evidenced-based practice at the advance · advanced nursing practice clinic the dnp is intended for...

Evidenced-Based Practice at the Advance Practice Clinic in Adult Health Care

SISA I Seminario Internacional em Saude do Adulto

Perspectivas para o milenio 3-5 Maio

Sao Paulo, Brasil

Howard K. Butcher, PhD, RN Associate Professor

Editor, Nursing Interventions Classification (NIC) Series Editor, Csomay Center for Gerontological Excellence Evidence-Based Practice

Guidelines University of Iowa, College of Nursing

Iowa City, Iowa USA

Iowa River and the University of Iowa

Iowa

University of Iowa Old Capitol

University of Iowa Performing Arts Hancher Audiotorium

University of Iowa Hospital and Clinics

University of Iowa Children’s Hospital

University of Iowa College of Nursing

“Nurses are living in the age of evidence-based practice (EBP). While the origin of

EBP has roots in medicine, today evidence-based practice is nursing’s

appel a l’action” (p. 25).

Butcher, H. K. (2016). Development and use of gerontological evidenced-based practice guidelines. Journal of Gerontological Nursing, 42(7), 25-32.

“Evidence Based Practice is becoming the global standard for nursing care” (Kautz & Van

Horn, 2008).

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Generalist Nursing Practice Clinic Undergraduate Level: The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008)

Essential III: Scholarship for Evidencebased Practice

Baccalaureate (professional nursing practice) is grounded in the translation of current evidence into practice. Scholarship involves 1) identification of practice issues; 2) appraisal and integration of evidence; and 3) evaluation of outcomes.

Baccalaureate nurses are uniquely positioned to monitor patient outcomes and identify practice issues. Evidencebased practice models provide a systematic process for the evaluation and application of scientific evidence surrounding practice issues. Dissemination is a critical element of scholarly practice as graduates are prepared to share evidence of best practices with the interprofessional team.

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Essential III: Scholarship for Evidencebased Practice (Continued)

Baccalaureate education provides a basic understanding of how evidence is developed, including the research process, clinical judgment, interprofessional perspectives, and patient preference as applied to practice.

Baccalaureate nurses integrate reliable evidence from multiple ways of knowing to inform practice and make clinical judgments. In collaboration with other healthcare team members, graduates participate in documenting and interpreting evidence for improving patient outcomes (AACN, 2006b).”

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Advanced Nursing Practice Clinic

The DNP is intended for nurses seeking a terminal degree in nursing practice and offers an alternative to research-focused doctoral programs. PhD programs in nursing typically focus on basic or clinically focused research.

The program of study for the DNP degree centers on leadership, knowledge, and refining skills in the areas of scholarly practice, practice improvement, innovation, and testing of care delivery models, and on clinical expertise for advanced nursing education.

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Advanced Nursing Practice Clinic

The DNP provides nurse practitioners with skills to complement the well-established clinical knowledge and skills acquired in current advanced practice programs. The DNP credential will establish title parity with other health professionals with whom

NPs collaborate in providing health care. Arlene M. Sperhac, PhD, CPNP, FAAN; Patricia Clinton, PhD, CPNP, FAAN. DISCLOSURES J Pediatr Health Care. 2008;22(3):146-151.

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Doctorate of Nursing Practice Terminal Practice Degree

Preferred degree in healthcare organizations

Replaced many MSN programs

Preferred Degree for Nurse Practitioners

300+ programs in the United States

In 48 states

18,000 students enrolled nationwide

Over 2,500 graduate each year

Typically 4 years in length full time

University of Iowa (In State Tuition= 90,000/4 years)

Nurse Practitioners

Nurse Practitioners make @ 100,000/year

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Clinical scholarship is described as an intellectual endeavor that entails systematic inquiry and scrutiny of practice in an effort to continually improve nursing practice; is informed by and inspires research, enhances the development of nursing knowledge by testing clinical realities against theories in varied settings with diverse populations (Dreher, 1999).

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Clinical Scholarship is Central to the DNP Role

DNP Role as Enacting Clinical Scholarship

Not proficiency, Not clinical research

An intellectual process

Willingness to scrutinize one’s practice

Challenge traditional nursing

Test ideas

Predict outcomes

Translation/application to practice

Dissemination

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Two of the essential elements of clinical scholarship are vision and passion. Includes: Building nursing knowledge Sharing knowledge Linking academic research to practice Doing practice-based research Translation and dissemination

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DNP as Clinical Scholarship

Evidence Based Nursing Practice is the Fuel for Clinical Nursing

Scholarship

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Advanced Nursing Practice Clinic Competencies

DNP Graduate Core Essentials (AACN)

Nurse Practitioner Core Competencies (NONPF)

Specialty Core Competencies

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DNP Graduate Core Essentials

Evidenced Based Practice

Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice

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DNP Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice

Research-focused doctoral programs in nursing are designed to prepare graduates with the research skills necessary for discovering new knowledge in the discipline.

In contrast, DNP graduates engage in advanced nursing practice and provide leadership for evidence-based practice. This requires competence in knowledge application activities: the translation of research in practice, the evaluation of practice, improvement of the reliability of health care practice and outcomes, and participation in collaborative research. Therefore, DNP programs focus on the translation of new science, its application and evaluation. In addition, DNP graduates generate evidence through their practice to guide improvements in practice and outcomes of care.

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DNP Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice

1.Use analytic methods to critically appraise existing literature and other evidence to determine and implement the best evidence for practice.

2. Design and implement processes to evaluate outcomes of practice, practice patterns, and systems of care within a practice setting, health care organization, or community against national benchmarks to determine variances in practice outcomes and population trends.

3. Design, direct, and evaluate quality improvement methodologies to promote safe, timely, effective, efficient, equitable, and patient-centered care. (AACN, DNP Essentials, 2008)

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4. Apply relevant findings to develop practice guidelines and improve practice and the practice environment.

5. Use information technology and research methods appropriately to:

a) collect appropriate and accurate data to generate evidence for nursing practice

b) inform and guide the design of databases that generate meaningful evidence for nursing practice

c) analyze data from practice

d) design evidence-based interventions

e) predict and analyze outcomes

f) examine patterns of behavior and outcomes

g) identify gaps in evidence for practice

6. Function as a practice specialist/consultant in collaborative knowledge-generating research.

7. Disseminate findings from evidence-based practice and research to improve healthcare outcomes (AACN, DNP Essentials, 2008)

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Nurse Practitioner Core Competencies Content (NONPF)-2014

Scientific Foundation Competency

Critically analyzes data and evidence for improving advanced nursing practice.

Quality Competency

Uses best available evidence to continuously improve quality of clinical practice.

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Nurse Practitioner Core Competencies Content (NONPF)-2014

Practice Competencies

1) Provides leadership in the translation of new knowledge into practice.

2) Generates knowledge from clinical practice to improve practice and patient outcomes.

3) Analyzes clinical guidelines for individualized application into practice

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Evidence-based practice (EBP) is the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision-making (Sackett, Straus, Richardson, Rosenberg, & Haynes,

2000).

Defining Evidence-Based Practice

Defining Evidence-Based Practice

A paradigm and life long problem solving approach to clinical decision making that involves the

conscientious use of the best available evidence (including a systematic search for and critical

appraisal of the most relevant evidence to answer a question) with one’s own clinical expertise and

patient values and preferences to improve outcomes for individuals, groups, communities, and systems

(Melnyk & Fineout-Overholt).

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Cautions Concerning Evidence-based Practice

Narrow views of what counts as evidence

Over emphasis on standardization denies focus on the human experience

Concerns about implementation that denies patient participation

Concerns about the loss of theory-practice link being replaced by EBP

EBP should be a shared institutional activity, not placed on the individual level

EBP needs to be situated within a nursing philosophy-science context

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Evidence-Based Practice as

Nursing Praxis

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Evidence-Based Practice as Praxis

Praxeis is a Greek term used by Aristotle to Marxist philosophers of science to describe the integration

of theory with practice.

Butcher, H.K. (2006). Unitary pattern-based praxis: A nexus of Rogerian cosmology, philosophy, and science. Visions: The Journal of Rogerian Nursing Science, 14 (2), 8-33.

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Marx believed praxis was ultimate harmony of theory and practice ---theoria and praxis--- not in

the sense that philosophy guides action, but rather in the sense that philosophy is the

comprehension of what is

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In the broadest sense, praxis refers to practical human conduct that can be can be

artistic, ethical, and scientific.

Butcher, H.K. (2006). Unitary pattern-based praxis: A nexus of Rogerian cosmology,

philosophy, and science. Visions: The Journal of Rogerian Nursing Science, 14

(2), 8-33.

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A synthesis of

theory/research/practice/ethics/aesthetics

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Evidence-based Practice and Practice-based Evidence

Practice is the experiences the nurse encounters during the process of caring for others

Practice based evidence acknowledges the importance of the environment of practice to determine practice recommendations

Practice based evidence values knowledge that is generated from practice as compared to knowledge that conforms to hierarchies of evidence that is created apart from the context of practice (Chinn & Kramer)

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The Role of Theory and Evidence-Based Practice

Conscientious, explicit, and judicious use of

theory-driven, research based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and

preferences (Ingersoll, 2000)

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The Role of Theory and Evidence-Based Practice

Advanced Practice Nursing needs to be designed

to strengthen the linkages between theory, research, and practice in a way that supports

evidence-based practice (Chinn & Kramer

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Sources of Knowledge used as Evidence

Tenacity (tradition)

Authority

A priori (intuition or common sense)

Personal, ethical, aesthetic, sociopolitical knowing

Empirics (theory-research)

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“Evidence” in evidence-based practice should be considered to be knowledge derived from a variety of sources that has been subjected to testing and has

found to be credible

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AN INCLUSIVE PANDIMENSIONAL VIEW OF WHAT COUNTS AS EVIDENCE

Pandimensional Sources of

Evidence Research (Qual and Quant)

Experience (Practical, Craft Knowledge, Intuition, Tacit)

Patients/clients/caregivers (individual/family experiences, values, preferences)

Local context and environment (audit and performance data patient stories and narratives knowledge about the culture of the organization and individuals within it social and professional networks

information from feedback, i.e. feedback from the fullest possible constituency of stakeholders local and national policy) Rycroft-Malone, Jo ; Seers, Kate ; Titchen, Angie ; Harvey, Gill ; Kitson, Alison ; Mccormack, Brendan(2004). What counts as evidence in

evidence-based practice? Journal of advanced nursing, 47(1),.81-90.

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Defining Evidence-Based Praxis (Emphasis on Theory)

Theories are evidence

Practice must be theory-based

Practice must be evidence-based

Evidence in the form of theory guides practice

Evidence is generated by theory based research (a systematic,

formal, rigorous process)

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“Nursing theory is the vehicle used to operationalize a disciplinary perspective by framing human health experiences in the core assumptions, beliefs, and

concepts of the profession.”

Butcher, H.K. (2011). Creating the Nursing Theory-Research-Practice Nexus. In P. Cowen & S. Moorhead (Eds.), Current issues in nursing (8th Edition) (pp. 123-135). St. Louis: Mosby Elsevier.

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What Type of Theory (Empirical Knowledge) to Use as

Evidence-Based Nursing Praxis

Evidence-based Nursing Praxis is Embedded Withinin a Nursing Lens

Nursing Philosophy (Holism-Humanism)

Ways of Knowing (Empirics, Aesthetics, Ethical, Personal, Sociopolitical)

Nursing’s Metaparadigm (Person-Environment-Health-Caring-Transitions)

Paradigms: (Simultaneity and Totality)

Nursing Conceptual Frameworks

Mid Range Nursing Theories

Nursing Practice Models (Nursing Process, OPT Model)

Nursing Classification Systems (NANDA-NIC-NOC)

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Butcher, H. K. (2004). Nursing's distinctive knowledge base. In L. Haynes, H. K. Butcher, & T. Boese (Eds), Nursing in contemporary society: Issues, trends and transition into practice (pp. 71-103). Boston: Prentice Hall.

A Pandimensional View of What Counts as Evidence

Aesthetic knowledge as a Source for Evidence –authentication of artistic practices through appreciation and inspiration

Personal knowledge as a Source of Evidence authenticated through self examination using aesthetic inquiry (self-reflection, personal stories, and journaling)

Ethical knowledge as a source of evidence authenticated through ethical inquiry (dialogue, and justification)

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What Type of Empirical Theories to Use in Evidence-Based Nursing Praxis

Nursing Conceptual Models

Mid-Range Theories Derived for Nursing Conceptual Models

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“To avoid further fragmentation of nursing knowledge, middle-range theory development should be connected to the theoretical, conceptual, and

philosophical systems of nursing”

Butcher, H.K. (2011). Creating the Nursing Theory-Research-Practice Nexus. In P. Cowen & S. Moorhead (Eds.), Current issues in nursing (8th Edition) (pp. 123-135). St. Louis: Mosby Elsevier.

What Type of Theory to Use as Evidence-Based Nursing Praxis

Empirical nursing theories

Descriptive

Explanatory

Predictive

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Other Types of Nursing Theories used to Guide Evidenced-based Nursing Praxis

Aesthetic Nursing Theories

Ethical Nursing Theories

Nursing Theories of Personal Knowing

Sociopolitical Nursing Theories-Emancipatory

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Chinn, P.L., & Kramer, M.K. (2015). Knowledge development in nursing (9th Edition). St. Louis: Elsevier Mosby.

“Evidence-based practice protocols need to be conceptually linked to the extant conceptual

frameworks of the discipline and integrated with nursing’s classification systems. Then, evidence-

based practice becomes synonymous with theory-

based practice.”

Evidence-Based Nursing Praxis

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Butcher, H.K. (2011). Creating the Nursing Theory-Research-Practice Nexus.

In P. Cowen & S. Moorhead (Eds.), Current issues in nursing (8th Edition)(pp. 123-135).

St. Louis: Mosby Elsevier.

Nurses must transform healthcare by leading interprofessional teams to improve delivery systems, achieve improved patient

desired outcomes, and affect quality healthcare requires the use of EBP to

enhance clinical decision making (Future of Nursing, Institute of Medicine, 2011).

EBP guidelines are systematically developed statements to assist a health care providers

make and patient decisions about appropriate heath care for specific health-

illness conditions or circumstances.

Guidelines usually are created in the form of protocols or evidenced-based guidelines that

convert scientific knowledge into clinical actions in a form that is available to clinicians. Guidelines describe a process of patient care management that has the potential to improve the quality of

clinical and consumer decision-making.

The EBP guideline includes recommendations intended to optimize

patient care informed by systematic reviews or critical appraisal of the

research evidence supporting assessment and treatment recommendations.

1) Nursing care specific; 2) Focusing primarily on topics which are significant issues, patient conditions, or treatments experienced by older adults in long term care settings; 3) Including an in-depth overview of the topic; 4) Including systematic literature search and appraisal of the research evidence supporting assessment and treatment recommendations;

EVIDENCED-BASED GUIDELINES

5) rating the level of evidence for assessment and treatment recommendations; 6) including a list of major standardized nursing interventions (NIC) and nursing outcomes (NOC) related to the topic; 7) including tools to evaluate of the implementation of the guideline; 8) including standardized assessment and evaluation tools in the appendices; 9) including a Quick Reference Guide (QRG) for rapid at the point of care use; and 10) being downloadable in an electronic and navigable PDF format for Android and OS devices, as well as desktop and portable computers

1. Acute Pain Management in the Older Adult 2. Assessing Heart Failure in Long Term Care Facilities 3. Bathing Persons with Dementia 4. Changing the Practice of Physical Restraint Use In Acute Care 5. Delirium 6.Detection and Assessment of Late Life Anxiety

Available Guidelines

www.iowanursingguidelines.com

6. Detection and Assessment of Late Life Anxiety 7. Detection of Depression in Older Adults with Dementia 8. Detection of Depression in the Cognitively Intact Older Adult 9. Elder Abuse Prevention 10. Elderly Suicide: Secondary Prevention 11. Exercise Promotion: Walking in Elders 12. Fall Prevention For Older Adults


13. Family Preparedness and End Of Life Support Before The Death Of A Nursing Home Resident 14. Family Involvement in Care for Persons with Dementia (FIC) 15. Guidelines for Writing Evidence-Base Practice Guidelines 16.Hydration Management 17. Identification, Referral, and Support of Elders with Genetic Conditions 18.Improving Medication Management for Older Adult Clients


19. Management of Constipation 20. Management of Relocation in Cognitively Intact Older Adults 21. Non-Pharmacologic Management of Agitated Behaviors in Persons with Dementia 22. Nursing Management of Hearing Impairment in Nursing Facility Residents 23. Nurse Retention 24. Oral Hygiene Care for Functionally Dependent and Cognitively Impaired Older Adults


25. Persistent Pain Management 26. Prevention of Deep Vein Thrombosis 27. Prevention of Pressure Ulcers 28. Progressive Resistance Training 29. Promoting Spirituality in the Older Adult 30. Prompted Voiding For Persons with Urinary Incontinence


31. Providing Spiritual Care to the Terminally Ill Older Adult 32. Quality Improvement in Nursing Homes 33. Treatment of Pressure Ulcers 34. Wandering 35. Wheelchair Biking for the Treatment of Depression


Example: Fall Prevention

Csomay Center EBP Guideline

• Appropriate and correct use of walking aids and other devices is a component of any fall intervention program for older adults (Agostini et al., 2001; AGS, 2010; Oliver et al., 2000, Evidence Grade = A).

• Note use of walking aids (e.g., canes, walkers, crutches, merrywalkers, etc.)

• Note use of other assistive technologies (e.g., wheelchairs, motorized scooters, etc.) (Nyberg & Gustafson, 1995; Vlahov et al., 1990, Evidence Grade = C).

• Note use of protective devices (e.g., hip protectors, helmets, etc.)

• Note use of footwear with respect to functionality such as slippery soles and how well they fit (Arnadottir & Mercer, 2000, Evidence Grade = C).

• Assess assistive and protective devices for proper fitting and signs of wear or damage.

• Assess correct use of walking aids, assistive technologies, and protective devices.

Csomay Center Criteria for

Level of Evidence

EBP guidelines embody the integration of scientific research evidence, combining the research evidence with clinical experience

for the achievement of optimal patient outcomes and quality of life. Currently few

EBP guidelines incorporate standardized nursing languages.

NIC intervention and NOC

outcomes can [DO] provide

appropriate foundations for

evidence-based guidelines

(Kautz & Van Horn, 2008)

“Evidence based practice guidelines are enhanced when NIC interventions are included as recommendations for effective

nursing treatments” (Butcher, Bulechek, Dochterman, Wagner, 2018).

NIC is a comprehensive, standardized

classification of interventions that nurses perform. The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care. An intervention is any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client.

NURSING INTERVENTION

CLASSIFICATION (NIC) DEFINITION

NNN and EBP Integration

NANDA-1: Risk for Falls (00155)

NIC: Fall Prevention (6490)

Fall Prevention 6490 Definition: Instituting special precautions with patient at risk for injury from falling Activities: • Identify cognitive or physical deficits of the patient that may increase

potential of falling in a particular environment • Identify behaviors and factors that affect risk of falls • Review history of falls with patient and family • Identify characteristics of environment that may increase potential for falls

(e.g., slippery floors and open stairways) • Monitor gait, balance, and fatigue level with ambulation • Ask patient for perception of balance, as appropriate • Share with patient observations about gait and movement • Suggest changes in gait to patient • Coach patient to adapt to suggested gait modifications • Assist unsteady individual with ambulation

• Provide assistive devices (e.g., cane and walker) to steady gait • Encourage patient to use cane or walker, as appropriate • Instruct patient about use of cane or walker, as appropriate • Maintain assistive devices in good working order • Lock wheels of wheelchair, bed, or gurney during transfer of patient • Place articles within easy reach of the patient • Instruct patient to call for assistance with movement, as appropriate • Teach patient how to fall as to minimize injury • Post signs to remind patient to call for help when getting out of bed, as

appropriate • Monitor ability to transfer from bed to chair and vice versa • Use proper technique to transfer patient to and from wheelchair, bed, toilet,

and so on • Provide elevated toilet seat for easy transfer • Provide chairs of proper height, with backrests and armrests for easy transfer • Provide bed mattress with firm edges for easy transfer

Activities:

• Use side rails of appropriate length and height to prevent falls from bed, as needed

• Place a mechanical bed in lowest position • Provide a sleeping surface close to the floor, as needed • Provide seating on bean bag chair to limit mobility, as appropriate • Place a foam wedge in seat of chair to prevent patient from arising, as

appropriate • Use partially-filled water mattress on bed to limit mobility, as appropriate • Provide the dependent patient with a means of summoning help (e.g., bell or

call light) when caregiver is not present • Answer call light immediately • Assist with toileting at frequent, scheduled intervals • Use a bed alarm to alert caretaker that individual is getting out of bed, as

appropriate • Mark doorway thresholds and edges of steps, as needed • Remove low-lying furniture (e.g., footstools and tables) that present a tripping

hazard

Activities:

• Avoid clutter on floor surface • Provide adequate lighting for increased visibility • Provide nightlight at bedside • Provide visible handrails and grab bars • Place gates in open doorways leading to stairways • Provide nonslip, nontrip floor surfaces • Provide a nonslip surface in bathtub or shower • Provide sturdy, nonslip step stools to facilitate easy reaches • Provide storage areas that are within easy reach • Provide heavy furniture that will not tip if used for support • Orient patient to physical “setup” of room • Avoid unnecessary rearrangement of physical environment • Ensure that patient wears shoes that fit properly, fasten securely, and have

nonskid soles • Instruct patient to wear prescription glasses, as appropriate, when out of bed • Educate family members about risk factors that contribute to falls and how

they can decrease these risks • Suggest home adaptations to increase safety • Instruct family on importance of handrails for stairs, bathrooms, and walkways • Assist family in identifying hazards in the home and modifying them

Activities:

Activities: • Suggest safe footwear • Instruct patient to avoid ice and other slippery outdoor surfaces • Develop ways for patient to participate safely in leisure activities • Institute a routine physical exercise program that includes walking • Post signs to alert staff that patient is at high risk for falls • Collaborate with other health care team members to minimize side effects of

medications that contribute to falling (e.g., orthostatic hypotension and unsteady gait)

• Provide close supervision and/or a restraining device (e.g., infant seat with seat belt) when placing infants/young children on elevated surfaces (e.g., table and highchair)

• Remove objects that provide young child with climbing access to elevated surfaces

• Maintain crib side rails in elevated position when caregiver is not present, as appropriate

• Provide a “bubble top” on hospital cribs of pediatric patients who may climb over elevated side rails, as appropriate

• Fasten the latches securely on access panel of incubator when leaving bedside of infant in incubator, as appropriate

1st edition 1992; revised 2000, 2004

Background Reading: Foley, G. (1999). The multidisciplinary team: Partners in patient safety. Cancer Practice, 7(3), 108. Kanak, M. F. (1992). Interventions related to safety. In G. M. Bulechek & J. C. McCloskey (Eds.), Symposium on nursing interventions. Nursing Clinics of North America, 27(2), 371-396. Maciorowski, L. F., Monro, B. H., Dietrick-Gallagher, M., McNew, C. D., Sheppard-Hinkel, E., Wanich, C., & Ragan, P. A. (1989). A review of the patient fall literature. Journal of Nursing Quality Assurance, 3(1), 18-27. Stolley, J. M., Lewis, A., Moore, L., & Harvey, P. (2001). Risk for injury: Falls. In M. Maas, K. Buckwalter, M. Hardy, T. Tripp-Reimer, M. Titler, & J. Specht (Eds.), Nursing care of older adults: Diagnoses, outcomes, and interventions (pp. 23-33). St. Louis: Mosby. Sullivan, R. P. (1999). Recognize factors to prevent patient falls. Nursing Management, 30(5), 37-40. Tack, K. A., Ulrich, B., & Kehr, C. (1987). Patient falls: Profiles for prevention. Journal of Neuroscience Nursing, 19(2), 83-89. Tideiksaar, R. (1997). Falling in old age: Prevention and management. New York: Springer

Vision of the Future

of EBP Guideline Development

Nursing Situation

NANDA-1

Evidenced Based NIC/Activities (level

of evidence)

Evidenced based NOC/Indicators

linked to NICs (level of evidence)

Howard K. Butcher, RN; PhD

Associate Professor

The University of Iowa

College of Nursing

Iowa City, Iowa 52242 USA

319-335-7039

[email protected]

Contact Information

evidenced-based practice at the advance · advanced nursing practice clinic the dnp is intended for...

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