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احلاج
Ministry of Health
FAMILY NURSE PRACTITIONER
overview
CLINICAL PRACTICE GUIDELINE
General Department of Nursing, 2021
Ministry of Health
MOH Agency for Therapeutic Services
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املاجيل
Ministry of Health
Contents
Acknowledgements....4
Glossary Index 6
Chapter One 10
Introduction 10
Rationale....13
Objectives and outcome....13
Advanced Nurse Practitioner Scope of Practice statement....14
Family Nurse Practitioner Scope of Practice statement....14
Advanced Family Nurse Practitioner Standards of Practice....15
Clinical domain: Direct comprehensive care and management of individuals/families through nursing process .. 16
Development of a comprehensive plan of care 17
The Importance of Family Nurse Practitioners....21
Barriers to Incorporating APRNs into the Saudi Healthcare System....21
Characteristics of Family Nursing Practitioners (FNP) 21
Job description....21
Qualifications 22
FNP roles and responsibilities....23
Models of Nurse Practitioner....23
Steps for Using Method/Tool....32
Proposed phases and timeline....38
Chapter Two 24
Definitions 24
Ethical Aspects 24
Legal Aspects 25
Conclusion 26
References....27
Appendics 30
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Ministry of Health
<table><tr><td>Title:</td><td></td></tr><tr><td>Applied to:</td><td>This clinical guideline is directed to All family nurse practitioner working at all healthcare settings</td></tr><tr><td>Replaces(if appropriate):</td><td>N/A</td></tr><tr><td colspan="2">Recommended References:American Nurses Association. (2021). Nursing: Scope and standards of practice (4th edition). American Nurses Association.International Nursing Council. (2020). INC guidelines on advanced practice nursing. Geneva, Switzerland: ICN.Practice Guidelines For Family Nurse Practitioners (4th edition). Karen Fenstermacher,</td></tr><tr><td>Approved by:</td><td>Mohammed G. Alghamdi, RN, PhD, NE-BCGeneral Director, General Department of Nursing AffairsDeputyship of Therapeutic Services,Ministry of Health, Saudi Arabia</td></tr><tr><td>Version</td><td>1.02</td></tr><tr><td>Issue Date:</td><td>23 December, 2021</td></tr></table>
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Ministry of Health
Acknowledgement
This clinical guideline reflects the work of dedicated individuals who worked intensively over the past two months whose commitment and generous contributions made this document possible. The General Department of Nursing would like to extend its sincere thanks and appreciation to the scientific committee for family nurse practitioner clinical practice guideline for their diligent work and important contributions in formulating and refining these clinical recommendations. Finally, we wish to recognize the leadership and foresight of the Deputy Minister of Therapeutic Services, Dr Tareef Alaama in recognizing the importance of this work and his continuous support for the completion of this project.
Workgroup Members
Fatimah S. Alotaibi, RN, MSN, BSN Supervisor of Performance Department, General Directorate of Nursing. MoH Agency for Therapeutic services, Ministry of Health, Riyadh.
Reem M. Alhumaidan, RN, MSN, BSN Supervisor of Performance Department, General Directorate of Nursing. MoH Agency for Therapeutic services, Ministry of Health, Riyadh.
Iman M. Alshammry, RN, MSN, BSN Director of Performance Department, General Directorate of Nursing. MoH Agency for Therapeutic services, Ministry of Health, Riyadh.
Sanaa Salem Alanazi, RN, MSN, BSN Supervisor of the Nursing Rights Unit in the Nursing Human Resources Department General Directorate of Nursing. MoH Agency for Therapeutic services, Ministry of Health, Riyadh.
Abdulrhman Albukhodaah, RN, MSN, BSN Supervisor of Performance Department, General Directorate of Nursing. MoH Agency for Therapeutic services, Ministry of Health, Riyadh.
Dina Alsamti, RN, BSN Supervisor of Performance Department, General Directorate of Nursing. MoH Agency for Therapeutic services, Ministry of Health, Riyadh.
Jehan Aljumeah, RN, BSN Director of Nursing Internal Communication Department, General Directorate of Nursing. MoH Agency for Therapeutic services, Ministry of Health, Riyadh.
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Ministry of Health
External Reviewers
Dr. Monir Almotary, RN, PHD, AGACNP-BC
Assistant Professor of Nursing at the College of Nursing at King Saud University.
Dr. Hamza Moafa, RN, PhD, FNP
Assistant Professor of Nursing at the College of Nursing at King Saud University
Please address correspondence to:
Fatimah S. Alotaibi
Nursing Performance Development Supervisor
General Department of Nursing
Digital City, PJVP+2M
An Nakheel, Riyadh 12382, Saudi Arabia
Phone: +966112125555
Email: nursing@moh.gov.sa
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اصيلات
Ministry of Health
Glossary Index
<table><tr><td>APN</td><td>Advanced Practice Nurse</td></tr><tr><td>CNP</td><td>Certified Nurse Practitioner</td></tr><tr><td>FNP</td><td>Family Nurse Practitioner</td></tr><tr><td>GNA</td><td>General Nursing Administration</td></tr><tr><td>NP</td><td>Nurse Practitioner</td></tr><tr><td>SCHS</td><td>Saudi Commission Health Specialist</td></tr><tr><td>SNA</td><td>Saudi Nursing Association</td></tr></table>
ARN/CNP/Advanced Practice Registered Nurse – A registered nurse who has completed an accredited graduate-level education programme to prepare the nurse for special licensure and practice for one of the four recognised APRN roles: certified registered nurse anaesthetist, certified nurse-midwife, clinical nurse specialist, or certified nurse practitioner (American Nurses Association [ANA], 2021, p.109).
Graduate-level Prepared Registered Nurse – A registered nurse prepared at the master’s or doctoral educational level; has advanced knowledge, skills, abilities, and judgement; functions at an advanced level, as designated by elements of the nurse’s role; and is not required to have additional regulatory oversight (ANA, 2021, p.112).
Advanced practice – where nurses incorporate professional leadership, education, research, and support of systems into their practice. Their practice includes relevant expertise, critical thinking, complex decision-making, and autonomous practice, and is effective and safe. Advanced practice nurses work within a generalist or specialist context and they are responsible for and accountable in managing people who have complex healthcare requirements.
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Ministry of Health
Core competencies – a standard set of performance domains and their corresponding behavioural standards, which a nurse is required to demonstrate.
Competence – performing successfully at an expected level (ANA, 2014).
Competency – an expected level of performance that integrates knowledge, skills, abilities, and judgement (ANA, 2014).
Competent – being able to demonstrate the necessary ability, knowledge, skills, and attitudes across the domains of competencies at a standard that is determined to be appropriate for the level at which a nurse is being assessed.
Standards of Professional Performance – a competent level of behaviour in the professional role.
Specialists – those who elect to focus their professional practice on their identified specialty.
Nursing Specialty – encompasses a specified area of 21 discrete areas of study, research, and practice as defined and recognised by the profession (ANA, 2017).
Specialty Nursing Standards of Practice – include specialty nursing standards of practice and professional performance modelled on the SCHS Standards of Professional Nursing Practice.
Standards of Practice – describe a competent level of nursing practice demonstrated by the critical thinking model known as the nursing process. These standards encompass significant actions taken by registered nurses and form the foundation of nurses’ decision making and action (ANA, 2021, p.114).
Standards of Professional Nursing Practice – authoritative statements of the actions and behaviours that all registered nurses, regardless of role, population, specialty, and setting, are expected to competently perform (ANA, 2021, p.114).
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Ministry of Health
Standards of Professional Performance – describe a competent level of behaviour in the professional role (ANA, 2021, p.114).
NSPS – Nursing’s Social Policy Statement is a document that articulates the parameters of the relationship between the profession of nursing and society (ANA, 2015).
Certifying Bodies – organisations that develop and administer certification programmes that may include examinations and other mechanisms, such as a portfolio review. The Saudi Commission Health Specialist Nursing Credentialing Centre is an example of a certifying body that confers a delineated credential for a designated time period.
Accrediting Organisations – specialised accrediting agencies accredit specific educational programmes that prepare students for entry into a profession, such as nursing. These organisations establish operating standards for educational or professional institutions and programmes, determine the extent to which the standards are met, and publicly announce their findings.
Nursing Process – a critical thinking model used by nurses that is represented as the integration of the singular, concurrent, iterative actions of these six components: assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation (ANA, 2021, p.113).
Domain – an organised cluster of competencies in nursing practice.
Performance criteria – descriptive statements that can be assessed and that reflect the intent of a competency in terms of performance, behaviour, and circumstance.
Reliability – the extent to which a tool will function consistently in the same way with repeated use.
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Ministry of Health
Prescribing – defined as the steps of information gathering, clinical decision making, communication, and evaluation that results in the initiation, continuation, or cessation of a medicine (Nursing and Midwifery Board of Australia, 2021).
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Ministry of Health
Chapter One
Introduction
According to the Saudi Healthcare Transformation Strategy, the population of the Kingdom continues to grow and age. Our population is expected to rise from 36.1 million in 2022 to 39.5 million by 2030. Therefore, nursing care needs to be advanced and focused more closely on care for senior citizens and primary care in general. Increasing healthcare costs, growing populations, and a shortage of human resources create challenges in meeting the demand for quality patient care worldwide. Saudi Arabia is grappling with a severe shortage of nurses, particularly those with advanced qualifications, due to a host of cultural, educational, and governmental barriers. World Health Organization (2013) reports also reveal encouragement for advanced nursing practice through its development to cover the global shortage of nurses. Nearly three decades ago, the United Kingdom (UK) reported that senior clinical nurses are equal to physicians in terms of providing medical treatment to individuals. Moreover, in the United States (US), the Institute of Medicine allowed nurses, along with medical doctors, to structure the healthcare system. Here, we examine the role of nurse practitioners and consider how they might be integrated into Saudi Arabia’s healthcare system in order to increase access to quality patient care (Hessa A. Almutairi ,elt ,2020)
An Advanced Practice Nurse (APN) is one who has acquired, through additional education, the expert knowledge base, complex decision-making skills and clinical competencies for expanded nursing practice – the characteristics of which are shaped by the context in which they are credentialed to practice (APRN Consensus Work Group, 2008). In addition to an overall nursing shortage, there is a severe shortage of nurses with advanced qualifications in clinical nursing. Although several studies have shown the importance of APRNs in the healthcare system, advanced nursing practice is still not implemented actively in Saudi Arabia, except in a tertiary hospital (King Faisal Specialist Hospital and Research Centre), which hires experienced expatriates for this role. The Cardiac Center at King Abdulaziz Medical City in Riyadh has implemented this role since 2000, but with a different tile (they call it a nurse specialist) with comparable scope of practice to many US states. In fact, it falls within the reduced scope of practice.
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Ministry of Health
Development Timeline of advanced practice nursing in Saudi Arabia
Table 1: Development Timeline of advanced practice nursing in Saudi Arabia
<table><tr><td>Date</td><td>Event</td><td>Progression</td></tr><tr><td>1980s</td><td>KFSHRC Job Descriptions for Specialty Practice</td><td>Stoma, Wound, Continence, Pain, Infection Control, Palliative Care</td></tr><tr><td>1990s</td><td>KFSHRC APN Job Description</td><td>Developed without nursing credentialing or a privileging framework</td></tr><tr><td>1990s</td><td>KFSHRC Policy on Non-Physician Prescribing</td><td>For pharmacists and nurses</td></tr><tr><td>Mar 2008</td><td>KFSHRC Clinical Ladder</td><td>Aimed at growing nurses in specialty practice from novice to expert, including APN and NC (Figure 2)</td></tr><tr><td>Jun 2010</td><td>Recognition by the SCFHS of the Enterostomal Therapy Diploma Programme</td><td>A 12-month full time programme, incorporating both theoretical and clinical components, aimed at developing Saudi nurses to care autonomously for patients with stomas, incontinence, defecatory dysfunction, and wounds, including nurse-led clinics</td></tr><tr><td>Oct 2011</td><td>KFSHRC tasked APN proposal</td><td>Both general and specialty APN pathways were proposed, along with nursing credentialing and privileging</td></tr><tr><td>Jun 2012</td><td>Publication: Specialist Nursing in Saudi Arabia</td><td>Perspectives on specialist nursing in Saudi Arabia: A national model for success</td></tr><tr><td>Jan 2013</td><td>KFSHRC Nurse Credentialing & Privileging Committee</td><td>Nurse credentialing and privileging committee established</td></tr><tr><td>Jan 2013</td><td>SCFHS Dialogue</td><td>Started dialogue with SCFHS</td></tr><tr><td>Jan 2014</td><td>Invited publication: ICN/APN Education Committee</td><td>Addressing issues impacting advanced nursing practice worldwide</td></tr><tr><td>Jan 2015</td><td>Invited publications: series based on the provision of specialty nursing services</td><td>1. Developing enterostomal therapy as a nursing specialty in Saudi Arabia: which model fits best?2. The development of nurse-led bowel dysfunction clinics in Saudi Arabia: Against all odds</td></tr><tr><td>Mar 2015</td><td>\( 1^{st} \) APN Thought Leadership Event, Riyadh</td><td>KFSHRC nurse and physician leaders and APNs, aimed at opening a local dialogue</td></tr><tr><td>Oct 2015</td><td>\( 1^{st} \) Nursing Symposium aimed at APN in Saudi Arabia</td><td>KFSHRC Riyadh Biennial Nursing Symposium main theme APN. Nurses from Saudi Arabia, the Gulf and invited international experts shared their experiences.</td></tr><tr><td>Oct 2015</td><td>\( 1^{st} \) Inaugural Saudi APN leadership meeting</td><td>Aimed at starting a national APN dialogue</td></tr><tr><td>Oct 2015</td><td>Chair, SCFHS, Nursing Scientific Committee, announces support from SCFHS</td><td>Dr. Ahmad Aboshaiqah (Chair, Nursing Scientific Committee, SCFHS) announced his and the SCFHS support for discussion and planning for APN in Saudi Arabia, in particular the community NP role</td></tr><tr><td>Jan 2016</td><td>First two KFSHRC Saudi nurses appointed as APNs</td><td>Ms. Hajer AlSabaa and Ms. Haifaa Hussain returned from scholarships in the USA after gaining their APN Master's degree,</td></tr></table>
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Ministry of Health
<table><tr><td></td><td></td><td>employed in APN positions (Colorectal and Paediatric populations)</td></tr><tr><td>Sept 2016</td><td>ICN/APN Hong Kong podium presentations include Saudi Arabian perspective</td><td>1. An international forum to share innovation strategies and creative modalities in advanced practice.2. A survey of clinical education of APN: A global perspective.Beachesne, M., Scanlon, A., Carryer, J., Debout, C., East, L.A., Hibbert, D., Honig, J.</td></tr></table>
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Ministry of Health
Rationale
- Nursing’s Social Policy Statement: It is about the relationship – the social contract – between the nursing profession and society and their reciprocal expectations. This arrangement authorises nurses as professionals to meet the needs involved in care (ANA, 2015).
- Life expectancy is increasing, leading to an increased ageing population and high proportion of patients living with chronic health conditions; this requires a workforce with advanced skills to meet capacity.
- As nursing practice evolves and the healthcare needs of the population change, new CNP/ANP roles or population foci may evolve over time.
• Healthcare systems globally are under transformation and face restructuring.
- Innovation and changes in nursing as a profession are dynamic, with changes to education aiding disease prevention and health promotion.
- An opportunity is created for more autonomy in patient care and a growing number of career options.
- FNPs are able to care for a large variety of patients: they can be found in nearly every care setting and in the wider healthcare industry.
- Increased access to healthcare services, such as primary care. See the comment below about this part.
- Increased professional development opportunities in the clinical arena/field.
Objectives and outcome
- As part of the “Vision 2030”, healthcare provision needs to be focused on promoting preventive rather than curative care.
- Advancing nursing roles and promoting specialised practice in primary healthcare.
- Procedural guide for the specialised nursing programme for workers in primary healthcare centres.
• Partnership with the Ministry of Education.
- Enhancing the integrated efforts with the SCFHS in adopting nursing certifications and credentialing nurse practitioners.
- ANP long-term relationships with patients and working in partnership with them to achieve optimum health.
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Ministry of Health
Advanced Nurse Practitioner Scope of Practice statement
An advanced nurse practitioner is one who has a minimum of a master's degree in nursing, ideally with a doctorate in advanced nursing, from an accredited academic institute/programme. ANPs practice both independently and in collaboration with other healthcare professionals, completing clinical and didactic work accredited by the Saudi Commission for Health Specialists.
Job description: Comprehensive healthcare practice, including autonomous examination and assessment of patients that includes initiating treatment and developing a management plan. Management commonly includes the authority to prescribe medications and therapeutics, conduct referrals, and monitor acute and chronic health issues, primarily in direct healthcare services. Practice includes the integration of education, research, and leadership in conjunction with an emphasis on direct clinical care.
Family Nurse Practitioner Scope of Practice statement
An FNP is a registered nurse at a master's or doctoral level who has acquired an expert knowledge base, complex decision-making skills, and clinical competencies for expanding practice nursing. FNPs provide a wide range of family-focused primary healthcare services and can perform independently or in collaboration with a treatment team. These nurses provide health promotion and disease prevention measures as well as providing treatment to individuals and their families, and help them to manage chronic conditions in primary care, acute and long-term care facilities, physicians' offices, private clinics, urgent care clinics, community health centres, public health departments, occupational health settings, and ambulatory care settings.
FNPs have a broad scope of clinical practice, such as education, health promotion, and disease prevention, focusing across the entire life span – the population in family practice includes new-borns, infants, children, adolescents, adults, pregnant and postpartum women, and seniors. The focus of care is the family health unit and the influence of mental health, sexuality, gender, values, value systems, ethnicity, environment, psychosocial factors, economic factors, and cultural issues on health and illness, and the impact on individuals and families. FNPs work with all aspects of family healthcare, perform health screening and physical examinations, order diagnostic tests, establish diagnoses, prescribe medications, and educate patients and family members on health, illness, and treatment plans using clinical judgement, critical thinking, and leadership skills (ICN, 2020).
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Ministry of Health
Figure 1: Setting of Family Nurse Practitioner
- Hospital
• Primary health care
- Patients Home
• Rehabilitation Centers
• Community Setting
- Long-term care
- Private sector
- Urgent care centers
• Physician office
- Schools
• Hospice facility
- Skilled Nursing Facilities
• Acute or Urgent Care Centers
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Ministry of Health
Advanced Family Nurse Practitioner Standards of Practice
The registered nurse competencies are the core entry level. Nursing standards of practice and professional performance include competencies and skills for each standard. This domain contains competencies related to independent and collaborative advanced level practice in delivering and managing client care.
A set of accompanying measurement criteria have been added to each standard to provide further evidence of the standard being met.
There are five domains of competence related to FNP. Evidence of safety to practise as a family nurse practitioner is demonstrated when the applicant meets the competencies within the following domains:
Clinical domain: Direct comprehensive care and management of individuals/families through nursing process
Focused physical examinations on patients of all ages (including developmental and behavioural screening, physical exam and mental health evaluations). Demonstrates advanced clinical decision-making processes for:
Assessment
- Assess the client’s health status and make differential, probable, and definitive diagnoses.
- Assess the complex and/or unstable healthcare needs of the person receiving care through synthesis and prioritisation of historical and available data.
- Assess the impact of comorbidities, including the effects of co-existing conditions, multiple pathologies, and prior treatments in the assessment of the person receiving care.
- Order diagnostic tests (including laboratory tests) to help with differentials in clinical examination including physical, mental health, and social, ethnic, and cultural dimensions.
- Assess the impact of acute and/or chronic illnesses or common injuries on the family.
Diagnosis
- Implement appropriate systematic decision-making process.
- Analyse the collected health history data and any diagnostic information and apply diagnostic reasoning.
- Form a differential diagnosis from history, physical examination, and diagnostic test results.
- Identify health and psychosocial risk factors of patients of all ages and families at all stages of the family life cycle.
- Order and interpret additional diagnostic tests as necessary.
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Ministry of Health
Development of a comprehensive plan of care
The family nurse practitioner, together with the patient and family, establishes an evidence-based, mutually acceptable, cost effective plan of care that maximises health potential or end of life decisions. Formulation of the plan of care includes:
- Setting priorities to address the healthcare needs of the individual, family, and/or community.
- Prescribing or ordering appropriate pharmacological and non-pharmacological interventions.
- Developing a patient education plan based on the patient’s health literacy abilities/learning needs.
- Ordering consultations or referrals based on evidence and professional standards, and sharing decisions with patients and families.
Implementation of the plan:
Interventions are based upon established priorities and are consistent with education and clinical practice. Actions by family nurse practitioners are:
- Individualised, recognising the patient’s preferences and abilities.
- Consistent with the appropriate plan for care.
- Based on scientific, evidenced based principles, theoretical knowledge, and clinical expertise.
- Inclusive of teaching and learning opportunities.
Evaluation:
During the follow-up and evaluation of the patient status, the nurse practitioner maintains a process for systematic follow-up by an evaluation of patient care outcomes and determination of the effectiveness of the plan of care.
The plan should be re-evaluated and modified as necessary to meet the health outcomes and goals of the individual and the family.
Research and education domain
- Maintenance of current knowledge by attending continuing education programmes.
- Develops new practice approaches based on the integration of research, theory, and practice knowledge.
- Translates research and other forms of knowledge to improve practice processes and outcomes.
- Analyses data and evidence to improve advanced nursing practice.
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Education and coaching domain
Through advocacy, modelling, and tutoring, the coaching function involves the skills of interpreting and individualising therapies by:
- Demonstrating knowledge and skills in dealing with sensitive topics with family members, such as sexuality, finances, mental health, terminal illness, and substance abuse.
- Providing information about the family and patient's healthcare goals, perceptions, and resources.
• Assessing and teaching educational needs of individuals and families.
- Assisting the patient and family with self-care through anticipatory guidance, teaching, counselling, and education.
Professional responsibility and leadership domain
- Practices within a nursing model to apply advanced nursing practice in the provision of healthcare services to individuals/families.
- Establishes and maintains a climate of mutual respect and shared values with individuals from other professions.
- Roles of the Family/Lifespan NP: healthcare provider, coordinator, consultant, educator, coach, advocate, administrator, researcher, and leader.
- Participates in continuous professional and interprofessional development to improve team performance.
Support of system domain
- Participates in developing standards, policies, procedures, or practice guidelines to improve family healthcare.
- Uses quality indicators to monitor and measure the effectiveness of strategies, services, and interventions to promote safe practice and use this data to improve practice.
• Interprets variations in outcomes.
- Organisational delivery subsystems (e.g., electronic prescription writing, pharmacy software).
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Ministry of Health
Implication for practice environment
• Hospitals, acute care or ambulatory care settings.
- Outpatient settings.
• Long-term care facilities and nursing homes.
• Private homes providing healthcare services.
• Hospice and palliative care services.
Interpersonal and interprofessional care and quality improvement domain
• Continuously improves the quality of clinical practice using the best available evidence.
- Professional development and the maintenance of professional competence and credentials: studies the relationship between access, quality, and safety in healthcare and how these factors impact healthcare.
- Analyses how organisational structure, care processes, financing, marketing, and policy decisions affect the quality of healthcare.
• Utilises peer review to promote a culture of excellence.
• Takes proactive measures to ensure quality by anticipating variations in practice.
- Participates in quality assurance reviews, including the systematic, periodic review of records and treatment plans.
Standards of professional performance
These standards describe a competent level of behaviours in the professional role, as demonstrated by the code of ethics.
FNP endorsement process
The demand for more expert health practitioners has increased due to the increasing number of advanced nurse practitioner graduates in the field and the growth of community needs. As nursing evolves and specialty practice becomes ever more apparent, certification and credentialing have become an increasingly important mechanism for ensuring quality. This includes, but is not limited to, continuing education, specialty certification, and advanced degrees.
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adallajlg Ministry of Health
The process of recognition, approval of specialty scope and standards, accreditation, and acknowledgement is paramount. Figure 1 shows the steps that are followed for nursing specialty approval, according to the Consensus Model for APRN Regulation (American Association for Nurse Practitioners, 2019).
Figure 2 Process for recognition of specialty and approval of specialty scope and acknowledgment of standards
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Ministry of Health
The Importance of Family Nurse Practitioners
- Limited access to healthcare services due to shortage of specialised healthcare providers.
- Increasing numbers of patients with complex health conditions.
- FNP will have considerable financial impact, which will drive healthcare service levels from the more expensive specialist provider to more cost-effective providers.
• Studies found that utilisation of NPs as primary care providers resulted in fewer unnecessary hospitalisations, increased access to healthcare, and improved health outcomes.
• Evidence suggests that APN care results in higher patient satisfaction.
Barriers to Incorporating APRNs into the Saudi Healthcare System
The World Health Organization (WHO) has acknowledged the need for APRNs in the Middle East, including Saudi Arabia [20]. However, various regulatory, institutional, and cultural barriers restrict the practice of APRNs. According to Hibbert et al. [21], reasons for the APRN shortage include a lack of higher education programmes, low pay, and a negative image of clinical nursing in Saudi Arabia. Barriers included policy restrictions on practice, poor physician relations, poor administrator relations, and others' lack of understanding of the APRN role. Barriers correlate with job dissatisfaction and increased intent to leave job (Lori Schirle, Allison A. Norful, Nancy Rudner and Lusine Poghosyan, 2020)
Characteristics of Family Nursing Practitioners (FNP)
Job description
A family nurse practitioner is a registered nurse with advanced training, specialisation, and certification. FNPs also have additional clinical practice and formal education requirements. FNPs are trained to provide treatment and care to children as well as adults. They generally work in the field of family practice, and may work with the same patients from childhood through to adulthood.
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Ministry of Health
Qualifications
- Completion of accredited master's, post-master's, or doctoral degree in nursing with a focus on the Family or Primary Nurse Practitioner (FNP/PNP) specialty is required.
There are several separate educational requirements, as well as comprehensive graduate-level courses in:
- Advanced physiology/pathophysiology, including general principles that apply across the life span.
- Advanced health assessment, which includes assessment of all human systems, advanced assessment techniques, concepts, and approaches.
- Advanced pharmacology, which includes pharmacodynamics, pharmacokinetics, and pharmacotherapeutics of all broad categories of agents.
- Current certification as a Family Nurse Practitioner (FNP).
- Current active licensure to practice as an advanced nurse.
Family Nurse Practitioners can, in addition to other duties:
- Identify the health needs of individuals, families, and the community.
- Conduct routine health assessments and family histories, and perform physical examinations.
- Provide comprehensive chronic condition care characterised by a long term relationship between the patient and the FNP, and create patient care plans.
- Order and review diagnostic tests (including laboratory tests) and interpret the results.
- Refer for consultation when an issue is outside the scope of their practice or level of expertise/experience.
- Share decision making with patients and their family members regarding the provision of healthcare and health education.
- Manage patient documents and records.
- Diagnose and treat patients of all ages.
- Promote optimal heath and provide preventive healthcare services.
- Treat minor acute injuries and illnesses.
- Oversee women’s health requirements, including contraception, preconception, and prenatal care.
- Prescribe acute/chronic pharmacological and non-pharmacological treatments.
- Provide immunisations.
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Ministry of Health
FNP roles and responsibilities
Nurse practitioners play an important role in increasing access to healthcare services, especially for people with complex health needs. Nurse practitioners have extensive roles, including assisting patients in decision-making, promoting patient and family engagement, providing continuity of care, improving patient satisfaction, improving interpersonal communication and professional relationships, decreasing morbidity and mortality rates, increasing treatment compliance, improving productivity, and reducing healthcare costs.
The role of the nurse practitioner is essential to meet current healthcare demands. A study found that physicians and nurse practitioners provide similar types of services. Yet, although their services are similar, nurse practitioners convey more information to patients regarding health monitoring.(The Future of Nursing: Leading Change, Advancing Health,2011)
Models of Nurse Practitioner
The concept of the NP was initiated in 1965 in the USA based on a public health model to provide primary healthcare (PHC) to children lacking access to healthcare services. The role was based on a person-centred, holistic approach to care with the addition of diagnostic, treatment, and management responsibilities previously limited to physicians. However, it was distinct from the medical model in that it also focused on prevention, health and wellness, and patient education (Dunphy et al., 2019). In the mid-1970s, Canada and Jamaica followed the USA's development, aiming to improve access to PHC for vulnerable populations in rural, remote, and underserved communities. In the 1980s in Botswana, as the country responded to healthcare reform and the population needs of the country spiralled, a Family Nurse Practitioner role was launched.
At King Faisal Specialist Hospital and Research Centre, the nursing professional practice model is patient centric care, which is further supported by the other characteristics of the model: organisational priorities, quality aims, EBP and research, education, and professional practice/credentialing. The NP is expected to participate in divisional, national, and international forums within their area of expertise and as leaders within the organisation, Saudi Arabia, and the Gulf Region. The NP is a licensed independent practitioner who provides the highest level of care for the patients of King Faisal Specialist Hospital and the Kingdom of Saudi Arabia.
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اصيلات
Ministry of Health
Chapter Two
Definitions
Ethics: the moral principles that govern a person's behaviour or the conducting of an activity.
Nursing Ethics: a branch of applied ethics that concerns itself with activities in the field of nursing. Nursing ethics shares many principles with medical ethics, such as beneficence, non-maleficence, and respect for autonomy. It can be distinguished by its emphasis on relationships, human dignity, and collaborative care.
Nursing Code of Ethics: a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.
Informed consent: the process by which a patient learns about and understands the purpose, benefits, and potential risks of any procedures, including clinical research trials, and then agrees to receive the treatment or participate in the trial.
Ethical Aspects
Nurses may strive to ensure patient autonomy and rights through appropriate participation in the informed consent process. Nevertheless, compliance with legal and regulatory requirements as well as ethical and patient family concerns can make the concept of informed consent challenging.
As patient advocates and direct care providers, nurses have a unique opportunity to meaningfully advocate for mutual decision making, a process that promotes:
• Patient Autonomy
• Patient Education
• Patient Comprehension
- Self-Determination.
Patient Autonomy
Expressing respect for patients' autonomy means acknowledging that patients who have decision-making capacity have the right to make decisions regarding their care, even when their decisions contradict their clinician's recommendations.
It is evident that some nursing care procedures have the potential to infringe patient autonomy if undertaken without consent. Furthermore, these procedures may not be easily identifiable.
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Ministry of Health
Self-Determination
The ethical principle of self-determination is a subset of autonomy.
Patient Education
Consent forms are potential meaningful education tools that nurses may use as springboards into important discussions about what to expect before and after a nursing procedure. Nurses, as healthcare professionals, may, within the scope of the informed consent process, move beyond simply informing a patient of risks to actually educating a patient. Approaching the informed consent process for a nursing procedure using an educational model may result in liability reduction by serving to develop an alliance between the patient and the nurse.
Patient Comprehension
Comprehension of the information provided is a precondition for obtaining a valid informed consent. Ideally, a patient would demonstrate full comprehension, but the practical application of that ideal can be problematic in implementation. Important factors such as (a) the disease itself, (b) anxiety, (c) pain, and (d) various therapeutic interventions can hinder a patient's ability to participate in shared decision making.
To maximise comprehension, information should be carefully provided in a manner that increases the patient's understanding of what is being explained. Nurses could contribute toward maximising comprehension by using a repeat-back process on comprehension after informed consent discussions by asking patients to recount what they had learned in the informed consent discussion. The repeat-back methodology has been shown to have an effect on patients' comprehension of information disclosed during informed consent for nursing procedures.
Legal Aspects
An ‘informed consent’ signed by the patient, from a legal standpoint, is not actual consent, but rather evidence that the patient is consenting to a particular procedure at a given time.
Legally, no one has the right to touch, let alone treat, another person without permission. This would be classified as ‘battery’ — physical assault — and is punishable by law. From this, one might say obtaining consent is necessary for anything other than a routine physical examination.
The only time consent is not necessary is in the event of an emergency, in which case a doctor may have to operate in the absence of consent to save the life of the patient.
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A patient has to be given the opportunity to ask questions and clarify all doubts. There must not be any kind of pressure. Consent must be voluntary, and a patient should have the freedom to revoke the consent. If consent is given under fear of intimidation, or if it includes misconceptions or the misrepresentation of facts, it can be considered invalid. Where there may be doubt that the consent is legal because of the capacity of the patient (e.g., a person under 18 years of age or with a significant mental health condition), then the opinion of the treating practitioner (that the patient is able to consent) should be documented.
Nurses should keep the following principles in mind when in doubt about how to interpret the legislation:
- Clients have a legal and ethical right to information about their care and treatment, and a right to refuse that treatment.
- Regardless of whether consent has been obtained by the nurse, nurses should always explain to the client the treatment or procedure they are performing.
- Nurses should not provide a treatment if there is any doubt about whether the client understands and is capable of consenting. This applies whether or not there is an order, or even if the client has already consented.
- Consent can be withdrawn at any time.
- Nurses need to advocate for clients' access to information about care and treatment if it is not forthcoming from other care providers.
- Informed consent does not always need to be written, but can be oral or implied.
Conclusion
Family Nurse Practitioners are trained to treat all ages of patient populations, from infants to the elderly, as primary care providers in primary and specialty care. Family Nurse Practitioners are able to operate with autonomy and work independently. Completion of an accredited master's or post-master's degree from a Family Nurse Practitioner (FNP) programme is an important part of becoming a nurse practitioner. In general, FNPs focus on identifying and dealing with the health needs of individuals, families, and the community. When all credentials, training, and professional development needs are met, it is possible to have a meaningful and fulfilling job as an FNP in healthcare centres in the Kingdom of Saudi Arabia.
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ارسط الجيلق
Ministry of Health
References
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Ministry of Health
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اصيل الجلد
Ministry of Health
السلام عليك
Appendices
TABLE 1: Family nurse practitioner Model
<table><tr><td>Model Definition</td><td>Essential Steps</td><td>Salient Points to Consider</td></tr><tr><td>Iowa Model of EBP (Titler et al., 2001). The Iowa Model focuses on the entire healthcare system (e.g., patient, practitioner, infrastructure) to implement and guide practice decisions based on best available research and evidence.</td><td>Identify either a “problem-focused trigger” or “knowledge-focused trigger” that will generate the need for a practice change.Determine whether the “trigger” is a healthcare organisation priority.Reflect a team’s topic of interest and include interested stakeholders. The team will search, appraise, and synthesise literature related to the topic.Evaluate the availability and merit (e.g., level of evidence, quality of evidence) of evidence.If evidence availability and merit are lacking, conduct research.If credible and reliable evidence is available, pilot the practice change.Appraise pilot for level of success. If pilot is successful, disseminate findings within the organisation and implement recommended change into practice.</td><td>Recommended for use at organisational systems level.Uses pragmatic problem-solving approach to EBP implementationDetailed flowchart (see Chapter 11) guides decision-making process.Clearly identified decision points and feedback loops throughout the model.Emphasises necessity of pilot project before initiating system-wide project.Designed for interprofessional collaboration.Has sustained test of time.Implementation of evidence-based practice (EBP) is essential for ensuring high-quality health care at minimum cost. Although all nurses have a responsibility to implement EBP at an individual patient level, nurse practitioners (NPs) as clinical leaders have additional responsibilities in leading and collaborating with transdisciplinary teams to implement EBP across patient</td></tr></table>
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Ministry of Health
<table><tr><td></td><td></td><td>groups and embed practice change into routine care.</td></tr><tr><td>Stetler Model (Ciliska et al., 2011; Stetler, 2001). The Stetler Model enables practitioners to assess how research findings and other pertinent evidence are implemented in clinical practice. The model examines how to use evidence to create change that fosters patient-centred care.</td><td>Steps in this model are referred to as phases.Phase I. Preparation: Identify a priority need. Identify the purpose of the EBP project, context in which the project will occur, and relevant sources of evidence.Phase II. Validation: Assess sources of evidence for level and overall quality. Determine whether source has merit and goodness of fit and whether to accept or reject the evidence in relation to project purpose.Phase III. Comparative Evaluation/Decision Making: Evidence findings are logically summarised and similarities and differences among sources of evidence are evaluated. Determine whether it is acceptable and feasible to apply summation of findings to practice.Phase IV. Translation/Application:Develop the “how to’s” for implementation of summarised findings. Identify practice implications that justify</td><td>groups and embed practice change into routine care.Designed to encourage critical thinking about the integration of research findings.Promotes use of best evidence as an ongoing practice.Helps lessen errors in critical decision-making activity.Allows for categorisation of evidence as external (e.g., research) or internal (e.g., organization outcome data).Emphasises use by single practitioner but may include groups of practitioners or other stakeholders.The Stetler Model, which in its original development focused on research utilisation, has been updated and refined to fit in the EBP paradigm. The model emphasises the critical thinking process and although practitioner-oriented, is also used by groups for implementing formal organisational change. An important assumption for the model revision is that internal factors such as the characteristics of individual EBP users and organisational practices influence implementation of evidence along</td></tr></table>
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Ministry of Health
<table><tr><td></td><td>application of findings for change.Phase V. Evaluation: Identify expected outcomes of the project and determine whether the goals of EBP were successfully achieved.</td><td>with external factors that include formal research and organisational standards and protocols. The Stetler Model consists of five phases.Phase I, preparation, includes definition of the purpose, contextual assessment and search for sources of evidence.Phase II is validation of the evidence found.Phase III is comparative evaluation/decision-making, where the evidence found is critiqued, synthesised, and a decision for use is made with consideration of external and internal factors.Phase IV refinements provide implementation/translation guidance for change in practice.Phase V is evaluation, which includes outcomes met and the degree to which the practice change was implemented.Steps for Using Method/ToolThe Stetler model of evidence-based practice consists of five phases (Stetler, 1994; Stetler, 2001; Stetler, 2010). Each phase is designed to:</td></tr></table>
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Ministry of Health
<table><tr><td></td><td></td><td>facilitate critical thinking about the practical application of research findings;result in the use of evidence in the context of daily practice; andmitigate some of the human errors made in decision making.</td></tr><tr><td>Ottawa Model of Research Use (Graham & Logan, 2004 Graham et al., 2006). The Ottawa Model is an interactive model that depicts research as a dynamic process of interconnected decisions made and actions taken by stakeholders.</td><td>The model is composed of three phases: (a) Assess barriers and supports. (b) Monitor intervention and extent of use. (c) Evaluate outcomes. Subsumed under the three phases are six designated primary elements that must be considered when integrating research into practice.Assess barriers and supports:Evidence-based innovation: Clearly identify what the innovation is and what the implementation will involve.Potential adopters: Identify potential adopters with characteristics that could influence the adoption of the innovation (see Rogers' Change Theory in Chapter 7).</td><td>Patients are central to the model's process and their health outcomes are the primary focus.The model focuses on the unit-level environment instead of the entire healthcare organisation.The prescriptive aim of the model is to assess, monitor, and evaluate.To improve performance of a family nurse practitioner by implementing a research-based family assessment instrument. Objectives included providing a structure for evaluating families and fostering the healthcare relationship.</td></tr></table>
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Ministry of Health
<table><tr><td></td><td>The practice environment:Identify leaders, formal and informal, who can inspire change. Assess environment for needed resources.Monitor intervention and extent of use:Implementation of intervention strategies: Select appropriate strategies to increase awareness of implementation and provide necessary education and training for conducting the implementation.Adoption of innovation:Determine the extent of adoption of implementation.Evaluate outcomes:Evaluate the impact of innovation on patients, practitioners, stakeholders, and healthcare organisation.</td><td></td></tr><tr><td>Promoting Action on Research Implementation in Health Services (PARiHS) Framework (Rycroft-Malone, 2004). The PARiHS Framework provides a method to implement research into practice by exploring the interactions among three key elements: (a) evidence, (b) context, and (c) facilitation.</td><td>Evidence: Search for and identify the best available evidence from research, clinician experience, patient values, organisation data, and information.Context: This is the local environment where the practice change will occur. Adoption of practice change is dependent on contextual features such as</td><td>Explicitly uses facilitation as a factor impacting integration of research findings into practice.Does not address generation of new knowledge.Focus is on unit settings more than system-wide environment.Codified (e.g., research data)
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