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Advanced Nursing Practice

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ADVANCED NURSING PRACTICE
1.1 Introduction
A good health care system should not only be easily accessible to the general population, but also
provide high quality service for those who seek care in it. Over the past score years, tremendous
progress has been made in addressing the issue of accessibility to health care through a wide range of
programs. These programs have mostly addressed the greatest impediment to accessing healthcare-
cost. Other than increasing accessibility, steps have also been made to improve the quality of the
health care system to be at par with some of the worlds best. Advanced Practice Nursing (APN) is
one such program that is meant to improve the quality of the healthcare services provided. The general
nursing practice, though very critical in the provision of healthcare services, has been found to be
significantly ineffective in meeting the diverse health care needs of the community. This is more so in
highly specialized care needs. At such level of care, the general practicing are not adequately trained
to be effective. Advanced Practice Nursing fills that void. With highly trained, experienced and skilled
nurses, the complicated services common at this level can be adequately met. In this way, the quality
of the health care system is maintained.
This paper looks into some of the pertinent issues regarding Advanced Nursing Practice. It covers its
nature, the principles behind it and the role it plays in the provision of quality health care services. In a
word, it seeks to understand the factors that have made it effective thus far.

1.2 DEFINITION
The term Advanced Practice Nursing is used to refer to a nursing practice level that makes use of in-
depth knowledge, comprehensive skills and experience in providing nursing care. At this level of
practice, the nurses have to use their skills, adequate experience and high level knowledge to assess,
plan and implement the required measures needed to effectively meet the needs of those who seek
them. As Brown, S. J. (1998) established, there needs to be a proper framework for advanced nursing.
The nurses who work at this level are highly trained and experienced. As such, they are able to
competently handle very complicated tasks that general practicing nurses might not be able to. In most
cases, they have a postgraduate education. Those who do not have a postgraduate education must have
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long years of experience that would have honed their skills to near perfection as well as widen and
deepen their knowledge about nursing practice.

2.1 NATURE OF ADVANCED NURSING PRACTICE
Advanced nursing practice is distinguished by the high level knowledge and skills as well as the
experience of the nurses and the application of these skills and knowledge to provision of solutions to
complicated patient needs. To ensure that these solutions provided have the desired effect, the nurses
at this level are thoroughly trained in critical analysis and accurate decision making. These among
other features looked into below are the ones that distinguish APN. The most important of the features
include clinical/professional leadership, facilitation of learning, research and development and
advanced clinical practice.
Clinical /Professional Leadership. This principle recognizes the crucial role that leadership plays in
the provision of quality health care. This leadership has to come from the nurses themselves since they
are the ones on the ground, and therefore are better placed to understand the needs of the practice and
the type of solutions needed. The healthcare industry keeps on changing with time. There is therefore
need to adequately handle these changes in a structured manner in a way that the quality of the
services provided is maintained at high levels. Through leadership areas requiring change are
identified and the required measures implemented.
In addition, leadership is required to effectively manage fellow nurses so that they maintain a high
level of efficiency and quality standards as well as be able to competently handle patients with diverse
racial, gender and class background. Leadership also ensures that the decisions made by the nurses
meet the laid down ethical standards, among other values of the nursing practice. Lastly, leadership is
required to foster the spirit of teamwork. It is only through teamwork that services can be provided
efficiently and effectively.

Facilitating Learning. Learning is highly valued in APN. There is recognition of the fact that highly
effective nurses have to be well learned as well. In view of this, a wide range of measures has been put
in place to ensure this. Among these are supporting the development of skills and knowledge among
the nurses, creating and promoting a conducive environment for learning and direct teaching of the
nurses. In addition to these, steps are taken to avail to the nurses as many educational materials as
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possible and organizing of coaching and mentorship programs that build the capacity and the
capability of the nurses.

Research and Development. An effective health care system that adequately meets the needs of the
patient has to be always on the lookout for methods that more efficient and effective in the
achievement of this goal. It is only through research and development that this can be achieved. To
this end, APN has measures in place that make it easy to access research materials and get involved in
the research itself through training in critical evaluation of academic materials among other research-
related skills. In addition, it also has structures in place that ease implementations of research findings
by reduction of red tape, and the dissemination of such findings through publications in recognized
journals and presentations at conferences.

Advanced Clinical Practice. APN encourages the development of skills required to competently
handle complex tasks. The kind of skills that are developed here include decision making skills that
enable the nurses to make accurate and timely decisions quickly. These decision making skills could
mean a lot while in the workplace since it could mean the life of a patient.

Analytical skills and critical thinking enable the nurse to dispassionately handle information for
correct decision making. These come in handy for the nurses since they can quickly analyze a situation
and know what kind of solution or what action to take while at work.

Other skills that prove to be beneficial to the nurses include great communication skills, self belief and
acknowledging that they have a very crucial responsibility mandated to them. The nurses are also
expected to have a good understanding of how to assess and manage any kind of risk that may arise.
As a result of these advances practices, the nurse is expected to improve the patients general outcome
as compared to when the patient came into the establishment.

The posts in Advanced Practice Nursing usually outline the salient features required of the nurse.
Some of those things required include extensive and intensive expertise in matters concerning nursing.
A good judgment would be a good starting point. Making a good judgement call really matters in the
daily running of the nurses life. A wider awareness of clinical operations is also essential for the
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nurse. A nurse may have to step in for another person, for example, the doctor when something goes
wrong in the workplace. A good nurse is also expected to have a good level of education in order to
have the title of an advanced nurse. Nursing is just like any other career where one is expected to
become even better through experience. The nurse could decide to get more education while still
practicing so as to eventually become an advanced nurse.

2.2 PRINCIPLES OF ADVANCED NURSING PRACTICE
APN has its own set of principles that govern the conduct of the nurses to ensure efficient and
effective service delivery. Key among these principles are:

Autonomous practice. This requires that the nurse be able to handle tasks independently. The nurse is
free to make decisions regarding the course of action needed based on his own assessment of the
situation. Apart from making the decisions, the nurse also has to own them. That means that he should
be able to bear responsibility for the consequences of such decisions.

Critical Thinking. More often than not, nurses practicing at this level have to deal with a lot of
information that enables them to make decisions. It is therefore important that they develop critical
thinking. With this type of thinking, they are able to dispassionately look into the information and
make the relevant decisions.

High Levels of Decision Making & Problem Solving. The environment APN nurses work in is a
highly complex one with difficult problems to handle. On a daily basis, they have to make decisions
that are very delicate in nature. It is therefore crucial that they develop the relevant problem solving
skills as well as decision making skills that are based on data analysis and critical thinking.

Values Based Care. Regardless of the amount of knowledge and skills possessed by the nurse their
practice will always fall short of expectations if they lack values. These values include humanity and
empathy as well as respect. The nurse needs to understand how to deal with patients from diverse
backgrounds and treat them with respect. Racism and sexism among other negative values should be
avoided at all costs. The same values should be applied in relating to colleagues.

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Improving Practice. Practitioners at this level have to always try to improve themselves as far their
effectiveness is concerned. That means constant learning and development of skills both in formal and
informal settings. The practitioner has to be ready to learn from colleagues as well as seniors and also
read current publications as much as possible in order to improve their service delivery abilities.


LITERATURE REVIEW
The program was supported by Watts et al (2004) study that established that general practice nurses
only received ad-hoc and non-formal education. The study also established the existence of a gap
between available programs of education and the needed education in support of general practices
four role dimensions. These are clinical organization, clinical care, integration and practice
administration.
As Halcomb et al. (2009) found out many of the clinical, educational programs meant to assist nurses
in general, practice have not neither been evaluated nor accredited. The credentialing topics identified
include professional practice like that dealing with legal issues, provision of clinical care like wound
care updates, diabetes updates as well as updates regarding immunization. Additionally, it was found
by the authors that modes used to deliver educational materials were very inflexible. There was
therefore a need to venture into other modes that were easily accessible like video conferencing and
online.

The survey, however, also had its own limitations. In particular, there was a lack of demographic data.
As Hegney et al. (1997) found out that the needs of the rural and urban areas are significantly
different. The nurses who received their training in urban were a huge disadvantage when dealing with
patients from rural areas as their urban-acquired education did not adequately prepare them to
effectively meet rural needs. A recent development was the proliferation of programs of education that
are focused more business rather than health leadership (University of New England, 2007). As some
research in other countries has shown, exposing nursing students to general practice would go a long
way in complimenting their formal education (Scottish Executive, 2004). In Australia, there has been a
growing realization of this fact with many universities developing clinical placement programs for
their students. An example is the Australian General Practice Network that has produced a guide that
seeks to ease clinical placement for students (NGPN, 2009). In 2001, mentoring was identified as one
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of the effective ways to develop nursing practice by the national workshop on Four Directions in
Practice Nursing (Gibson &Hearfield, 2005).

In 2002, the Department of Health and Ageing of the Australian Government established a
commission aimed at developing flexible, modern and sustainable framework for mentoring that
would increase the capacity of the nurses to deliver high quality services (Heartfield et al., 2003). That
commission identified a wide range of challenges to this effect. Among them were the fragmentation
of the sector, size and structure variation, cultural differences in the nursing practice, diversity of
nursing roles and lack of professional development before accreditation could be acquired. As the
study showed, the mentoring of nursing students and those in general practice could be achieved only
if awareness was developed as well as an increase in commitment in the provision of accessible and
flexible mentoring programs.


Intersectoral collaboration. In the current health care system, there is the complexity of the
consumer needs and collaboration among health care disciplines is alleged to be an effective solution
to many problems, including the pursuit of cost-effective quality care (Fagin, 1992). It has also been
indicated in the primary health care strategic policy directions that the fundamental underpinning of
integrated service delivery models is a range of diverse health care service providers. The WHO
(1997) promoted the concept of intersectoral action for health (IAH) as an important relationship that
brought together different parts of the healthcare sector as well as parts from other sectors in order to
achieve desirable outcomes in healthcare in a sustainable, effective and efficient way that would have
been unachievable without such collaborations. A statement encouraging the working together of
general practice with other related health care sectors to achieve better patient outcomes was given by
The Department of Human Services (DHS, 2007).

The increasingly complex and challenging health care system requires an increasing need for
collaboration between and across the various sectors. This is in accordance to Patterson and McMurray
(2003).

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According to WHO (1978), health is when the body is in a state of full mental, social and physical
well being. However, these wider aspects of wellbeing are well above what the health sector can
deliver on its own. There is a wide range of issues surrounding the introduction of advanced nursing
positions. These issues have been as a result of the implementation of poorly defined new roles, which
end up receiving inconsistent organizational and professional support. As a result, many countries are
now looking towards workforce planning procedures as well as organizational frameworks to develop,
implement and to evaluate APN roles more effectively (Micevski et al. 2004, Rutherford et al. 2005,
Coombs et al. 2007, and Holloway et al.2010).

To reduce role incoherence and instead enhance the effective introduction and adoption of such roles,
Lloyd-Jones (2005) identified a number of barriers and facilitators to role development for APNs and
highlighted the need for clear role definitions and objectives. This goes a long way to enhance the
effective introduction as well as adoption of the same roles. In addition to this, a vital part of the
development process for the APN role should be a clear definition of the specific features of the role,
namely the activities undertaken, and the skills, attributes as well as the competencies. A tool that
clearly articulates the role of practice should then be considered a useful component to an APN
framework.

ROLES OF ADVANCED NURSING PRACTICE
While variability among APN roles is expected and desirable, consistency in core characteristics is
important for advanced nursing practice to occur. This is due to the fact that advanced nursing practice
roles can be shaped to address complex and dynamic health care system needs and also demand for
flexibility in service delivery. Within the nursing profession, however, there is confusion about the
terminology used to describe APN roles.

First off, it is important to note that the terms advanced nursing practice and advanced practice nursing
are often used interchangeably. This is because understanding the difference between these related
concepts is necessary for defining, as well as developing the full potential of the roles of Advanced
Nursing Practice.

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Advanced Practice roles in nursing are increasingly seen as key to the development and delivery of
health and wellbeing services. Good governance regarding such role development and implementation
must be based upon consistent expectations of the level of practice required to deliver the service and
this is best achieved through the benchmarking of such posts against nationally agreed standards and
processes.

The Nursing and Midwifery Council (NMC 2006) has been reluctant to formally recognize the Nurse
Practitioner role. The same Nursing and Midwifery Council has also been reluctant to set standards for
educational programs basing on the competencies required to underpin the role. Thus, according to
Tye and Ross, 2000; Ash burner et al, 1997, this reluctances may have contributed to a general lack of
clarity in the role The Prime Ministers Commission in 2010 has given the NMC. The Nursing and
Midwifery Council have been accorded a clear mandate to regulate Advanced Nursing Practice and
protect the title 'nurse, hence, NMC must now begin to regulate ANP and ensure that they are
recorded on the register and have the required competencies. They must also consider how to reduce
and standardize the proliferation of roles and job titles in nursing (DOH, 2010). This definition
involves all variant titles associated with such advanced practice roles including nurse practitioner
(NP), advanced nurse practitioner (ANP) (RCN, 2010) clinical nurse specialist (Castle Dine, 2002);
nurse clinician); and consultant nurse. The advanced practice nurse (APN) position emerged as a result
of changing health care needs and workforce requirements, with societal forces such as economic
climate, changes in technology and healthcare delivery influencing its evolution.

The positive outcomes of advanced practice roles on patient outcomes have been documented widely
and these include health improvement and increased patient satisfaction (Loftus & Weston 2001,
Wong & Chung 2006), reduced hospital admissions and shorter lengths of stay (Pearson & Peels 2002,
Naylor et al.2004). Economic savings to the health care system are natural consequences. However,
despite this, the introduction of APN roles has often occurred in an unplanned manner in some
countries and this resulted in barriers to the full utilization of this role (Jamieson &Williams 2002,
Bryant-Lukosius & DiCenso 2004, Bryant-Lukosius et al. 2004).

A systematic evidence-based process which includes collection of data relevant to service needs and
role requirements is required to implement and Out of Hours setting, covering a number of GP
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surgeries with a variable clientele in terms of social and racial composition. The author has worked in
this role for twelve years, and yet colleagues with the same title are unable to perform the same
breadth of tasks and treatments despite completing post graduate qualifications. This is a worrying
issue that despite these courses, clinical skill is not met.

ROLE OF EDUCATOR
Educators play a very key role in APN. They pass on the relevant knowledge about APN to the
practicing nurses. Many nursing practitioners are increasingly getting themselves in a variety of areas
in multi-professional care in health organizations that are complicated. A lot of the studies, however,
direct their focus on the individual level comparing the service provided by other professionals in the
healthcare industry and that provided by the practicing nurses.
At an organizational perspective, there are few studies that have looked into the roles of nursing
practitioners. A study by Ofenbeck & Knip (2004) tried to evaluate the performance and
organizational effect of nurse practitioners in hospitals in the Netherlands. In this study, a case study
approach was used. A conceptual model based on systems of certain patterns was proposed.
It can therefore be seen that there is a consensus that advanced nursing has at its core of concerns the
workings of nurses and how this work benefits the patients. It describes the advanced level of nursing
practice that uses in-depth knowledge in nursing and extensive skills to provide quality healthcare to
patients. These may be families, individuals, groups or even whole communities.
The main competencies of the role must be shown in a way that requires very autonomous,
accountable, independent, and ethical practice in ambiguous, complex and quickly changing
environments. While the literature shows an increase in the number and modes of advanced nursing
practice functions, there is a need to look further into the concept within the specialty of palliative
care.




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Conclusion
Advanced Nursing is one of the practices that has to be acquired through experience unlike other
professions. For a nurse to offer the required high standards of services, it takes more than a good
education. Some of the things that are required of the nurse include critical or advanced thinking, high
level of decision making and a good support system.

With the introduction of Advance Practice Nursing (APN), the health care system is expected to be
effective and reliable compared to the normal healthcare system which proved to be partly ineffective.
The nurse has to have the necessary equipment for the right kind services to be offered at the
workplace. All the pertinent issues that we have discussed have to be considered in order to have a top
notch advanced nursing practice.




















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REFERENCES

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