Christopher Manacci, MSN, ACNP The National Flight Nurse Academy

1. Mandatory Postgraduate Education: Advanced Nursing Education in the U.S. to Achieve High Quality of Nursing Practice Christopher Manacci, MSN, ACNP The National Flight Nurse Academy Frances Payne Bolton School of Nursing Case Western Reserve University

2. Objectives • Discuss the definition and educational requirements for becoming a Nurse Practitioner • Understand the differences between Nurse Practitioners and other providers. • Discuss the Acute Care Nurse Practitioner scope of practice

3. Historical Perspective • Late 1950’s-Ingles/ Stead • 1960-CNS • Mid 1960’s-NP’s • 1990 ACNP

4. Historical Perspective

5. Advanced Practice Nurses (APN) • Clinical Nurse Specialist • Certified Nurse Midwife • Certified Registered Nurse Anesthetist • Certified Nurse Practitioner

6. Clinical Nurse Specialist (CNS) • Registered nurses who: • Are master’s or doctoral prepared • Has become an expert clinician in a specialty area. • National certification is optional. • The functions of the CNS include clinician, leader, educator, and change agent to improve quality of care. Ohio Association of Advanced Practice Nurses, 2001

7. Certified Nurse Midwife (CNM) • Registered nurses who: • Have advanced training in Women’s health and midwifery. • Have a master’s degree and • Are nationally certified • The functions of the CNM include labor and delivery, prenatal, postpartum, newborn and routine gynecological care Ohio Association of Advanced Practice Nurses, 2001

8. Certified Nurse Anesthetist (CRNA) • Registered nurses who: • Have critical care training • Have a master’s degree in the delivery of anesthesia • Is nationally certified • CRNA functions include: administration of anesthetic agents/drugs for surgical, diagnostic procedures, and acute and chronic pain control Ohio Association of Advanced Practice Nurses, 2001

9. Certified Nurse Practitioner (CNP) • Registered nurses who: • Have a master’s degree or doctorate • Are nationally certified • Have advanced training and education in a specialized area of health care • CNP functions include: management of acute and chronic illnesses and disease prevention to a variety of age ranges in a variety of care settings Ohio Association of Advanced Practice Nurses, 2001

10. Certified Nurse PractitionerSpecialized Training • Neonatal nurse practitioner • Family nurse practitioner • Adult nurse practitioner • Acute Care Nurse Practitioner

11. Collaboration vs. Supervision • Nurse Practitioner • CNP works under his/her license • Responsibility rests on competence of individual • In collaborative arrangement, parties interact under mutual respect and authority.

12. Scope of Practice • Written guideline which defines responsibilities, accountabilities, and obligations of the specific CNP practice. • Limited by: • State legislation • Standard Care Agreement • Credentialing institution • Collaborating Physician Scope of Practice

13. Collaborating Physician • Physician licensed to practice medicine in Ohio who agrees to work with the Advanced Practice Nurse in order to mutually establish a procedure for patient care Ohio State Board of Nursing, 2001

14. Standard Care Arrangement • Systematic formal guide for planning and evaluating health care. State of Ohio Board of Nursing, 2001 • Written agreement between CNP and collaborating physician regarding guidelines of care and scope of practice.

15. Nurse Practitioner Roles

16. Scope of Practice: Clinical • Rounds • H&P’s/discharges • Physical exams • Evaluation/initiation of plan of care • diagnostics • pharmacotherapy • multidisciplinary collaboration

17. Scope of Practice: Clinical • Intubation • Line placement: central, Swan, arterial • Tube Thoracostomy • Wound Closure • Lumbar drain • Subdural drain removal • CSF specimens • C-spine clearance • Laceration repair • VP shunt reprogram

18. Scope of Practice: Research • Identify research opportunities • Collaborate to develop research study/design • Incorporate evidenced based practice • Identify quality/performance issues • Communicate specialty knowledge through professional publications

19. Scope of Practice: Education • Prioritize patient/family learning needs • Conduct formal/informal teaching • Provide teaching to other health care disciplines or community agencies as requested

20. Scope of Practice: Consultant & Independent Provider • Clinical resource and continuity • Quality assurance involvement • Multidisciplinary contact to assist with patient flow/resource utilization

22. ACNP Formulary Blood Plasma Expanders Parenteral vitamins Parenteral electrolytes Systemic alkalinizers Anticoagulants IV-Aminoglycosides NSAIDS-prescription

23. ENA and ASTNA Joint Statement The Emergency Nurses Association and the Air & Surface Transport Nurses Association state that staffing for “air medical services must minimally consist of at least one specially-trained registered professional nurse who has extensive experience and expertise in caring for critically ill and injured patients.” - 2005

24. ENA and ASTNA Joint Statement The specially-trained registered nurse brings the skills of independent judgment, analytical thinking, decision making, and management of highly technological equipment to patient care in the inter-facility transfer environment. - 2005

25. Current Goal in United States "Advance the practice of transport nursing and enhance the quality of patient care." -Air and Surface Transport Nurses Association

26. ENA and ASTNA Joint Statement If independent practitioners such as physicians and nurse practitioners are not included as members of the transport team during transfer of critically ill or injured patients, protocols must be in place and online medical direction made accessible so that the transport team can effectively respond to changes in patient status while functioning within their licensure standards. - 2005

27. American Association of Critical Care Nurses • Key elements of the acute care nurse practitioner : • Advanced clinical expertise • Development of differential diagnoses • Use of medical diagnostic reasoning to formulate the plan of care • Order and prescription of pharmacologic and non-pharmacologic therapy

28. American Association of Critical Care Nurses • Key elements of the acute care nurse practitioner : • Planning and management of patient care across the acute care continuum • Utilization and performance of invasive and non invasive interventions and procedures to promote physiologic stability or obtain diagnostic information • Surveillance of care • Accountability and authority for patient care outcomes across settings and boundaries

29. American Association of Critical Care Nurses • Key elements of the acute care nurse practitioner: • Evidence-and research-based clinical practice. • Monitor, evaluate and refine care in a continuous fashion • Accountability and authority for patient outcomes across settings • Clinical leadership • Managing and negotiating health care delivery systems, • Prevention and promotion of health • Provide care for awareness of the uniqueness of the individual.

30. Formal Preparation • Diagnostic reasoning • Advanced pharmacology • Invasive interventions • In keeping with the standards of the nursing profession • Introducing graduate level academic preparation for research and practice.

31. The challenge. The opportunity. • Provide the highest level of care to those most in need. • Create a mechanism for the distribution of research into clinical practice. • Advance science and Nursing. • Reduce cost by early intervention. • Educate those already trained and meet today’s societal needs.

32. Advanced Practice Model

33. The First UniversityDegree Programwith Subspecialty in Flight Nursing The Case Western Reserve University Frances Payne Bolton School of Nursing, in collaboration with our clinical partners: Louis Stokes Cleveland VA Medical Center

34. The flight nurse program leads to • Master of Science in Nursing (MSN) • Core advanced practice courses of assessment, physiology, pharmacology (10 semester hours) • Acute Care Nurse Practitioner clinical courses (14 semester hours) • Flight Nursing Seminar I and II (1 semester hour each) • Emergent Care of Children (2 semester hours) • Advanced Internship in Flight Nursing (2-5 semester hours)

35. Semester 1 (Fall)NURS 405Inquiry I (3)NURS 438Theoretical Foundations of Acute Care Nursing (4)NURS 453Physiologic Foundations of Adv Practice Nursing (4)NURS459Advanced Assessment (3)Semester 2 (Spring)NURS406Flight Nursing Seminar I (1)NURS415Inquiry II (4)NURS430Pharmacology and Therapeutics (3)NUNP 443Acute Health Problems of the Adult II (6) Plan of Study; Full-time study 48 semester hours

36. Semester 3 (Fall)NURS 404Emergent Care of the Child (2)NURS 407Flight Nursing Seminar II (1)NURS 443Professionalism in Advanced Practice (3)NURS 444HC Delivery, Legal and Ethical Issues in APN (3)NURS 503Inquiry III (2)NUNP 444Advanced Management of Acutely Ill Adults (4)Semester 4 (Spring)NURS 523Advanced Internship in Flight Nursing (1-5)

37. Synthetic Natural Environment • Headquartered at the Frances Payne Bolton School, the Flight Nurse Academy features environmental and human simulators for in-flight training.

38. Education in the fourth dimension Summer Camp

39. Multidisciplinary training Synthetic Natural Environments

40. Human Simulation

41. Advanced practice definitive intervention training Summer Camp

42. Flight Nursing Program “Taking critical care from the bedside to the roadside”