Advanced nursing practice


  • Mary Chiarella PhD RN LLB FCN

    1. Professor of Clinical Practice Development and Policy Research, Centre for Health Services Management, Faculty of Nursing, Midwifery & Health, University of Technology, Sydney, Sydney, New South Wales, Australia
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30th Anniversary Invited Editorial reflecting on: Lorentzon M. & Hooker J.C. (1996) Nurse practitioners, practice nurses and nurse specialists: what's in a name? Journal of Advanced Nursing 24, 649–651

Reading Lorentzon and Hooker's (1996)JAN Editorial engendered mixed emotions as I tried to produce a 2006 ‘report card’ on their recommendations. In summary, they advocated the need for research on the effectiveness of advance practice roles (tick); the need for studies to compare and describe different innovative roles (tick); the need for improved team building amongst professions (working on this, could do better); and the need for vigilance over the boundary issues implicit in practice nurses being employed by doctors (requires careful attention and needs further discussion).

In terms of research, we now have data that support the effectiveness of advanced practice roles (e.g. Chang et al. 1999, Mundinger et al. 2000) and we can say with confidence that nurse practitioners are able to deliver care that is safe and effective and of a comparable quality to their medical counterparts. However, whilst data to support the effectiveness of these roles is critical, making comparisons is arguably a reactive benchmark, necessary only to demonstrate that medical practitioners do not have a monopoly on safe healthcare delivery. Physician substitution ought not to be the raison-d'etre for introducing an advanced nursing practice role into the healthcare setting. Instead, the introduction of new roles should be based on an assessment of service needs and best fit in terms of patient outcomes and benefits.

In terms of descriptive studies, we have both original research and secondary research, the latter in the form of reviews of the now-vast literature describing the work and experiences of nurse practitioners, clinical nurse specialists and nurse consultants/consultant nurses (Kleinpell 1998, Wilson-Barnett 1999, Read et al. 2001, Fahey-Walsh 2004, Jones & Way 2004, Lloyd 2005). In fact, when declining to partake in a recent review of nurse practitioner roles in New South Wales in Australia, one of the most senior nurse practitioners commented that she was ‘investigated out’. But, however overloaded they may feel in terms of evaluation, we do know what nurses working in advanced practice roles do, and we know also that overall they derive significant satisfaction from what they do (Collins et al. 2000, Brown & Draye 2003).

The nomenclature continues to be a problem. There is still overlap and confusion between the various titles and the roles that are used around the world to describe ‘advanced nursing practice’ (see, for example, Mick & Ackerman 2002– USA; Jamieson & Williams 2002– Australia; Carnwell & Daly 2003– England, UK; and Jones & Way 2004– Canada). In Australia, my own country, not all new roles relate either to an award description or a qualification requirement. But herein begins the circularity of the concern. Advanced practice roles are often introduced in an opportunistic manner – through a grant here, a new government initiative there. The determination of what level of remuneration should be set is more likely to depend on how much money is available or able to be obtained than whether or not it is the proper level of remuneration for the role and the level of preparation of the appointee concerned. The risk then is that the role is established in haste without an evaluation framework being instituted simultaneously. This, in turn, leads to a post hoc justification of safety and efficacy and, once again, we are back ‘on the back foot’. If roles are introduced without adequate consultation, then the need to build up a team around the role is doubly difficult because established ‘stakeholders’ feel no ownership of the decision-making process. Nurses in innovative roles often feel isolated and lack professional support, despite their enjoyment of the work that they do (Read et al. 2001).

So, the ongoing challenge from our ‘2006 report card’ is how to find a place for advanced practice nurses to stand secure and supported in their roles. Much has been written about the need for improved collaboration between the various healthcare disciplines (see the literature review on this topic by Jones & Way 2004). But whether or not these roles are well received seems to be far more a question of perceived financial threat, rather than professional solidarity. Medical practitioners, nurse practitioners and allied health practitioners can and do get on very well together, and this is true across the globe. Where this occurs there is a shared focus on improving patient care, a clear understanding of each other's roles and responsibilities and faith in the system to provide ongoing infrastructure to enable each group to fulfil its remit. But this level of collegial generosity evaporates when medical industrial organizations perceive the introduction of advanced nursing roles as a threat to their ongoing income monopoly.

The challenge for governments and human resource planners in healthcare systems is to develop strategic workforce plans that address both the needs of local communities and the infrastructure required to move the key stakeholders forward. We face a workforce shortage due to our ageing demographic, not only in nursing but also in all of the healthcare professions. There will be plenty of work to go round for all of the professions. But proper planning is required. The cycle of ad hoc implementation and post hoc evaluation must be broken if there are ever to be proper safety and quality frameworks in place to support advanced practice roles.