Although there have been other studies of APNs providing transitional care (see Chapter 8 ), Brooten's work is highlighted because of the additional analyses that were done and the ultimate influence on health policy of this program of research (e.g., Naylor, Aiken, Kurtzman, et al., 2011 ). The findings help us understand the APN characteristics and interventions that have contributed to the success of the interventions and a model of care that evolved from the skilled care provided by APNs. 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 that is dominated by medicine and one in which medical language (i.e., the International Classification of Disease Codes [ICD-10-CM]) is the basis for reimbursement. They proposed the “Circle of Caring: A Transformative Model” 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, which has been slightly revised since its original publication ( Dunphy, Winland-Brown, Porter, et al., 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 ).
FIG 2-12 Dunphy and Winland-Brown's Circle of Caring model. (From Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., et al. . Primary care in the twenty-first century: A Circle of Caring. In L. M. Dunphy, J. E. Winland-Brown, B. O. Porter, & D. J. Thomas [Eds.]. Primary care: The art and science of advanced practice nursing [3rd ed., pp. 3—18]. Philadelphia: F. A. Davis.) When first proposed, the authors argued that a model such as theirs was needed because nursing and medicine have two different traditions, with the medical model being viewed as primarily reductionistic and nursing being regarded as primarily humanistic. Neither model, by itself, provided a structure that allowed APNs to be recognized for their daily practice and the positive
patient health outcomes that can be attributed to APN 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 APN 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.
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