However, this is not something ANPs have generally encountered in practice. Within the primary care locality, suitably qualified ANPs who have attended education sessions can request X-rays in adherence with hospital policy for ANP radiology requests.

The most common referrals to secondary care are to the breast clinic, acute eye unit or deep-vein thrombosis clinic. And ANPs who have requested the admission of a patient to secondary care for medical or surgical assessment have not encountered any obstacles to having their requests accepted . In fact, on many occasions, the admission is accepted a fellow ANP. This enables the ANP to complete an episode of care and provide the patient with an effective service.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

A central element in the introduction of the ANP role is the supervision and ongoing education provided by GPs. This supervision is recognised as essential for ANPs who may encounter patients with problems or requirements that are not within their scope of practice or competences.27 While being autonomous in practice, ANPs must work within their competence and agreed NMC scope of professional practice.28

In a GP training practice, a GP is allocated daily to provide supervision and mentoring to trainee GPs and the ANP. It is crucial to deal with patients effectively to ensure service quality. Supervision and learning from the GPs is an important element in developing the role within a general practice. McLoughlin, Shewbridge and Owens acknowledge that ongoing education from GP ensures that patients benefit from the ANP role.29NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Satisfaction with the role

The ANP role was introduced to improve service delivery and provide more access for patients with acute healthcare needs who had to be seen on the day rather than expect them to wait for the next routine GP appointment. The use of an advanced practitioner to see such patients in place of a GP has increased access to the on-the-day service.

The introduction of the ANP role has also been successful from the point of view of GPs. It has alleviated some of the pressure and allowed time to be used more efficiently. GPs spend less time consulting patients with acute illnesses since these are competently dealt with by the ANP. GPs can now spend their time seeing patients with more complex care needs or long-standing conditions. This effective use of services was identified by Long et al,who observed that patients were seeing the most appropriate person able to deal adequately with their healthcare need. 17

After their consultation the ANPs completed a satisfaction questionnaire. When the role was initially introduced over the period of one, week 50 questionnaires were distributed to patients.

The results were collated from 40 questionnaires that were returned. The feedback was very positive, with all patients saying that they:NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Were very satisfied with the advice or treatment they received from the ANP
Had confidence in the advice or treatment they had received
Would see the advanced practitioner again or suggest seeing the ANP as an alternative to a GP appointment to others.

The role has not been in place long enough to asses if it has had an impact on A&E or out-of-hours attendances, but there has been a reduction in negative comments received about waiting times to be seen

Conclusion

The use of an ANP has increased the efficiency of practice and streamlined the GP services, while maintaining high quality care and increasing patient satisfaction. The role of the ANP within the GP practice is always going to be sustainable as demand from patients continues to grow. It enhances the effectiveness of primary care service delivery and increase patients’ and GPs’ confidence.

Practice nurses are in the ideal position to take on the role of advanced practitioner. They already work in GP practices and understand how the practice operates. They are aware of the quality of care required in primary care practice, as well as the protocols and guidance within which they to work.

The wealth of knowledge and experience already gained is an ideal base to build skills and competences further to provide a different level of care for patients. Although the transition to an ANP is arduous and requires further education, training and supervision, greater job satisfaction, increased confidence and autonomy is certainly make the process well worth the effort.

ORDER A PLAGIARISM-FREE PAPER HERE

Nurse practitioners can play an important role in expanding primary care capacity in the Medicaid program. Nurse practitioners (NPs), often called mid-level providers, are able to provide some aspects of primary care, complementing the work of primary care physicians. Nurse practitioners are nurses with advanced clinical training. They need fewer years of training than physicians making them a more immediate support to a stretched primary care workforce. Additionally, NPs reduce cost because their average earnings are half those of primary care physicians.

NPs are important for areas of the country that face severe primary care physician shortages – this shortage is particularly acute for rural areas and southern states where the patient-to-primary care physician ratio is higher and where fewer physicians are choosing to practice. Studies show that NPs are more likely to practice in these under served areas than primary care physicians, increasing access for Medicaid patients and the uninsured.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Although NPs are trained to provide primary care, states differ in scope-of-practice guidelines. Scope-of-practice guidelines dictate what authority NPs have with their patients. Some states allow NPs to provide primary care, diagnose, and prescribe without physician oversight, while others have more restrictive scope-of-practice guidelines that require physician oversight and may limit NP practice and prescription authority. For example, Alaska allows NPs to diagnose and prescribe all medications without physician oversight while Missouri requires written documentation of physician involvement for NPs to diagnose and prescribe.

Expanding NP scope-of-practice strengthens primary care capacity. Greater NP autonomy increases consumer access to primary care while freeing up physicians to manage more complex patient cases. States can support consumer access to health care by passing legislation that eases restrictions on NP scope-of-practice.

Evidence for Quality Improvement

There is extensive research documenting nurse practitioner’s ability to provide high quality care, resulting in similar patient outcomes to physician-provided care. Similarly, patients that see NPs report high levels of satisfaction.

Harnessing NPs can also help address a common barrier to care for Medicaid beneficiaries: the shortfall of primary care providers. The 2014 expansion of the Medicaid program, mandated by the Affordable Care Act, will enroll approximately 16 million new participants, many needing a primary care provider for the first time. Empowering NPs to diagnose and prescribe without physician oversight is one important tool in helping to ensure that there is an adequate primary care workforce to serve this new population, especially since NPs are more likely than MDs to treat patients in settings where provider resources are scarce.NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper

Evidence for Savings

Studies show that a higher concentration of primary care physicians results in higher quality, lower cost care. One recent study shows that a 10 percent increase in primary care physician to patient ratio results in a 7 percent spending drop ($369) per Medicare beneficiary, on average. This suggests that increasing primary care capacity is a bridge to cost savings and better care.

Analysis of Massachusetts’ data revealed that patient visits with nurse practitioners or physician assistants were, on average, 35 percent less expensive than physician visits. The authors estimated that expansion of nurse practitioner scope of practice laws in states could save between $4.2 billion and $8.4 billion over ten years for the state. NURS 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Assignment Paper