Christina Godfrey

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice

AIM To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice. METHODS Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion. RESULTS Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies. CONCLUSION Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.

Guidance for conducting systematic scoping reviews

ABSTRACTReviews of primary research are becoming more common as evidence-based practice gains recognition as the benchmark for care, and the number of, and access to, primary research sources has grown. One of the newer review types is the ‘scoping review’. In general, scoping reviews are commonly used for ‘reconnaissance’ – to clarify working definitions and conceptual boundaries of a topic or field. Scoping reviews are therefore particularly useful when a body of literature has not yet been comprehensively reviewed, or exhibits a complex or heterogeneous nature not amenable to a more precise systematic review of the evidence. While scoping reviews may be conducted to determine the value and probable scope of a full systematic review, they may also be undertaken as exercises in and of themselves to summarize and disseminate research findings, to identify research gaps, and to make recommendations for the future research. This article briefly introduces the reader to scoping reviews, how they are different to systematic reviews, and why they might be conducted. The methodology and guidance for the conduct of systematic scoping reviews outlined below was developed by members of the Joanna Briggs Institute and members of five Joanna Briggs Collaborating Centres.

Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach

Aims:With the increase in the number of systematic reviews available, a logical next step to provide decision makers in healthcare with the evidence they require has been the conduct of reviews of existing systematic reviews. Syntheses of existing systematic reviews are referred to by many different names, one of which is an umbrella review. An umbrella review allows the findings of reviews relevant to a review question to be compared and contrasted. An umbrella reviews most characteristic feature is that this type of evidence synthesis only considers for inclusion the highest level of evidence, namely other systematic reviews and meta-analyses. A methodology working group was formed by the Joanna Briggs Institute to develop methodological guidance for the conduct of an umbrella review, including diverse types of evidence, both quantitative and qualitative. The aim of this study is to describe the development and guidance for the conduct of an umbrella review. Methods:Discussion and testing of the elements of methods for the conduct of an umbrella review were held over a 6-month period by members of a methodology working group. The working group comprised six participants who corresponded via teleconference, e-mail and face-to-face meeting during this development period. In October 2013, the methodology was presented in a workshop at the Joanna Briggs Institute Convention. Workshop participants, review authors and methodologists provided further testing, critique and feedback on the proposed methodology. Results:This study describes the methodology and methods developed for the conduct of an umbrella review that includes published systematic reviews and meta-analyses as the analytical unit of the review. Details are provided regarding the essential elements of an umbrella review, including presentation of the review question in a Population, Intervention, Comparator, Outcome format, nuances of the inclusion criteria and search strategy. A critical appraisal tool with 10 questions to help assess risk of bias in systematic reviews and meta-analyses was also developed and tested. Relevant details to extract from included reviews and how to best present the findings of both quantitative and qualitative systematic reviews in a reader friendly format are provided. Conclusions:Umbrella reviews provide a ready means for decision makers in healthcare to gain a clear understanding of a broad topic area. The umbrella review methodology described here is the first to consider reviews that report other than quantitative evidence derived from randomized controlled trials. The methodology includes an easy to use and informative summary of evidence table to readily provide decision makers with the available, highest level of evidence relevant to the question posed.

The psychosocial spiritual experience of elderly individuals recovering from stroke: a systematic review

Objectives The objective of this review was to appraise and synthesise best available evidence on the psychosocial spiritual experience of elderly individuals recovering from stroke. Inclusion criteria This review considered qualitative studies whose participants were adults, mean age of 65 years and older, and who had experienced a minimum of one stroke. Studies were included that described the participants own experience of recovering from stroke. Search strategy The search strategy sought to find both published and unpublished studies and papers, not limited to the English language. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of text words contained in the title and abstract, and of index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms. Methodological quality Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the Qualitative Assessment and Review Instrument (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third reviewer. Data collection Information was extracted from each paper independently by two reviewers using the data extraction tool from QARI developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third reviewer. Data synthesis Data synthesis aimed to portray an accurate interpretation and synthesis of concepts arising from the selected populations experience during their recovery from stroke. Results A total of 35 studies were identified and of those 27 studies were included in the review. These qualitative studies examined the perceptions of elderly individuals who had experienced a stroke. Findings were analysed using JBI‐QARI. The process of meta‐synthesis using this program involved categorising findings and developing synthesised topics from the categories. Four syntheses were developed related to the perceptions and experiences of stroke survivors: sudden unexpected event, connectedness, reconstruction of life and life‐altering event. Conclusion The onset and early period following a stroke is a confusing and terrifying experience. The period of recovery involves considerable psychological and physical work for elderly individuals to reconstruct their lives. For those with a spiritual tradition, connectedness to others and spiritual connection is important during recovery. The experience of stroke is a life‐altering one for most elderly individuals, involving profound changes in functioning and sense of self.

Care of self – care by other – care of other: the meaning of self‐care from research, practice, policy and industry perspectives

BACKGROUND Currently, no single definition of self-care is broadly accepted in the literature. Definitions vary as to (i) who engages in self-care behaviour; (ii) what motivates self-care behaviours; and (iii) the extent to which healthcare professionals are involved. Perspectives of self-care differ between healthcare professionals and the general public, and between healthcare professionals in different disciplines and different roles. As different professions view self-care within their own domain of practice, we are left with a multitude of explanations and descriptions. This variety of conceptualisations does impact and complicate research on self-care. As part of a larger enquiry focused on the clarification of this complex concept, this study provides a content analysis of documented definitions of self-care, and a summary of the evolution of the definition of self-care over time. OBJECTIVES To examine the diversity of definitions of self-care from the perspectives of research, practice, policy and industry, and to identify themes or trends in the evolution of the definition of self-care over time. SEARCH STRATEGY The search strategy was designed in consultation with a library scientist to find both published and unpublished papers. A three-step search strategy was used to locate the literature. The databases searched included CINAHL, Medline, EMBASE, PsycINFO, AMED, Cochrane Library, Scirus and Mednar. DATA COLLECTION AND ANALYSIS The definition of self-care was extracted from each paper included in the study. Using an inductive process, a content analysis was performed identifying common terms and phrases from the definitions. The definitions were then divided into four decades, 1970s, 1980s, 1990s and 2000s, and the evolution of the definition of self-care was examined. RESULTS AND CONCLUSIONS In this study we sought to clarify the concept of self-care by examining in detail the definition of self-care. Content analysis of 139 definitions identified seven components of the definition and a range of terms that were applicable to each component. Evolution of the definition over time showed a more expansive definition by the end of the 2000s. Current and evolving definitions of self-care would benefit by being comprehensive and encompassing as many facets of the concept as possible. IMPLICATIONS FOR PRACTICE Healthcare professionals assess, guide, instruct and support individuals as they initiate or engage in self-care. Using a comprehensive definition of self-care would provide an anchor linking each discipline as they interact not only with the individual but also among themselves. IMPLICATIONS FOR RESEARCH The concept of self-care is a many-layered one. Identifying the components in the definition of the term delineates the different areas for potential research in this area. When planning a research project, the definition of the key concept guides the research and shapes the approach to the investigation. For researchers in this area, this study illustrates the wealth and diversity of the definitions of self-care.

The symptom of pain in individuals recently hospitalized for heart failure.

The symptom of pain is not typically associated with heart failure. Yet, emerging evidence suggests that pain is an important issue for this population. Objectives: (1) To determine whether pain was reported by a cohort of individuals with heart failure at the time of discharge from hospital, at 2 and 6 weeks postdischarge; (2) To examine the profile of individuals who reported pain at discharge and to determine if there were differences from individuals who did not report pain; (3) To determine whether there was a difference in health-related quality of life between reported pain and no pain groups. Methods: This study was part of a larger randomized controlled trial with a 3-month follow-up. Data were obtained from 169 individuals diagnosed with heart failure who completed the first 6 weeks of the follow-up period. Results: At time of discharge, 68% of the cohort reported pain. Both frequency and severity of pain fluctuated throughout the study for the entire cohort. There were no sociodemographic characteristics that distinguished those who reported pain from those who did not report pain. Differences in health-related quality of life were found between the reported pain and no pain groups at discharge and week 2. Depression, worry, feeling a loss of control over ones life, and feeling as if one was a burden to family were significantly more prevalent in individuals who reported pain. Differences were also found in self-rated health status, and number of prescription medications taken daily. Throughout the 6 weeks, 63 individuals (37%) consistently reported pain and 23 (14%) never reported pain. Conclusion: Pain was a concern for this cohort of individuals diagnosed with heart failure and was noted to impact their health-related quality of life. Further research is needed into the nature of the pain and the role of pain in self-management once patients are discharged home.

Safety in home care: a mapping review of the international literature

Aim This integrative study on safety in home care provides a synopsis of evidence in the Canadian and international literature. The objectives of this study were to: (i) develop/test a comprehensive search strategy to locate the literature on harmful incidents (previously called adverse events (AEs)) in the home care environment to track emerging evidence; (ii) determine what has been documented about AEs in the home care setting; and (iii) catalogue definitions of safety in home care by analysis of reported/published definitions. Methods The review was characterised by a process of mapping and categorising existing literature in practice, health services and policy literature. Methods included a thorough search strategy determined by time/scope constraints, quality assessment of study sets relevant to design and graphic/tabular representation of the synthesis. This multi-step, iterative process used an explicit search and retrieval strategy based on Cochrane and Joanna Briggs Institute methodologies. A modified Problem, Intervention, Comparison, Outcome template was used to design the search. To facilitate concept clarification, key definitions relevant to patient safety and AEs in home care were catalogued. Results Multiple runs on searches were performed for sensitivity and specificity using the Peer Review of Electronic Search Strategies methodology developed by the Canadian Agency for Drugs and Technologies in Health and additional other approaches. Ninety-two research studies published from 1993 to 2010 and representing 14 countries (the majority North American) met the inclusion criteria (i.e. addressing AEs within the context of home care). Studies varied in scope from one home healthcare agency/site to nationwide investigations that involved more than five million participants. Quantitative research methods included experimental, descriptive and retrospective designs. Qualitative research methods included focus groups, interviews and consensus workshops. The nature of AEs was categorised as types of patient injury/harm related to an AE, caregiver instigated injury/harm and organisational/services/staff injury/harm. Conclusions There is an emerging evidence base about safety in home care. A predominant theme was the lack of conceptual clarity with the terms patient safety and AEs in the home care environment. An important finding was that innovative strategies/tools appear in the grey or peer-review literature as quality initiatives with/without evaluation elements. Traditionally, we do not concentrate heavily on the grey literature, but to advance the field, it may be necessary to place more emphasis on this source. A glaring limitation was the paucity of research on the occurrence of AEs and a lack of quality of research that documents prevalence estimates/incidence rates. Interventional research to evaluate risk reduction strategies was very limited and will advance only when tracking and documentation of various AEs improves.

Utilisation of theoretical models and frameworks in the process of evidence synthesis.

Background A systematic review is a comprehensive enquiry or study of secondary data sources. There is a research question, an a priori articulation of methods and a set of procedures to focus the investigation. Despite these rigorous structures to guide the review, synthesising evidence is a challenging, resource intense and time consuming process. Large volumes of information complicate not only the search functions, but also the conceptualisation of the evidence needed to create the concise and integrated results. Use of a theoretical model or framework could serve as an essential element in effectively focusing the review and designing the methods to respond to the knowledge question. Objective This scoping review sought to confirm the value of models or frameworks used by authors working within traditional methodologies for evidence synthesis. Inclusion criteria Types of participants The focus of this review was on the context of health care. Types of intervention(s)/phenomena of interest All studies that discussed models or frameworks used specifically to address the process of synthesis were included. Types of studies Discussion, scholarship or methodology papers and reviews were included. Types of outcome All theoretical models or frameworks were described, with specific attention to the purpose of the framework for each study, and the contribution of the framework to the process of synthesis. Search strategy The search strategy aimed to find both published and unpublished studies. A three‐step search strategy was utilised. The databases for published material included CINAHL; Medline; EMBASE; PsycINFO; AMED; Cochrane; Biomed Central; Scirus; and Mednar. Databases for unpublished material included Dissertation Abstracts; Sociological Abstracts; Conference proceedings. Methodological quality The review was a focused scoping review to locate and describe the contribution of theoretical models or frameworks to the process of synthesis. The methodological quality of the discussion papers was therefore not assessed. Data collection Data was extracted from the discussion papers using an adaptation of the standardised data extraction tool from the Joanna Briggs Institute Data Extraction for Narrative, Expert opinion & text (JBI‐NOTARI). Data synthesis Results were discussed in narrative form. The use of frameworks in each step of the synthesis process was discussed. Results Eight studies (nine papers) formed the final set included in this review. The studies targeted the following issues: Child protection; end‐of‐life care; predictors of adolescent sexual behaviour and intention; primary care career choice; prognosis of acute whiplash; reluctance to care; use of Information Technology; young childs post‐divorce adjustment. Frameworks were used in four of the seven steps of synthesis, and integration of the data indicated that the use of frameworks in the process of evidence synthesis was valuable and had many advantages. Conclusion This review illustrates that the addition of structure and guidance provided by a framework can serve to benefit the process of integration. Studies in this review indicated that the use of frameworks helped to inform the association between variables, guide the search strategy, structure and clarify the outcomes, identify knowledge gaps and indicate areas for future research. Used in this manner, frameworks could provide a valuable foundation for the process of synthesis. Implications for practice Evidence from systematic reviews informs practice. The incorporation of a theoretical model or framework helps to guide the process of synthesis and clarify the outcomes. This added transparency will facilitate the assimilation of the evidence by the target audience. Implications for research Systematic reviews are the highest level of evidence available at this time. The use of theoretical models or frameworks in the review process strengthens the rigor and transparency of the integrative method. Further research into the contribution of theoretical models or conceptual frameworks to the process of synthesis may be valuable.

Homecare safety and medication management with older adults: a scoping review of the quantitative and qualitative evidence

Background Healthcare safety is a current national and international priority, and within healthcare safety, one of the most prevalent, high‐risk issues is medication safety. While medication safety in general demands consideration, there is a critical gap in our understanding of medication safety in the homecare sector. Understanding what factors contribute to, and/or reduce the risk of adverse drug events in the home setting will enable the identification and promotion of safer medication administration practices. Objectives In this review we focused on the pertinent issues specifically related to medication management for individuals living at home and receiving homecare services. Inclusion criteria Types of participants We considered studies that included older individuals, mean age 65 years or older, who were receiving homecare services. Types of intervention(s)/phenomena of interest We considered studies that focused on individuals living at home and receiving homecare services and evaluated the process of medication management involving either providers (licensed and unlicensed) or caregivers (family/friends paid or unpaid). Types of studies We included all quantitative and qualitative research designs. Types of outcomes The purpose of this review was to map existing literature on this topic and to identify what outcomes were being measured by the current research. Research to date has identified outcomes such as: death, re‐hospitalization, emergency room use and adverse drug reactions; adherence; deterioration in primary condition; and experience of medication management (individual report and/or provider/caregiver report). Search strategy A three‐step search strategy was utilized in this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles were searched for additional studies. Studies published in English and French were considered for inclusion in this review. No date limitation was imposed. Methodological quality This review is a scoping review to provide a broader picture of the existing literature on this topic. Hence, assessment of methodological quality was not performed to exclude studies based on quality scores. Data collection Data was extracted using an expanded extraction tool from the Joanna Briggs Institute Meta‐Analysis of Statistics Assessment and Review Instrument (JBI‐MAStARI). Data synthesis The findings are presented in narrative form including tables and figures to aid in data presentation where appropriate. Results Thirty‐six studies published in English were included in this review. No French studies were located. Research designs of the included studies are heavily weighted in descriptive designs (n=28), one randomized controlled trial, three controlled before and after designs, three pre‐post designs and one qualitative design. There was a single mixed methods study combining results from a pre‐post (not controlled) investigation and qualitative focus groups. There was a single qualitative study using interpretive qualitative methods. Following the three research questions proposed for this review, three main categories were analyzed: issues (including contributing factors and risk factors) (n=21 studies), documented adverse events or errors that occur in the homecare environment (n=13 studies), and strategies or interventions to prevent the occurrence of errors in the homecare environment (n=11 studies). Conclusions In this scoping review, we sought to gather information to shed light on the current evidence related to medication management in the homecare setting. This is an area of emerging evidence on both the issue and risks in this context, as well interventions to ameliorate the problems. There was a common theme that did emerge across the study designs with respect to polypharmacy, which is recognized as a significant issue and predictor of medication errors, and/or potential inappropriate medication use. Benefits were reported by two experimental studies with the inclusion of a pharmacist to assess medications: improvements in medication use and increased coordination of information between healthcare providers and individuals. Further evidence describing and substantiating the issues and problems specific to home care and medication management is needed to develop and test appropriate interventions in this setting.

Exploring conceptual and theoretical frameworks for nurse practitioner education: a scoping review protocol.

Review question/objective The objective of this review is to examine conceptual and/or theoretical frameworks that are relevant to nurse practitioner education. The specific review question is: What conceptual and/or theoretical frameworks are available that are relevant to the structuring of nurse practitioner education? Background The use of conceptual and theoretical frameworks to organize the educational curriculum of nursing programs is essential to protect and preserve the focus and clarity of nursings distinct contribution to health care.1 Conceptual frameworks of nursing provide a means to look at nursing in relationship to external factors, thereby assigning meaning to the practice.1 Graduate level nursing education in the preparation of Nurse Practitioners (NPs) specifically and Advanced Practice Nurses (APNs) in general, is significantly compromised by the tendency to conceptualize the learning in these complex programs as being primarily related to skills‐based tasks and competencies alone. According to Baumann,2 advanced nursing education must focus on the uniqueness of the NP position, in contrast to other health care professions. To do this, Baumann2 suggests using a conceptual nursing model and nursing theory as opposed to a strictly biomedical model. This allows NPs to interpret information in a way that differs from the strict biomedical model, providing opportunities for the NPs to be truly present in the lives of their patients. Canadian Nurse Practitioner (NP) practice competency documents are based primarily on the Canadian Nurses Association (CNA) Nurse Practitioner (NP) Core Competency Framework.3 This document defines the core set of entry‐level competencies required for all NPs to practice in all Canadian jurisdictions, settings and client populations. The Core Competencies in the CNA NP Framework are organized within four main categories: professional role, responsibility and accountability; health assessment and diagnosis; therapeutic management; and health promotion and prevention of illness and injury. Although vital to the organization of provincial entry‐level registration standards, this framework provides little direction to educational providers for curricula organization and philosophical perspectives. The Canadian Association of Schools of Nursing developed a national framework for NP education4 following a multi‐phase consultation and literature and curriculum synthesis project. While the task force addressed the guiding principles and essential components of NP education along with contextual factors that impact on the delivery of curricula in Canadian jurisdictions, the philosophical approaches guiding and organizing the education were not addressed. A similar set of documents has been created in the United States by the National Organization of Nurse Practitioner Faculties (NONPF).5 These documents are organized by six population level foci (including the specialty of family/individual across the lifespan) and outline core competencies for entry to practice and registration and educational standards. The Core Competency documents provided by the NONPF are presented in the same manner as the CNA NP Framework and likewise, do not provide a guiding or organizing framework or philosophy for NP education. A full curriculum overhaul based on the NONPF competency requirements was performed at a university center in Oregon.6 The new curriculum was based on competencies that students must acquire, rather than learning objectives.6 While the NONPF Framework does provide an extensive list of entry‐level requirements for NPs, the challenges faced by the institution as it aimed to incorporate the framework into the curriculum clearly provide evidence that these overarching frameworks need to include both a philosophical and organizational component to help guide educators. Conceptual frameworks in graduate nursing education Conceptual frameworks are useful for establishing a congruent relationship between program curricula, objectives and content. Walker and Avant7 advance the utility of conceptual frameworks as providing the logic behind the interrelationships of terms and variables, and improving explanation and understanding. Gold, Haas & King1 assert that conceptual frameworks facilitate grounding of a nursing lens in the curricula of advanced practice nursing programs. It has been noted that newly practicing NPs have demonstrated an allegiance withmedical model thinking, second only in importance to wellness/health promotion considerations.8 Blasdell and colleagues9 surveyed 188 practicing NPs to investigate the relationship between education and the use of theory in clinical practice. Educated graduate NPs rated the importance of nursing theory to the NP practice role significantly higher than did diploma and baccalaureate degree NPs (4.05±2.06 versus 2.65±1.69, p<.001) but both groups rated the nursing models as less important for practice than a medical model approach. Huckabay10 highlighted the need for the use of a harmonized nursing model at the undergraduate level to ensure that students have a thorough understanding of what nursing is and what nursing care entails. At the graduate level, Huckabay10 suggested the use of multiple nursing models, depending on specialty. Regardless of the educational level, a conceptual framework used for education must enable nurse educators to have sufficient guidelines to construct a curriculum and determine what knowledge and skills are needed by the nursing students.11 Further, Furlong12 identified the need for Advanced Practice Nursing (APN) curriculae to be innovative and critically reflective, preparing students to be readily adaptable to challenges in the work place. Furlong12 suggests that to do this, the curriculum must rely upon an interdisciplinary framework to deliver content. Gold, Haas & King1 suggest that core curricula based on a medical model or a skill‐related task list do not reflect the critical thinking of nurses, nor the uniqueness of the profession. Thus, conceptual models used for curricula development must: encompass the distinct nursing worldview, promote learning, and be efficient and comprehensive. Frameworks have been proposed and tested to guide the development and implementation of inter‐professional education (IPE) and collaborative practice curricula for NP and medical students. A qualitative assessment of a framework guided IPE module illustrated the benefit of improving the focus on role awareness in participating students.10 However, this particular curriculum was limited to a two‐week period and not presented as a pervasive approach to the educational programs of each discipline. In education, an overarching philosophy can provide a road map for goal identification, teaching material development and the formulation of evaluation methods.1 For instance, when creating a curriculum that was a result of the collaboration of three different post‐secondary institutions, the SHARE (students, humor, administrative support, resources, and educational technology) model was used.13 This model brings together resources, students and faculty, surrounding them with humor, which was viewed as a fundamental part of the process while the program was still in its early stages.13 According to the authors, the program has been widely successful and the reliance on humor as an underlying philosophy has enabled the students and faculty to deal with problems arising in the new program.13 Focusing on evaluation, Kapborg & Fischbein14 promoted the use of the Education Interaction Model. The model identifies how educational influences can interact with abilities of students and how the consequences of this interaction can be evaluated by observing changes in both students and programs. The authors argue that, while the educational interaction model is effective, it is not the only model that can be used to carry out evaluations.14 The authors stress that the model chosen to perform an evaluation should be based upon what or who is going to be evaluated. The standards outlined in the CNA NP framework are an essential part of organizing the education process for NPs and ensuring that NPs have acquired the necessary skills to practice in Canada as an NP. However, the framework is lacking philosophy and organization regarding NP education programs to ensure that the curriculum is preparing the NPs for the ever‐changing work environment. An Australian survey of NP education documents from relevant universities as well as interviews with NPs and academic conveners from Australia and New Zealand found that, while NP educational programs need to have strong clinical and science based learning components, student directed and flexible learning models act to ensure the capability of NPs as they strive to adapt to practice situations.15 Capability, as an approach to the learning process, includes the flexibility to respond to the specific, self‐identified learning needs of students.15 Knowing how to learn, having high self‐efficacy, applying competencies to new tasks, collaborating with others, and being creative are all signs of a capable practitioner.16 Gardner et al.15 emphasized the need for a program that fosters both competent and capable NPs. In a follow‐up study, using the same data, Gardner et al.17 confirmed that NPs viewed the attributes of a capable NP as imperative to practice. Thus, a framework for NP education must include both competency building elements, such as those currently found in the CNA NP framework and capability building elements which can be fostered through self‐directed learning.17 Similarly, Schaefer18 investigated the role of caring in nursing practice through a class for APN students in which the students reflected on their narratives of caring for patients. This qualitative study revealed that when APN students provide care by meeting the complex needs of suffering patients, the art and science of nurs