Advanced nursing practice is the deliberative diagnosis and treatment of a full range of human responses to actual or potential health problems (Calkin, 1984). Advanced nurse practitioners attempt to maximize the use of knowledge and skills and improve the delivery of nursing and health care services. The field of advanced nursing practice differs from basic practice as the former requires clinical specialization at the master’s level. At this level, nurses become expert practitioners whose work includes direct and indirect patient care. Direct patient care involves caring for patients and their families; this is the focus of my section on nurse clinicians. Indirect patient care includes work as an educator, researcher, and a consultant. One aspect of all these nursing roles that has fascinated me is the collaboration that occurs with other medical professions. Collaboration occurs at all levels of nursing practice and not just expert practitioners. By practicing collaboratively with medical staff, other nurses, and members of an interdisciplinary team, patient outcomes can be greatly improved.
Strength and Weakness of the advanced practice nursing
One of the challenges facing the advanced practice nursing education programs is to provide educational opportunities that have a grounding in nursing perspectives and methods to support evidence-based practice The nursing profession and health officials must resist the temptation to provide minimal education which merely adds functions and tasks the nursing role. This approach will undermine the sustainability and development of the advanced practice nursing.
For advanced practice nurses to be effective in initiating and negotiating change they must be placed in organizational contexts which give them the authority and power to affect change. The basis and strength of the advanced practice nursing role lies in its clinical expertise. The multiple sub-roles, such as researcher and educator, need to be placed in a perspective of the primacy of clinical practice.
Nursing experience is a prerequisite to developing clinical expertise. Learning to make good clinical judgments is dependent on experiential learning where the use can one can refine, challenge or disconfirm expectations8. This development is a requirement for establishing credibility essential in the provision of clinical leadership. The findings of this study underline the value in a strong theoretical base which, coupled with the nurses’ experience is used to advance nursing practice.
Nurse as Clinician
As clinicians, nurses have an “in-depth knowledge of a clinical population, advanced re-cognitional abilities, and increased use of past whole situations of situation specific referents for understanding the clinical situation” (Benner, 1984). Advance nurse practitioners focus on client and situations which enhance positive outcomes for the client. Thus, the practitioner’s actions are purposeful, directed towards excellence and pragmatic (Sutton & Smith, 1995). Nurse clinicians practice with distinct characteristics while aiming for an effective management of the health problems of patients. Clinicians become competent in managing the complex health issues of patients and thus are in a front-line position to improve patient quality of care (Chuk, 1997). Nurse clinicians possess expert nursing skills which results in an acceleration of the nursing process. This allows them to focus on the root of the problem without wasting time on fruitless assessment (Chuk, 1997). As a result of their education and experiences, clinicians intervene more for meeting patient’s needs than do basic practitioners.
Nurse as Educator
Nurses take on educator roles both in educating the public on their health and as educators in clinical practice and academic settings. As a public educator, nurses teach and counsel patients and families to enhance health and well-being. Patient and family health education is an important step in preventing disease. In order to be able to properly educate their clients on health promotion and well-being, nurses must first fully understand “health”. Nurses do not view health as “the absence of illness” but “define health as the extent to which an individual or group is able to realize aspirations, to satisfy needs and to change or cope with the environment in which they live.” (CARNA, 2005, p.2). Nurses hold a holistic view of the person and health and address health within the context of a person’s wholeness, including biological, emotional, psychological, social, cultural, and spiritual dimensions. Nurses recognize the broad determinants of health as income & social status, education, culture, physical environments, gender, health services, social support networks, employment & working conditions, health services, personal health practices, and biology & genetic endowment. A nurse educator in a clinical setting recognizes that continuing competence through life-long learning is essential to professional nursing. A clinical educator promotes and facilitates an atmosphere of life-long learning through the development and implementation of a variety of learning opportunities such as continuing education opportunities in the work environment and orientation programs (CARNA, 2005). In an academic setting, advanced nurses are involved in classroom teaching for undergraduate and postgraduate nursing students. Through teaching, students benefit from learning hot theories and advanced nursing practices are blended in delivering direct patient care (Chuk, 1997). As an educator in an academic setting, the nurse “ensures the development and implementation of a broad-based educational preparation for students that includes a breadth of knowledge and skills from nursing and related disciplines to meet the complex health needs of clients in constantly evolving practice environments.” (CARNA, 2005, p.5).
Nurse as Researcher
Advanced nurse practitioners participate in nursing research in an effort to “support and guide nursing practice as well as improve nursing care, client outcomes, and the health care system” (CARNA, 2005, p.6). Anderson & Hicks (1986), describe three levels of nursing research. At the first and most basic level, practitioners should be able to explain, evaluate, and communicate the nursing research related to their clinical specialty to staff nurse. Practitioners should keep up to date with relevant research literature, and undertake appropriate training in research method to enable judgment of the validity and reliability of findings and their relevance to nursing care. The second level involves practitioners being able to test and apply the research findings of others to patient care. At the highest level, practitioners should conduct research and not simply analyze and apply other research (Chuk, 1997). As nurse researchers engage in ongoing research, they can better explore the concepts of evidence, evidence dissemination, and utilization in nursing practice (CARNA, 2005). Patients will benefit from any level of research practitioners engage in.
Nurse as Consultant
Another way of improving patient care is the involvement of nurses in consulting. Nurses can be consultants for patients or staff nurses. Due to the expertise of advance practice nurses, staff nurses would seek advice from them in cases of complex patient care (Chuk, 1997). Through the consultation process, a number of patient care problems can be identified and solved. To identify and solve these problems, the nursing process is used (Anderson & Hicks, 1986). The nursing process is a problem-solving mode of action which guides “nurses to develop a style of thinking that leads to sound clinical judgments.” (Vye-Rogers, 2007). As a problem-solving model, the nursing process consists of five stages: assessment, diagnostic, planning, implementing, and evaluation. The nursing process involves decision making in every stage and allows for the nurse consultant to be highly creative when using the nursing process. Overall, the goal of nurse consultants is to help define problems, identify appropriate resources, and support nurses in problem solving.
How to improve the nature of advance nursing practice
Central to the development of advanced nursing practice is the need to achieve sufficient conceptual clarity about the nature of advanced practice has not been articulated clearly. A common belief is that advanced practice nurses provide services quite differently and somewhat independently of the mainstream of nursing practice. Participants who could share their practice experience as advanced practice nurses. Participants in this study are practicing advanced practice nurses, either in the role of Nurse Practitioner or Clinical Nurse Specialist, and all hold a Master’s degree in advanced practice nursing.
Participants were involved in taped conversational interviews with the researcher. The focus of the interview was to gain increased insight into how advanced practice nurses conduct nursing practice, given their theoretical background, nursing perspective and expanded scope of practice. Data collection was conducted using open-ended interview techniques. Participants in the study have indicated otherwise. These advanced practice nurses clearly understood that their role as developing practice by capitalizing on opportunities to move nursing staff to a higher level of functioning (Roach, M.S. 1992). One participant expressed this notion, saying:
We need to advance nursing practice, we need to take it beyond what is known and we should be leaders in saying this is the clinical question. Our goal really is to develop practice, so that eventually we can work ourselves out of a job’ this really is development work.
Having Clinical Experience
Participants emphasized the critical importance of experience in the clinical field in addition to their graduate degrees, in order to function as an advanced practice nurse. The limits of formal education were clearly stated by the participants as exemplified by this acute care nurse practitioner. You need a bank of experience to apply your thinking skills to. I don’t think a textbook approach will work (Chuk, P. K. 1997). You won’t know that a patient’s color is off, unless you have seen other patients whose color is off-you can’t just say there’s something wrong here that comes from experience. You just won’t have the same quality of practice when you are done no matter how well you’re thinking skills and your theoretical ideas are developed because you have no context to put it around. Your previous experience allows look back and search for options and make a decision (Cohen, A. 1991).
Judgment & Reasoning
The depth and breadth of knowledge that underpins advanced practice includes the ability to link theoretical concepts to practice, make complex decisions and choose from a wider range of alternatives for patient care. The transcripts clearly revealed that these advanced practice nurses use intellectually disciplined processes to guide nursing practice. A neonatal nurse practitioner shares her experience:
Nurse Practitioners are taught how to critically think-think through what to do for a patient and then do the right thing. With a broader background you take into account a broader more holistic assessment and use a wider range of interventions rather than just the skills that you were taught (Calkin, J.D. 1984).
Blending Care & Cure
Advanced practice nurses perform a wider range of skills, and have more highly developed competencies and they approach the care of patients differently. One of the nurse practitioner described her practice this way:
The advanced practice nurse is a bridge between medicine and nursing. It is kind of a nice way to think about it Some days you aren’t sure which side of the bridge you are on or if you are in the middle. Advanced practice nurses with their wider range of competencies face the dilemma of having to function within this system where they take on some of the curing functions; yet, at the same time, because of their intensive grounding in nursing values, trying to preserve the “caring” functions that are associated with nursing (Bridges, J.M. 1990).
Preservation of Caring
Participants talked about holism becoming increasingly significant in advanced nursing practice because a perception is created that nurse practitioners are mini-physicians or physician substitutes. The nursing perspective is articulated by this neonatal nurse practitioner:
Things are getting assessed on doctor’s rounds now that didn’t get assessed before we nurse practitioners took over this role. Now when we are doing the medical plan of care we project when this baby is going to go home, then we can start talking early about things like: Is the mom able to breast feed? Does she have enough milk? How does she feel about a supplement? We look at the whole picture in trying to decide how well the baby is doing (Anderson & Hicks, 1986).
Often the health care system becomes very organizationally focused and fails to deal adequately with patients who have needs outside the norm. The advanced practice nurses in this study clearly indicate that their role in advocacy for individual patients and groups of patients is increasingly important. A nurse specialist describes her role in advocating:
Advocating for clients is a big part of the role. Sometimes it is just a matter of being with them [patients] when they need someone to talk to about an issue-or being a sounding board. A lot of times it is a matter of getting the staff together and saying are we doing what is in the best interests of the client or are we doing what is in the best interests of the staff? I suppose I am doing those things that most times the manager and staff are not able to do or it means that they cannot go and spend as much time as I do. I need to be able to advocate for better nursing practice. (Sutton, F. & Smith, C. 1995).
The data provided by the participants confirms that advanced practice nurses advocate at various levels for patients. They work for and with individual patients or groups of patients to achieve better health care services.
Consistently, participants in this study expressed a clear vision of how research is central to practice development. Research from this perspective becomes more fundamental in driving the clinical practice of advanced practice nurses. The integration of research findings, or evidence, and conducting research, appears to be a central component of the work of advanced practice nurses. A cardiovascular nurse specialist/nurse practitioner explains it this way:
Nurses question all the time, but they don’t have the background, skill or time to take those questions to the next level. I think it is important to have a master’s degree and the reason I think it’s important is because you need to have a research background and with this type of training you can actually move practice forward (Chuk, P. K. 1997).
The relative powerlessness, real or perceived, of nurses in general practice is contrasted with the power and authority of advanced practice nurses. Advanced practice nurses armed with their advanced knowledge and clinical expertise, and the power and authority inherent in the nature of their roles are able to definitively practice nursing. The autonomy and independence associated with their role functioning is clearly identified as a theme by the participants. A clear sense is evident from the conversations with these advanced practice nurses that the role provided them with authority to practice not only those added functions previously held by physicians, but the authority to practice nursing autonomously (Bridges, J.M. 1990).
Leading the Development of Nursing Practice
Advanced practice nurses are leaders in developing nursing practice. They practice at the edges of the expanding boundaries of nursing’s scope of practice. Their commitment to nursing practice through leadership, mentoring, and role-modeling serves as a catalyst for further development because the general nursing population does not have the background and orientation to do so. They have been successful in changing the traditional power relationships and have broadened professional boundaries to become central players as expert clinicians and decision-makers. Advanced practice nurses who have sound clinical expertise are able to use evidenced-based practice guidelines, participatory methods and demonstrate a nursing perspective in clinical mentoring and teaching (Roach, M.S. 1992).
Grounding Practice in Nursing Values and Perspectives
Advanced nursing practice is grounded in the values and perspectives in which caring, health promotion, involvement with people in helping to deal with their reality, and an understanding of context and a broad range of factors that influence health and illness are stressed. The conscious awareness of the advanced practice nurses in this inquiry helped to alleviate concerns that the importance of nursing practice will be lost by the movement to take on medical functions. Developing advanced nursing practice with a sound grounding in nursing’s values and perspectives is contingent on a number of factors that include nursing experience (Bridges, J.M. 1990). A nursing identity is developed during clinical experience as nurses assimilate and integrate the art, science and spirit of professional nursing. Their thinking processes amplify and transform relevant portions of their nursing experience to guide both present and future practice. The depth and breadth of the theoretical background of the advanced practice nurse allows them to practice from a much different perspective because they have a deep understanding of the rationale and the significance of nursing interventions. The deliberate use of theory or a theoretical framework to drive practice is a clear understanding in the data (Sutton, F. & Smith, C. 1995).
Using Emerging Evidence to Guide Practice
The use of research is a distinguishing characteristic of advanced practice nursing. The drawing of research and practice together is evident as the study participants used appropriate research evidence to deal with specific patient problems, applied the evidence and then evaluated the effects of the research grounded evidence. The research role of the advanced practice nurse includes conducting studies and using existing research for improving nursing practice (Chuk, 1997).
The development of the scopes of Advanced Practice Nursing has historically been linked with advances in educational opportunities. However, more recent developments in health care reform have been greatly influential in the designation of APNs, and more specifically, Nurse Practitioners, as primary care providers. Techniques and technologies in the medical field constantly evolve and change. With such a huge increase in information, there is no doubt that nurses should update their skills constantly. Nursing education provides from basic building blocks of nursing knowledge to competence in the nursing profession. Seeking higher education in nursing not only expands one’s practice but also permits nurse to remain up to date with the latest practice issues which links to patient’s overall outcome. The Institute of Medicine (IOM) suggests several keys to upgrade nursing practice. Nurses play critical roles in clinical setting with patient-directed and patient-centered quality of care. Since the patient care setting is unique and unpredictable day to day, nurses must build up advanced knowledge and skills in order to response to the problems appropriately to achieve optimum outcome. Nurses must incorporate thoughtful strategies, critical thinking skills, and competence based on one’s education, knowledge, and experience. Seeking higher education as a professional nurse, will allow nurse to collaborate with other healthcare personals as a partner and leader which can achieve common goal of safe, appropriate, patient-centered care (Bridges, J.M. 1990).
Bridges, J.M. (1990). Literature review on the images of the nurse and nursing in the media. Journal of Advanced Nursing, 15(7), 850-854.
Calkin, J.D. (1984). A model for advanced nursing practice. The Journal of Nursing Administration, 14(1), 1037-1043.
Chuk, P. K. (1997). Clinical nurse specialists and quality patient care. Journal of Advanced Nursing, 26(3), 501-506.
Cohen, A. (1991). Two portraits of caring: a comparison of the artists, Leininger and Watson. Journal of Advanced Nursing 16(8), 899-909.
College and Association of Registered Nurses of Alberta. (2005). Scope of Practice for Registered Nurses. Edmonton, AB: Author. Retrieved September 27, 2007 from http://www.nurses.ab.ca/pdf/Scope%20of%20Practice.pdf.
Gordon, S. & Nelson, S. (2005). An end to angels: moving away from the ‘virtue script’ toward a knowledge-based identity for nurses. American Journal of Nursing, 105(5), 62-69. Gordon, S. (2006). What do nurses really do? Topics in Advanced Practice Nursing eJournal, 6(1).
Kalisch, P. A. & Kalisch, B.J. (1987). The changing image of the nurse. Menlo Park, California: Addison-Wesley Publishing Company.
Kozier, B., Erb, G., Berman, A.J., Burke, K., Bochal, D., & Hirst, A.P. (2004). Fundamentals of Nursing: the nature of nursing practice in Canada. Toronto: Pearson Education Canada Inc.
Roach, M.S. (1992). The human act of caring: A blueprint for the health professions. Ottawa, ON, Canada: Canadian Hospital Association Press.
Strong, A.A. (2004). Gender Bias and Discrimination in Nursing Education: Can We Change It? Nurse Educator, 29(3), 121-125.
Sutton, F. & Smith, C. (1995). Advanced nursing practice: new ideas and new perspectives. Journal of Advanced Nursing, 21(6), 1037-1043.