Dunphy and Winland-Brown’s Circle of Caring: A Transformative, Collaborative Model
A central premise of Dunphy and Winland-Brown’s model (1998) is that the health care needs of individuals, families, and communities are not being met in a health care system dominated by medicine in which medical language (i.e., the International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM] codes) is the basis for reimbursement. They proposed the Circle of Caring to foster a more active and visible nursing presence in the health care system and to explain and promote medical-nursing collaboration. Dunphy and Winland-Brown’s transformative model (Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011; Fig. 2.12) is a synthesized problem-solving approach to advanced practice nursing that builds on nursing and medical models (Dunphy & Winland-Brown, 1998).
Dunphy and Winland-Brown’s Circle of Caring: A Transformative, Collaborative Model
Primary care: The art and science of advanced practice nursing [3rd ed., pp. 3–18]. Philadelphia: FA Davis.)
The authors argued that a model such as theirs is needed because nursing and medicine have two different traditions, with the medical model being viewed as reductionistic and the nursing model being regarded as humanistic. Neither model, by itself, provided a structure that allowed APRNs to be recognized for their daily practice and the positive patient health outcomes that can be attributed to APRN care. The model’s authors viewed the development of nursing diagnoses as an attempt to differentiate nursing care from medical care, but because few nursing diagnoses are recognized by current reimbursement systems, the nursing in APRN care was rendered invisible.
The Circle of Caring model was proposed to incorporate the strengths of medicine and nursing in a transforming way. The conceptual elements are the processes of assessment, planning, intervention, and evaluation, with a feedback loop. Integrating a nursing model with a traditional medical model permits the following to occur:
· • The assessment and evaluation are contextualized, incorporating subjective and environmental elements into traditional history taking and physical examination.
· • The approach to therapeutics is broadened to include holistic approaches to healing and makes nursing care more visible.
· • Measured outcomes include patients’ perceptions of health and care, not just physiologic outcomes and resource use.
The assessment-planning-intervention-evaluation processes in linear configuration are encircled by caring. Caring is actualized through interpersonal interactions with patients and caregivers to which NPs bring patience, courage, advocacy, authentic presence, commitment, and knowing (Dunphy & Winland-Brown, 1998; Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011). Conceptual definitions of these terms would add to the understanding of how these processes interact with and affect the care provided by APRNs. The authors suggested that the model promotes the incorporation of the lived experience of the patient into the provider-patient interaction and that the process of caring is a prerequisite to APRNs providing effective and meaningful care to patients.
The Circle of Caring is an integrated model of caregiving that incorporates the discrete strengths of nursing and medicine. This is an important concern for many graduate students because some may struggle with integrating their nursing expertise and philosophy with new knowledge and skills that were traditionally viewed as medicine. Although the authors regard the concept of caring as a way to bridge the gap between advanced practice nursing and medicine and raise awareness, the model provides no clear guidance on how faculty can help students to use the model to bridge this gap.
Several issues remain to be considered. For example, if one goal of proposing the model is to resolve differences about the diagnostic language used by medicine and nursing to obtain reimbursement, no specific mechanism is offered for APRNs to resolve this issue using the model. The model does not seem to be described in enough detail to guide policymaking. The conceptual significance of encircling the four practice processes with the six caring processes is unclear, although the primary care textbook by Dunphy, Winland-Brown, Porter, and Thomas (2011) devotes a chapter to caring in the NP role (Boykin & Schoenhofer, 2011). Given today’s health policy context, the value of this model, with its emphasis on the APRN-patient relationship and caring processes, could inform practice evaluation and research on APRN practices. For example, the Circle of Caring model has been used for the development of an online risk assessment of mental health (McKnight, 2011), evaluation of medication adherence (Palardy & March, 2011), and neonatal transport (Thomas, 2011). In addition, the primary care textbook (Dunphy, Winland-Brown, Porter, & Thomas, 2011) is informed by their Circle of Caring model.
Given the emphasis on interprofessional education and efforts to distinguish advanced practice nursing from medical practice, empirical testing of this model is warranted. This testing would help determine whether the model has the following features: (1) is applicable to all APRN roles; (2) has the potential to be used to distinguish expert by experience practice from advanced practice; (3) is viewed by other disciplines as having an interprofessional focus that would promote collaboration; and (4) will result in more visibility for NPs and other APRNs in the health care system.
Donabedian Structure/Process/Outcome Model
Donabedian’s structure/process/outcome model (2005) has been used as the conceptual model by several recent studies to evaluate the quality of APRN care (e.g., Bryant-Lukosius et al., 2016; Kilpatrick, Tchouaket, Carter, Bryant-Lukosius, & DiCenso, 2016; Kilpatrick et al., 2013). Originally designed to evaluate the quality of medical care, this model compasses three quality-of-care dimensions: structure, process, and outcomes. Structure is the care delivery context (e.g., hospitals, health care staff, cost, equipment) and the factors that dictate how health care providers and patients behave and are system measures of quality of care (Donabedian, 1980, 1986, 1988). Process involves the actions taken in the delivery of health care (e.g., diagnosis, treatment, education), whereas outcome is the effect of the health care on patients and populations. Outcome is often viewed as the key quality indicator of care delivery.
Kilpatrick et al. used this model to describe the relationship between CNS role implementation, satisfaction, and intent to stay in the role (Kilpatrick et al., 2016) and to evaluate team effectiveness when an ACNP is added to the health care team (Kilpatrick et al., 2013). The model provided the framework to examine outcomes and barriers to CNS practice in Canada and the frequency with which components of the CNS role (clinical, education, research, leadership, scholarly and professional development, and consultation) were enacted. Findings indicate that CNS role components of clinical and research, along with balanced scholarly and professional development and consultation activities, were associated with role satisfaction. Additional research is needed to determine if implementation of the CNS role influences intention to remain in or actual departure from the role.
Guided by the Donabedian model, Bryant-Lukosius et al. (2016) developed an evaluation framework to inform decisions about the effective utilization of APRNs in Switzerland (Fig. 2.13). An international group of stakeholders (e.g., APRNs, APRN educators, administrators, researchers) from Canada, Germany, Switzerland, and the United States convened to develop and refine the framework. The developed framework is deliberately broad and flexible to respond to the evolving APRN roles in Switzerland. Key concepts of the model are introduction stage, implementation, and long-term sustainability. The introduction stage includes the type of APRN and corresponding competencies. The implementation stage focuses on the resources (policies, education, funding) to support the different APRN roles and promote the optimal utilization and implementation of the role. Long-term sustainability focuses on long-term benefits and impact of APRN roles (consumers, system, providers) in Switzerland. Because the role of the APRN is in its early stage, the authors have indicated their plan to engage in concerted efforts with policymakers and other stakeholders to actively involve them in its use and application. Several resources have been developed to actualize this (e.g., toolkit, evaluation plan template).
Recommendations and Future Directions
Given the variety of conceptualizations and inconsistency in terminology, it is not surprising that APRN students and practicing APRNs would find the conceptualization of advanced practice nursing confusing. The challenge for APRNs (students and practicing nurses) is to find a model that works for them, that enables them to understand and evaluate their practices and attend to the profession’s efforts to create a coherent, stable, and robust conceptualization of advanced practice nursing.
