Advanced nursing Practice The aim of this essay is to demonstrate the development of existing skills in health assessment and critically utilise outcomes of advancing health assessment as the basis for expert decision making in stroke patient care. This assignment will compare four cases describing my journey through the development of health assessment skills using the medical model of assessment, ‘history, examination and diagnosis ‘and joining it with the nursing assessment to give a holistic approach.
The process of formulating a diagnosis will be explored, together with how advancing practice has enabled me to use collaborative working and expert decision making to improve the care of stroke patients. The identity of all patients and colleagues referred to in this essay will be anonymised as in accordance with the NMC Code of Conduct (2008) Stroke is now considered a medical emergency. The department of health now categorise potential stroke event as category A response similar to a Myocardial infarction (DH 2007a). Saver (2006) had estimated that for each minute untreated a person will lose 1. million neurones and 14 billion synapses. The acute care of a patient with a suspected stroke is dependent on rapid recognition of the symptoms and signs of the stroke, immediate CT scanning to exclude a haemorrhage and treatment where possible including potential thrombolysis to improve blood flow to the ischaemic brain. Once a diagnosis of a stroke has been made and haemorrhage excluded on CT and a symptom onset within four and half hours has been determined (ECASS 3) the patient may benefit from thrombolysis using alteplase.
In selected patients alteplase can considerably improve the outcome for patients in reducing long term disability (NINDS 1995). The increasing focus on acute and hyperacute stroke care together with development of stroke units and community stroke services mean that nursing staff with advanced health assessment skills play a vital role in the early rapid assessment and initiation of stroke care. Avoidance of complications and secondary prevention of further events is also vital. Throughout the assessment and reflection of each of the cases eferred to, the emphasis on time and good history taking is essential to clinical decision making/reasoning within the emergency setting where patients initially present. The cases were selected based on their presentation and underlying theme of a classic stroke presentation. Good assessment starts with good history taking from the patient from which a provisional diagnosis is then tested by examination and then diagnostic tests (Epstein et al 2004). History taking is commonly utilised as a key factor in formulating a diagnosis (Mursell 2010).
The success of the medical consultation depends not only on the assessor’s clinical knowledge and interview skills but also on the nature of the relationship that exists between AP and patient. For this reason, increasing emphasis is being placed on communication skills alongside history-taking in advanced health assessment training in order to enhance the AP-patient relationship and promote more effective consultations. How we communicate is just as important as what we say. The patient needs to feel sufficiently at ease to disclose any problems and express any concerns, and to know they have been understood by the assessor.
The patient also needs to reach a shared understanding with the practitioner about the nature of any illness and what is proposed to deal with it. As well as being more supportive for patients, good Communication skills make history-taking more accurate and effective. The ability to take an accurate medical history from a patient is one of the core clinical skills and an essential component of clinical competence. All four cases had a dysphasia therefore the efficacy of questioning a patient who presents with expressive or receptive dysphasia appeared to be limited.
It could be argued that this may hamper the use of clinical reasoning models such as the pathognomonic approach as in nevertheless the approach is supplemented with additional assessment and investigations involved in a complete neurological assessment and brain imaging to deduce a final diagnosis of a stroke. Kirk (2006) asserts that there are two parts to a history taking that of the presenting complaint and secondly the physical and mental background of the patient and their pre existing co-morbidities.
Traditionally nurses in the UK have not been involved in diagnosis (Reveley 2001) or if a nursing diagnosis is accepted it would be in an area nurses had the capacity to treat as defined in Mosby’s dictionary ( 2002 ). It is therefore unsurprising that the transition from a nurse who may happily diagnose a grade four pressure sore and implement the appropriate treatment to a advanced nurse practitioner diagnosing a stroke and implementing a treatment plan I felt quite overwhelming.
The RCN defines an advanced nurse practitioner as a registered nurse who has undertaken a specific course who makes professionally autonomous decisions, for which he or she is accountable, receives patients with undifferentiated and undiagnosed problems and makes an assessment of their health care needs, based on highly developed nursing knowledge and Skills, including skills not usually exercised by nurses, such as physical examination.
All of the four case reflections were able to be assessed in an orthodox manner by utilising a systemic approach of inspection, palpation, percussion and auscultation allowing me to gather a great deal of objective clinical information during the physical examination ( Bickley and Szilaghyi 2003 ) The RCN believes that the advanced nurse practitioner offers a complementary source of care to that offered by medical practitioners and other health care professionals.
Advanced nurse practitioners enhance the care that a team can deliver, and can also act as primary care providers in their own right. The National drive to reduce the hours worked by junior doctors has resulted in initiatives that have extended and expanded the traditional scope of the nurse within hospital based settings, for example, night nurse practitioners (DH, 2005) and pre-operative assessments.
The term nurse practitioner has increasingly been used to distinguish where these emerging roles have a higher degree of autonomy and application of expertise. Although the patient is under the overall care of a medical consultant, the advanced nurse practitioner provides the first point of contact, dealing with whatever problems the patient brings. The advanced nurse practitioner can proactively address any issues that could negatively impact on the patients’ pathway and length of stay.
The four cases appear similar but they layout a time line showing advancing skills as an advanced practitioner particularly in the area of expert assessment and influencing decision making. However it would appear that the client group who are more complex in their care planning are the patients as an AP that I would more likely to be asked to review therefore ways of appropriate assessment had to be developed these had to be patient centred utilising nursing skills underpinned by the advancing knowledge and practice.
Following my completion of the OSCE (case 8) I was feeling more confident and by becoming more confident in practice had undergone the process of development described by Benner (1984) moving from a novice through the continuum towards expert. The vision for me as an advanced practitioner would be to move the assessment process from the emergency department where the majority of the assessments occurred to the ward and follow the patients through the pathway with a consideration to having my own caseload of patients who were continuing on the rehabilitation pathway.
This would allow the correct pathway to be determined for the patient from acute to rehabilitation and allow referral to the appropriate health professionals which is one of the Chief Nursing Officers 10 key objectives together with improving end of life care as listed as one of the key objectives for the National Stroke Strategy (2007) Advanced nurse practitioners are highly educated and demonstrate high level clinical and cognitive ability, yet they are often thwarted by lack of formal recognition of their ability to practice safely and competently, and they are denied certain rights which other health professionals.
The lack of an explicit description of advanced Nurses and doctors identified a need for the advanced nurse Practitioner, but the blurring of boundaries between doctors and nurses can result in inter-professional conflict unless this is addressed prior to the introduction of such advanced practitioners. The development of nursing practice has blurred the boundaries between nursing and medicine (McGee, 2003 ? ). Bryant – Lukosius et al (2004) recommended a patient – centred, health focused, holistic nursing orientation to practice, otherwise the nursing components to advanced clinical practice will disappear.
The literature provides several definitions of nurses clinical reasoning. The three main components of the role of the advanced nurse practitioner are : dynamic practice, professional efficacy and clinical leadership according to Carryer et al. (2007) Advanced nurse practitioner practice is self-motivated because it involves the application of a high level of clinical knowledge and skills across a wide range of contexts. In my personal practice, I am responsible for a variety of tasks, including, but not limited to, doing physical assessments, sending patients for investigations and providing an individual care plan.
This means that I need to possess a range of clinical and interpersonal skills and to manage these in a dynamic manner in order to be able to deliver care that is holistic and effective (Manley, 1997). In the absence of my ability to liaise with other health professionals, for example through failures in my communication skills, could lead to failures in patient care (McCormack et al. , 1999). As Carryer et al. (2007) describes the good advanced nurse practitioner is an individual that is a clinical leader, “…with a readiness and an obligation to advocate for their client base and their profession”.
This, for me, is the essence of being a good advanced nurse practitioner. To have the confidence to be autonomous, to make decisions effectively and autonomously when appropriate but to realize when help is needed, as a way of building ones clinical skills and knowledge as reflected in cases1-4. The readiness to act as an advocate for patients is a fundamental part of being autonomous, I would argue, as, sometimes, patients feel more comfortable with nursing staff and will confide in them something that they feel uncomfortable about.
This information can then be used as part of patient advocacy to help to change the situation so the patient comes to feel more comfortable. This level of autonomy – to have the freedom to listen to patients and then to act as advocates for them – is important, I believe, in delivering quality patient care. Advanced nursing practitioners who do not take time to listen to their patients may make more time to be autonomous in terms of other aspects of their practice but I believe that these advanced nursing practitioners fail their patients.
A fully autonomous advanced nurse practitioner is, more likely to feel confident about their abilities and about the care plan that needs to be followed and, as such, will provide a better level of care delivery timeliness and appropriate care delivery mode, building trust with the patient in the process (Lloyd Jones, 2005). I know, from my own clinical practice and experience that patients feel safer if I am confident in the autonomous decisions I make.
In conclusion I feel that advanced nurse practitioners should value their contribution to patient care and strive to develop nursing practice and theory ( Cutts 1999 ) and it can be said that the I experienced a journey of professional development, by utilising reflection to grow as a clinical practitioner and enhance the holistic care of patients. As my role of the advanced nurse practitioner expands, this re-affirms the importance of inter-professional collaboration when seeking approval for role expansions in nursing, whilst fostering a new emphasis on shared working .
It is imperative that the advancing nurse takes on the knowledge that underpins good assessment and diagnosis but does not lose the fundamental caring art of nursing, thus enhancing the nursing role not merely replacing a doctor (Bald H 2006) The journey undertaken has been very positive and built on my nursing skills and knowledge to deliver a holistic assessment and diagnosis that embraces all aspects of advancing nursing practice. References Bald H (2006) Differential diagnosis in advanced nursing practice.
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