Family Nurse Practitioners: A Case Study
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Anticoagulation Management in Primary Care: Case Study for Nurse Practitioners
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Even in cases where no formal measures were taken to support horizontal exchanges Case 2 , the PHCNP maintained contacts with other PHCNPs in more or less informal ways, such as meeting outside work hours. The existence of this parallel network shows the need for this type of support. Another successful horizontal support practice was the dyadic integration of nurses in the healthcare settings. Although the relationship between the two nurses varied according to their years of experience senior—junior in Case 1 and junior—junior in Case 3 , the fact of there being two PHCNPs in one setting gave them the opportunity to create alliances, develop and share a vision of their role, validate ideas related to their clinical practice or their integration into the setting, and suggest, when needed, changes to make the most of advanced nursing practices.
It was so stressful in the beginning. Being at least two in the same clinic also presented advantages in terms of work efficiency and coverage during absences. Our analysis also showed that patient management was a challenge when more than three partner physicians were involved, especially in settings based on a joint patient management model. The consultative model Cases 1 and 2 was easier to manage and fostered collaborative relationships between MDs and PHCNPs, whereas the joint model Case 3 tended to lead more toward supervision-based relationships. Apart from the question of the number of physicians, most of the coordination mechanisms between physicians and PHCNPs seemed to be based on mutual adjustment and were modified over time. In all cases, the need for physician support was much higher in the first 6 months and diminished as the PHCNP developed greater confidence and expertise.
As the PHCNP developed complementary services Case 2 , relationships with the physician became increasingly consultative and less interdependent. Certain formal measures, such as narrowing the type of caseload selected Cases 2—3 and having a set consultation plan between PHCNP and physician Case 2 helped PHCNPs develop independence and fostered satisfying interprofessional consultations.
The need for formal mechanisms depended mostly on setting size and quality of communication between members. There was no uniform process common to all three cases to support the teams after the introduction of the PHCNPs. Team support was provided by different institutions and people inside and outside the team itself. In the smaller settings Cases 1 and 2 , integration processes seemed to work more smoothly, as logistical adjustments were simpler than in the larger setting and communication between members of the smaller teams was generally more fluid. The physicians in charge of the clinics also appeared to play an important role in team support.
They were more invested in dealing with day-to-day relationships among team members, while the nursing department managers adopted more of a counselling role. In general, the head physicians had, to a certain extent, developed their own mechanisms for supervising and integrating the PHCNPs into their clinics. With regard to systemic support, the nursing department was again the key player. The nursing department was also involved in advocacy and education to promote the administrative integration of additional PHCNPs in other institutions within the CSSS. Despite their involvement in such support activities, the Directors of Nursing had few formal opportunities to meet with colleagues from other CSSSs in their region, and some had built their own informal networks with other nursing departments.
According to the integration plan developed by the MSSS, systemic integration was to be supported by local and regional implementation committees. However, while our respondents saw the role of the nursing department as unequivocally central in systemic support practices, their opinions about the role and usefulness of these committees were generally mixed. Only one primary healthcare setting had established an official local implementation committee, and the three settings had variable experiences with the government-mandated regional committee.
As the actors were already in regular interaction with each other in the CSSS, and most decisions were taken outside of formal meetings, this additional committee was seen as not really necessary. A first observation to be made is that there does not seem to be a unique and straightforward process to integrate PHCNPs and support development of their practice in primary care settings. The three settings studied were examples of relatively successful integration, but all relied on very different implementation structures and practices. The major drawback of this high variability in local practices was that most issues were addressed in an ad hoc way, leading to overlaps and the involvement of many actors from different organizational levels.
This was especially true in larger settings, as it was more difficult to coordinate changes and adjustments on an informal basis, given the complexity of the structure and the large number of team members. The absence of standardized management structures and practices was less of a challenge in smaller contexts, where there was greater reliance on individual and informal coordination mechanisms. It should also be mentioned that, in all cases, despite the existence of formal coordination structures, many of the communication processes between PHCNPs, nursing departments, and the settings were, in practice, based on informal and personal relationships.
The contingency theory approach developed in the field of organization studies can be helpful in formalizing those observations. More specifically, from a contingency theory perspective, size matters. Structural arrangements that make sense in a large organization might make no sense at all in a small one [ 38 , 39 ]. The same logic applies to other parameters, such as environment complexity. Implementation processes whose evolution is difficult to predict and that are carried out in complex environments diffuse responsibilities and participation are ill-suited for standardized structures. Moreover, any implementation process is, by its very nature, evolving. Thus implementation structures and practice will have to adapt and evolve as well.
Even though one set of support structures and practices cannot benefit and be relevant to all settings equally, two general recommendations can still be formed in light of the successful support practices we observed in this study. The first relates to the role of the nursing department. Our findings on the centrality of the role played by the nursing department in integrating PHCNPs in primary care institutions are consistent with those of other studies on the topic [ 11 , 26 , 30 , 32 ].
The three levels of support approach, however, constitutes an additional tool to clarify the role of nursing departments and understand how it can be most productively enacted at each support level. It appears there is still room for improvement in that area, given the lack of legitimacy felt by the nursing department managers when intervening at the team level, for example. The second recommendation also relates to the role of nursing actors in support practices but, in this case, at the horizontal level. Moreover, in contexts where the number of nurse practitioners being integrated into primary care settings is meant to increase, being able to share successes and challenges with those who have already experienced the process becomes even more vital.
At a higher level, nursing administrators and managers also benefit from horizontal exchanges with other nursing departments in the region. Formalizing the time commitment and creating meeting opportunities could be useful to support this need for horizontal support. As other studies have found [ 11 , 17 , 21 , 31 , 36 , 41 ], managers trained in nursing seem better equipped than their non-nursing counterparts to conceptualize the integration process in terms of scope of practice and role redefinition, and this appears to be more productive than working from a narrower task-based perspective.
However, this general observation needs to be considered in the light of specific contexts. Our study makes two original contributions to the field. As we have argued, there are distinct needs and responsibilities at the clinical, team, and systemic levels. This brings us to the second contribution to the field, which is the observation that, as support practices for PHCNP integration involve a variety of actors from different backgrounds and structural positions, there is a need for strong but adaptive coordination structures.
A balance must be struck between relying on highly formalized statutory committees—which will likely be less adaptable—and counting exclusively on informal communication and personal involvement, whose effectiveness is unpredictable and unreliable. This is where contingency theory arguments—that there are no best organizational structures to produce strong but adaptive coordination—provide a useful conceptual framework. The best structure will be the one best fitted to the contingencies of a given organizational system. Cost effectiveness and outcomes of a nurse practitioner—paramedic—family physician model of care: the long and Brier Islands study.
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Concurrent chronic illness i. Normocytic anemia, with an MCV of 80—fL, correlates with anemia of chronic disease. Chronic blood loss is associated with iron deficiency anemia, a microcytic anemia. Deficiency in vitamin B12 results in the development of macrocytic anemia. Inadequate globin synthesis occurs in beta thalassemia, a microcytic anemia. The FNP is following up with a patient previously diagnosed with anemia who complains of a sore tongue and numbness and tingling of the hands and feet.
The case presentation is that of vitamin B12 deficiency. The FNP is following up with a young adult woman previously diagnosed with microcytic, hypochromic anemia. The FNP recognizes that it is important to rule out:. In young adult women, abnormal uterine bleeding is a common cause of iron deficiency anemia, a microcytic, hypochromic anemia. Inadequate intake of folic acid would result in macrocytic anemia.
Low carbohydrate diets still allow for adequate intake of iron from meats and green leafy vegetables. Acute infectious processes stimulate an increase in the production and release of mature neutrophils and mobilization of less mature neutrophils or bands. When interpreting findings in an individual with leukocytosis, the FNP recognizes that a "left shift" is represented by an increase in the proportion of:. The term "left shift" is almost always associated with neutrophils. The left shift means that the population of cells is shifted toward most immature cells, with an increased percentage of immature neutrophils i.
An elevated red cell distribution width RDW correlates with which of the following findings on the peripheral smear? Anisocytosis describes variance in RBC sizes that is common in anemia as new cells formed are larger macrocytic or smaller microcytic than the healthy cells which were formed prior to the underlying processes that resulted in anemia. This variance in sizes of circulating red blood sizes correlates with an increased RDW. Women of childbearing age should have an adequate intake of what micronutrient to decrease the risk of fetal neural tube defects? Folic acid deficiency in early pregnancy has been linked to the teratogenic effect of neural tube defects.
Pancytopenia a deficiency in all three cellular components of the blood is indicative of aplastic anemia. A bone marrow aspiration biopsy is needed to rule out myelodysplastic syndrome and metastatic tumor deposits. The hypoplastic bone marrow of aplastic anemia will have fatty replacement which is often accompanied by a relative increase in nonhematopoietic elements i. The presence of schistocytes on the peripheral smear of a patient with decreased platelets should raise the suspicion of:. Thrombotic thrombocytopenic purpua is a microangiopathic hemolytic anemia that is accompanied by systemic microvascular thrombosis that can impact any organ s within the body. Within this potentially fatal condition, RBCs within the circulation become severed as they come in contact with thrombi within the vessels.
The remaining fragmented cell is known as schistocyte. The FNP is educating an anemic patient about the procedure s for a Schilling test. The practitioner recognizes that a Schilling test involves:. The Schilling test is used to determine whether the body absorbs vitamin B12 normally. Patients undergoing testing receive two doses of vitamin B The first is an oral radioactive form; an intramuscular injection of non-radioactive vitamin B12 is administered one hour later. The patient then collects urine over the next 24 hours, and the specimen is evaluated to determine how much vitamin B12 is excreted in the urine.
What is the most likely diagnosis for a patient with the following CBC findings? The MCV of this patient with anemia reveals a normocytic anemia. Iron deficiency anemia is a microcytic anemia, while folic acid and vitamin B12 deficiencies result in the production of RBCs that are larger in size than normal cells, macrocytic anemia. The MCV of this patient with anemia reveals a microcytic anemia. Anemia of chronic disease is most commonly a normocytic anemia, while folic acid and vitamin B12 deficiencies result in the production of RBCs that are larger in size than normal cells, which is called macrocytic anemia.
Which diagnostic test could help identify whether the cause of anemia is hemolytic in nature? Standard blood tests for the workup of suspected hemolytic anemia include a CBC with peripheral smear, serum LDH, serum haptoglobin, and indirect bilirubin. Changes in the LDH and serum haptoglobin are the most sensitive of these tests. Within intravascular hemolysis, free hemoglobin is released into the circulation and quickly bound by haptoglobin; thus, circulating haptoglobin levels decline.
The lab index that has demonstrated reliability as an early marker of microcytic and macrocytic anemias is the:. Marked reticulocytosis results in transient changes to the RDW because the reticulocytes differ in size from the cells produced under healthy conditions. The FNP is seeing a patient who has been taking ferrous sulfate. Which statement by the patient demonstrates a need for additional education? Iron is best absorbed when taken on an empty stomach, but does have GI effects that limit tolerability i.
Ascorbic acid does enhance iron absorption in the GI tract. An older adult with ESRD who is undergoing hemodialysis is in the office for follow-up. The patient is on erythropoietin therapy, but has not been able to attain a hemoglobin level greater than 9. Patients undergoing hemodialysis are at risk for physical damage to the RBC membranes because it causes them to break down faster than normal. Drug-induced hemolytic anemia is linked to chemotherapy, quinine and antimalarial medications, levodopa, and anti-inflammatories, among others.
Hereditary or inherited hemolytic anemias including sickle cell anemia, thalassemia, G6PD deficiency, and hereditary spherocytosis and elliptocytosis most commonly have manifestations that begin earlier in the lifespan. Though these retail clinics could be used for positive purposes, there are a large number of issues for the government to address, including safety, quality, treatment of the uninsured, and time to time evaluation of nursing practitioner performances.
Despite these uncertainties. Their roles has expanded that in some states a nurse practitioner can work in a clinic stand-alone without an overseeing physician. Do all states offer these privileges to nurse practitioners some ask and the answer is no. Some states still have the requirement that nurse practitioners must be overseen. There are four types of Advanced Practice Nurse roles, the nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse-midwife.
The Family Nurse Practitioner is the advanced practice role that will be discussed. According to Hamric, Hanson, Tracy, and O 'Grady the primary care NP provides care for patients in diverse settings, including community-based settings such as private and public practices, acute, and long-term care settings across the. Starting out, I would research starting salaries in my region…. Houston, Texas. Then I would narrow my search down to family practice, or any other specialty area I may.