Advanced nursing practice: policy, education and role development

Aims and objectives. This paper aims to explore the critical elements of advanced nursing practice in relation to policy, education and role development in order to highlight an optimal structure for clinical practice. Background. The evolution of advanced nursing practice has been influenced by changes in healthcare delivery, financial constraints and consumer demand. However, there has been wide divergence and variations in the emergence of the advanced nurse practitioner role. For the successful development and implementation of the role, policy, educational and regulatory standards are required. Conclusion. The paper highlights the value of a policy to guide the development of advanced nursing practice. Educational curricula need to be flexible and visionary to prepare the advanced nurse practitioner for practice. The core concepts for the advanced nursing practice role are: autonomy in clinical practice, pioneering professional and clinical leadership, expert practitioner and researcher. To achieve these core concepts the advanced nurse practitioner must develop advanced theoretical and clinical skills, meet the needs of the client, family and the community. Relevance to clinical practice. In a rapidly changing people‐centred healthcare environment the advanced nurse practitioner can make an important contribution to healthcare delivery. The challenges ahead are many, as the advanced nurse practitioner requires policy and appropriate educational preparation to practice at advanced level. This will enable the advanced practitioner articulate the role, to provide expert client care and to quantify their contribution to health care in outcomes research.     

Differentiated practice: The evolution of professional nursing

Differentiated practice identifies and uses three distinct nursing roles to create a comprehensive nursing care delivery system that meets client needs across the health care continuum. Clearly defined associate degree in nursing, bachelor's of science in nursing, and master's science in nursing competencies present career opportunities for professional nurses at the bedside providing, integrating, or managing client care as well as options in management, education, and regulation. An evolutionary paradigm shift required of all nurses is the awareness that each nurse is not the whole of nursing, but rather each nurse contributes to the whole of nursing. A nursing community comprised of differentiated roles that are mutually valued and well integrated will position nursing as a powerful force in meeting the diversity and complexity of health care needs in contemporary society.     

Toward an integration of competencies for advanced practice mental health nursing

As new models of health care delivery evolve, the work of advanced practice nurses is growing in importance. Graduate programs in nursing have traditionally prepared advanced practice nurses for separate roles as clinical nurse specialists or as nurse practitioners. However, there are increasing trends toward the blurring of boundaries between these two types of advanced practice roles. Hence, a future blended role is projected by many nurse educators. The merger of clinical nurse specialist and nurse practitioner roles, however, requires corresponding shifts in academic programs. The purposes of this article are to discuss the need for a blended clinical specialist-nurse practitioner role in mental health, to identify populations of clients who would be served by a blended role provider, to discuss the competencies associated with such a role, and to share an approach to the preparation of advanced practice mental health specialist/practitioners.     

Shaping the advanced practice psychiatric-mental health nursing role: a futuristic model

As advanced practice psychiatric-mental health nursing has transitioned from earlier models of practice, elements of clinical specialist and psychiatric nurse practitioner roles are being blended to produce a new type of practitioner. The challenge of preserving mental health expertise while expanding advanced practice primary and primary mental health care competencies is addressed in several nursing education models. At New York University's Division of Nursing, faculty have designed a program around elements identified as essential to the autonomy demanded of the evolving role, knowledge, and skills basic to broad based health care and mental health care delivery with quality patient care outcomes and the competencies necessary for accountability as care providers in a changing health care delivery system. Essential elements, resources to identify them, and strategies to attain them are discussed. Approaches that promote student, clinician, and faculty development and maximize education affirm the specialty's capacity for innovation and the profession's capacity for new direction and futuristic change.     

SHAPING THE ADVANCED PRACTICE PSYCHIATRIC-MENTAL HEALTH NURSING ROLE: A FUTURISTIC MODEL

As advanced practice psychiatric-mental health nursing has transitioned from earlier models of practice, elements of clinical specialist and psychiatric nurse practitioner roles are being blended to produce a new type of practitioner. The challenge of preserving mental health expertise while expanding advanced practice primary and primary mental health care competencies is addressed in several nursing education models. At New York University's Division of Nursing, faculty have designed a program around elements identified as essential to the autonomy demanded of the evolving role, knowledge, and skills basic to broad based health care and mental health care delivery with quality patient care outcomes and the competencies necessary for accountability as care providers in a changing health care delivery system. Essential elements, resources to identify them, and strategies to attain them are discussed. Approaches that promote student, clinician, and faculty development and maximize education affirm the specialty's capacity for innovation and the profession's capacity for new direction and futuristic change.     

Preparing the FNP Workforce for the Increasingly Complex Work Environment

In 1965, the University of Colorado became the first university to develop a curriculum for the nurse practitioner role, preparing clinicians to meet contemporaneous, across-the-life span, general-practice health care needs. However, in the succeeding 5 decades, individual- and population-level health care needs have grown both in scope and complexity (eg, management of multifaceted chronic diseases and behavioral health conditions). Therefore, family nurse practitioner (FNP) education programs must themselves evolve to match the current, evolving health care environment. This article reviews how an FNP curricular redesign at a college of nursing assisted the faculty in meeting this charge.     

对我国临床护理专家业务能力期望的研究

目的　探讨适合我国国情的临床护理专家 (clinicalnursespecialist,CNS)应具备的业务能力。方法　运用问卷法咨询 1 5 0名护理专家。结果　临床工作能力是CNS最基本、最重要的业务能力 ,教育能力和科研能力是CNS重要的业务能力 ,具备一定的管理能力是CNS工作的需要 ,社区护理能力是CNS需争取具备的能力。结论　根据调查结果 ,得出临床护理工作能力、教学能力、科研能力、管理能力、社区护理能力为CNS基本业务能力。     

Genogram: a useful tool for nurse practitioners

This paper presents the genogram, originated by family therapists and utilized in the psychosocial field, as a valuable tool to be used by the nurse practitioner. The nurse practitioner from any area of practice, primary care, women's health, paediatrics, geriatrics, psychiatry, in any setting (hospital, clinic, school, industry, community and home), requires a tool that provides a comprehensive assessment of the client and the factors that affect their health. The theoretical background of Bowen's family systems theory and of systems theory is reviewed as the genogram evolved from the theories. Two hypothetical case illustrations utilizing the genogram are presented, one presenting only medical problems, the other presenting medical, psychiatric and family relationships. The usefulness of the genogram is not new, but it is reviewed here for its value to the nurse practitioner. Evidence leads to the conclusion that the genogram is an assessment tool that enhances intervention strategy and communication in the client's record. It augments treatment planning, care provision, health promotion and prevention, as well as cost management.     

HIV-infected client care: case management and the HIV team.

No one discipline can meet the complex needs of the HIV-infected client. Because of the diverse nature of disease manifestations, an HIV Team concept is promoted. The clinical nurse specialist (CNS) is uniquely prepared to initiate the team and support holistic client care through case management. Current HIV statistics with implications for the rural community are provided, and reasons for the lack of community involvement with HIV care are suggested. The case study illustrates complex needs of an HIV-infected woman, as well as issues that evolve during HIV-infected client care. Interventions that promote care for persons living with HIV in addition to support of involved health care workers are addressed. Practical suggestions for initiating this process are included.     

A literature review of advanced clinical nursing practice in the United States of America

Advanced nursing practice in the United States of America has evolved over the past decades in two related but distinct directions:- the nurse practitioner (NP) and the clinical nurse specialist (CNS). This two-role evolution was in response to social demands for increased access to affordable, quality primary health care, and at the same time to the specialised nursing care requirements of increasingly complex patients. Thus, nurse practitioners became synonymous with primary and clinical nurse specialists with specialised, acute care. There is evidence that there is an advanced practice role for both the CNS and the NP and that much of the knowledge, skills and competencies are shared depending on the clinical situation. There have been successes and failures in the development of the two roles. The clinical nurse specialists have a more respectable image among the powerful nursing education elite, but nurse practitioners are widely recognised by consumers and other health care professionals and are valued by cost-conscious managers as a viable, cheaper alternative to physicians. The literature suggests it may well be time to take the best attributes of the two roles and merge them under the term 'advanced nurse practitioner'.     

The clinical nurse specialist and nurse practitioner roles: room for both or take your pick?

OBJECTIVE: The aim of this paper is to contribute to pertinent discussions regarding advanced practice nursing roles. In particular discussion will focus on the potential implications for the developing nurse ractitioner (NP) role on the existing clinical nurse specialist (CNS) roles. SETTING: The literature presented originates primarily from the United States of America (USA), United Kingdom and Australia. Specific emphasis is placed on the psychiatric/mental health nursing context. PRIMARY ARGUMENT: Amidst the confusion in terminology to describe and explain advanced, expanded or extended nursing roles, and to distinguish between the clinical nurse specialist and the nurse practitioner, there is a need to establish clarity. The need for both clinical nurse specialist and nurse practitioner roles has been hotly debated in the USA. CONCLUSIONS: The roles of clinical nurse specialist and nurse practitioner may be complementary but fulfil different functions. It is therefore important that both roles be maintained and implemented in response to consumer and health service needs.     

Reinstating district nursing: A UK perspective

As policy directives gather pace for service provision to be delivered in primary care, district nursing has not been recognised as a valuable asset to facilitate this agenda. Investment in district nursing and specialist district nursing education has fallen. This is concurrent with an ageing district nursing workforce, a lack of recruitment and growing caseloads, as district nursing adapts to meet the challenges of the complexities of contemporary healthcare in the community. The district nurse role is complex and multifaceted and includes working collaboratively and creatively to coordinate care. Redressing the shortages of specialist district nurse practitioners with increased numbers of health care support workers will not replace the skill, knowledge, experience required to meet the complex care needs of today's society. District nursing needs to be reinstated as the valuable asset it is, through renewed investment in the service, research development and in specialist practice education. To prevent extinction district nurses need to be able to demonstrate and articulate the complexities and dynamisms of the role to reinstate themselves to their commissioners as a valuable asset for contemporary practice that can meet current health and social care needs effectively.     

The Pediatric Mental Health Specialist: Role Delineation

Advanced practice registered nurse (APRN) specialties build on regulated role and population competencies and add expertise in a discrete area of practice. The Consensus Model speaks to the need for the nursing profession to create mechanisms that validate APRN competencies in new specialty areas that emerge from patients’ health care needs. The Pediatric Nursing Certification Board conducted a role-delineation study to examine the specialty area of pediatric primary care mental health. The result is a new certification and examination that validate knowledge, skills, and expertise for the role of the pediatric mental health specialist.     

Defining the unique role of the specialist district nurse practitioner

Due to the reorganization of primary care trusts across the country, certain trusts proposed a reduction in the specialist district nurse practitioner numbers in favour of less qualified community nurses and health care assistants. Such proposals in one PCT were blocked, partly in response to documentation compiled by practitioners at the sharp end of nursing practice. With the new agenda of practice based commissioning, it is imperative that commissioners and management alike are aware of the scope of specialist district nurse practitioners. This is the first of a series of articles looking at specific case histories where the role of the district nurse is highlighted. It is the intention to stress the importance of the clinical expertise and confidence required by the district nurse to care for patients with complex needs in the community.     

Advanced practice nursing role: clinical nurse specialist

The public continues to demand quality health care that focuses on the achievement of quality patient outcomes. The clinical nurse specialist is an advanced practice role that originated in the early 1900s as a result of similar public demand, and continues to evolve to meet quality health care needs. Advanced practice nurses have many opportunities to create expanded nursing roles. Orthopaedic nurses also continue to refine their practice roles, and the clinical nurse specialist is one such example.     

Faculty mentorship: support for nurse practitioner students and staff within the rural community health setting

As pointed out in the introduction, there are certain practical concepts within our base of nursing knowledge that can only be taught through experience. Many things are easier to teach by example. As we turn back the clock in nursing, we can see how Florence Nightingale, Clara Barton, and Lillian Wald were role models to their nursing peers in their era. They taught nursing by example, by role modeling their clinical expertise. Today, this model is still effective and faculty mentoring of nurse practitioner students and CHNs in a compassionate and collegial leadership results in higher quality of health care for our nation's needy clients and their families. But greater yet are the opportunities for flexible nurse practitioner faculty practice and personal interactions on many levels for nursing faculty who wish to share their expertise. Mentorship by nurse practitioner faculty for nurse practitioner students and CHNs in a rural clinical setting has revealed many positive aspects in providing quality care for rural clients and growth for nurses. Exposure to the rural community health system helps us, as nurses, to identify the many strengths it possesses for innovative rural nursing practice.     

The future of graduate education in nursing: Scholarship, the health of communities, and health care reform

The authors critically examine the urgent needs posed by national health care reform and the forces impinging on the nursing profession to prepare nurse practitioners to meet these needs. With references to other struggles in nursing's professional history, the authors caution against exclusive investment in the nurse practitioner role as the discipline's hope for long overdue recognition of nursing's value to society. They argue that with health care reform, nurses have the chance to make graduate nursing education more responsive to the actual health needs of the populace and more relevant for practice in communities. The actions advocated include reflecting carefully on the articulation of nurse practitioner roles with others in the discipline, taking a partisan stand with vulnerable groups, developing substantive expertise in community-based practice and research, applying an understanding of the broader environmental context of health, and committing as a discipline to practice and scholarship that really makes a difference in the health of the public.     

Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review

BackgroundAdvanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness.ObjectiveTo examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles.MethodsOur methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel.ResultsThe narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles.ConclusionCurrent guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.     

Gerontic nurse specialists: an examination of their roles with dementia sufferers and their caregivers

Dementia sufferers and their caregivers have multiple and complex needs. To meet these needs the gerontic nurse specialist assumes a number of interrelated roles: role model, implementer, consultant, educator, researcher, manager, advocate and mentor. This paper discusses the multiple roles of the gerontic nurse specialist in meeting the health care needs of dementia sufferers and their caregivers. It is recognized that caregivers encompass family members and nursing staff.