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Introduction

  1. Top of page
  2. Introduction
  3. Advanced practice: what it is and what it is not
  4. Advanced practice and expert practice
  5. Challenges
  6. References

Conceptual clarity is critical to the continued development of advanced practice nursing and to the development of the nursing profession itself (Hamric 2005). The systematic literature review by Mantzoukas and Watkinson (2007) serves to provide much welcome additional clarification on the concept of advanced nurse practitioner (ANP) by exploring and developing its generic features. Much of the literature addresses the role of the ANP (Elsom et al. 2005, Furlong & Smith 2005) without explicitly outlining the defining characteristics of the practice itself. Hence, the definitions of advanced practice from a role perspective limit understanding of the concept, ignore the existence of other roles and negate the creation of new future roles (Hamric 2000). Thus it seems preferable to define advanced practice nursing without reference to particular roles (Hamric 2005). According to Davies and Hughes (1995) advanced practice extends beyond roles and is ‘a way of thinking and viewing the world based on clinical knowledge, rather than a composition of roles’ (p. 157).

Advanced practice: what it is and what it is not

  1. Top of page
  2. Introduction
  3. Advanced practice: what it is and what it is not
  4. Advanced practice and expert practice
  5. Challenges
  6. References

Mantzoukas and Watkinson (2007) refer to the definition presented by Hamric (1996) and subsequently expanded by Hanson and Hamric (2003) to include core competencies. However, the essential point here is that these core competencies are not exclusive to advanced practice nursing. Experienced nurses may master several of these competencies over time, referred to as ‘exemplary performance’. The distinguishing features of the advanced nurse practitioner (ANP) are the expectation that these competencies are not only visible in their practice, but are the fundamental elements of that practice (Hamric 2005). The core competencies of advanced practice nursing need to be created around the core values and principles of nursing, i.e. to do patients no harm, to put them in the best condition for nature to cure and to enhance their sense of well-being and wholeness in order to live life to the fullest and gain satisfaction and pleasure from a full life (Fawcett & Graham 2005). These core professional ideals can also illuminate the fundamentals of advanced practice. The core of advanced practice nursing lies within nursing's disciplinary perspective on human–environment and caring interrelationships that make possible health and healing, which is demarcated specifically in the philosophic and theoretic foundations of nursing (Smith 1995).

Hamric (2005) recommends that any definition should clarify the critical point that advanced practice nursing involves advanced nursing knowledge and skills; it is not medical practice, although ANPs perform expanded medical therapeutics in many roles. While there is a rich reservoir of disciplinary knowledge that contributes to understanding human life (Levine 1995), there is no unique nursing contribution if nurses speak the theoretical language of another discipline to the exclusion of their own (Malinski 2005). Building on Johnson's (1993) conclusion that nurse practitioners have three voices, Brykczynski (1996) described ANPs as tricultural and trilingual, meaning they are ‘fluent in the languages of biomedical science, nursing knowledge and skill and everyday parlance’ (p. 85). The importance of the medical component is recognised and incorporated into the nursing perspective, yet the holistic person-oriented focus of nursing remains dominant. There is a postmodern blending of nursing and medical knowledge and skills in the nurse practitioner role, an and as opposed to an either–or (Brykczynski 1999). In most situations, advanced nursing practice needs to be understood as complementary to, rather than in competition with, medical practice. ANPs must be able to clearly and forcefully articulate this critical point if their practices are to survive continued cost cutting in health care (Hamric 2005), and more significantly, for the direction and development of the nursing profession (Wand & Fisher 2006).

Mantzoukas and Watkinson (2007) point to the debate on specialisation, which is in essence advanced clinical nursing (Barton 2006) in a selected clinical area (Hamric 2005), and is a component of advanced practice nursing (MacDonald et al. 2006). Accordingly, expanded practice and advanced practice need to be clearly distinguished in relation to the nurse practitioner role; using the two terms interchangeably can only be damaging to the profession (Elsom et al. 2005). Moreover, advancement only occurs when nursing practice functions synergistically to produce a whole that is greater than the sum of its parts (Bryant-Lukosius et al. 2004).

Advanced practice and expert practice

  1. Top of page
  2. Introduction
  3. Advanced practice: what it is and what it is not
  4. Advanced practice and expert practice
  5. Challenges
  6. References

In conceptualisations of advanced practice nursing there is a lack of a clear distinction between the expert practice of experienced nurses and the expert practice of ANPs (Oberle & Allen 2001). The generic features of advanced practice that Mantzoukas and Watkinson (2007) present can be readily associated with those of expert practice, thereby begging the question ‘how is advanced practice dissimilar to expert practice?’Oberle and Allen (2001) postulate that the intrinsic difference between expert and advanced practice is that the expert nurse's knowledge is acquired experientially for the most part, whereas the ANP has a greater store of theoretical knowledge acquired through graduate study, with a disposition to situate him or herself in a dialogue between the general and the particular knowledge, such that the interplay opens possibilities that result in a more refined sense of ‘knowing that’ (Oberle & Allen 2001).

Mantzoukas and Watkinson refer to the work of Benner and her colleagues (Benner et al. 1999) who have extensively studied expert nurses and who have described the engaged clinical reasoning and domains of practice that have contributed to our understanding of clinically expert nursing practice. The important point to be made here is that, while some of the participants in this research were ANPs, the majority were nurses with wide-ranging clinical experience who did not have ANP preparation, and were thus experts by experience (Calkin 1984). Expert nurses have been described as being at the pinnacle of performance in their discipline (Bagley et al. 1990). Although ANPs do many things in addition to direct clinical practice, it is direct care expertise that provides the necessary foundation for ANPs to demonstrate other competencies, such as consultation, patient and staff teaching and leadership within organisations (Hamric 2005). Hence, the competencies referred to by Mantzoukas and Watkinson (2007) and defined by Hamric (2005) as necessary for advanced practice incorporate the term ‘expert’, and include such competencies as expert clinical practice, expert guidance and coaching skills, consultation, and clinical and professional leadership. Expertise is a necessary but not sufficient condition for advanced practice (Hamric 2005).

Mantzoukas and Watkinson also highlight the unique contribution of nursing's ways of knowing and the holistic approach to the patient care as a generic feature that distinguishes the ANP from other healthcare providers. Practice involves processes, dynamics and interactions that can only be fully understood when science, ethics, aesthetics and personal knowing come together and the best practices depend on the integration of all together to form a whole (Chinn & Kramer 2004). In addition, Mantzoukas and Watkinson represent ‘praxis’ within the generic feature of changing practice. Praxis should resonate across all core competencies of the ANP. Praxis involves continually noticing what is happening in practice, asking critical questions about that practice, creating changes to shift practice in a desired direction and noticing what happens as a result, inspiring formal inquiry processes and ensuring ongoing knowledge development (Chinn & Kramer 2004). In addition, practical wisdom must be informed by praxis (Oberle & Allen 2001), that is thoughtful reflection and action occurring in synchrony (Chinn 2001). Practical wisdom is at the heart of advanced practice nursing, and clinical judgement is the essence of practical wisdom (Brykczynski 1999a).

Mantzoukas and Watkinson (2007) identify research skills as a generic feature of the advanced nursing practice. DePalma and McGuire (2005) argue that as ANPs assume visible leadership positions in the future, they will require the three research competencies of interpretation and use of research, evaluation of practice and participation in collaborative research. However, the research aspect of the ANP role appears not to be viewed as important by many of nurses and doctors (Norris & Melby 2006), and there is the risk that the clinical remit of ANPs will dominate, thereby leaving them with little time for the research remit.

Challenges

  1. Top of page
  2. Introduction
  3. Advanced practice: what it is and what it is not
  4. Advanced practice and expert practice
  5. Challenges
  6. References

The development of the ANP role faces many challenges, particularly in the UK, and the ‘hotchpotch’ approach to providing credentials and titles may be an obstacle to the promotion and development of ANP roles. Reporting on the current situation in relation to the ANP role in the UK, Aikenhead noted that the National Council of Nursing and Midwifery was awaiting a positive response from the Privy Council in order to open a sub-part of the nurses’ register for ANPs (Aikenhead 2006). The test for any profession is to guarantee that its work is ordered so that it is receptive to the needs of the people it serves. If the goal of nursing is to transform health care by bringing nursing from its marginal adjunctive position to become a central aspect of health care (Locsin 2002), then a common identity for advanced practice may be an ideal way to situate nursing and the values of nursing in the forefront of health care (MacDonald et al. 2006). The conceptualisation of advanced practice nursing, as further examined by Mantzoukas and Watkinson (2007) will focus the efforts of the profession to prepare its ANPs, promulgate polices and nurture research, thereby maximising the social contribution of advanced practice nursing to the health needs of society and promoting the actualisation of ANPs (Spross & Lawson 2005).

References

  1. Top of page
  2. Introduction
  3. Advanced practice: what it is and what it is not
  4. Advanced practice and expert practice
  5. Challenges
  6. References
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