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Do nurse practitioners need a doctorate?

It is timely to ask whether the qualifications for nurses working in advanced positions need reviewing, writes Andrew Cashin.

In Australia there are about 18 universities offering courses leading to nurse practitioner qualifications as standalone courses or in partnerships.

Some of these programs have now been running for over a decade. Nationally the level of qualification required to become eligible to apply for endorsement through the specific nurse practitioner course route with the Nursing and Midwifery Board of Australia (NMBA) is a master’s degree.

Without making any comment related to the quality of the courses that do exist it is timely to raise the question of whether the level of qualification needs reviewing. This is not a question existing in isolation; rather it is occurring in the context of the acknowledged need to clarify the meaning of terms in nursing such as “advanced practice” and the volume of learning required to support this.

This need arises from the much discussed difficulty in making sense of advanced practice requirements for endorsement by the NMBA and the proliferation of Advanced Practice Nursing positions arising outside of industrial or professional regulatory frameworks in Australia.

This question of the appropriate entry-level of qualification for nurse practitioners internationally is an old question. It was raised in the US prior to 2004 when a decision was reached to change the entry level requirement for nurse practitioners to a doctorate. The question in Australia and possible answer has been further shaped by the new Australian Qualifications Framework.

In Australia currently the endorsement requirements for nurse practitioners requires completion of an appropriate master’s level qualification and the demonstration of a required number of advanced practice hours pre-endorsement. To allow us to understand the requirements in hours we need to bring to light a definitive definition of advanced practice in nursing.

The International Council of Nurses (ICN) writes of this advanced practice knowledge, where they are readily available, to be positioned at master’s degree level. There was not a universal declaration made related to this as it was acknowledged advanced practice may develop in countries that do not have the education infrastructure in which such formal degrees are available. Of course, in Australia master’s degrees in nursing are readily available. With regards to cost in many jurisdictions this is offset by industrial awards that reward completion of such degrees and a case can be made for reasonable affordability. Further to this for some specialties within nursing there are generous government-funded scholarships.

The latest Australian Qualifications Framework envisages learning in the terms of volume. This allows us to evoke the metaphor of a cup. If advanced practice fills, as the ICN would suggest, a master’s cup in terms of volume of learning there appears parity between discipline expectations and the Australian Qualifications Framework. Logically as we are discussing advanced practice developing in the context of a master’s degree we are discussing advanced practice within the Registered Nurse (RN) scope. If advanced practice requires, as suggested by many writers and embedded in the NMBA requirement for practice hours, a praxis type relationship between learning, reflection and practice, one is left with a conundrum.

How can any nurse demonstrate completion of advanced practice hours until they have completed the required volume of learning? That is, the clock to start counting advance practice hours must be after the master’s degree cup is full. Otherwise you are counting emerging advanced practice as the applicant has not reached the required volume of leaning; they are in effect still filling the cup. In trying to reach clarity autonomy is raised as a defining feature, yet all RN hours are by definition autonomous in terms of the professional standards.

So the first conundrum is whether we are in fact speaking of advanced practice as advanced within the RN scope or advancing the RN scope? If advancing the RN scope we are left with the question of legality, as only those already endorsed as nurse practitioners are legally recognised as being able to extend the scope of RN practice. If this were the case we find ourselves in an even more daunting place, which is that only those endorsed as a nurse practitioner can demonstrate advanced practice hours. So logically you would need to be endorsed before the clock starts to count the hours required for endorsement.

In terms of proliferating Advanced Practice Nursing positions popping up unregulated one is left asking how to differentiate these from RN positions. Does it make sense to advertise RN positions as positions only utilising one part of the scope of practice that is the advanced bit. Can one really segment scope in that way in a meaningful manner? If we segment the RN scope, of course the question needs considering then of how the advanced portion sits with a specialist portion of practice. Does advanced build on specialist?

In terms of volume of learning in the Australian Qualification Framework does advanced practice arise in the four units of study (four single subject weightings) between an eight-unit graduate diploma (the benchmark for specialist practice in many of Australia’s national nursing organisations) or does it build across the 12 units of the master’s degree in combination with reflective (supervised) practice? As further pursuing this idea is beyond the scope of this brief discussion it is enough that it leads into the next conundrum specifically related to nurse practitioners.

Nurse practitioners are promoted as embodying advanced and extended practice. Reflecting back on the master’s degree cup metaphor one is left wondering if the cup is filled by advanced practice how can you squeeze preparation for extended practice into the same cup without overflowing the cup?

Using the Australian Qualifications Framework language it is clear the preparation for extended practice requires some volume of learning. The only way to include this volume in the same cup filled by advanced practice, without increasing the volume of the cup is to have less advanced practice volume. Of course another possibility is getting a bigger cup. In 2004 in the US that was the exact conclusion reached after a lengthy and rigorous debate. In qualification terms this meant jumping to a doctorate degree as the entry level requirement for nurse practitioners. The determination was made by the American Association of Colleges of Nursing to do this and have the process completed by 2015.

The type of doctorate varies but in many cases was informed by surveys of nurse practitioners who relayed feeling a need for more preparation to optimise practice, more volume of learning, in the area of extended practice including entrepreneurial practice. In a lot of cases these doctorates have evolved as coursework or taught doctorates as opposed to two-thirds research professional doctorates.

This makes a lot of sense, however, moving to such a taught doctorate is not possible under the new Australian Qualifications Framework as doctorates are viewed as having a primarily research focus. There does exist a possibility of a bigger cup under what is called an extended master’s degree. This is a degree that has capacity for more learning volume (although less than a doctorate) and completion entitles the use of the title Doctor. However, this is restricted currently to five named professions; medical practice, physiotherapy, dentistry, optometry and veterinary practice.

It would appear that definitional clarity has become essential in nursing. It is also clear that we have a learning volume conundrum that could only be solved by rethinking the concept of nurse practitioners or more desirably being able to accommodate the required volume of learning. I am yet to have become aware of any lobbying by the profession to become a named profession, eligible to offer an extended master’s degree. I am guessing we need to do the internal work first on definitional clarity before we recruit the federal government in helping us come to terms with our now overflowing cup.

Andrew Cashin is professor of nursing in the school of health and human sciences at Southern Cross University. He is a Foundation Fellow of the Australian College of Nurse Practitioners.

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