Advanced nursing practice: an idea whose time has come

Aims and objectives. This paper aims to analyse the concept of advanced nursing practice critically and to demonstrate an appreciation of the development of the role of the advanced nurse practitioner in the Irish context. Background. The concept of advanced nursing practice has existed in the US since the 1960s and in the UK since the early 1980s. The first signs of the advanced nurse practitioner began to emerge in Ireland in the late 1990s as a result of increasing demands and changes occurring within nursing and health care. Currently, there are 31 advanced nurse practitioners in the country, many of whom practice in the general setting. Strategies are in place to introduce advanced nursing practice into other nursing disciplines in the future. Methods. A literature review was conducted to address the various issues inherent within this concept. Results. There is a body of evidence indicating that advanced nursing practice has brought about an improvement in patient outcomes. In light of this, the advanced nurse practitioner has a valuable role to play in providing a beneficial contribution and filling a gap in healthcare services. Conclusion. This paper has demonstrated that nursing continues to be a dynamic and ever‐changing phenomenon where the onus is firmly on the advanced nurse practitioner as expert, leader and collaborator, to capture the hearts and minds of nurses and healthcare workers, so as to challenge traditional values and transform clinical practice. Failure to do so may allow medicine or other interested parties to shape the future of nursing or even absorb it. Relevance to clinical practice. Nurses working at an advanced level are striving to develop their expertise, initiate nurse‐led services and practice, in collaboration with other professionals in an effort to provide the highest quality care to the patient. Although the idea of the advanced nurse practitioner is relatively new to nursing in Ireland, it is the result of an idea whose time has come and there is nothing more powerful than an idea whose time has come.     

An evaluation of a community aged care nurse practitioner service

Evaluation aims. An evaluation is presented that aimed to augment current understandings of the nurse practitioner role by investigating potential outcomes of a community aged care nurse practitioner (ACNP) service on clients and the health care team. Background. In Australia, the nurse practitioner role is being implemented in a variety of health care settings and is characterized by extended practice: prescribing of medications, requests for diagnostic investigations, referral to medical specialists and admitting clients to inpatient facilities. Design. An exploratory qualitative evaluation method through data collection by interview and thematic analysis was undertaken. Method. All clients referred to the ACNP service between June and August 2003, and a convenience sample of health professionals, were invited to participate in individual semi‐structured interviews. Results. Findings suggested that an ACNP could provide a high quality of holistic nursing care and positively affect clients’ physical and psychological symptom management, enhance clients’ quality of life, assist with supplies, provide health education and assist with advocacy. Health professionals commented on effective collaboration with the ACNP service during their partnerships in client care provision. Conclusions. Overall, the positive effects of the ACNP service on clients and the health care team support the full implementation of the role within the community setting. Relevance to clinical practice. Funding support for the nurse practitioner role is a vital addition to consideration in the development of international policy on advanced practice nursing. Without adequate funding, the full benefits of the nurse practitioner role in clinical practice, as suggested by the findings presented in this evaluation, will be compromised.     

Steering a course towards advanced nurse practitioner: a critical care perspective

Aim: This article is a report of a study of the experiences of expert critical care nurses in their transition to the role of advanced nurse practitioner within an intensive care unit (ICU) setting. Background: The advanced nurse practitioner role was developed to support the ICU team and to undertake many of the roles traditionally associated with junior medical staff in this specialized area. The impetus for this study therefore was generated from the need to explore the role development experiences of trainee advanced nurse practitioners to inform future developments and practice. Methods: This study used grounded theory methodology to conduct and analyse data from 25 participants. The data were collected between March 2010 and August 2010, using interview format. Data collection and analysis was conducted simultaneously using methods associated with grounded theory, theoretical sampling and the constant comparative method. Results: ‘Staying the course to advanced nursing practice’ emerged as the core category, with four related major categories and substantive codes. In conjunction, the substantive theory explaining the essential processes involved comprised of three inextricably linked processes: situational, development and conceptual meaning. The developed conceptual model captures the unique experiences of expert critical care nurses during their transition to confident and competent advanced nurse practitioners. Conclusion: This study provides an account of the role transition from expert critical care nurse to advanced nurse practitioner, specifically the synthesis of expert nursing practice with traditional medical values. The conceptual model has the potential to be utilized as a framework for others embarking upon similar projects, informing advanced nurse practitioner roles within and out with critical care settings.     

Reporting a research project on the potential of aged care nurse practitioners in the Australian Capital Territory

Aim. This paper reports a project investigating the potential role of the nurse practitioner in aged care across residential, community and acute care venues in the Australian Capital Territory. Background. Australia, like many other countries, faces unprecedented challenges in the provision of health care. Escalating health care costs, an ageing population, increasing prevalence of comorbidities and chronic illnesses, inefficient health care delivery, changing models of health care and shifting professional role boundaries are factors that have contributed to the development of advanced practice roles for nursing. Design. This was a mixed methods study using multiple data sources. Methods. Student aged care nurse practitioners were examined across the continuum of care in the acute, community and residential aged care settings. The potential role of the nurse practitioner in these areas was evaluated qualitatively and quantitatively to identify a model of care to enhance the delivery of efficient and effective health care. Results. The project findings have demonstrated that there is potential for significant improvement in client outcomes arising from a transboundary aged care nurse practitioner model. The improved outcomes are associated with a decrease in acute hospital admissions for residential care clients, timely intervention for a range of common conditions and strengthened multidisciplinary approaches to care provision for older people. Conclusions. Overall the project findings strongly support the potential of a transboundary aged care nurse practitioner role. This role would focus on skilled assessment, timely assessment and intervention, brokering around access to care and clinical leadership and education for nurses. Relevance to clinical practice. This paper offers further evidence of support for the role of nurse practitioners in complementing existing health services and improving delivery of care.     

Telemedicine: benefits to advanced practice nursing and the communities they serve

PURPOSE: To review the use of telemedicine in a variety of advanced nursing practice settings, its contribution in expanding the service and role of the nurse practitioner, and the regulatory issues of reimbursement and licensure. DATA SOURCES: Literature review of relevant journals, research articles, case examples, and web searches. CONCLUSIONS: Although telemedicine has been utilized for many years, it has historically been used primarily by physicians. In recent years, telemedicine has been demonstrating its growing potential in advanced nursing practice in terms of economy, efficacy, and quality of care. When used appropriately, telemedicine complements advanced nursing practice in cost-effective ways and improves healthcare access to the populations served. IMPLICATIONS FOR PRACTICE: Incorporating telemedicine into the advanced nursing practice can be rewarding for both clinicians and their patients. Because of the high variability that exists among state regulations and payer reimbursements, clinicians are advised to verify their respective Board of Nursing Examiners, State, and payers' policies prior to investing in the establishment of telemedicine in practice.     

The advanced practice nurse in gastroenterology serving as patient educator.

The role of the advanced practice nurse is evolving in the specialty of gastroenterology, requiring flexibility and an openness to change on the part of the practitioner. The gastroenterology advanced practice nurse performs history and physical assessments, orders diagnostic studies, determines medical and nursing diagnoses, prescribes and evaluates pharmacologic and other therapeutic regimens, manages followup care, and evaluates patient outcomes. The advance practice nurse also provides patient, family, and group education and screening programs. Collaboration with other healthcare professionals; serving as a mentor and as a consultant; participating in continuing education, research and quality management; and providing professional leadership underscore the professional aspects of advance practice nurse activities. The focus of this article is the educational role of the advanced practice nurse. The body of knowledge applicable to the educational role is discussed, in addition to contributory professional activities.     

Infusion nursing: aspects of practice liability.

As the healthcare arena continues to evolve with the advent of novel clinical practices and technologies, the practice of infusion nursing is no exception to this phenomenon. Given this situation, it is imperative that nurses practicing infusion therapy be aware of the Infusion Nursing Standards of Practice to optimize patient care and safety and avoid potential litigious situations. Aspects of practice liability specific to the delivery of nursing care, product liability concepts, and a case study including the role of the nurse expert witness provide a basis for ascertaining the importance of adherence to these standards.     

Praxis and the role development of the acute care nurse practitioner

Acute care nurse practitioner roles have been introduced in many countries. The acute care nurse practitioner provides nursing and medical care to meet the complex needs of patients and their families using a holistic, health-centred approach. There are many pressures to adopt a performance framework and execute activities and tasks. Little time may be left to explore domains of advanced practice nursing and develop other forms of knowledge. The primary objective of praxis is to integrate theory, practice and art, and facilitate the recognition and valuing of different types of knowledge through reflection. With this framework, the acute care nurse practitioner assumes the role of clinician and researcher. Praxis can be used to develop the acute care nurse practitioner role as an advanced practice nursing role. A praxis framework permeates all aspects of the acute care nurse practitioner's practice. Praxis influences how relationships are structured with patients, families and colleagues in the work setting. Decision-makers at different levels need to recognize the contribution of praxis in the full development of the acute care nurse practitioner role. Different strategies can be used by educators to assist students and practitioners to develop a praxis framework.     

Education for differentiated role development for NP and CNS practice: one nursing program''s approach

Development of nurse care providers who best meet the public's health care needs is imperative. Some nurses believe the functions of nurse practitioners and clinical nurse specialists should be combined. However, the experience of the authors' nursing program argues otherwise. Two graduate nursing tracks, family nurse practitioner and rural health specialist, were developed to meet the health care needs of rural populations. Although the two tracks share expected competencies and areas of expertise to some extent, differences in practice are apparent in identified domains of practice and terminal competencies. Family nurse practitioner practice focuses on assessment, diagnosis, and management of health and illness conditions of individuals and families across the life span. Clinical nurse specialist practice incorporates traditional roles of client assessment, monitoring and coordination of care, outcome assessment, and client, family, and community education, with a new focus on case management strategies. These differences are important to care delivery in the managed care era.     

Emerging role of the pediatric nurse practitioner in acute care

The pediatric nurse practitioner role in the tertiary setting is one of several emerging roles gaining recognition in the various groups of advanced practice nursing programs today. The advanced practice nurse (APN) who is a pediatric nurse practitioner (PNP) in an acute care setting helps to provide cost-effective, quality patient care for critically and chronically ill children who are in these settings. The foundation of advanced practice nursing in this role incorporates the general role expectations of advanced nursing preparation, including case management, clinical pathway development, consultation and education, research, and collaboration, with the specific knowledge and skills of the pediatric nurse practitioner to function effectively with sick children in the acute care areas.     

Illuminating the clinical nurse specialist role of advanced practice nursing: a qualitative study

As the advanced practice nursing initiative in Canada gains momentum, effort is being directed towards clarifying and defining advanced practice roles. A qualitative study was undertaken to increase understanding of the clinical nurse specialist role of advanced practice. Sixteen nurses who worked in advanced practice roles, organizing and providing healthcare for children with complex health needs and their families across the continuum of care, participated in in-depth conversations about the nature of their practice, the knowledge that informs it and the factors that influence it. Findings suggest that clinical nurse specialists have a unique role in the organization and delivery of healthcare for specialized populations with complex health needs in their dual focus on the system level of healthcare and on population health needs. Initiatives directed to children and families within the study participants' specialties included program development, consultation and educational outreach and the development of clinical guidelines and policies. Although the nurses described their practice as focusing both on individual children and families and on the population of children and families within their specialty, it is at the population level that they see their greatest potential for contributing to the delivery of high-quality, cost-effective healthcare.     

Development and implementation of the specialized nurse practitioner role: Use of the PEPPA framework to achieve success

In 2003, amendments to the Nurses' Act in Quebec, Canada, allowed for an expanded nursing role. Specialized nurse practitioners were introduced to the health-care system in 2005. By merging medical knowledge with advanced practice nursing, the specialized nurse practitioner is gaining in popularity and acceptance with staff members and patients. To guide our team through the process, we used the PEPPA (participatory, evidence-based, patient-focused process for guiding the development, implementation, and evaluation of advanced practice nursing) framework. By using a framework specifically designed for the development, implementation, and evaluation of an advanced practice nursing role, we were better prepared for the path that lay ahead. Ultimately, the goal of the implementation of the specialized nurse practitioner role is to improve the quality of care to a specific population of patients, whether it is through individualized clinical follow-up, evidence-based practice, patient teaching, or promoting continuous education for the nurses.     

Knowledge, perceptions, and attitudes of advanced practice nursing students regarding medical genetics

PURPOSE: To describe the current medical genetic knowledge and perceptions of graduate advanced practice nursing (advanced practice nurse [APN]/nurse practitioner and nurse anesthetist) students using survey data for future integration of genetic topics, principles, and healthcare issues into curriculum. DATA SOURCES: Survey data of APNs' perceived knowledge of genetics and a review of the literature from past research studies of students and current articles from professional journals and organizations. Web sites were those of the National Coalition of Health Professions for Education in Genetics and National Institutes of Health, Human Genome Research Institute; professional organizations; and the authors' professional, clinical, and educational experiences. CONCLUSIONS: Most APN students perceived they had minimum knowledge and prior training regarding medical genetics. There is a need to integrate genetic concepts, principles, and medical conditions into advanced practice nursing curriculum and to provide clinical experiences in genetic conditions across the life span and throughout the health and illness spectrum. APN students have positive attitudes toward integrating genetics into graduate curricula. Potential methods for program integration include readings, small group discussion, standardized patients, and role-play as measures to increase information. IMPLICATIONS FOR PRACTICE: The National Coalition for Health Profession Education in Genetics, the American Nursing Association, and the American College of Nursing Education have recommended integration of genetics knowledge and skills into routine health care to provide effective interventions for individuals and families. However, previous research and data from this study have revealed that many nurses have minimal training in genetics. Advanced practice nurses must be knowledgeable on genetic principles, topics, and the ethical, legal, and social implications related to medical genetics to increase the ability to diagnose, prevent, and treat diseases and to provide effective care for individuals and families.     

Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis

AIMS: This paper reports a study whose aim was to identify and synthesize qualitative research studies reporting barriers or facilitators to role development and/or effective practice in specialist and advanced nursing roles in acute hospital settings. BACKGROUND: The number of clinical nurse specialist, nurse practitioner, advanced nurse practitioner and consultant nurse roles has grown substantially in recent years. Research has shown that nurses working in innovative roles encounter a range of barriers and facilitators to effective practice. METHODS: Systematic literature searches were undertaken, and relevant studies identified using specific inclusion and exclusion criteria. The selected studies were appraised, and their findings synthesized using Ritchie and Spencer's 'Framework' approach. RESULTS: Fourteen relevant studies were identified, mostly from the UK. They described a range of barriers and facilitators affecting specialist and advanced nursing practice. These related to the practitioner's personal characteristics and previous experience, professional and educational issues, managerial and organizational issues, relationships with other health care professionals, and resources. The factors most widely identified as important were relationships with other key personnel, and role definitions and expectations. CONCLUSIONS: Relationships with other staff groups and role ambiguity are the most important factors which hinder or facilitate the implementation of specialist and advanced nursing roles. These factors seem interlinked, and the associated problems do not appear to resolve spontaneously when staff become familiar with the new roles. In order to reduce role ambiguity and the consequent likelihood of negative responses we recommend that, when specialist and advanced nursing roles are introduced, clear role definitions and objectives are developed and communicated to relevant staff groups; these definitions and objectives should be updated as necessary.     

Delineating advanced practice nursing in New Zealand: a national survey

Background

A variety of advanced practice nursing roles and titles have proliferated in response to the changing demands of a population characterized by increasing age and chronic illness. Whilst similarly identified as advanced practice roles, they do not share a common practice profile, educational requirements or legislative direction. The lack of clarity limits comparative research that can inform policy and health service planning.

Aims

To identify advanced practice roles within nursing titles employed in New Zealand and practice differences between advanced practice and other roles.

Method

Replicating recent Australian research, 3255 registered nurses/nurse practitioners in New Zealand completed the amended Advanced Practice Delineation survey tool. The mean domain scores of the predominant advanced practice position were compared with those of other positions. Differences between groups were explored using one‐way ANOVA and post hoc between group comparisons.

Results

Four nursing position bands were identified: nurse practitioner, clinical nurse specialist, domain‐specific and registered nurse. Significant differences between the bands were found on many domain scores. The nurse practitioner and clinical nurse specialist bands had the most similar practice profiles, nurse practitioners being more involved in direct care and professional leadership.

Conclusions

Similar to the position of clinical nurse consultant in Australia, those practicing as clinical nurse specialists were deemed to reflect the threshold for advanced practice nursing. The results identified different practice patterns for the identified bands and distinguish the advanced practice nursing roles.

Implications for nursing policy

By replicating the Australian study of Gardener et al. (2016), this NZ paper extends the international data available to support more evidence‐based nursing workforce planning and policy development.     

Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors

AIM: This paper reports a study to determine the attitudes of nurses, doctors and general medical practitioners towards the development of an advanced nurse practitioner service within an emergency department. BACKGROUND: The role of advanced nurse practitioner in emergency care has emerged in a number of countries, and has brought with it confusion about titles, role boundaries, clinical accountability and educational requirements. Initially, the role resulted from a need for healthcare professionals to provide a service to the increased numbers of patients presenting to hospital with less urgent problems. Since then, the service has evolved to one where nurse practitioners provide high-quality and cost-effective care to persons who seek help for non-urgent, urgent or emergent conditions in a variety of emergency care settings. However, little research could be identified on the attitudes of relevant nursing and medical staff towards the development of this role. METHODS: A questionnaire survey was carried out, and a 29-item Likert rating scale was developed to measure attitudes. Along with some demographic variables, two open-ended questions were added to allow respondents to elaborate on what they perceived as benefits and difficulties associated with an advanced nurse practitioner service. All general practitioners, emergency nurses and emergency doctors in one health board in the Republic of Ireland were targeted, and 25 emergency nurses, 13 emergency doctors and 69 general practitioners were approached to take part. Data were collected in February 2004. FINDINGS: An overall response rate of 74.8% was achieved. All respondents were positive towards the development of an advanced nurse practitioner service, with general practitioners being less positive. The principal differences appeared between general practitioners and hospital emergency care staff. CONCLUSION: There is a need for a multidisciplinary approach to the planning of advanced nurse practitioner services. To achieve multiprofessional acceptance, an accredited and standardized education programme is required, and this must address existing role boundaries.     

The evolution of the role of nurses: the history of nurse practitioners in pediatric oncology.

The role of nursing has been around since the beginning of time as demonstrated historically by caretakers who have attempted to relieve the suffering of children and of the sick within their community. In the late 1940s, the field of pediatric oncology nursing began emerging, and by the early 1970s, there were 2 pediatric nurse practitioner programs specific for pediatric oncology. The practice strategies for this role include not only directing and providing patient care to children with oncologic diseases but also negotiating the healthcare delivery system, monitoring and ensuring the quality of health care practice, offering family-centered care, and demonstrating cultural competency. In essence, the nurse practitioner role is multifaceted, requiring independent and interdependent decision making and direct accountability for clinical judgment in managing the care of children with cancer and their families.     

Advanced practice nursing and the role of the pediatric critical care nurse practitioner

Advanced practice nursing, since its inception in the early 1960s, has constantly changed in an effort to establish standardized core graduate education, specialization of practice, and autonomy, now common in the 1990s. Nurse practitioners, nurse midwives, and certified registered nurse anesthetists have followed in the footsteps of the clinical nurse specialist by enhancing their practice through advanced education. Nurses in these advanced areas are graduating from established programs with a master's of science in nursing and a specialty in their chosen field. The pediatric critical care nurse practitioner is one such specialty. This article highlights the results of a national survey that described pediatric critical care nurse practitioner practice over a broad geographic area. With change as a constant, nurses will look to the future of advanced practice roles, which are ever changing, and continue to provide safe, quality care to patients.