Download NSG6006 Study Guide-comprehensive.docx and more Exams Nursing in PDF only on Docsity!
NSG6006 Study Guide-
comprehensive
Policies & Practice Standards • State Nurse Practice Act
NSG6006 Study Guide 5000 (Roles)
- _History and Developmental Aspects of Advanced Practice Nursing
- Definition of advanced practice nurse (APN) - A nurse who has completed an accredited graduate-level education program preparing her or him for the role of certified nurse practitioner, certified registered nurse anesthetist, certified nurse- midwife, or clinical nurse specialist; has passed a national certification examination that measures the APRN role and population-focused competencies; maintains continued competence as evidenced by recertification; and is licensed to practice as an APRN involves advanced nursing knowledge and skills; it is not a medical practice, although APNs perform expanded medical therapeutics in many roles
- History of APN movement History and evolution of nursing science Knowledge development APN Roles CNSs have a strong and tumultuous history. Over the past 20 years, the departure from direct patient care as being a main focus to working predominantly in the nursing education and systems improvement domains has created confusion within nursing and the public because non- CNSs (e.g., nurse educators, quality improvement managers) function in the same capacity. However, CNSs are uniquely educated to provide advanced practice and specialist expertise when working directly with complex and vulnerable patients, educating and supporting interdisciplinary staff, and facilitating change and innovation in health care systems that those in other roles in health care cannot. As health care reform continues to gain momentum to improve the health care system, there will be many new opportunities for CNSs. As masters of flexibility and creativity, CNSs can develop new roles to meet the needs of patients and health care systems. For example, in nurse- managed clinics, perhaps NPs could deliver the primary care to patients in the management of hypertension. Once first- or second-line therapies or interventions are found to be ineffective, a referral could be placed to the cardiovascular CNS for specialized pharmacologic and nonpharmacological treatment. Also, the cardiovascular CNS could integrate the latest evidence to create educational materials for patients and other health care professionals. Perhaps a CNM who is caring for a pregnant woman who develops gestational diabetes, preeclampsia, and is in breech position could ask the perinatal CNS to commonage the patient by following the patient and fetus or neonate in the prenatal setting through hospital discharge into the postpartum phase. The perinatal CNS could establish interagency processes to facilitate care delivery across practice settings to provide seamless transitions of care. The possibilities are endless if CNSs understand their role, improve understanding of the importance of this role in advanced practice nursing, and maximize the driving forces and minimize the restraining forces in the health care system. Primary care is the foundation of the evolving U.S. health care system. If access to primary care for all is the goal, while containing costs and focusing on quality outcomes, then NPs will be crucial to achieving these aims. In our current system, there just aren't enough PCPs to meet the need and, with an additional estimated 32 million more people who will be covered and need access to full primary care, based on the PPACA, we will need additional providers more than ever. Physicians are not choosing primary care practice for complex reasons. On the other
hand, most NPs choose primary care practice roles (e.g., family, adult, and pediatric NPs) because they enter these programs specifically to provide primary care. Two areas in particular must be addressed before NPs will be able to contribute fully to primary care delivery nationwide:
- There must be changes in the outdated state scope of practice laws and regulations of nurse practitioners. This is because the variation in state regulations on scope of practice and prescribing authority has been a major barrier to using NPs fully and providing increased access to quality, cost-efficient primary care.
- There must be substantive changes in health professional education to foster true collaboration and teamwork among physicians, NPs, and other health care disciplines in general to obtain the full benefit of diverse competencies inherent in a team.
system. Nurse anesthesia, the earliest nursing specialty, was also the first nursing specialty to have standardized educational programs, a certification process, mandatory continuing education, and recertification. Nurse anesthetists have been involved in the development of anesthetic techniques along with physicians and engineers. CRNAs have been nursing leaders in obtaining third-party reimbursement for professional services and in coping with challenges such as the prospective payment system, managed care, and physician supervision. Nurse anesthetists provide surgical and
nonsurgical anesthesia services in a variety of settings in the United States and other parts of the world. CRNAs work collaboratively with physicians, as do other APNs, and are capable of providing the full spectrum of anesthesia services. Activism at the state and federal legislative and regulatory levels is a recognized CRNA activity. Increasing coalition building among nurse anesthetists, other APNs, and nursing educators is congruent with a shared nursing vision. This vision values health care for all Americans, provided in a safe and cost-effective manner by APNs collaborating with other health care professionals. John F. Garde was a distinguished health care leader who served as AANA Executive Director from 1983 to 2001, and again on an interim basis from February 2009 until his untimely death in July 2009. A statement of his holds true today (Garde, 1998, p. 15): The profession has an optimistic future. I point out with pride the commitment that AANA members have toward the future of their profession—a commitment that encompasses being outstanding anesthesia practitioners who belong to their Association. I am reminded, too, what Dick Davidson, President of the American Hospital Association, said when asked about what will remain in health care 100 years from now: ‘There will always be personal contact and caring. We will always have hands touching patients. Everything we do is about human need. That's the constant over time.’ And, that is the legacy of the nurse anesthesia profession. SCOPE OF PRACTICE scope of practice describes practice limits and sets the parameters within which nurses in the various advanced practice nursing specialties may legally practice. Scope statements define what APRNs can do for and with patients, what they can delegate, and when collaboration with others is required. Scope of practice statements tell APRNs what is actually beyond the limits of their nursing practice (American Nurses Association [ANA], 2003, 2012; Buppert, 2012; Kleinpell, Hudspeth, Scordo, et al., 2012). The scope of practice for each of the four APRN roles differs (see Part III). Scope of practice statements are key to the debate about how the U.S. health care system uses APRNs as health care providers; scope is inextricably linked with barriers to advanced practice nursing. CRNAs, who administer general anesthesia, have a scope of practice markedly different from that of the primary care nurse practitioner (NP), for example, although both have their roots in basic nursing. In addition, it is important to understand that scope of practice differs among states and is based on state laws promulgated by the various state nurse practice acts and rules and regulations for APRNs (Lugo, O'Grady, Hodnicki, et al., 2007, 2009; NCSBN, 2012; Pearson, 2012). On the Internet, scope of practice statements can be found by searching state government websites in the areas of licensing boards, nursing, and advanced practice nursing rules and regulations, or by visiting the NCSBN site (www.ncsbn.org). Recent federal policy initiatives, including the IOM Future of Nursing Report, (2011). the PPACA (HHS, 2011), and the Josiah Macy Foundation (Cronenwett & Dzau, 2010) have all issued recom mendations with important implications for expanding the scope of practice for APRNs. The National Health Policy Forum (http://www.nhpf.org/library/background- papers/BP76_SOP_07-06- 2010.pdf) and Citizen Advocacy Center (https://www.ncsbn.org/ReformingScopesofPractice-WhitePaper.pdf) reports state firmly that current scope of practice adjudication is far too technical, subject to political pressure, and therefore not appropriate in the legislative sphere. There must be a more powerful forum so that the public can enter into the dialogue (see Chapter 22). As scope of practice expands, accountability becomes a crucial factor as APRNs obtain more authority over their own practices. First, it is important that scope of practice statements identify the legal parameters of each APRN role. Furthermore, it is crucial that scope of practice statements presented by national certifying entities are carried through in language in state statutes (Buppert, 2012). Our society is highly mobile and APRNs must recognize that their scope of practice will vary among states; in a worst case scenario, one can be an APRN in one state but not meet the criteria in another state.
- Throughout the century, APNs have been permitted by organized medicine and
- The efforts of national professional organizations, national certification, and the move toward graduate education as a requirement for advanced practice have been critical to enhancing the credibility of advanced practice nursing.
- Intraprofessional and interprofessional resistance to expanding the boundaries of the nursing discipline continue to recur.
- Societal forces, including wars, the economic climate, and health care policy, have influenced APN history. _- Scope of practice cont. The term scope of practice refers to the legal authority granted to a professional to provide and be reimbursed for health care services. The ANA (2010) defined the scope of nursing practice as “ The description of the who, what, where, when, why, and how of nursing practice.” This authority for practice emanates from many sources, such as state and federal laws and regulations, the profession's code of ethics, and professional practice standards. For all health care professionals, scope of practice is most closely tied to state statutes; for nursing in the United States, these statutes are the nurse practice acts of the various states. As previously discussed, APN scope of practice is characterized by specialization, expansion of services provided, including diagnosing and prescribing, and autonomy to practice (NCSBN, 2008). The scopes of practice also differ among the various APN roles; various APN organizations have provided detailed and specific descriptions for their particular role. Carving out an adequate scope of APN practice authority has been an historic struggle for most of the advanced practice groups (see Chapter 1) and this continues to be a hotly debated issue among and within the health professions. Significant variability in state practice acts continues, such that APNs can perform certain activities in some states, notably prescribing certain medications and practicing without physician supervision, but may be constrained from performing these same activities in another state (Lugo, O'Grady, Hodnicki, & Hanson, 2007). The Consensus Model's proposed regulatory language can be used by states to achieve consistent scope of practice language and standardized APRN regulation (NCSBN, 2008). A scope of practice is a state-based legal framework (i.e., statutes, codes, and regulations) that defines who is authorized to provide clearly delineated services, to whom and under what circumstances those services can be provided, and who can be reimbursed for those services. All health professions have an autonomous domain of practice and a delegated authority within the medical domain (Lyon, 2004). The autonomous domain of nursing practice “encompasses the diagnosis of health conditions (e.g., nursing diagnoses) that are amenable to nursing interventions [and] therapeutics, the implementation of interventions, and evaluation of the effectiveness of nursing interventions [and] therapeutics” (Lyon, 2004, p. 9). Historically, the medical profession developed a broad, overarching scope of practice that encompassed almost all health care activities (see Chapter 1; Safriet, 2010). As a consequence, other health professionals (e.g., nurses, physical therapists, pharmacists) have had to carve out their scopes of practice out of the medical scope of practice. The ANA's restrictive 1955 definition of nursing reinforced the practice of nursing as having independent functions and being dependent on and delegated to by the profession of medicine. It also prohibited nurses from diagnosing and prescribing. By definition, the term scope of practice describes practice limits and sets the parameters within which nurses in the various advanced practice nursing specialties may legally practice. Scope statements define what APRNs can do for and with patients, what they can delegate, and when collaboration with others is required. Scope of practice statements tell APRNs what is actually beyond the limits of their nursing practice (American Nurses Association [ANA], 2003, 2012; Buppert, 2012; Kleinpell, Hudspeth, Scordo, et al., 2012). The scope of practice for each of the four APRN roles differs (see Part III). Scope of practice statements are key to the debate about how the U.S. health care system uses APRNs as health care providers; scope is inextricably linked with barriers to advanced practice nursing. CRNAs, who administer general anesthesia, have a scope of practice markedly different from that of the primary care
nurse practitioner (NP), for example, although both have their roots in basic nursing. In addition, it is important to understand that scope of practice differs among states and is based on state laws promulgated by the various state nurse practice acts and rules and regulations for APRNs (Lugo, O'Grady, Hodnicki, et al., 2007, 2009; NCSBN, 2012; Pearson, 2012). On the Internet, scope of practice statements can be found by searching state government websites in the areas of licensing boards, nursing, and advanced practice nursing rules and regulations, or by visiting the NCSBN site (www.ncsbn.org). Recent federal policy initiatives,
education. It also advocated standardizing nursing licensure and national certification and developed a model nurse practice law suitable for national application. In addition, the committee called for further research related to cost-benefit analyses and attitudinal surveys to assess the impact of the NP role (HEW, 1972). This report resulted in increased federal support for training programs for the preparation of several types of NPs, including family NPs, adult NPs, and emergency department NPs.
he 1960s are most often noted as the decade in which clinical nurse specialization took its modern form. Peplau (1965) contended that the development of areas of specialization is preceded by three social forces: (1) an increase in specialty-related information; (2) new technologic advances; and (3) a response to public need and interest. In addition to shaping most nursing specialties, these forces had a particularly strong effect on the development of the psychiatric CNS role in the 1960s. The Community Mental Health Centers Act of 1963, as well as the growing interest in child and adolescent mental health care, directly enhanced the expansion of that role in outpatient mental health care. CNSs have a strong and tumultuous history. Over the past 20 years, the departure from direct patient care as being a main focus to working predominantly in the nursing education and systems improvement domains has created confusion within nursing and the public because non-CNSs (e.g., nurse educators, quality improvement managers) function in the same capacity. However, CNSs are uniquely educated to provide advanced practice and specialist expertise when working directly with complex and vulnerable patients, educating and supporting interdisciplinary staff, and facilitating change and innovation in health care systems that those in other roles in health care cannot. As health care reform continues to gain momentum to improve the health care system, there will be many new opportunities for CNSs. As masters of flexibility and creativity, CNSs can develop new roles to meet the needs of patients and health care systems. For example, in nurse- managed clinics, perhaps NPs could deliver the primary care to patients in the management of hypertension. Once first- or second-line therapies or interventions are found to be ineffective, a referral could be placed to the cardiovascular CNS for specialized pharmacologic and nonpharmacologic treatment. Also, the cardiovascular CNS could integrate the latest evidence to create educational materials for patients and other health care professionals. Perhaps a CNM who is caring for a pregnant woman who develops gestational diabetes, preeclampsia, and is in breech position could ask the perinatal CNS to comanage the patient by following the patient and fetus or neonate in the prenatal setting through hospital discharge into the postpartum phase. The perinatal CNS could establish interagency processes to facilitate care delivery across practice settings to provide seamless transitions of care. The possibilities are endless if CNSs understand their role, improve understanding of the importance of this role in advanced practice nursing, and maximize the driving forces and minimize the restraining forces in the health care system. o Nurse practitioner (primary care; acute care) 1985 The idea of using nurses to provide what we now refer to as primary care services dates to the late nineteenth century. During this period of rapid industrialization and social reform, public health nurses played a major role in providing care for poverty-stricken immigrants in cities throughout the country. In 1893, Lillian Wald, a young graduate nurse from the New York Training School for Nurses, established the Henry Street Settlement (HSS) House on the Lower East Side of Manhattan. Its purpose was to address the needs of the poor, many of whom lived in overcrowded, rat-infested tenements. For several decades, the HSS visiting nurses, like other district nurses, visited thousands of patients with little interference in their work (Wald, 1922). The needs of this disadvantaged community were limitless. According to one account (Duffus, 1938): most NPs choose primary care practice roles (e.g., family, adult, and pediatric NPs) because they enter these programs specifically to provide primary care. As with other advanced practice roles, direct clinical practice is the foundation of the work of the primary care NP, which unfolds around the premise that individuals seek care for a broad range of health care concerns over time and across the life span. Relationships evolve over time, which facilitates a sense of mutual respect and trust. In that relationship, a deep understanding of the patient's life and the meaning of the illness or health issue at hand develops. Knowing patients and their family members, their jobs and careers, and their challenges in raising children and caring for aging parents is part of accompanying patients through the transitions of life
Association of American Medical Colleges decried the shortage of physicians in poor rural and urban areas” (Fairman, 2002, p. 163). At the same time, consumers across the nation were demanding accessible, affordable, and sensitive health care while health care delivery costs were increasing at an annual rate of 10% to 14% (Jonas, 1981). o Certified nurse midwife- 1955 Throughout the eighteenth and nineteenth centuries, lay midwives, rather than professional nurses or physicians, assisted women in childbirth. Midwives who were brought to the United States with the slave trade in 1619, and others who arrived later with waves of European immigration, were respected community members. In the late nineteenth and early twentieth centuries however, these untrained midwives would lose respect as scientific, hospital-based deliveries became the norm. Meanwhile, women in isolated communities throughout the country, particularly in rural settings, continued to employ lay midwives for deliveries well into the twentieth century. In the early twentieth century, national concern about high maternal-infant mortality rates led to heated debates surrounding issues of midwife licensing and control; lay midwives would soon be blamed for the high maternal and infant mortality rates that plagued the United States. In 1914, Dr. Frederick Taussig, speaking at the annual meeting of the National Organization of Public Health Nursing (NOPHN) in St. Louis, proposed that the creation of “nurse-midwives” might solve the “midwife question” and suggested that nurse-midwifery schools be established to train graduate nurses (Taussig, 1914). Later in the decade, the Children's Bureau called for efforts to instruct pregnant women in nutrition and recommended that public health nurses teach principles of hygiene and prenatal care to so- called granny midwives (Rooks, 1997) There are many different settings in which a CNM may practice. A CNM may engage in full-scope practice, which can include care of women from adolescence though the postmenopausal period. She or he may also choose one segment of practice—for example, ambulatory care or hospital care—or work exclusively with a population of interest, such as HIV-positive women or young adolescents. Nurse-midwives practice in urban, suburban, and rural areas. Their practice settings can include private practice (nurse-midwife— owned or physician- owned), hospitals, free-standing birth centers, clinics, or homes. Nurse-midwifery practice can be part of a group practice, with any combination of physicians, nurse- practitioners, physician assistants, or other health care providers, or solo practice. The nurse-midwife's actual practice depends on the needs of the population being served, willingness to undertake a variety of functions or roles, particular requests of patients, availability of physicians and nurse-midwife colleagues for backup and coverage and, finally, personal and philosophical beliefs of the individual midwife (Ament, 2007). A nurse-midwife—assisted birth can take place in homes, free-standing birth centers, birth centers in hospitals, or traditional hospital settings (community, regional, or tertiary). For nurse-midwives and the women for whom they provide care, the choice of setting may be a matter of philosophy, comfort, convenience, or degree of medical risk, or a combination of these factors. Each setting has unique advantages and disadvantages. Home births are very family-centered. Risks of iatrogenic and nosocomial infections are minimized. After the birth, the woman can rest or sleep in her own bed, nurse her infant at will, and enjoy the attention and support of her family and friends. A study by Hutton and coworkers (2009) documented the outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario Canada. The rate of perinatal and neonatal mortality was very low for both groups (0.1%), and no between-group differences in morbidity or mortality were noted. Access to emergency transfer is critical to safe care and good outcomes, as is an integrated maternity care system with excellent communication among providers (Home Birth Consensus Summit, 2011). Analgesia and regional anesthesia are not available in the home setting. The free-standing birth center has a homelike environment, with some select emergency equipment. Most birth centers do not use analgesics or narcotics. Local anesthesia may be used for perineal repair. Disadvantages are similar to those of a home birth in that
emergency transport to a hospital may be necessary if the mother or baby develops complications during labor or birth. Most families are discharged within 6 to 12 hours of birth. Current U.S. hospital units for labor and birth tend to be dual-purpose rooms; women labor and give birth in the same room, and almost all rooms are private. The room has a rocking chair, pull-out couch, and private bath, with a tub or shower. Although individual and nicely appointed, these rooms are part of the larger medical environment, with fetal monitoring, operating rooms, anesthesia services, and
has also broadened to include nurses with specialties such as informatics, administration, and public health. See Chapter 3 for further discussion of DNP education for non- APNs.) Moreover, the proposed curriculum for DNPs would include competencies deemed essential for nursing practice in the twenty-first century, including the following: (1) scientific underpinnings for practice; (2) organizational and systems leadership; (3) clinical scholarship and analysis for evidence-based practice; (4) information systems technology; (5) health care policy; (6)
interprofessional collaboration; and (7) clinical prevention and population health (AACN, 2006). Although it is too early to evaluate this initiative from a historical perspective, the national dialogue to move APN education to a practice doctorate offers significant opportunity for the profession to connect scientific evidence and practice (Magyary, Whitney, & Brown, 2006). Expanded educational preparation could position APNs to be vital players in the translation of research evidence at the point of care, help nursing education achieve parity with physician education, and potentially decrease interprofessional tensions.
- Core competencies of practice- 1- Although clinical expertise is a central ingredient of an APN's practice, the direct care practice of APNs is distinguished by six characteristics: (1)use of a holistic perspective; (2)formation of therapeutic partnerships with patients; (3) expert clinical performance; (4)use of reflective practice; (5)use of evidence as a guide to practice; and (6)use of diverse approaches to health and illness management 2-Guidance and coaching 3-Consultation 4-Evidence-based practice 5-Leadership 6- Collaboration 7- Ethical decision making
- _ Fenton and Brykczynski’s Expert Practice Domains The seven domains are as follows ( Benner, 1984): 1-the helping role, 2-administering and monitoring therapeutic interventions and regimens 3-effective management of rapidly changing situations 4-diagnostic and monitoring function 5-teaching and coaching function 6-monitoring and ensuring the quality of health care practices 7-organizational and work role competencies.
- _ Practice environments, regulation, reimbursement Later in the decade, with the new requirement that CRNAs have a master's degree, the number of nurse anesthesia education programs declined significantly, largely because of the closure of many small certification programs. However, the new requirement that programs offer a graduate degree did, in fact, promote nurse anesthesia eduction. In 1973, the University of Hawaii opened the first master's degree program for nurse anesthesia, moving the role forward in the evolving criteria of advanced practice nursing. Reimbursement for CRNA practice was not as clear-cut. In fact, third- party payment had its own set of issues. Beginning in 1977, the AANA led a long and complex effort to secure third-party reimbursement under Medicare so that CRNAs could bill for their services. The organization would finally succeed in 1989. Meanwhile, the financial threat posed by CRNAs to physicians was the source of continued interprofessional conflicts with medicine. During the second half of the twentieth century, tensions escalated, particularly in relation to malpractice policies, antitrust, and restraint of trade issues. In 1986, Oltz v. St. Peter's Community Hospital established the right of CRNAs to excellence in direct clinical practice
The creation of the National Association of Clinical Nurse Specialists (NACNS), followed by third- party reimbursement for their services, represented two major steps for the CNS. NACNS was formed In 1995, promoting organization of the role at the national level. Soon thereafter, in 1997, the Balanced Budget Act (Public Law 105-33) specifically identified the CNS as eligible for Medicare reimbursement (Safriet, 1998). The law, providing Medicare Part B direct payment to NPs and CNSs, regardless of their geographic area of practice, allowed both types of APNs to be paid 85% of the fee paid to physicians for the same services. Moreover, the law's inclusion and definition of CNSs corrected the previous omission of this group for reimbursement (Safriet, 1998). The possibility of reimbursement for services was an important step in the continuing development of the CNS role because hospital administrators would continue to focus on the cost of having APNs provide patient care. Some CNS roles require prescription of medications and the ability of a CNS to prescribe depends on state regulations. As of January 2012, CNSs have independent prescriptive authority in 11 states and in Washington, DC, no prescribing authority in 15 states, and nonindependent prescriptive authority in the remaining 24 states (National Council of State Boards of Nursing, 2012). NPs worked outpatient clinics, health maintenance organizations, health departments, community health centers, rural clinics, schools, occupational health clinics, and private offices_
- _Dreyfus & Dreyfus: Development of the APN role-novice to expert theory (add theories and models) Acquisition of knowledge and skill occurs in a progressive movement through the stages of performance from novice to expert, as described by Dreyfus and Dreyfus (1986, 2009), who studied diverse groups, including pilots, chess players, and adult learners of second languages. The skill acquisition model has broad applicability and can be used to understand many different skills better, ranging from playing a musical instrument to writing a research grant. The most widely known application of this model is Benner's (1984) observational and interview study of clinical nursing practice situations from the perspective of new nurses and their preceptors in hospital nursing services. Although this study included several APNs, it did not specify a particular education level as a criterion for expertise. As noted in Chapter 3, there has been some confusion about this criterion. The skill acquisition model is a situation-based model, not a trait model. Therefore, the level of expertise is not an individual characteristic of a particular nurse but is a function of the nurse's familiarity with a particular situation in combination with his or her educational background. This model could be used to study the level of expertise required for other aspects of advanced practice, including guidance and coaching, consultation, collaboration, evidence-based practice ethical decision making, and leadership (see Brykczynski [2009] for a detailed discussion of the Dreyfus model). The overall trajectory expected during APN role development is shown in Figure 4-1; however, each APN experiences a unique pattern of role transitions and life transitions concurrently. For example, a professional nurse who functions as a mentor for new graduates may decide to pursue an advanced degree as an APN. As an APN graduate student, she or he will experience the challenges of acquiring a new role, the anxiety associated with learning new skills and practices, and the dependency of being a novice. At the same time, if this nurse continues to work as a registered nurse, his or her functioning in this work role will be at the competent, proficient, or expert level, depending on experience and the situation. On graduation, the new APN may experience a limbo period, during which the nurse is no longer a student and not yet an APN, while searching for a position and meeting certification requirements (see later). Once in a new APN position, this nurse may experience a return to the advanced beginner stage as he or she proceeds through the phases of role implementation. Even after making the transition to an APN role, progression in role implementation is not a linear process. As Figure 4-1 indicates, there are discontinuities, with movement back and forth as the trajectory begins again. Years later, the APN may decide to pursue yet
another APN role. The processes of role acquisition, role implementation, and novice to expert skill development will again be experienced—although altered and informed by previous experiences —as the postgraduate student acquires additional skills and knowledge. Role development involves multiple, dynamic, and situational processes, with each new undertaking being characterized by passage through earlier transitional phases and with some movement back and forth, horizontally or
