Commentary on Mantzoukas S & Watkinson S (2007) Advanced nursing practice: reviewing the international literature and developing the generic features. Journal of Clinical Nursing 16, 28–37
Article first published online: 14 APR 2008
© 2008 The Author
Journal of Clinical Nursing
Volume 17, Issue 9, pages 1247–1249, May 2008
How to Cite
Rushforth, H. (2008), Commentary on Mantzoukas S & Watkinson S (2007) Advanced nursing practice: reviewing the international literature and developing the generic features. Journal of Clinical Nursing 16, 28–37. Journal of Clinical Nursing, 17: 1247–1249. doi: 10.1111/j.1365-2702.2006.01901.x
- Issue published online: 14 APR 2008
- Article first published online: 14 APR 2008
This paper (Mantzoukas & Watkinson 2007) represents an extremely timely literature review regarding advanced nursing practice. It is pertinent for UK readers, in particular, in light of the immanent planned regulation of advanced nurse practitioner (ANP) status by the Nursing and Midwifery council (NMC 2005, 2006). This important step will bring the UK into line with most other Western countries, where the regulation of nurse practitioner status is well established.
The initial background to the ANP role given in the paper is helpful, summarising the long history of the evolution of advanced nursing practice across different countries, and clearly articulating the importance of not confusing the notions of ‘advanced’ and ‘specialist’ practice. Indeed, the United Kingdom Central Council on Nursing, Midwifery and Health Visiting's failure to differentiate adequately these two important concepts during the 1990’s may well have been instrumental in the considerable delay the UK has faced in establishing ANP regulation, so reminders of this distinction are always important.
The authors then cite useful definitions of the ANP; although it is interesting to note that Hamric and Hanson's (2003) definition arguably lists hallmarks that might be expected of any senior, experienced healthcare practitioner. It is not quite clear whether the definitions offered are viewed by the authors’ as optimal, or as exemplars of the lack of clarity which is clearly evident in the literature to date.
The following section then begins to explore issues of definitional conflict within the published literature, and it is here the authors begin to differentiate between the role of the ANP and advanced nursing practice. This is important as, up to this point, the terms have been used somewhat interchangeably (contrast for example the title and the stated aim in the abstract) which may have reduced clarity for some readers. The authors recognise that, whilst some nurses see the two terms as synonymous, others see advanced nursing practice as far broader than the ANP role. In light of this distinction, it is particularly interesting to note the authors’ subsequent acknowledgement of the ‘points of convergence’ within the various definitions of advanced nursing practice. These common hallmarks in respect of autonomy, decision-making and ‘expert nursing’ are important to recognise, as is the need to retain the essential core elements of ‘nursing’ and ‘caring’ within any advanced practice role. However, the contention that specialisation may pose a greater risk of ‘medicalisation’ than the ‘ANP’ role is one which some critics of the ANP role might contend, and certainly a issue worthy of further debate.
The methodology for the literature review itself is then explained, with a narrative approach justified in respect of its inclusivity across the evidence based hierarchy. The search described suggests that a systematic and rigorous process was conducted to generate the best available evidence. The criteria used to select emergent themes are only briefly explained, although appears congruent with the narrative process undertaken.
The review itself then takes an interesting direction, ‘focusing in’ predominantly on the ANP role and framing their review in terms of the seven ‘generic’ role features identified within the literature. However, the earlier debate regarding whether or not advanced nursing practice is broader than just the ANP role is never resolved and the terminology continues to be used somewhat interchangeably. Also unresolved (and indeed unasked) is the question of whether there are any distinctions between the titles nurse practitioner and ANP; another potential area of confusion within the current UK nursing nomenclature.
The seven emergent themes are extensively discussed and, as they evolve, seem in part to mirror the therapeutic process of gathering and interpreting knowledge and making clinical decisions and judgements based on the knowledge gained; all hallmarks of advanced practice. Links to Benner et al. (1999) work and their notions of ‘advanced practice’ and ‘expert nursing’, alongside links to the work of other nursing theorists, are central to the review and helpful in contextualising the discussion. However, beyond the congruence with the therapeutic process, it is often difficult to identify the ‘unique’ features of the ANP from those of other differently titled senior practitioners who incorporate aspects of ‘advanced’ or ‘expert’ nursing practice into their role; most of the themes identified would apply equally well to the ‘nurse consultant’ role, for example. The three final themes of ‘coaching/mentoring skills’‘research’ and ‘changing practice’ serve to reinforce this argument; surely effective coaching and mentorship, insightful use of research and a commitment to moving practice forward should be amongst the key characteristics of any senior practitioner. Thus, whilst these might reasonably be defined as hallmarks of ‘advanced nursing practice’ if the very broadest ‘umbrella’ definition of the concept is used, they are arguably insufficient to differentiates the ANP from other senior nursing roles, or indeed many senior roles in other healthcare professions. Importantly though, this is unlikely to be the fault of the authors and is, arguably, far more likely to be a manifestation of a literature and evidence base that has repeatedly failed to articulate the key ‘identifying’ characteristics of nursing and its various subgroups and specialities.
In conclusion, both the value and the limitations of the paper are important to identify. An understanding of some of the generic features of advanced nursing practice will be valuable for practitioners, educators and researchers involved in a wide variety of advanced nursing roles, and may have particular value for those teaching advanced practice curricula, or researching the concept of advanced practice. But what it regrettably fails to offer is a clear articulation of the ANP role itself, or any of its unique identifying features. These remains somewhat elusive within the literature, although the NMC's recent (2006) definition of an ANP goes someway towards bridging this gap and perhaps offers the clearest and least ambiguous advice available for UK practitioners at the current time. However, only when the role is established will it be possible to explore whether the definitions and competencies agreed thus far are borne out in reality. Robust evaluative research over the next few years will therefore be of pivotal importance to illuminate further this increasingly important nursing role.
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