My personal philosophy of advanced practice nursing goes along with what my personal philosophy for nursing practice has been over the past 35 years. First do no harm and provide client centered care, goal oriented toward achieving and maintaining wellness. However in the early part of moving toward the goal of earning a doctor of nursing practice (DNP) degree, I have discovered that this program offers to prepare me and my colleagues to acquire an additional skill set to become an agent of change through research and clinical leadership. Accordingly, this educational process of transitioning from general nursing practice to advanced practice nursing doesn’t change the imperatives; it rather brings us to focus more on what our primary objectives need to be and places additional responsibility in our hands which brings us to rely heavily on the support of allied health care disciplines. Therefore, the purpose of this paper is to state the mission objectives for my future performance as an advance practice nurse with a Doctor of Nursing Practice (DNP) degree and present support for my philosophical approaches from the nursing, public health and medical literature.
First do no Harm
To “first do no harm” is inherent in all aspects of nursing as a discipline, science and practice profession. The idea of leaving a client worse off is unthinkable. “Informed caring for the well-being of others,” is one of the well-known definitions of nursing (Swanson 1993). Dr. Swanson’s “structure of caring” (P. 355) encompasses invoking all thought, speech and action of the nurse totally focused on the goal of enhancing the client’s well-being. The nurse must start with a caring attitude toward people in general and the client specifically; then learn about the client’s condition covering all aspects of being human (thought), convey the appropriate message to the client (speech), and then perform the necessary therapeutic procedures (action). Next, the nurse has to assess the outcome to determine if he/she has helped the client to achieve the goal of enhanced well-being.
On the other hand, we have learned over the last dozen years that health care delivery as a whole has itself become a leading cause of death in the United States (Institute of Medicine 1999). The institute of medicine (IOM) is a quasi-federal government agency that first called attention to the fact that health care delivery in the United States is unsafe when it published its book, “To Err is Human.” The editors identified the errors of health care personnel in general as those of omission and commission resulting in the failure to address treatable conditions and ending in common hands-on blunders that cause injury and death, respectively. There is also the failure to prevent nosocomial infections when hospital personnel forget to wash their hands between patients (Goldman, D. 2006).
There are other sources of data pointing to an indictment of the U.S. health care industry in its inability to maintain basic standards of patient safety. A pair of sociologists from the University of California at San Diego, conducted a retrospective study of reported prescription medication errors across the United States and found a 243% increase in the number of fatalities between 1983 and 1998 (from 2,876 to 9,856) (Phillips and Bredder 2002). In the area of trauma medicine, Gruen, R. L., Jurkovich, G. J., McIntyre, L. K., Foy, H. M. and Maier, R. V. identified error patterns that contribute to in-patient trauma deaths. These authors reviewed 2,594 charts of trauma patients who died after admission and found that 601 (23%) had died unexpectedly. Gruen, et al. attributed those deaths to a pattern of errors including faulty intubation, delay in treating abdominal/pelvic hemorrhage, delayed intervention for intrathoracic hemorrhage, failure to provide DVT prophylaxis and other errors of omission.
In the realm of nursing, Benner, P., Sheets, V., Uris, P., Malloch, K., Schwed, K. and Jamison, D. reviewed 21 case studies of nursing errors from the disciplinary files of 9 State Boards of Nursing and determined that there were 8 categories identified as follows: “1) lack of attentiveness; 2) lack of agency/fiduciary concern; 3) inappropriate nursing judgment; 4) medication errors; 5) failure to intervene on the patient’s behalf; 6) lack of prevention; 7) missed or mistaken md/healthcare provider’s orders; 8) documentation errors” (P. 512, Brenner, P. et al. 2002). In a similar vein, during my 28-year tenure as a legal nurse consultant I have reviewed well over 1,500 cases involving lawsuits against hospitals and individual nurses and I have found a comparable common theme and commonality of nursing errors which I reported in my previous book (Sharon 2003). Therefore, in view of the ongoing pandemic of injurious and fatal health care errors, I am compelled to begin with “first do no harm” in presenting my personal philosophy of advanced practice nursing in that the new role of DPN’s bringing forth evidenced-based practice (EBP) is vital for improving outcomes in patient care and reducing the sometimes catastrophic and fatal consequences of misapplied health care services.
At first glance, the catch-phrase, “client-centered care” seems superfluous. Where else would the nurse’s care be focused other than the client? However, when the advanced practice nursing (APN) provider makes a choice to tailor a program of care to incorporate the client’s cultural world view rather than simply offering the same treatment plan to everyone who has the same or similar diagnosis, the term takes on a new meaning. Josepha Campinha-Bacote, PhD, R.N., introduced her model of “cultural competence” to address rapid increases in cultural diversity through immigration from all parts of the world (Campinha-Bacote, J. 1999). Dr. Campinha-Bacote introduced a tool in the form of a self-test for nurses to measure their ability to develop knowledge of different cultures and incorporate such cognition in providing culturally sensitive care. She concluded that cultural competence is an essential component of effective health care.
My personal philosophy of mobilizing thought, speech and action in advanced practice nursing to enhance the clients’ well-being is consistent with the work of Drs. Sharon A. Cumbie, Virginia M. Conley and Mary E. Burman who brought about a practical application of the philosophical construct of caring into the management of chronic disease (Cumbie, S.A., et al. 2004). These authors developed the model for promoting access management. They noted that the medical model was acute disease-oriented and therefore left chronically ill patients wanting for improved management and prevention of complications. They defined chronic illness as any protracted loss of comfort and well-being taking place for months to decades. It was apparent to these nurse practitioners that they were uniquely qualified to provide flexible empathic care to chronic illness sufferers because of their philosophical orientation toward client-centered care. Although APN’s overlap with physicians in many of their tasks, Dr. Cumbie and her colleagues approach their clients holistically rather than biologically. The primary focus is the person and not the disease and the client is a major part of the health care decision-making process.
Value Added Skills of the DNP Graduate
Any personal philosophy of advanced practice nursing can’t be complete without examining the value added skills of the DNP graduate. The advance role of designing and implementing plans of treatment, notwithstanding the collaborative agreement with a physician required in most states, empowers the APN to provide total care within the nursing paradigm. In their proposal to standardize the education of DNP’s, Drs. M.O. Mundinger, S.S. Cook, E.R. Lenz, K. Piacentini, C. Auerhahn, and Ms. J. Smith proposed that the DNP graduate would bring a higher level skill set in bringing the nursing components of care into the primary care setting, which includes health education, illness prevention interventions, greater access to community resources and wellness promotion. However, these authors also pointed out that there has been confusion among lay persons and allied professionals as to what the APN can contribute to health care. This was the most compelling reason for establishing a terminal degree that would have the same professional level as other practice doctorates like MD, DDS, DPM, and the like (Mundinger, M.O. et al. 2004) and for all of the programs to be standardized as to scope and content.
The Question of Ethics
The question of ethics revolving around the evolution of the DNP as the standard terminal practice doctorate for the nursing profession as a whole looms large in my personal philosophy of APN. Ethical considerations tie all of the components together regarding first do no harm, client-centered care and value added skills of the DNP. One would think that adopting a strong sense of ethical values would be inherent in the educational process; yet Drs. M.C. Silva and R. Ludwick raise questions about the ethics of the fast growing trend of developing DNP programs. These authors state that they based their debate on “four ethical principles associated with the DNP: (a) social responsibility, (b) respect for persons, (c) do no harm, and (d) justice as fairness.” They claim that those values are not appropriately addressed by an organizational body that represents a consensus among practicing DNP’s and that the DNP programs may not hold up under scrutiny by the ethical standards set forth in the ANA’s Nursing’s Social Policy Statement of 2003 (Silva, M.C. and Ludwick, R. 2005). Although, the foundational basis for these contentions are rather vague in their unfounded attack against the DPN degree, this voice of opposition serves as a reminder that our new leadership branch of nursing must have some form of organizational consensus to serve as an ethical guide that is consistent with but not necessarily subservient to the autocratic principles of the American Nurses Association (ANA).
In conclusion, my personal philosophy of advanced nursing practice is fourfold. First do no harm. As DNP graduates, we will need to become aware of the unsafe manner in which the health care industry conducts itself and formulate a basic standard for patient safety in all practice areas. Second, my philosophy involves client-centered care driven by all of the needs of the individual and not by the presence or absence of disease. The medical model focuses on the biological being while in the nursing model the biological factors are merely a means to an end. Thirdly, the value added skills of the DNP are absolute in that the DNP graduate has a social responsibility to be an agent for change in the way we deliver health care services. However, such change requires the solicitation of support from allied professionals such as physicians who may perceive DNP’s as a competitive threat. Therefore, the DNP’s program needs to include preparation in interpersonal dynamics to equip the graduate with the social skills needed to transform negative attitudes of refutation and wariness to those of acceptance and trust. Finally, the community of DNP graduates needs to complete the process of forming a professional organization to establish a consensus for maintaining standards for patient safety and ethics which seem to be inherent in the well-established DNP program principle of evidenced-based practice.
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