Exploring the role of advanced clinical practitioners (ACPs) and their contribution to health services in England: A qualitative exploratory study

BackgroundAn extended role being explored globally is the advanced clinical practitioner (ACP). In England this is an extended role for allied health professions, nurses and midwives in a range of settings.ObjectivesThis paper focuses on three research questions: 1) What is the role of ACPs in England? 2) What are the barriers and facilitators to implementing the role? and 3) What is the contribution of ACPs to health services in England?Design/settingA qualitative, exploratory study to explore perspectives on the ACP role in a range of clinical settings.ParticipantsWe recruited 63 stakeholders, including 34 nurses, working in a ACP role or ACP education. A purposive snowball sampling technique identified participants meeting inclusion criteria.MethodsOne-to-one semi-structured interviews throughout 2020, recorded and transcribed verbatim, anonymised and thematically analysed.ResultsThe ACP role in England was undertaken in a broad range of clinical contexts. In England ‘advanced clinical practitioner’ was not a protected title. There were high levels of variability and ambiguity of understanding and deployment of the ACP role in England. Facilitators to the implementation process included training and education, clinical supervision and organisational support. Lack of protection for the role and variances in experience were barriers. Employer support facilitated development of the ACP role, however where support was limited, at either an individual or organisation level, this was a barrier. Our study highlighted the wide range of ways the ACP role benefitted patient outcomes and workforce development.ConclusionsThis study outlines the contribution that ACPs can make to health services, contributing factors and key barriers and facilitators to implementing this role. The work showed the positive contribution ACPs can make to service redesign, workforce development and patient outcomes, whilst accepting there is much work to do to ensure protected status and parity across all professions and clinical contexts     

The evolution of the neonatal nurse practitioner role in Australia: A discussion paper

AimThe neonatal nurse practitioner role originated in the 1960's in the Unites States from a short fall in physicians. This occurred because of changes in medical training which reduced time in specialist areas and in conjunction, the demand for neonatal care increased due to the survival of premature babies and advances in specialised care. The aim of this review is to identify the discrepancies between roles and responsibilities, highlight the challenges NNP face and explore possible role development opportunities to make the position sustainable.MethodCurrent review of the literature (MESH TERMS – neonatal and/or nurse practitioner, Australia) revealed fourteen published articles and government documents identifying requirements for endorsement and standards for nurse practitioner practice.ResultNeonatal nurse practitioners spend most of their time delivering direct patient care regardless of the clinical setting, however elements of research, education and leadership are still incorporated within clinical practice. Alongside the clinical role, antenatal counselling, facilitation of communication amongst the multidisciplinary team and parents, prescribing, ordering diagnostic tests have all became core components to define the scope of the NNP. However, as the role has expanded NNP must adapt to changes to continue to be recognised as a valuable member of the multidisciplinary team especially as registered nurses start to take on extended roles.ConclusionThe senior clinical role of the neonatal nurse practitioner continues to evolve. There are challenges to be overcome, however there are now more than thirty neonatal nurse practitioners in Australia and together the possibilities for expansion of their role are limitless. This can only be of benefit to our babies, their families and the nursing profession.     

Pushing boundaries in paediatric intensive care: training as a paediatric retrieval nurse practitioner

Traditionally in the UK, the transportation of the critically ill child to a paediatric intensive care unit has been carried out by a medically led team of doctors and nurses. However, in countries such as the USA and Canada, appropriately trained nurse practitioners have proven to be competent in the transportation of these vulnerable children. This nurse-led team model has also been shown to be successful in the speciality of neonatal care in the UK. The impact of changes in the National Health Service (NHS) has led to an increased demand for the transportation of the child requiring paediatric intensive or high-dependency care, the lifting of restrictions on nursing practice and the reduction of doctors' hours in keeping with the European Working Time Directive. This has led to one NHS Trust in the UK developing the role of paediatric retrieval nurse practitioners (RNP): nurses who lead the retrieval team. The purpose of this article is to describe a pilot initiative to develop the role of RNPs. The comprehensive process of recruitment, training and assessment of competency will be detailed. Personal reflection on the project will also explore the pertinent nursing issues around; role impact and definition, conflict and change management, communication, legislation and personal and professional growth. Recommendations for future initiatives will also be explored.     

The effectiveness of a nurse practitioner-led pain management team in long-term care: A mixed methods study

BackgroundConsidering the high rates of pain as well as its under-management in long-term care (LTC) settings, research is needed to explore innovations in pain management that take into account limited resource realities. It has been suggested that nurse practitioners, working within an inter-professional model, could potentially address the under-management of pain in LTC.ObjectivesThis study evaluated the effectiveness of implementing a nurse practitioner-led, inter-professional pain management team in LTC in improving (a) pain-related resident outcomes; (b) clinical practice behaviours (e.g., documentation of pain assessments, use of non-pharmacological and pharmacological interventions); and, (c) quality of pain medication prescribing practices.MethodsA mixed method design was used to evaluate a nurse practitioner-led pain management team, including both a quantitative and qualitative component. Using a controlled before-after study, six LTC homes were allocated to one of three groups: 1) a nurse practitioner-led pain team (full intervention); 2) nurse practitioner but no pain management team (partial intervention); or, 3) no nurse practitioner, no pain management team (control group). In total, 345 LTC residents were recruited to participate in the study; 139 residents for the full intervention group, 108 for the partial intervention group, and 98 residents for the control group. Data was collected in Canada from 2010 to 2012.ResultsImplementing a nurse practitioner-led pain team in LTC significantly reduced residents' pain and improved functional status compared to usual care without access to a nurse practitioner. Positive changes in clinical practice behaviours (e.g., assessing pain, developing care plans related to pain management, documenting effectiveness of pain interventions) occurred over the intervention period for both the nurse practitioner-led pain team and nurse practitioner-only groups; these changes did not occur to the same extent, if at all, in the control group. Qualitative analysis highlighted the perceived benefits of LTC staff about having access to a nurse practitioner and benefits of the pain team, along with barriers to managing pain in LTC.ConclusionsThe findings from this study showed that implementing a nurse practitioner-led pain team can significantly improve resident pain and functional status as well as clinical practice behaviours of LTC staff. LTC homes should employ a nurse practitioner, ideally located onsite as opposed to an offsite consultative role, to enhance inter-professional collaboration and facilitate more consistent and timely access to pain management.     

Intensive care nurse practitioners in Australia: A description of a service model in an adult tertiary intensive care unit

BackgroundAlthough well-established internationally, nurse practitioners (NPs) in Australian adult intensive care units (ICUs) are rare. Australian literature clearly highlights the importance of creating ICU NP roles to meet emerging demands. An ICU NP model of care at a metropolitan hospital in Sydney provides care in four core practice areas: complex case management, vascular access, tracheostomy management, and intrahospital transport of critically ill patients. The ICU NPs also provide training and assessment for ICU nurses and medical officers in these same core practice areas and can efficiently meet service gaps in crisis such as the most recent COVID-19 pandemic.ResultsThe ICU NP program described is an innovative model of care that has demonstrated potential benefits to patients and their families. Potential benefits to the healthcare system including supporting advanced practice nursing development in regional and rural Australia and in addressing future ICU workforce issues are also identified. This model of care provides a clear role and structure for the integration of NPs in the adult ICU. Research to evaluate the impact of the role is required and is underway.ConclusionsThis model is being used to develop a national adult ICU NP fellowship training program for ICU transitional NPs preparing for endorsement or endorsed NPs who require additional ICU-specific training. This immersive clinical training program combined with didactic learning modules offers a framework to support the implementation of the adult ICU NP role as well as a framework for NP fellowship programs in other specialties.     

HIV Primary Care Curriculum Improves HIV Knowledge,Confidence and Attitudes

To meet the goals of the National HIV/AIDS Strategy and the need for a human immunodeficiency virus (HIV)-competent primary care workforce, education and training of nurse practitioners are critical. The University of California, San Francisco School of Nursing developed and implemented an HIV primary care curriculum and evaluated this curriculum for a graduating cohort of 55 students. Results show gains in students’ HIV knowledge and confidence in providing basic HIV care and improvements in attitudes toward people living with HIV. We have been able to show that HIV content can be successfully integrated into a nurse practitioner generalist curriculum.     

Alignment of Pediatric Nurse Practitioner Licensure,Accreditation, Certification,and Education for Employers

Advanced practice registered nurses (APRNs) are a critical member of the health care team, providing essential frontline care to patients and families. Given the evolution of the use of pediatric-focused APRNs in more acute and critical care settings, it is essential to understand the APRN consensus model. Understanding the APRN consensus document and its relationship to selecting the pediatric nurse practitioner who is appropriately qualified for the population of interest is crucial. Compliance with regulatory guidelines during the credentialing and privileging processes, along with organized clinical onboarding after hire, can optimize outcomes for employers and providers alike.     

Protected therapy services for critical care: A subanalysis of the UK-wide workforce survey

BackgroundThe existing United Kingdom (UK) allied health professional (AHP) workforce in critical care does not meet national standards, with widespread variation in the source of funding, service availability, and regularity of input.ObjectivesThe aim of this subanalysis was to determine the impact of protected services on the involvement of AHPs on direct and nondirect aspects of patient care.MethodsThis is a subanalysis of the previously published AHPs in critical care UK-wide workforce survey, an observational study using online surveys distributed to 245 critical care units across the UK.Results/FindingsServices with protected funding provided more daily input within critical care. This was most apparent for occupational therapy where daily input varied from 82.1% of units with protected services compared to just 10.3% in those without (p < 0.001). For all professions, most notably occupational therapy and speech and language therapy, protected services increased the regularity in which specific interventions were completed and had impact on involvement in nonclinical aspects of care including involved in multidisciplinary team meetings, clinical governance, and research.ConclusionsThe absence of protected AHP services reduces compliance with national standards for therapy workforce. Based on these findings, UK and international critical care guidelines should promote protected AHP services for critical care.     

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.     

Point of care ultrasound use by Registered Nurses and Nurse Practitioners in clinical practice: An integrative review

BackgroundNurses and nurse practitioners (NPs) are utilising point of care ultrasound (PoCUS) in practice. PoCUS is a useful tool to enhance clinical assessments and improve patient care. There have been no published literature reviews on this topic.AimsThe objective of this review is to examine the literature on PoCUS and draw conclusions to determine the implications of the use of PoCUS by registered nurses and nurse practitioners to inform nursing practice.DesignIntegrative review.MethodsData bases MEDLINE, EMBASE, CINAHL and Google scholar were searched for relevant articles between 2008 and 2018. The inclusion criteria were registered nurses and nurse practitioners using PoCUS in their clinical practice. Articles retrieved were in English and with full text. Articles were assessed for quality using TREND and a PRISMA flowchart is presented.FindingsSix eligible articles were examined identifying major findings of education in PoCUS, accuracy and mastery of a skill and clinical influence.DiscussionAn evaluation of the use of PoCUS by registered nurses and nurse practitioners provides evidence of its efficacy and potential to improve patient care and inform nursing practice.ConclusionSome registered nurses and nurse practitioners are expanding their scope of practice to include PoCUS to improve patient care. PoCUS requires investment in time and education.     

A task-based approach to defining the role of the nurse practitioner: the views of UK acute and primary sector nurses

There exists within the United Kingdom considerable confusion relating to the definition and occupational boundaries of the nurse practitioner (NP). In consequence, the clinical practice and training of the NP remain unregulated, unstandardized and heavily dependent on local forces. Such a situation is regrettable, particularly in view of the potential value the nurse practitioner has for health care provision and also for influencing national policy decisions. It is conceivable that one reason for the current failure to reach agreement over the role definition of the nurse practitioner relates to the fact that their essential job functions depend upon the context in which the nurse practitioner operates, with primary-based practice differing from acute sector service delivery in sufficient critical ways as to make a generic, inclusive definition impossible. To investigate the veracity of this view, two cohorts of United Kingdom nurses were sampled, one of which worked within the acute sector (n = 49) and the other in the community (n = 420). These groups were surveyed using a unique training needs analysis instrument that had been developed along formal psychometric principles. Both groups perceived advanced clinical activities, including examination and diagnosis, and a range of research activities to be central to the role of the nurse practitioner. The primary sample, however, reported business and management activities as essential tasks, while the acute sector nurses regarded high levels of communication skills, autonomy and risk management to be more important. The implications of the similarities and differences between the two data sets are discussed with reference to different clinical domains.     

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.     

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.     

Evaluating new roles within emergency care: a literature review

Introduction

In recent years economic and political drivers have strongly influenced the development and introduction of new roles such as medical substitution roles within emergency care in the National Health Service (NHS) in the United Kingdom (UK).

Aims

The aims of this literature review were to establish the national and international evidence available which examine the scope of practice of emergency nurse practitioners, emergency care practitioners and extended scope physiotherapists; to establish the national and international evidence which explores patient satisfaction with non-medical roles in emergency care; to establish the national and international evidence which explores the acceptability of emergency nurse practitioner, emergency care practitioner and extended scope physiotherapists services from a healthcare professional perspective.

Methods

A search of the literature was undertaken using BNI, CINAHL plus, International Bibliography of the Social Sciences, MEDLINE and SPORTDiscus databases combined with searches of the Cochrane library collection, NICE and the grey literature. Critical assessment of the literature is presented.

Results

A high level of patient satisfaction was found with all the new roles. Interestingly the scope of practice of Emergency nurse practitioners appears to be most limited in the UK. Five major themes were identified from healthcare professionals’ perceptions of these new roles.

Conclusion

There is general agreement that non-medical roles help to reduce waiting times in emergency departments, as well as attracting a high level of patient satisfaction, confidence and acceptance of these roles. Several issues were identified which warrant further study; including the current UK evidence surrounding the limited scope of practice of these roles.     

Between two roles – Experiences of newly trained nurse practitioners in surgical care in Sweden: A qualitative study using repeated interviews

The position of Nurse Practitioner is a new role in Nordic countries. The transition from a registered nurse to the Nurse Practitioner role has been reported to be a personal challenge. This study, guided by the Nordic theoretical model for use in the education of advanced practice nurses, represents a unique opportunity to describe this transition for newly graduated Nurse Practitioners in an interprofessional surgical care team in Sweden. The aim was to explore how the first Nurse Practitioners in surgical care experienced the transition into a new role and what competences they used in the team. Eight new Nurse Practitioners with parallel work in clinical practice were interviewed twice around the time of their graduation. The qualitative analyses show that the participants integrated several central competences, but the focus in this early stage in their new role was on direct clinical praxis, consultation, cooperation, case management, and coaching. Transition from the role of clinical nurse specialist to nurse practitioner was a challenging process in which the positive response from patients was a driving force for the new Nurse Practitioners. The participants felt prepared for and determined to solve the challenging situations they approached working in the interprofessional team.     

Nurse Practitioner Role,Independent Practice,and Teamwork in Primary Care

Primary care nurse practitioner (NP) workforce represents a substantial supply of primary care providers able to meet the demand for care. However, many barriers influence NP practice and care. This study conducted a survey of NPs in New York state to better understand NPs' role, independent practice, and teamwork in primary care organizations. Overall, 278 NPs completed the online survey. Forty-two percent of NPs had their own patient panel. The mean score of the Autonomy and Independent Practice scale was higher than that of the Teamwork scale. These scales were positively correlated, suggesting that NP independent practice may improve teamwork.     

A trial of nurse practitioner scope of practice

AIMS: The aim of this paper is to report a trial to investigate the feasibility of the nurse practitioner role in local health service delivery and to provide information about the educational and legislative requirements for nurse practitioner practice. BACKGROUND: Nurse practitioners have been shown to offer a beneficial service and fill a gap in health care provision. However, the lack of publications describing, critiquing, or defending the way that existing nurse practitioner roles have been developed may lead to a lack of clarity in comparing the nurse practitioner scope of practice internationally. In Australia, credible exploratory research is needed to realize the potential of nurse practitioners to bridge the divide of inequitable distribution of health services. A trial of nurse practitioner services in the Australian Capital Territory provided an excellent opportunity to investigate these scope and continuity issues. METHODS: This was an observational analytic study using multiple data sources. Four models of nurse practitioner service were chosen from a competitive field of applications that were evaluated according to efficacy, feasibility, and sustainability across specified selection criteria. Each model in the trial included a clinical support team, with the nurse practitioner candidate 'working-into-the-role' and collecting demographic, clinical practice, patient outcome, and health service and consumer survey data over a 10 month period. FINDINGS: The trial identified the broad potential of the nurse practitioner role, its breadth and limitations, and its impact on selected health services in the Australian Capital Territory. Data from individual models were compared highlighting generic elements, and formed the basis for the development of the scope of practice for the Australian Capital Territory nurse practitioner models. CONCLUSIONS: This study has validated a research-based, iterative process for initial development of nurse practitioner scope of practice for any Australian specialization. Importantly, the study concluded with the scope of practice as a finding, rather than commencing with it a priori. Although general areas of health care need and under-servicing were identified at the outset, the process tested both the expansion and parameters of the roles.     

Alignment of Nurse Practitioner Educational Preparation and Scope of Practice in United States Emergency Departments: A Systematic Review of the Literature

IntroductionNational debate persists surrounding the expanded use of nurse practitioners in the emergency department. Current understanding of the alignment of nurse practitioner educational preparation and practice parameters in United States emergency departments is inchoate. The objective of this review was to seek evidence to support that nurse practitioner education and training align with current practices in the emergency department.MethodsA Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided systematic review of the existing literature was conducted of 4 relevant databases. Level of evidence and quality assignments were made for each article using Grading of Recommendations, Assessment, Development, and Evaluation or Confidence in Evidence from Reviews of Qualitative Research as appropriate.ResultsNurse practitioners are increasingly staffing emergency departments, providing care to both patients classified as high-acuity and low-acuity. Reports of nurse practitioner scope of practice vary widely. No studies evaluated alignment of educational preparation and training for actual clinical practice.DiscussionThis review of the literature was inconclusive, and the review team we was unable to find evidence that supports the alignment of nurse practitioner educational preparation and training with scope of clinical practice in United States emergency departments. Future research should seek to articulate the landscape of nurse practitioner academic preparation for specialty practice in the emergency department and to specifically examine the alignment of educational preparation with scope of practice and impact on clinical outcomes of patients seen in the emergency department.     

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.