Elizabeth Ho NUS APN Role Assignment

Yr 05/06 Cohort
Philosophy of Nursing

Nursing is both a science and an art. An evolving science which requires a strong
education foundation, built on strong knowledge and evidence of research works.
An art which demands a continuous search for innovative ways to understand
human beings and create a caring relationship with people from all walks of life.

Persons are viewed as unique individuals, beautiful in each own ways. Each
person is also viewed as a functional individual with specific social roles that hold
meaning to him/ her. Persons’ behaviors are influenced by cognitive, spiritual,
psychosocial, cultural, contextual and biological dimensions of the individual.
Persons’ responses towards health are the focus of nursing practice, research,
education and administration. The concept of person extends beyond the
individual to the families and communities.

Health is a state of balance an individual achieves to allow him/her to function

effectively in his/her world. It is a complex state of balance between the aspects
of biological, psychological, spiritual and sociological functioning. Illness will thus
be viewed as a disruption in health, causing an unbalance of the different aspect
thus preventing effective functioning.

Environment is viewed as an important influence to Person’s behavior towards

health. Environment can be a stressful stimulus in Singapore’s fast paced
culture. However, environment can also be a nurturing stimulus towards a Person
with illness from supportive healthcare professionals, and understanding family
members.
“A Nurse Practitioner/Advanced Practice Nurse is a registered nurse who has
acquired the expert knowledge base, complex decision-making skills and clinical
competencies for expanded practice, the characteristics of which are shaped by
the context and/or country in which s/he is credentialed to practice” (International
Council of Nursing, 2003).

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Elizabeth Ho NUS APN Role Assignment
Yr 05/06 Cohort

Nursing practice for the Advanced Practice Nurse (APN) is a continuous path of
learning through practice. A higher level of nursing practice is demonstrated in
every clinical decisions and possible situations. This comes from the choice to
make a conscious effort synergizing the concepts of persons, health, nursing and
environment together to make a clinical nursing decision based on strong clinical
knowledge. Nursing practice for APN will serve as a stimulus for learning and
individual self-growth through constant reflection and critical analysis of own
thoughts and actions.

Nursing is viewed as an academy of Life, where lessons are taught to me from

each clinical encounter. Lessons of hope, death, strength, fear, respect and love,
etc are taught by individuals from all walks of life. Nursing is a profession which
has not only brought me into a world of healing science but also the art of living
and loving.

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Elizabeth Ho NUS APN Role Assignment
Yr 05/06 Cohort
Proposed Roles of APN
These proposed roles of the Advanced Practice Nurse are for Singapore primary
community care setting. In Singapore, primary community care is divided mainly
into 2 sectors, the private sectors and the government related clinics known as
polyclinics. These polyclinics deal mainly with primary care which involve (1)
children and women health and (2) adult health which includes treating acute
illnesses and managing chronic diseases. In the polyclinics, nurse clinicians who
are specially trained in managing patients with chronic diseases specializes in
disease management are known as care managers. The following proposed
roles discussed will be specific for the Advanced Practice Nurse in care
management. In Singapore, the title Case Manager is reserved for registered
nurses involving in disease management within the hospital and the title Care
Manager is reserved for registered nurses involving in disease management in
the primary and community settings.

Expert Clinical Care Manager

The characteristics of the patient population served by this APN include adult
patients with the following chronic diseases:
• Diabetes Mellitus (mainly Type 2)
• Hyperlipidemia/ hypercholestremia
• Hypertension
• Heart Failure
• Stroke
• Asthma
• Chronic Obstructive Pulmonary Diseases

The main component for the role of expert clinical care manager is clinical
excellence. APN is to clinically manage patients with chronic diseases within the
organization. She works collaboratively with the physician in charge in the clinical
management of the patient. Health promotion and health education remains the

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Elizabeth Ho NUS APN Role Assignment
Yr 05/06 Cohort
main component of her care towards her patients. Care management of the
patients with chronic diseases include: changing and promoting health behaviors
through health education and counseling strategies, involving the family in the
care of the patient and teaching skills to empower patients in self-management.
Coordinating services among care sites and multiple providers is also a main
component of care managing.

The role of the APN as an expert clinical care manager in managing patients with
chronic diseases besides setting the standard of nursing care is to incorporate
advanced nursing skills in the duty of care. The advanced nursing skills include
thorough health assessment, physical examinations and the ability to furnish
medications. The advanced skills provided can also benefit the patients in terms
of reducing clinic waiting time and costs of healthcare.

Her roles towards her patients include sub-roles of being a nurse, a care
manager, an educator, a friend and an advocator. Her role towards caring for her
patients extends to include the family into the plan of care. Patient focus is the
center of her nursing care. An APN views each individual patient as a unique
individual, with a delicate balance of biological, psychological, spiritual and
sociological dimensions, and individualizes her plan of clinical nursing decisions
for each patient encounter.
The care that is delivered by the APN is been through a careful conscious
thought process using critical thinking skills. Formulation of accurate and
appropriate differential diagnoses in clinical encounters, recognizing important
risk factors contribution to diseases, identifying early indicators of problem are
some of the skills needed to provide a timely preventive action for the patients.
These skills require not only a strong clinical medical as well as nursing
knowledge, but also a diligent and “suspicion” attitude towards ill-defined
symptoms that might be presented. An APN’s care decision also requires a high
level of cultural sensitivity and awareness of ethical dilemmas.

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Elizabeth Ho NUS APN Role Assignment
Yr 05/06 Cohort
Though there are studies that measure the effectiveness of case management in
the clinics, there is no evidence of effectiveness of the distinguished features
between APN Case Manager and Nurse Case Manager in clinic disease
management till date (Mahn and Zazworsky, 2000). The job descriptions of the
nurse practitioners and the patient population in the study by Mundinger et al
(2000) are the same as the proposed clinical role in chronic disease
management. The results of the study showed that the outcomes are comparable
to the primary care physicians. Also a study by Litaker et al (2003) showed that a
new chronic disease management program involving a nurse practitioner-
physician team model of care significantly reduced 0.7% HbA1C level and 6%
increase in HDL levels. The subjects in the new model of care also showed
improved satisfaction in the care and health-related quality of life.

Collaborator, Consultant and Leader

The role of being an expert collaborator requires the following characteristics:
collegiality, communication (good interpersonal skills), goal sharing (common
purpose), task interdependence, clinical competence and a sense of humor
(Hanson, Spross and Carr, 2000). The role as an expert collaborator is important,
as an APN needs to influence and be a change agent in improving or maintaining
the standards of nursing at a broader level.

As a recognized expert clinical care manager, she functions as a consultant for

the nursing personnel in consult of issues relating to clinical management of
patients with chronic diseases. She also serves as a consultant for other
healthcare providers in consult of nursing management issues and holistic care
management issues of the patients. She being a consultant requires the
fundamental basis of a continuous learning attitude from clinical experiences and
evidenced based studies. A consciousness to base her decisions on concepts
and theories and constant reflection on her personal clinical encounters also help
in developing her to be an all rounded consultant.

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Elizabeth Ho NUS APN Role Assignment
Yr 05/06 Cohort
An APN functions as a leader in disease management programs and health
promotion services. Being an effective collaborator will only enhance her
leadership skills in being a effective change agent when it comes to develop and
implement care guidelines, protocols, care management pathways or decision
algorithms. APN’s involvement in direct clinical care benefit her role as a leader
in clinical quality improvement committee, as she is constantly exposed to
critically analyzed care delivery systems for costly inconveniences and
inefficiencies that can “threaten” quality care. Below are person attributes for an
effective APN leader (Hanson and Malone, 2000, p. 288):
• Vision, coupled with the ability to set priorities
• Good sense of timing
• Self confident, assertive and willingness to take risks
• Expert communication skills
• Boundary management
• Respect for cultural diversity
• Balance in personal and professional life
• Willingness to collaborate, change and negotiate, fail and begin again.

Researcher
The role of APN as a researcher used to focus on conducting research. Currently
the focus is on the following: interpreting research findings, utilizing research in
clinical settings and promoting the usage of evidenced based practice. To carry
this role out effectively, the APN has to reach a certain level of research
competency. Research competencies include (1) interpretation and use of
research in practice (2) evaluation of practice and (3) participation in
collaborative research (McGuire and Harwood, 2000). The APN ultimately is
expected to perform at an advanced level of (1) developing programmatic and/or
departmental research utilization process (2) identifying and/or developing
practice specific outcome indicator criteria and finally (3) leading and conducting
of evaluation studies. The focus of all these research studies and research

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Elizabeth Ho NUS APN Role Assignment
Yr 05/06 Cohort
utilization will be on disease care management, health promotion, health
education, and counseling strategies.

Educator/ Mentor
An APN as a clinical expert, collaborator, leader, consultant and researcher, is
the best or rather the most appropriate person to be the role model of the nursing
in the organization. I will be the first APN intern in Singapore community and
primary nursing profession. It is definitely important that the knowledge I have
had learnt is shared and continued. Encouraging nurses to take on the challenge
to join me as a team of APNs, personal mentoring is essential at the beginning to
help potential and passionate nurses in disease management.

Diagram of APN Proposed Roles

(5%)
COLLABORATOR Administrator
and LEADER COLLABORATOR
(always) and LEADER
(always)
CONSULTANT and
MENTOR (10%)

RESEARCHER (15%)

EXPERT CLINICAL CARE MANAGER (75%)

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Elizabeth Ho NUS APN Role Assignment
Yr 05/06 Cohort
Goals of Service
Clinical Goals
• Achieve organization’s targeted medical outcomes (e.g. HbA1C < 7%,
HDL >1mmol/L etc.).
• Increase patient knowledge of disease process and disease self
management.
• Increase patient compliance with medications.
• Increase patient compliance with health promoting behaviors (e.g. proper
diet intake, increase exercise activities, smoking cessation, weight
reduction, etc.).
• Increase patient compliance with disease monitoring behaviors (e.g. blood
sugar monitoring, weight taking for CHF patients, blood pressure
monitoring, etc.)
• Achieve 100% diseases complication screening attendance (e.g. diabetic
retinopathy, diabetic foot screening, urinary microalbumin screening, etc.)
• Decrease occurrence or delay secondary complications of chronic
diseases.
• Improve patient quality of health (e.g. evidence of increase symptoms
control etc.)

Organization Goals
• Impact patient satisfaction surveys
• Reduce clinic waiting time
• Improve nursing knowledge and skills
• Impact clinical practice through promoting utilization of evidence based
practice.
• Increase nursing involvement in evidenced based activities.
• Reduce clinic resource utilization costs

<Curriculum Vitae and Organization APN Job Description

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Elizabeth Ho NUS APN Role Assignment
Yr 05/06 Cohort
are left out intentionally>
References

Hanson, C.M. and Malone, B.L. (2000). Leadership: empowerment, change

agency, and activism. In A.B. Hamric, J.A. Spross and C.M. Hanson (Eds),
Advanced nursing practice – an integrative approach, 2nd ed., (pp. 279 – 313).
Philadelphia: W.B. Saunders Company.

Hanson, C.M., Spross, J.A. and Carr, D.B. (2000). Collaboration. In A.B. Hamric,
J.A. Spross and C.M. Hanson (Eds), Advanced nursing practice – an integrative
approach, 2nd ed., (pp. 315 – 347). Philadelphia: W.B. Saunders Company.

International Council of Nursing (2003). Nurse practitioner/ advanced practice

network – frequently asked questions. Retrieved 24 October 2005 from
http://www.aanp.org/INP%20APN%20Network/FAQ/FAQ.asp

Litaker, D., Mion, L.C., Planavsky, L., Kippes, C., Mehta, N. and Frolkis, J.
(2003). Physician-nurse practitioner teams in chronic disease management: the
impact on costs, clinical effectiveness, and patients’ perception of care. Journal
of Interprofessional Care, 17(3), 223 – 237.

Mahn, V.A. and Zazworsky, D.J. (2000). The advanced practice nurse case
manager. In A.B. Hamric, J.A. Spross and C.M. Hanson (Eds), Advanced nursing
practice – an integrative approach, 2nd ed., (pp. 549 – 606). Philadelphia: W.B.
Saunders Company.

McGuire D.B. and Harwood, K.V. (2000). Research. In A.B. Hamric, J.A. Spross
and C.M. Hanson (Eds), Advanced nursing practice – an integrative approach,
2nd ed., (pp. 245 – 278). Philadelphia: W.B. Saunders Company.

Mundiner, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W., Cleary, P.D.,
Friedewald, W.T., Siu, A.L. and Shelanski, M.I. (2000). Primary care outcomes in
patients treated by nurse practitioners or physicians – a randomized trial. Journal
of American Medical Association, 283 (1), 59 – 68.

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