CARALYN ARTICLE / CLINICAL CARE SOLUTIONS / DNS APRIL 23, 2024 – Found on the AARP website with a subscription
Increasingly, nurse practitioners (NPs) and clinical nurse specialists (CNSs), also known as advanced practice registered nurses (APRNs), work either directly for or closely with nursing homes to improve resident care outcomes, as do physician assistants (PAs). That growth may accelerate as providers transition to more value-based payment models amid the ongoing national physician shortage. Note: See “The Rise of APRNs in Long-Term Care” at the end of this article for more information.(https://www.ama-assn.org/press-center/ press-releases/ama-president-sounds-alarm-national-physician-shortage)
“You don’t want to ignore the APRN’s availability as a resource, although some of what they can do maydepend on the specialized skills of the individual APRN,” says Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP, professor in the Department of Organizational Systems and Adult Health and the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore, MD.
“Staff often know the APRN’s strengths and, in many facilities, will call them individually to help with, for example, the management of clinical problems,” says Resnick. “However, as the director of nursing services(DNS), you also need to understand that you can use the APRN on a larger scale as a facility-wide resource.”
Keys to taking full advantage of the APRN’s skills include the following:
Start expanding the APRN’s role with QAPI
“Today, the majority of APRNs are Doctors of Nursing Practice (DNPs),” says Resnick. “They should have expertise in how to do quality assurance and performance improvement (QAPI). However, even if they haven’t had that training, the APRN should at least know how to collect outcome data (e.g., for urinary tract infections, falls, or pain management) and do some basic statistical analysis. So, there is still a lot that they can help with that the DNS and even the medical director may not have much experience in.”
“If the APRN does have that QAPI expertise, you can partner with them to create a good team to lead some of the quality improvements that need to take place,” adds Linda J. Keilman, DNP, GNP-BC, DEGN, FNAP, FAANP, a gerontological nurse practitioner who has been working with nursing homes since 1989 and an associate professor at the Michigan State University College of Nursing in East Lansing, MI. “For example, if you are working on pain management, the APRN can help you figure out some therapeutic nonpharmacologic interventions that may be used to make residents more comfortable without medications—and how to determine what actually works for each individual.”
6/4/25, 10:10 AM Working With NPs and Other APRNs: Learn to Maximize the Benefits – AAPACN https://www.aapacn.org/article/working-with-nps-and-other-aprns-learn-to-maximize-the-benefits/
Note: The Centers for Medicare & Medicaid Services (CMS) expects nursing homes to “develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life,” according to F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt)in Appendix PP of the State Operations Manual. Compliance related to data collection and analysis can be demonstrated via “evidence of systems and reports demonstrating identification, reporting, investigation, analysis, and prevention of adverse events ”and “data collection and analysis at regular intervals.”(https://www.cms.gov/medicare/provider-enrollment-and-certification/ guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf)
Take advantage of the APRN’s ability to navigate two worlds
The APRN can serve as a bridge builder, suggests Pam Duchene, PhD, RAC-MT, DNS-CT, QCP, APRN-BC, NEA,FACHE, vice president for Patient Care Services and chief nursing officer at Southwestern Vermont Medical Center in Bennington, VT, and a part-time geriatric nurse practitioner at the hospital’s nursing home. “As anNP myself, I can speak to the practitioner’s perspective, and I understand the quality drivers and the quality metrics that can make a difference there. However, I also can understand the nursing perspective, so often Iam able to help ‘interpret sides for a more collaborative approach to improve resident care.”
Let the APRN shine in clinical teaching and education
The DNS often has an administrative focus due to the nature of the job, says Resnick. “At this point in your career, you may not be engaged in hands-on care on a day-to-day basis. Turning to the APRN who has a strong clinical background to assist with your staff’s clinical training can be beneficial. For example, the APRN could strengthen the nursing staff’s assessment skills, teach them how to identify the underlying cause of a clinical concern, and help them to understand management opportunities related to that clinical issue.”
The APRN often can serve as a mentor and coach, agrees Duchene. “For example, if a long-stay resident onpalliative care needs a drainage catheter to be able to come home from the hospital, the APRN cancollaborate with the surgeon to get that catheter put in—and work with the nursing staff to ensure that theyhave the supplies and skills to decompress the resident’s fluid buildup when they return from the hospital.”
Involve the APRN in reducing hospital readmissions
The APRN also can play a pivotal role in reducing rehospitalizations, says Duchene. “There must be really close involvement and good communication among the nurses, the DNS, and the APRN.”
Four key areas of potential APRN involvement include the following:
Testing. “The APRN should be able to look to see what testing you can bring into the facility so that you can reduce the risk of having to send out a resident who otherwise may not need to be sent out,” saysDuchene.
Diagnostic equipment. “The APRN can make sure that you have the right equipment (e.g., blood pressure cuffs) and that the equipment is being used appropriately,” says Duchene. “That can make a big difference in whether you have accurate assessment information.”
Training and education. “The APRN can work with the nurses to ensure that they follow facility procedures for assessment in non-emergent situations,” says Duchene. “For example, that may include taking new vital signs before calling the APRN or the physician about a possible change in condition and making sure that the nurse has done the vital signs as opposed to delegating that task to the certified nursing assistant (CNA).”
Relationship building at the hospital. In an environment where both skilled nursing facilities (SNFs) and hospitals benefit from reducing hospital readmissions, the APRN may be able to develop relationships with staff at the local emergency department (ED), notes Duchene. “When a resident is declining or there’s a question about their overall status, the APRN then can call over to the ED and figure out whether immediately sending them out to the hospital is necessary. If the APRN can get the right lab work or bloodwork done timely, that can often provide a good indication of how sick the resident is and whether the resident can be safely managed in the nursing home.”
Be aware of the range of possibilities for APRN assistance
“APRNs should be able to assist with almost any care management issue,” says Resnick. Examples of other potential areas of collaboration include the following:
- Wound care;
- Fall prevention;
- Polypharmacy;
- Immunizations and health promotion work;
- Advance directives and advance care planning; and
- Infection prevention and control, including antibiotic stewardship, in conjunction with the infection preventionist.
Work with the APRN to learn what they can do
The DNS and the APRN should be on the same page about what exactly the APRN can and can’t do, saysResnick. “Sometimes, there are specific regulatory requirements related to the APRN’s practice, for example, around physician visits or prescribing. So, you need to work with them to be sure that you understand the tasks that they can take on.”
Note: See F710 (Resident’s Care Supervised by a Physician – F714 (Physician Delegation of Tasks to Non-Physician Practitioner (NPP)) in Appendix PP of the State Operations Manual for information on the core federal regulations relevant to APRNs and other NPPs. Learn about the state practice environment for NPs at the American Association of Nurse Practitioners. Learn about the state practice environment for CNSsat the National Association of Clinical Nurse Specialists .(https://www.cms.gov/medicare/provider-enrollment-and-certification/ guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf) (https://www.aanp.org/advocacy/state/state-practice-environment) (https://nacns.org/advocacy-policy/policies-affecting-cnss/scope-ofpractice/)
Ask the APRN to attend the morning meeting
“Getting the NP involved in the morning meeting is a way to increase their visibility and build that relationship,” says Duchene. “It helps them stay aware of the critical care issues that you face on a daily basis.”
Involve the APRN in care plan meetings
Teamwork is critical across all areas of individual resident care, including care planning, says Resnick.“However, the APRN and physicians, whether it’s the primary care physician or the medical director, often are excluded from direct participation in the care plan meeting. At one facility, I actually had to say, ‘Can you let us know when the care plan meetings are? We would like to come.’”
Especially now that care plan meetings are more flexible and can be attended via video or phone, it’s a good idea to include the APRN, says Resnick. “In addition, you should invite them to family meetings when there are family issues related to the resident’s clinical care.”
Reinforce nursing management structure with staff—and the APRN
“The APRN’s role in a nursing home doesn’t include any nursing staff oversight,” says Resnick. “Obviously,staff management is the role of the DNS. However, sometimes a staff member will call the APRN, complain about another staff member, and ask them to do something about the situation. That’s inappropriate, and your staff need to know that they should never ask the APRN to reprimand a staff member or deal with a staff issue.”
Similarly, if the APRN has a concern about something they see a staff member do on the unit, they need to know that they should bring that concern to the DNS, says Resnick. “It’s not their business to get involved in staff management issues.”
Build trust from the start
A successful partnership between the DNS and the APRN hinges on having a trusting relationship that puts the resident at the center, says Resnick. “You must have trust that you will have honest communication; trust that you will stay within your own roles; and trust that you have the support of each other. You have to know that the other person won’t try to blame you whenever there is a problem.”
Building that type of trust takes time, says Resnick. “It can be particularly difficult and stressful when there is turnover in either the DNS or the APRN position.”
Create a formal process for regular DNS/APRN communication
Setting up a routine (e.g., quarterly) one-on-one meeting between the DNS and the APRN can improve relationship building, says Resnick. “In addition, it can help you work together to be more forward-thinking so that you aren’t always focused on just dealing with the next crisis.”
And, if there is a change in either position, the one who is still there should be part of the pre-hire interview process to set the groundwork for developing that relationship, suggests Resnick. Note: Learn the ins and outs of doing pre-hire interviews with NPs in the AAPACN article “How to Hire the Best NP—Even if Someone Else Is Doing the Hiring”(https://www.aapacn.org/article/how-to-hire-the-best-np-even-if-someone-else-is-doing-the-hiring/)
“If a pre-hire meeting isn’t possible, there should be an immediate post-hire meeting,” says Resnick.“Sometimes, when a new DNS comes on board, it may be weeks before the APRN has the opportunity to do more than walk by them on the unit because the DNS is busy doing training and figuring out the job. However, it’s important to meet and begin developing that relationship as soon as possible so that you don’t end up with negative outcomes. You could start with a discussion of your philosophies of care to find common ground.”
All nurses, including all APRNs, should have a personal practice philosophy or philosophy of care, explains Keilman. “A personal practice philosophy, whether or not it’s written down, is a compass—a vision—that guides your practice. For example, what kind of nurse or APRN do you see yourself as? What are your professional values? Do you know the American Nurses Association’s Code of Ethics for Nurses and live by that? What are your professional goals? Do you have a mission statement?”(https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/)
In some nursing homes, the DNS and the APRN don’t have a trust-based professional relationship, saysResnick. “Sometimes, you can work through points of contention. For example, there may be turf issues, and depending on the model that you use, bringing in the medical director to clarify the role of the APRN may improve the situation. However, having that upfront meeting to set a positive tone can help the DNS and the APRN avoid the kind of difficult relationship that often results in one of them leaving.”
When there is ill will, it’s worth trying to re-frame the relationship to center on the residents, says Keilman.“For example, working together through the facility’s QAPI program could help the DNS build a better relationship with the APRN.”
No one is perfect, points out Keilman. “We all make mistakes and can learn from our mistakes. Using QAPI as a launchpad to establish open, transparent communication—and actually listen to each other—is a great opportunity for the DNS and the APRN to support each other and help build a Five-Star culture in the facility.”
Note: The Oct. 25, 2022, AAPACN article “Partner Up! Working With the DNS to Create a Shared Vision Reaps Rewards ” helps nurse assessment coordinators (NACs) build a better relationship with the DNS. However, there are relevant links to articles about conflict management and conflict resolution. In addition, the February 2020 Harvard Business Review article “How to Mend a Work Relationship ”and the Jan. 23, 2024 AAPACN article “Communication Basics: How Nurse Leaders Can Build a Two-Way Street ” may be useful. (https://www.aapacn.org/article/partner-up-working-with-the-dns-to-create-a-shared-vision-reaps-rewards/) (https://hbr.org/2020/02/how-to-mend-a-work-relationship) (https://www.aapacn.org/article/communication-basics-how-nurse-leaders-can-build-a-two-way-street/)
The Rise of APRNs in Long-Term Care The following studies and articles provide more insights about the growing use of APRNs in nursing homes:
“The Advanced Practice Registered Nurse Leadership Role in Nursing Homes: Leading Efforts Toward High Quality and Safe Care” in the June 2022 Nursing Clinics of North America
“The Future Includes Nurse Practitioner Models of Care in the Long-Term Care Sector” in the February 2022 Journal of the American Medical Association
“The Ever-Expanding Role of Nurse Practitioners in LTC” in the June 2019 Annals of Long-Term Care
“How the Nurse Practitioner Has Become ‘Front and Center ’ as I-SNPs Demand More Complex Care” in the June 15, 2022, Skilled Nursing News
“Why Advanced Practice RNs Could Be MVPs in Skilled Nursing Cost Savings, Care Outcomes” in the Dec. 19, 202,2 Skilled Nursing News
“Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents” in the March 15, 202,4 JAMA Network Open
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