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Keywords:

  • Advanced Practice Nursing;
  • Finland;
  • Higher Education;
  • Nurse Practitioner;
  • Scope of Practice

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Discussion
  6. Summary
  7. Conclusion
  8. References
  9. Supporting Information

Background:  The reorganization of Finnish healthcare services has required a restructuring of the areas of responsibility between healthcare professionals.

Aim:  To describe the need for Advanced Practice Nurses in Finland and the development process of a Master's programme in Health Promotion, Advanced Clinical Care.

Methods:  The study consisted of a survey of nurse managers (24) and focus group interviews with clinical nurse specialists (46).

Findings:  The expanded role includes advanced clinical skills and responsibility for health prevention and promotion, education, supervision, leadership, research and development.

Conclusions:  The legislation, scope and models have to be supported and further developed to promote the full scope of advanced practice.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Discussion
  6. Summary
  7. Conclusion
  8. References
  9. Supporting Information

Finland is currently undergoing extensive changes in healthcare. An aging population is increasing the demand for healthcare services. A shortage of physicians has resulted in new and more clinically demanding activity models for nurses in many municipalities and organizations. The Finnish Ministry of Health and Social Affairs in 2002 recommended a reorganization of future healthcare services. New models for the restructuring of work tasks and responsibility areas between different personnel categories were recommended based on an analysis of 31 pilot projects, conducted between 2003 and 2004. In these projects, tasks were transferred from physicians to nurses and public health nurses (Hukkanen & Vallimes-Patomäki 2005). According to De Witt & Ploeg (2005), such external forces may promote the process of searching for evidence through research. An assessment of the need for Advanced Practice Nurses (APNs) before introducing the role in each country has been recommended (Schober & Affara 2006). These findings, in addition to a number of international research results (Daly & Carnwell 2003; Schober & Affara 2006), emphasize that, in developing the scope of practice, more research is needed as well as further education for registered nurses.

During the period 2003–2005, the Svenska yrkeshögskolan (SYH) University of Applied Sciences, Finland, participated in the Thematic European Nursing Network, with the aim to develop the APN role in Europe (Åberg & Fagerström 2006). Representatives from Cumbria University in England, where APN training has been active for many years, led the network. University College, Dublin, which has trained APNs for 5–10 years also participated in the network. The University of Skövde, Sweden was the first university among the Nordic countries to start education in 2003 for the Advanced Specialist Nurse. These international influences inspired the development of the APN role in Finland.

According to international standards, further education is required for an advanced role, therefore SYH, University of Applied Sciences in Vaasa applied for research funding for the year 2004 from the Ministry of Education in Finland. The aim was to develop the advanced nursing role in Finland according to the International Council of Nurses' (ICN 2005) definition:

The APN is a ‘registered nurse that has the expert knowledge required, the ability to make complex decisions and clinical competence for an expanded work description, whose character is formed by the context and/or the country where he/she has the right to work’.

The aim of the research was to develop the ‘expert nurse function’ (APN role) in the western coastal region (Ostrobothnia) of Finland (Åberg & Fagerström 2006).

The aim of this short report is to describe the need for the APN role and the development process of the first education programme in Finland.

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Discussion
  6. Summary
  7. Conclusion
  8. References
  9. Supporting Information

Setting

Three primary healthcare centres and one central hospital from the western coastal region of Finland participated during 2004 in the investigation of the regional need for APNs. In this bilingual region, comprising approximately 173 000 inhabitants, there are approximately 52% Swedish-speaking and 48% Finnish-speaking Finns. The first step was to investigate the regional needs for APNs. A steering group consisting of teachers, nurse managers and chief physicians from the participating organizations led the project.

Subjects and data collection

The data comprised a questionnaire (five open-ended questions about the APN role) aimed at nurse managers (n = 24) and nine focus group interviews with clinical nurse specialists (n = 46), within both hospital care (n = 1) and primary health care (n = 3). The discussions about the APN role were transcribed verbatim and consisted of 165 pages. The data were analysed using descriptive content analysis.

Findings

The findings showed that APNs were needed for tertiary preventive care and follow-up of patients with chronic diseases within many special areas (e.g. cardio-vascular diseases, diabetes, eye diseases, chronic pain, skin diseases and mental health care). The APN role in secondary prevention will also be increasingly emphasized in the future with increasing numbers of older people. The APN could also be responsible for the assessment of acute care needs and have the right to order laboratory tests and x-rays, for example, when a patient suffers from pneumonia. The APN is also needed within family health care, for example, to prescribe contraceptives and to give family planning advice. The APN not only works as a clinical expert, but also has a role in education, supervision, leadership, quality assurance, research and development.

The nurse managers in this study expressed clear expectations regarding the APNs (see Fig. 1). They should have a vast amount of work experiences, competence in evidence-based nursing and be able to work independently with an expanded scope of practice. This requires thorough education after the Bachelor's degree in nursing, and not only shorter further training.

image

Figure 1. Nurse manager's opinions of the Advance Practice Nurse model. APN, Advanced Practice Nurses.

Download figure to PowerPoint

APNs were considered to be a resource for patients and relatives, and also for the physicians in the team as well as for the organization generally, since this new role within Finnish health care is aimed to make the care more efficient. The nurse managers emphasized the necessity of developing new opportunities for career development for nurses, but at the same time they stressed that this will require a new scope of practice and therefore new work models, as well as more resources in the form of higher salaries. Thorough and solid further education was asked for within acute care, pharmacology, medical science, nutrition, laboratory tests and examinations.

The development process of the first education programme for APNs

The curriculum draft for the APN was developed based on current literature and research, and based on international guidelines and experiences from other countries in Europe (Furlong & Smith 2005; Horrocks et al. 2002; Schober & Affara 2006). The results from surveys in the local region were also considered during the development of the content of the curriculum (Åberg & Fagerström 2006). Certain specifications were made regarding Finnish conditions, and the steering group of the project approved the programme during the autumn 2004.

The first APN training course was arranged as a specialized study programme of 40 study weeks [= 1 year of full time study =60 European Credit Transfer System (ECTS) study points] during 2005–2006 (Åberg & Fagerström 2006). The aim has been to provide a deeper clinical competence than at Bachelor degree level (210 ECTS = 3.5 years full-time study), and also more than the former specialist nurse education (1 year of full-time study during 1975–1993). The first group comprising 19 students concentrated on two main areas: assessment of acute care needs, such as infections and minor accidents, and care and follow-up of patients with chronic diseases.

The students developed their clinical and theoretical competence in assessing care needs (physical assessment), in conducting comprehensive patient health histories and in deepening their knowledge in medication and examinations such as laboratory tests, x-rays and other clinical examinations. The scope of practice includes providing nursing activities at an advanced level and taking responsibility for the care of common acute and chronic health problems and circumstances, that is, providing holistic nursing care for each individual patient. Other important responsibility areas are to lead and coordinate health promotion and prevention, to refer the patient to other healthcare institutions and to admit patients as well as discharge them. In addition, the APN's role in leading, evaluating, developing and improving nursing care and initiating and conducting research projects is of crucial importance for the scope of practice.

The first Finnish APN programme did not lead to an official examination, and so the contents were then developed into a curriculum at the Master's degree level. SYH started the Master's programme in health promotion with the line ‘Advanced Clinical Care’ (90 ECTS) in the autumn 2006. It is completed as part-time study during a period of approximately 2.5 years (contact studies approximately 2 days per month). The programme is focused on three main areas: preventive nursing and health promotion, assessment of care needs and care and follow-up of patients with acute and chronic illnesses (see Table S1). The content of the curriculum follows, to a great extent, the European Master's programme for APNs. The goal of the presented European network is to offer a joint Master's degree programme in APN on a Nordic level in the future.

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Discussion
  6. Summary
  7. Conclusion
  8. References
  9. Supporting Information

The empirical study presented in this article was limited to one region in Finland, but the results are in accordance with earlier national (Hukkanen & Vallimes-Patomäki 2005) and international studies (Schober & Affara 2006). A major factor for introducing the APN role in Finland has been, and still is, the shortage of physicians, which also has been the case in other countries such as Canada (De Witt & Ploeg 2005). On the other hand, well-functioning teamwork with the physicians is a prerequisite for the APN role (Schober & Affara 2006).

Rapidly evolving political, environmental, professional and patient-led demands require health personnel to review and develop their scope of practice (Daly & Carnwell 2003). This is a fact in Finland, where, because of an ongoing restructuring of municipalities, a process of merging smaller healthcare centres into bigger ones has begun. In the present study environmental scanning and stakeholder assessment was carried out before introducing the role (Schober & Affara 2006) together with very fruitful cooperation with the nurse managers and chief physicians of the region.

Advanced Practice Nurses in the Finnish context have, to a great extent, the same roles as in many other countries, but a lack of clarity in the role and the scope of practice remain. The role of the APN is characterized by autonomous extended practice requiring advanced clinical knowledge and skills in stable, variable and complicated conditions (Schober & Affara 2006). APNs possess the competence to work independently and professionally at an advanced clinical level and will often be the first contact link in terms of the patient's acute health problems. The advanced tasks (role extension) do not define the professional role. Role expansion involving greater responsibility, accountability and autonomy is needed in combination with the core values and nursing perspective in order to effect real role development (Daly & Carnwell 2003; Schober & Affara 2006). The APN role has to be differentiated clearly from elementary and specialist roles and a greater degree of clarity between the roles will benefit patients, employers and professional colleagues (Daly & Carnwell 2003).

Summary

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Discussion
  6. Summary
  7. Conclusion
  8. References
  9. Supporting Information

A critical mass of APNs is needed in each country in order to demonstrate the effectiveness of the new advanced role and to create confidence among other professionals, politicians and patients. Today an evolving body of international evidence supports the effectiveness of the APN role in hospital settings, in primary health care, as well as in long-term care (Bryant-Lukosius et al. 2004; Daly & Carnwell 2003; Stolee et al. 2006), but still a systematic evaluation of the role is necessary in each country. The introduction of APN roles requires a collaborative, systematic and evidence-based process designed to provide data to support the need and goals for a clearly defined APN role (Bryant-Lukosius et al. 2004). A holistic nursing orientation is needed, together with the promotion of full utilization of all the role domains and creation of an environment that supports the role. Organizational factors influence the ability of APNs to work effectively to their full scope of practice (Stolee et al. 2006).

Conclusion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Discussion
  6. Summary
  7. Conclusion
  8. References
  9. Supporting Information

The future role of the APNs in Finland will depend on how the legislation is developed, including their rights to conduct more demanding care decisions and to prescribe medicines, and also the extent to which nurse managers succeed in creating opportunities for graduating Master's students to practice their advanced skills.

References

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Discussion
  6. Summary
  7. Conclusion
  8. References
  9. Supporting Information
  • Åberg, J. & Fagerström, L. (2006) Does the professional role of a specialist nurse correspond to the international ‘Nurse Practitioner’ role? Journal of Nursing Science, 18, 266276 (in Swedish).
  • Bryant-lukosius, D., Dicenso, A., Browne, G. & Pinelli, J. (2004) Advanced practice nursing roles: development, implementation and evaluation. Journal of Advanced Nursing, 48, 519529.
  • Daly, W. & Carnwell, R. (2003) Nursing roles and levels of practice: a framework for differentiating between elementary, specialist and advancing nursing practice. Journal of Clinical Nursing, 12, 158167.
  • De Witt, L. & Ploeg, J. (2005) Critical analysis of the evolution of a Canadian nurse practitioner role. Canadian Journal of Nursing Rearch, 37, 116137.
  • Furlong, E. & Smith, R. (2005) Advanced nursing practice: policy, education and role development. Journal of Clinical Nursing, 14, 10591066.
  • Horrocks, S., Anderson, E. & Salisbury, C. (2002) Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324, 819823.
  • Hukkanen, E. & Vallimes-Patomäki, M. (2005) Co-operation and Division of Labour in Securing Access to Care. A Survey of the Pilot Projects on Labour Division Carried Out within the National Health Care Project. The Ministery of Social Affairs and Health in Finland, Helsinki.
  • International Nursing Council (INC) (2005) Nurse practitioner/advanced practice network. Definition and characteristics of the role. Draft 6 & 7.
  • Schober, M. & Affara, F. (2006) Advanced Nursing Practice. International Council of Nurses. Blackwell Publishing, Oxford.
  • Stolee, P., et al. (2006) Examining the nurse practitioner role in long-term care. Journal of Gerontological Nursing, Oct , 2836.

Supporting Information

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Discussion
  6. Summary
  7. Conclusion
  8. References
  9. Supporting Information

Table S1 Master's programme in Health Promotion, Advanced Clinical Care

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FilenameFormatSizeDescription
INR_673_sm_Supporting_Information.doc49KSupporting info item

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.