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Advanced practice nursing: the missing link

The authors are preparing to survey all Australian nurses early in 2014 in an attempt to define the evolving discipline of advanced practice nursing and resolve the many ambiguities and confusions that beset it. 

"This planned survey is essential if Australian nursing is to achieve clarity for the profession and the health industry relating to the service capability of different levels of nursing practice."

Australian nursing is a complex tangle of expertise, roles, levels and titles. Sorting through the meaning of these titles and levels is difficult for those of us in the profession; to colleagues in other health professions, patients and the community it can be utterly incomprehensible.

Take for example the following scenario, which will be familiar to many nurses and some midwives. A patient presents to a specialist outpatient clinic and is greeted by a nurse.

Jason: Hello, Mrs Tyler, I’m Jason. I’m a clinical nurse consultant and I’ll be co-ordinating your care during your treatment here at the hospital.

Mrs Tyler: What’s a clinical nurse consultant?

Jason: Well, I’m an expert nurse with postgraduate university qualifications and lots of experience with patients who have your health problem.

Jason organises a range of services for Mrs Tyler and arranges for her to return in a week to have her medication reviewed after blood results are through.

A week later, the patient presents again at the clinic and is greeted by a different nurse.

Sandra: Hello, Mrs Tyler, my name is Sandra; I’m a nurse practitioner. I’m going to talk with you about your blood result and then we’ll go over your medication and talk about your diet.

Mrs Tyler: So you must be very experienced and educated – are you the same as Jason?

Sandra: Well… yes and no.

By now Mrs Tyler is confused and she has not yet been confronted with greetings of “I’m your nurse for today” or “I’m just going to take your observations and the RN will be with you soon”.  And so on.

The fictitious Mrs Tyler represents a growing healthcare consumer population of people who are old, chronically ill and increasingly dependent on healthcare. The healthcare landscape has changed significantly over the past 40 years and nursing has changed in response. Nurses are playing key roles in the health service reform agenda, developing innovative service models and roles that draw upon advanced and extended skills; these have come to be labelled advanced practice nursing.

The number and titles related to these roles have proliferated. While these innovations have been effective in addressing short-term service problems, the consequence of uncoordinated development at this level is that advanced practice nursing has a confusing array of titles and roles. At the same time there is scant information available about the service capability of this level of nursing practice.

This issue is a problem internationally. The volume of literature on advanced practice nursing is vast, attesting to the need to advance and refine knowledge about this evolving level of nursing service. A consistent theme in the international literature is that advanced practice nursing is ambiguous, lacks universal understanding and is variously defined. In Australia there is an added complexity as each state and territory uses different nomenclature for roles and titles that are considered advanced practice.

A particular point in this discussion is the ambiguity about the nurse practitioner and advanced practice nursing. Australian nurse regulators moved early to standardise the nurse practitioner role. Consequently, it is recognised as a specific level and type of nursing service with regulation and a legislative framework that extend nursing practice activities beyond the legislated parameters of the registered nurse. No such clarity exists for other nursing roles that involve advanced practice within the practice scope of the registered nurse.

The challenge now is to break the nexus between advanced practice and specific roles and titles, and to delineate advanced practice from the foundation practice of the registered nurse and the advanced extended practice of the nurse practitioner.

We have been researching and publishing on this topic for several years. We examined the practice of a random sample of nurses in nominated advanced practice roles. The findings from that study showed that advanced practice activities were able to be identified and measured. Furthermore the results showed that all nurses in the study worked across the same broad areas of practice. We followed this study with a state-wide survey of registered nurses and midwives in Queensland. From this we validated our tool and showed that advanced practice could be delineated from other levels of nursing.

We are now preparing for our most ambitious and inclusive study into advanced practice nursing. Our aim is to use our previously validated instrument to survey all Australian registered nurses and midwives. This will be early in 2014 and it will amount to a national census that will achieve two objectives:

1. We will map the titles and roles of advanced practice nursing in all eight Australian states and territories.

2. We will delineate advanced practice from the foundation practice of the registered nurse and the advanced extended practice of the nurse practitioner

In conducting this survey we have extensive and high level support. The Australian Nursing and Midwifery Federation is funding the survey and making available essential facilities to support information dissemination and data collection. Additionally, the Australian Nursing and Midwifery Accreditation Council is supporting this survey by drawing upon its extensive nursing networks to assist with recruitment for survey participation.

This planned survey is essential if Australian nursing is to achieve clarity for the profession and the health industry relating to the service capability of different levels of nursing practice. It also has implications for nursing and midwifery clinicians in career planning and postgraduate education options.

Many definitions of advanced practice nursing are offered and most of these make sense as they speak to the values and practices that we all recognise as central to the best of nursing practice. But none of them are drawn from robust research that takes the question of what advanced practice consists of for the Australian nursing and midwifery population. Our national census will do this. Every nurse and midwife in Australia will have the opportunity to participate in this defining research.

If you would like more information about the survey you can contact Glenn Gardner at [email protected] or Christine Duffield at [email protected]  

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