Competencies in Advanced Practice Registered Nurses

Over the past several decades, the number of the Advanced Practice Nurses (APRNs) has increased. Also, the increase has shown the expanding capabilities of these nurses in healthcare systems. As a result, the value of APRNs has elevated as they now form an integral part of the medical system. Considering their importance, it is, therefore, necessary to analyze and synthesize the competencies that the nurses have to ensure the quality of health provision. In healthcare, the goodwill of the patient is the most important requirement. To achieve this, there is a need to incorporate several factors from all the players in this field for a successful recovery and quality service ( ANA, 2010) . 

APRNs are one of the players in this cycle. They have various standards or codes of practice that govern them. The APRNs owe their accountability to the regulatory agencies, the patients, the licensing board, and the nursing profession to comply and to ensure that they practice according to the requirements of the nurse practice act of the state and those of the advanced nursing care. In this paper, we will look at the literature on competencies that equip the nurses with the right procedures of care. Also, we will report on an interview with Kim, an APRN, to see his side of narration. 

To understand the roles of APRNs, it is important to realize the scope of nursing as a process. The nursing procedure is regularly conceptualized as the coordination of particular activities of appraisal, determination, and distinguishing proof of results, planning, implementation, and lastly, assessment ( ANA, 2010) . The nursing procedure, practically speaking, is not direct as frequently conceptualized, with an input circle from evaluation to assessment. So in simple terms, the APRNs are the carriers of the above tasks, with aid from other players in the healthcare field. For the sake of this paper, I interviewed one of the professionals to get his view on several competencies in nursing. Some of these competencies are as discussed below. 

Ethical Decision Making 

The current situation in the nursing field sees the encounter of a complicated system. The field is changing fast, and this brings with itself the complexity of the ethical issues facing nurses in the healthcare facilities. Every nurse experiences dilemmas from the difficult moral issues they need to address. However, the success of solving these matters varies from one to another. As the many-sided quality of issues increases, the role of an APRN turns out to be especially critical in the identification, consultation, and determination of entangled and troublesome ethical problems ( Hamric et al., 2013; ANA, 2010 ). 

The principal subject experienced in numerous moral situations is the disintegration of transparent communication. Clear correspondence is a fundamental essential for professional and mindful primary leadership. Evidence show that poor communication is the key to conflicts instead of differing in qualities. The APRN's communication abilities are connected in several fields. Inside the medical care team, discourse is best when individuals are responsible for showing data in an exact and compact way. In patient experiences, the differences between the patient and a relative or inside the family can be established in a bad communication, which then prompts ethical clash ( ANA, 2010) . The expertise of listening is similarly as vital in successful communication as having capable verbal abilities. Listening includes perceiving and acknowledging different points of view and indicating respect to people with different thoughts. To listen well is to permit others the essential time to shape and present their thoughts. 

Risks, Benefits, and Outcomes 

As an APRN, the professional should make sure that the Codes of Ethics for Nurses with Interpretive Statements (ANA, 2001) are followed correctly. The outcomes of patients who are seeking medical care depend on the stance of the nurse and their soundness in making ethical decisions. However, moral contemplations are affected by a large number of elements, for example, culture, religion, childhood upbringing, personal qualities, and convictions. These variables shape our moral perspectives and affect moral choices that influence medical caretakers and their patients. According to Kearney and Penque (2012), there are numerous ethical issues nurses can experience in the work environment. 

These include quality versus the amount of life, personal decision versus professional life, flexibility versus control, truth telling versus misdirection, and observational learning versus personal convictions. The role of nursing in the ethical sense is to identify the risks, benefits, and outcomes of a particular set of treatment approaches ( ANA, 2010) . The work of the nurse is to prevent the risks while maximizing the benefits of the results. In many healthcare situations, the APRN has to take action related to the ethical principles that are written in the Codes of Ethics for nurses. They prevent risks to the patient in many ways. 

First, they intervene when the patient’s health and safety are at risk. Also, they promote physical and safety of the psychological environment by checking on the safety hazards. The APRNs also act to promote healthcare benefits. They tackle and remove harmful or unsafe conditions such as unsafe insertion of catheters and PEG tubes. The errors that confront the health systems are dangers that can reduce the advantages of the systems. Therefore, the nurse should report any mistakes and confront the unsafe practices that cause them. 

In addition, the registered nurse improves benefits by encouraging and assisting in promoting healing by carrying out activities such as deep breathing and post-surgical patient ambulation ( ANA, 2010) . They also implement measures that reduce deterioration such as early mobilization to reduce pressure sores in intensive care unit patients. The actions can be scheduled to be carried out in intervals or it may be the responsibility of the healthcare professional to recognize the necessity of such measures and act on them. Hence, the solutions to such actions should be carried out bearing in mind ethical benefits of the population, or individuals. 

Theory 

As the scholar Hildegard Peplau states in the interpersonal theory, the nursing practice is a process of helping others find their felt difficulties ( D'antonio et al., 2014 ). The theory explains the different phases of the process and the roles in nursing. The various stages involve assessment, orientation, diagnosis, and identification of goal setting, implementation, exploitation where the patient is seeking help, evaluation, and resolution. As far as ethical decision making is concerned, assessment and implementation phases are important issues to pay attention to. These two are the phases where the nurse ought to think in an ethical direction to implement and evaluate the plans based on the mutually accepted and logical treatment. 

Peplau’s theory is applied where the nurse and patient have to be in a situation that provides a logical and systematic means of looking into the practice of care ( D'antonio et al., 2014 ). The interactions between the nurse and the patient are what matters, and the practitioner must understand the environment, human being, nursing, and health concepts to make sound and ethical decisions. In concurrence with this theory, the basis of APRNs practice is to maintain a helpful and proficient consumer–nurse relationship in healthcare inside fitting professional role limits. As Peplau’s theory insists on the interpersonal relationship between the nurse and the patient, the practitioner is responsible for taking the right action concerning the instances of unlawful, inappropriate, or unethical behavior that can put into jeopardy the best interests of the patient or their situations ( D'antonio et al., 2014 ). 

Interviewee 

To exemplify the competency of ethical decision making, the interviewee expounds on the maintenance of boundaries with acutely ill patients who seem to blur them. On that matter, Kim (the APRN interviewed for this paper) says that the APRN should not do anything personally. Those patients who are severely ill are inclined to say things that would annoy the nurse. The most important thing is to note that they are sick and not functioning normally. Kim added that the mentally ill patients are difficult to interview or stay focused in the topic, while others are not willing to open up to the nurse. Others seek solace from the nurse by attaching themselves to the practitioner. To avoid such incidences, it is paramount to have another co-worker, especially when dealing with patients of the opposite sex. 

Direct Clinical Practice 

Some of the ways to ensure an APRN can provide for the better outcome of clients is by checking on the second competency. This is direct clinical practice. It informs and oversees the execution of the other types of skills. Direct care is the one responsible for various essentials. First, in order to collaborate, consult, and lead important programs and staff in an efficient manner, the APRN has to have credentials and qualifications that enable them to make sound decisions based on the nursing standards. 

Education and Data Collection 

One of the ways of gaining such credentials is primarily through education. The nurse takes on an active role to transfer the knowledge learned to the patient in order to develop a sense of the possibility of positive outcomes ( Hamric et al., 2013) . The patient may be uneducated in the first place. But with the thorough understanding of the system and the clinical procedures, the nurse is able to make various decisions. Hence, the APN would be in the forefront to make the patient knowledgeable. The nurses are also supposed to upgrade their knowledge over time due to the dynamic nature of their field of practice. The developments experienced in the nursing profession prompts seeking further knowledge. 

According to Virginia Henderson’s Nursing theory (Alligood, 2014), there are fourteen essentials to be carried out to maintain better recovery of the patient. Some of these essentials are done by the patients themselves. However, the nurse can improve the outcomes by being there to provide guidance on the things that would otherwise not be feasible or knowledgeable to the client. The basic educational requirement of an advance practice nurse is a graduate degree ( Hamric et al., 2013; ANA, 2010) . The nurse is an interface that helps the patient recover. That is why the competency here is known as direct care. 

The nurse and the patient share the care directly. Education is paramount in understanding the rationale of doing what is being done. For example, the patients are required to have good hygiene. But without prior knowledge of why hygiene is important, it is impossible to obtain a positive outcome. Thus, the APN must provide the message on the importance of hygiene to recovery. The nurses connect the theories and information obtained from school and the care required by the patient. 

Data collection is another function of nurses that makes them have an active role in the healthcare system. Data is a crucial requirement for the treatment of a patient ( ANA, 2010) . The nurse collects the clinical data on the patient, determines the history of medication, and makes the relevant and appropriate course of action. The data is collected through effective communication and information gathering. The data is also obtained through the real diagnosis of the underlying diseases and monitoring the patients in the care unit. 

Theory 

Peplau’s theory is relevant here as it expounds on the interpersonal relationships between the nurse and the patients. Information sharing is the most important source of diagnosis and the basis of treatment ( D'antonio et al., 2014 ). The theory concentrates on the interpersonal interaction between the two parties. The first phase of the method is assessment. The essentials of assessment include data collection and analysis. Hence, the mid-range theorist explains the connection between the theory and the competency. 

Interviewee 

Kim continued by saying that she would first consider getting to the bottom of the matter. For example, when providing education to a patient with depression, it is advisable first to determine the cause of the problem before treatment and teaching commence. For Kim, she uses different modes of communication skills, such as written messages on cards or verbal encounter, that are within the therapeutic standards of relationships with the patient to convey the message of good hygiene. 

As Kim recounted, the outcomes of patients are what the nurses are there for. She said that the APRN should continually improve to serve the clients better. The improvements should be taken as a challenge, and the nurse should find a way of fitting them into their daily practice. The ones which are not feasible are left out, and those that can quickly help the performance of the patients should be taken into consideration. In short, the quality of practice is always important in healthcare. 

In detecting an underlying problem, Kim states that it is important to collect the external information about the patient. Those are the signs and symptoms that are exhibited openly. In such a situation, there are always those diagnoses that are hidden, and the nurse should be well equipped to crack the codes to help him or her find the underlying problem. For instance, in our case, Kim was to explain how she would tell if a person is not self-ambulating safely. The response was a detailed investigation that would be carried out on the patient ( George, 2011 ). Some of the things she would look at include gait, muscle tone, diet, musculoskeletal and neurological status. That is data collection. 

Then the APRN would relate the findings with the potential risks to the safety of the patient, their autonomy, and the ability for personal care. The gathered information would help the nurse make the correct inferences. This needs proper education. Also, when the patient does not understand the medication instructions, Kim assesses the effects of interactions among the patient, family and social systems on health and illness. The nurse uses any mode of communication as long as she conveys her message to the patient. In short, she teaches the patients. The nurse is in close contact with his patients by telling them the different ways patients respond to treatment. 

Collaboration 

In the healthcare system, the real deal is that the field is a multi-disciplinary one. There is a vast spectrum of professionals on the ground, and thus there is a need to ensure all are joining hands in the betterment of the recovery of the client. Due to that, the APRN is required to be able to collaborate with other professionals in the field ( ANA, 2010) . They have to be relentless in the pursuit and forging of a team and partnership. The other part of collaboration include non-professionals like the patient and the family members or caretakers. The interdisciplinary collaboration is essential in providing quality healthcare outcomes for improved care. Evidence-based practice has shown that the collaboration of nurses with other professionals has contributed largely in the provision of faster recovery plans. 

The advanced practice nurses and the other professionals share knowledge on the delivery of high-quality care. This often creates the overlaps and dynamic proficient practice limits. The boundaries of practice APRNs are always flexible, and this is necessitated by the demands of the industry. The interdisciplinary team includes the recognition and appreciation of the capabilities and expertise of the rest within the profession and beyond and it helps in initiating referrals to those professionals when need be. In such collaborations, there is always a common goal that the party needs to achieve as far as patient recovery is concerned. 

Implementation 

The nursing practice may require the information and evidence from the various disciplines to implement an action or group mission of treatment. The team identifies a plan, and the advance practice nurses perform it. According to the standards set for the APRNs, the task of the nurses is also to coordinate such plans and be on the forefront of the care delivery ( George, 2011 ). The master-level nurse is supposed to offer the consultation of others to influence the implementation of the project in question, effect the change, and control the abilities of other professionals. However, during the collaboration process, the nurse should not leave out the input of the clients or their families. The partnerships should include these parties as appropriate as possible to design the implementation procedure of the plan in a safe, timely and realistic way. 

The collaboration with the patient and the corresponding caregivers ensures the nurse applies the proper knowledge of the main problems in the healthcare system in the implementation of the plan of care. The implementation process can go as far as employing the community resources to integrate the program. Also here, the partnership with the different health care providers from diverse backgrounds is of great help to the nurse. In short, the APRN is responsible for the documentation of the implementation plan, including any modifications, omissions or changes. The graduate-level nurse also has a share in the implementation process. They facilitate the usage of systems, community resources, and organizations to help in the implementation of the plan. The junior nurse is in support of the partnership of the APRNs with the other professionals. 

Theorist 

In this competency, Virginia Henderson’s approach upholds as it expounds on the communication with the patients and other parties ( Alligood, 2014 ). The phase that goes in concurrence with our competency is the plan and implementation step. In this section, the theory states that every plan that is set should be aimed at helping the individual to meet his or her needs through cooperation. The goals can be those of the team or the ones set between the nurse and the patient or their relatives. The people accorded the power of implementing the plan are the nurse, patient or family. 

Interviewee 

According to Kim, the competency is a paramount requirement in nursing as it defines the ease with which help will transit from the healthcare providers to the patient. The APRN is the connection. Kim clearly indicates that the healthcare system is a team effort that requires different inputs from various practitioners. She would not hesitate to call on a co-worker to offer a secondary opinion on the patient she is treating. The APRN is considering that way a mode of channeling all the problems and challenges they face to the other parties. Also, in this way, the nurses find a means of sharing their knowledge if someone needs the advice. One of the articles supporting the collaborative leadership in APN is known as the “The Role of Nursing Leadership in Integrating Clinical Nurse Specialists…” (2010). In this article, the authors describe the forms of roles the nurses take to ensure effective leadership. 

To support the interviewee’s words, another article which relates to this is titled “Caring for Dying Children: Assessing the Needs of the Pediatric Palliative Care Nurse” (2009). In this article, the care that a patient requires is tightly connected to the education the nurse offers for improved outcomes. The sole purpose of this article is to demonstrate the duty of advocacy to knowledge that the APRNs hold. They are the voice of the voiceless. This can be achieved through education. In a palliative setting, the APRN can act as the base of knowledge for both the staff nurses and the patients. They can assist the nurses with the sophisticated patient care procedures. The education of nurses can be done through meetings in evidence-based conferences. Through the conferences, the APRNs can teach them on the how to cope with the stresses. This article is a detailed one in the field of pediatrics. The guidance and policies that the APRNs formulate are aimed at providing information on issues such as pain management in the dying patients. 

Research 

The final competency is research. The APRNs are tasked with the duty of carrying out and integrating research results into their routine practice. As the advanced practice nurses have different functions, there are a good number of registered nurses who have accustomed themselves to being researchers. The nursing research methods have their roots in the nineteenth century when Florence Nightingale devised a way of differentiating the nursing practice from basic home medical care. She proved that it is possible to collect evidence empirically to make sure that what the patient requires is not just opinions but established facts. They have to use conceptual models to carry out the research. These model theories are grafted from other disciplines like biology, psychology, physics and sociology ( George, 2011 ). 

Quality of practice 

The basis of research is to improve the quality of practice. The nurses are mandated with contributing to such competency by documenting the practices and connecting them to the evidence garnered. The approach of improving quality in nursing is by carrying out several modalities. The activities include identification of aspects of practice that apply to quality monitoring. The methods also use the indicators that detect quality in the nursing practice. The indicators monitor effectiveness and safety of the nursing practice. Through research, the APRNs can collect the data that can be used to control quality in practice. After the collection, the analysis is done to find out the loopholes and opportunities for improvement in the nursing field. The final step is formulating recommendations and implementing the corrected research activities to make sure there is an enhanced quality of nursing practice. 

Theory 

Back to the theorist, Papleu stresses the collection of data as seen in the section under ongoing clinical care. The theory defines the nurse as an intelligent person who provides the required information that is needed to help in the understanding of a new situation or problem ( Alligood, 2014 ). However, the theory has a limitation in that there are several aspects in which a hypothesis for a detailed research can be developed. 

Interviewee 

In the interview, Kim explained the importance of research and evidence-based practice. She revealed that evidence-based practice is the mantle of the provision of optimum care for patients. The APRN is always looking for ways to improve on their knowledge. Kim does this by checking on new research and what currently works so that she can apply it to her patients. Due to the dynamic nature of healthcare, the nurse is always on the lookout for new information regarding best practices. This search for knowledge is crucial in getting to the edge in the industry, and it helps develop oneself as well as developing the sector as a whole, thus improving the quality of healthcare provision. The nurse should ensure they are not complacent but always seek improvement on the research and practices due to their changing nature. Dedication is all that is needed for quality improvement. 

To strengthen the argument of the interviewee, a supportive document of choice is “Advanced Practice Nurses Help Meet Nursing Research Needs” (2009). This article uses information on the works of Maureen Cavanagh. In the field of research, the nurse is tasked with the duty of taking part in healthcare by using technology, new knowledge, and improvements. The article suggests the different roles in which a nurse can be helpful in advancing the practice through research. One of them is through mentorship. The article suggests that Cavanagh used her time to mentor the research council of the hospital. This was done through achieving stepwise sharing of her research-based projects with them. She developed a timeline, demographic tools, checked the data, carried out the data analysis, and displayed the results. Through this, the APRNs were able to help nurses at a moment’s notice. The APRNs still carry out the leadership skills as discussed in the collaboration part. Other forms in which the APNs add to research is by showcasing research and seeing the success through outcomes. 

Competencies and Future 

The discussed competencies are crucial for the future of APRNs. The support for this is found in the Master’s Essentials publication (AACN, 2011). Ethical guidelines help in shaping the professionalism of the nurse. The consistency in demonstrating this value with other professionals to achieve favorable outcomes makes them grow in the field of nursing. For a successful outcome, the APRN has to incorporate several principles including excellence, caring, respect, accountability, altruism, and ethics. Ethics underlies the core values of the Masters-prepared nurse. The rationality with which they make their decisions would depend on the ethical decisions. Through this, the APRN would improve the quality of healthcare because they would be guided by reason and evidence-based practices to carry out the selection of decent alternatives. Integrity would, therefore, be at the root of the professional’s career. 

They would act by the principles and codes that govern the conduct of nurses. As the healthcare system is changing, nurses have to be on par with the changes, and thus they have to prepare through the competencies properly (AACN, 2011). This would give them leverage to carry out their duties properly. The patients are advocated for by the policies that govern how they are treated. Nursing comprehends and coordinates the significance of current life conditions, gives direction and consolation to roll out improvements. Thus in future, the APRN practice will strengthen the ties that help improve healthcare. 

In the master's plan programs, the APRN develops the ability to analyze the systems and functions to bring out a culture with justice to the patients and the profession. In such an environment, the personnel would feel comfortable when revealing errors, theirs included, while they maintain accountability in their respective fields. The ethical decision-making process would improve the patient quality. The knowledge of both the benefits and risks of the outcome are essential for benchmarking. Changes in medical care provision with the presentation of Medicare's rundown of "never events" and the legislative push for more integrity and transparency on quality outcomes require APRNs to have the capacity to decide whether the results of standards of practice, execution, and, capability have been met and maintained. 

In conclusion, the advanced practice registered nurses have roles more than just the known care. As the number of the nurses has increased drastically, there is an increased competency level in the field prompting every nurse to be at the forefront of healthcare provision. It is possible to be competent by first understanding the basis of nursing at the academic or graduate level. Hence, the information gathered can be applied to the practice to improve the outcomes of patients. The future of the nursing practice also depends on the competencies. 

References 

Alligood, M. R. (2014).    Nursing theorists and their work . Elsevier Health Sciences. 

American Association of Colleges of Nursing. (2014). the essentials of master’s education in nursing March 21, 2011. 

American Nurses Association. (2001).    Code of ethics for nurses with interpretive statements . Nursesbooks. org. 

American Nurses Association. (2010).    Nursing Scope and standards of practice . Nurses books. org. 

Carter, N., Martin-Misener, R., Kilpatrick, K., Kaasalainen, S., Donald, F., Bryant-Lukosius, D., & DiCenso, A. (2010). The role of nursing leadership in integrating clinical nurse specialists and nurse practitioners in healthcare delivery in Canada.  Nursing Leadership ,  23 , 167-185. 

D'antonio, P., Beeber, L., Sills, G., & Naegle, M. (2014). The future in the past: Hildegard Peplau and interpersonal relations in nursing.    Nursing inquiry ,    21 (4), 311-317. 

George, J. B. (2011).    Nursing Theories: The Base for Professional Nursing Practice, 6/e . Pearson Education India. 

Hamric, A. B., Hanson, C. M., Tracy, M. F., & O'Grady, E. T. (2013).    Advanced practice nursing: An integrative approach . Elsevier Health Sciences. 

Kearney, G. & Penque, S. (2012). Ethics of Everyday Decision Making. Nursing Management, 19(1), 32 – 36. 

Morgan, D. (2009). Caring for dying children: assessing the needs of the pediatric palliative care nurse. Pediatric nursing, 35(2), 86. 

HealthLeaders Media Staff,. (2009). Advanced Practice Nurses Help Meet Nursing Research Needs. Health Leaders Media. Retrieved 6 April 2017, from http://Advanced Practice Nurses Help Meet Nursing Research Needs