Advanced nursing practice: new ideas and new perspectives

The authors of this paper contend that advanced nursing practice differs substantially from other forms of nursing practice, such as expert and specialist practice Additionally, they contend that the difference resides in the way that advanced nurse practitioners think about, see and experience clinical practice Historically, nursing in Australia has been strongly influenced by events and ideas generated in North America The authors argue this has led to the development of an emphasis on the nature, role and function of specialist and expert nursing practice to the detriment of ascertaining and fostering the notion and nature of advanced nursing practice This influence of North American nursing has also significantly directed and influenced the way in which we use and understand the term 'advanced nursing practice', and further, that the way in which we use the term does not give full regard to the context of Australian nursing The authors outline some of the key issues and ideas emerging in South Australia with respect to advanced nursing practice and in particular offer beginning theonzations into the different ways in which advanced nurse practitioners think, see and experience nursing practice     

Psychiatric nurse practitioner versus clinical nurse specialist: moving from debate to action on the future of advanced psychiatric nursing.

The psychiatric nursing literature recently has included a proliferation of discussions regarding the nature and direction of change impacting the future of advanced practice psychiatric nursing. The debate has focused most commonly on the role of the clinical nurse specialist versus the role of the nurse practitioner. The debate has produced little in the way of outcomes other than an entrenchment of positions. The stalemate in psychiatric nursing is producing a slow but steady surrender of the boundaries of psychiatric nursing to other fields of nursing. Although advanced practice psychiatric nurses disagree on what to become and what to be called, people with conditions such as depression, anxiety disorders, and other psychiatric disorders are being treated increasingly by family nurse practitioners. The time for debate has ended. Unless consensus regarding what constitutes the domain of psychiatric nursing is reached soon, the discussions will be moot because few clients will remain to be treated. This article began as a discussion between colleagues. The two authors teach at a regional state university, but they share diverse opinions regarding the substance and nature of advanced practice psychiatric nursing. These diverse views led to discussions that have implications not only for faculty practice, but for curricular design, and for decisions regarding how to best educate future nurses. The discussion developed into a presentation at the 20th Southeast Conference of Clinical Nurse Specialists. It was presented as a point-counterpoint discussion regarding this debate; one author advocated the perspective of traditional clinical nurse specialist and one advocated the perspective of a psychiatric nurse practitioner role. We conclude with a projected model of a merged role, with delineation of traditional clinical nurse specialist and nurse practitioner that must be blended for the new role.     

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.     

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.     

Advanced nursing practice from a cross-cultural perspective

This article describes the perceptions of a visiting lecturer exchange experience between Wolverhampton University, School of Nursing and Midwifery, and the University of Kentucky, Lexington, in the American state of Kentucky. The major goal of the visit was to learn health assessment skills to bring back to future advanced practice programmes within the university. The opportunity to work with a variety of nurse practitioners culminated in a unique review of the training development and evolution of advanced nursing practice in Kentucky. Some of the conceptual confusions of advanced nursing practice are explored, together with the features of a new blended role which combines the practice of two traditional positions: the medical skills of nurse practitioners and the expertise of clinical nurse specialists.     

A nurse practitioner model of practice in the neonatal intensive care unit

PURPOSE: The purpose of this study was to describe the practice of the nurse practitioner (NP) in the neonatal intensive care unit (NICU) in an attempt to define an advanced practice nursing model that is unique to NP practice in the NICU. DESIGN: This qualitative research used an ethnographic case study design to answer the research question: 'What is the practice model of nurse practitioners working in the NICU?' METHODS: Seven nurse practitioners working in five level II/III NICUs in Massachusetts and Rhode Island were interviewed and observed in practice. Audiotaped interviews using open-ended questions and field notes from participant observations were analyzed for patterns of behavior. RESULTS: These nurse practitioners practiced within a model of advanced practice nursing that emphasized health, holism, and caring within the highly technological and medical NICU environment. CLINICAL IMPLICATIONS: A model of NP practice in the NICU is emerging and needs further development and testing. Nurse educators and administrators must find ways to support the nursing model in the advanced practice nursing role in the NICU. Nurse practitioners need to be more active in promoting a clearer understanding of their practice and contributions to the NICU care delivery team.     

Conceptualizing advanced nursing practice: curriculum issues to consider in the educational preparation of advanced practice nurses in the UK

The findings from a Florence Nightingale Scholarship to the USA and Canada, investigating the educational preparation of advanced practice nurses, are reported. The author considers a number of issues facing curriculum designers who might wish to develop clinically based advanced practice nurse programmes in the UK. Utilizing the experiential nature of personal visits, along with the available literature, the strategy adopted by some American and Canadian universities is highlighted to exemplify curriculum issues likely to be encountered in the UK. A definition of advanced nursing practice is provided as a foundation for discussion on curricular construction. This is followed by a discussion on advanced role nomenclature and components and characteristics of the 'nurse practitioner', 'clinical nurse specialist', 'nurse consultant' and 'nurse clinician', in order to clarify terminology and disentangle different advanced practice roles. The issues examined include the academic level of advanced practice nurse programmes; the determination of curricular content based on both a 'generalist' and 'specialist' model of practice; factors considered when exploring advanced practice competencies; and the resource implications for delivering opposing curriculum models. The paper suggests that there is a unique opportunity for advanced practice nursing to establish a key collaborative relationship in the delivery of health care, based on a nursing model, graduate study and the integration of key nursing and related concepts into clinical practice.     

The role of the advanced practice nurse in facilitating a clinical research study. Screening for delirium

As advanced practitioners, clinical nurse specialists and nurse practitioners have a leadership role in integrating and promoting nursing research in clinical settings. In this quasi-experimental study, the role of the advanced practice nurse in developing and implementing an intervention that improved delirium screening by staff nurses is described. Screening practices of the treatment group nurses were accurate in 100% of the cases. Control nurses failed to detect any cases of delirium. A discussion of study findings and their relevance to advanced practice nursing are discussed.     

A critical engagement with the concept of advancing nursing practice

AIM: This paper aims to elucidate the concept of advancing nursing practice by engaging critically with developments in policy in the UK and ongoing debates in the international literature. BACKGROUND: Advancing practice to the outer edges of nursing's scope of practice is a challenge for the profession both in the UK and elsewhere. However, defining what advancing nursing practice is and what it might become remains problematic. EVALUATION: Critical analysis of published papers and policy documents pertaining to the concept of advancing nursing practice. KEY ISSUE: Advancing nursing practice as a concept offers enormous potential for nurses and has been the subject of numerous debates over the last 25 years. Previous history of advanced practice offers no imperative practice and informs us little about the future roles of advanced nurse practitioners. CONCLUSION: Current understanding about the role of advanced nurse practitioner and the nature of advanced practice remains unclear. Measuring the impact and outcome of the complex advanced practice nursing roles remains a challenge. IMPLICATIONS FOR NURSING MANAGEMENT: While it is difficult to articulate succinctly what constitutes advancing nursing practice, defining the activities nurses engage in, the skills and competencies involved and the qualities and attributes required help reduce the ambiguities of the role.     

Acute care nurse practitioner practice: results of a 5-year longitudinal study.

The role of acute care nurse practitioners (ACNPs) has developed in capacity. More than 3500 advanced practice nurses have been certified as ACNPs, and the number of practice settings where these professionals work is continually expanding. Beginning in 1996, a series of surveys were conducted of nurse practitioners seeking national certification as ACNPs. What started as an attempt to gather information on the role of ACNPs evolved into a national 5-year longitudinal survey of ACNP practice. The cumulative results of the project are reported, and how the role of the ACNP was established in advanced practice nursing is discussed.     

Promoting leadership and management in Australian general practice nursing: what will it take?

Aim This paper outlines the current state of Australian practice nursing, describes the context of general practice and establishes the importance of promoting leadership and management in this setting. Background Australian general practice nurses have emerged as key stakeholders in primary health care. However, their role in leadership and management has been largely invisible. The reasons for this are multifactorial, including the delay to establish a strong professional organization, their negative power relationships with general medical practitioners, limited nursing leadership and poorly defined roles. To date, the impetus for practice nurse growth has been largely external to the nursing profession. Growth has been driven by the increasing burden of chronic disease and workforce shortages. This has further weakened the control of nurse leaders over the development of the specialty. Conclusions The Australian practice nurse role is at a crossroads. While the practice nurse role is a viable force to improve health outcomes, the growing strength of the practice nurse challenges traditional professional roles and practice patterns. Implications for nursing management There is an urgent need to develop practice nurse leaders and managers to not only embrace the challenges of Australian general practice from an operational perspective, but also undertake a clinical leadership role. As clinical leaders, these nurses will need to develop a culture that not only optimizes health outcomes but also advances the status of the nursing profession.     

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.     

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 lecturer practitioners in Ireland

Nursing continues to struggle to integrate the theoretical and clinical aspects of nurse education for the development of competent practitioners. Collaborative approaches to nurse education as well as the development of joint clinical-academic roles have had questionable success to date on merging the theoretical and clinical components of nursing. Lecturer practitioners' posts are new in Ireland. These posts were created as nurse educators were cognizant of the need for students to integrate theory to practice. The aim of the lecturer practitioner role was to increase the support forstudent nurses in both academia and practice. An evaluation of the impact of the lecturer practitioner role from three key perspectives was conducted in three Irish teaching hospitals in 2007. The results of this study suggest that as lecturer practitioners have both a clinical and academic remit they can integrate theory to practice through collaborative practice.     

Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice

In the United Kingdom nurse practitioners are assuming responsibilities traditionally considered to be within the domain of general practitioners. Important amongst these is the referral of patients to medical consultants in secondary care, a responsibility commonly associated with the general practitioner's role as 'gatekeeper' to health care. This paper describes a study designed to identify issues raised by the challenge that a developing nursing role presents to interprofessional working at the interface between primary and secondary care. When invited to comment, study participants (nurse practitioners, nurse educators, medical consultants and general practice registrars) related nursing referrals to issues associated with professional boundary changes, namely: teamwork, regulation of practice, communication, professional conflict and professional relationships. This paper discusses the views of primary and secondary care practitioners about who should take responsibility for the referral of patients in the light of concerns raised about professional competence and accountability. Individual nurse practitioners and their colleagues have found pragmatic ways to manage their work however, although UK government policy supports development of advanced clinical nursing, there remains much work to be done to provide the professional and legal infrastructure to support the role.     

The attitudes of GPs towards the nurse-practitioner role

In recent years, nursing and health-care policy have promoted the advanced role of the nurse -- that of nurse practitioner. But such a role has not been integrated widely into the primary health-care team. This study investigates the knowledge and attitudes of GPs who do not employ nurse practitioners to find out what prevents them doing so. Ten GPs who did not already employ a nurse practitioner took part in semi-structured interviews. Our findings show that GPs, although confused about the role, were generally supportive of advanced nursing practice. Skills identified with the role were prescribing, disease diagnosis and minor-illness management. GPs thought that protocols and guidelines should govern practice, which differs fundamentally from the Royal College of Nursing definition. None of the GPs had encountered the role in primary care, and the lack of professional regulation and role definition for practice nurses and nurse practitioners who work in primary care may have affected GPs' perceptions.     

Culture Care Theory: a proposed practice theory guide for nurse practitioners in primary care settings

Leininger's Theory of Culture Care Diversity and Universality is presented as a foundational basis for the educational preparation, primary care contextual practice, and outcomes-focused research endeavours of advanced practice nursing. Discussion emphasises the value of care and caring as the essence of advanced practice nursing through the use of three modes of care, use of the Sunrise and other enablers, and the ethnonursing method. Education, research, practice, and key concepts of the theory are connected as essential components toward the provision of culturally congruent care to meet the healthcare needs of diverse individuals, families, groups, and communities by family nurse practitioners.