Becoming a nurse practitioner is an achievable goal: a nurse practitioner believes many nurses practising at an advanced level could achieve nurse practitioner status. She wants to demystify the knowledge and skills needed for this advanced practice role and urges nurses already practising in an advanced role to consider embarking on the nurse practitioner pathway.

There is a perception among many nurses that the nurse practitioner (NP) role is virtually unattainable; that it is a status available only to a selected few. That is not my experience, and through this article, I would like to demystify the journey to becoming an NP. The article explores my role as an NP in mental health and intellectual disability and attempts to illuminate the Nursing Council's NP competencies so they are meaningful in terms of everyday nursing practice. Some of nurses' everyday practices fit within advanced competencies. The examples I use, which relate to my mental health experience, are applicable to general nursing. I want to dispel the myth that becoming an NP is unachievable. Many nurses in New Zealand are working in advanced rotes and are potential NPs but they have not recognised that possibility.

Competency One: Articulates scope of practice and its advancement.

The patients I work with are adults with a diagnosed intellectual disability and a concurrent mental health condition requiring specialist mental health assistance, or those prescribed psychotropic medications in the past and who require a medication/clinical review. My day-to-day clinical practice involves principal responsibility for patients throughout their contact with our service, ie from initial contact through to recovery and discharge. This often involves providing the particular interventions the person requires to recover from their current crisis, eg medication therapy and management, psychoeducation, cognitive or behavioural intervention, counselling, teaching life-skills, risk assessment and management, or initiating and overseeing in-patient acute intervention.

Another significant part of my rote is working alongside community support staff in non-governmental organisations and trusts which provide intellectual disability care, and working with families and GPs, empowering them to gain the knowledge and skills to ensure patients have the care/support plans to meet their needs. The ability to work with a high degree of autonomy maximises the continuity of care for this group of clients, who often receive marginal or fragmented mental health care. It also allows for a holistic wellness approach, which has been shown to lead to better patient outcomes and quality of life. (1)

Competency Two: Shows expert practice, working collaboratively across settings and within interdisciplinary environments.

This competency allows for examination of actual clinical skills. In my specialty area, I conduct the initial mental health assessment following referral This is a comprehensive assessment, which brings together all the relevant historical and current issues, including the presenting problem, so I can formulate the case, ie develop an hypothesis about the cause of the presenting behaviour or condition, make a diagnosis/differential diagnosis and, in many cases, provide the necessary interventions. Included in this process is ordering any relevant laboratory tests, a full interpretation of medications currently or previously used, and consideration of physical health and psycho-social issues. As an advanced community mental health nurse, I had conducted comprehensive mental health assessments. But my NP rote differs from my earlier advanced practice role, mainly in the areas of formulation of cases, diagnosis, the ability to order and interpret laboratory tests, and a significantly deeper understanding of medication issues and physical health issues. These advanced skills mean the patient doesn't have to be seen by a variety of health professionals in a range of settings. I am now able to work with a significantly higher degree of autonomy and assume direct accountability for clinical judgments and management. The responsibility clearly sits with me to consult with other colleagues if I believe it is necessary.

To gain the skills necessary to become an NP, I, like other nurses, had to examine my skills at the time I was contemplating the NP pathway, evaluate where the gaps were, and decide how these gaps could be filled.

Some schools of nursing now have papers aimed specifically at NP competencies. Two of the papers I required for the NP endorsement (advanced health assessment and prescribing) were very focused in my area of practice and allowed me to undertake course assessment and supervised practice, while working with my usual patient caseload. There are papers available to gain the generic competencies for NP endorsement, but I have had to gain additional knowledge relevant to my speciality scope. These additional studies have given me the ability to provide a wider range of interventions to patients I work with. I have gained a certificate in cognitive behavioural therapy, completed a psychotherapy course and studied sexuality and bioethics, with a focus on intellectual disability. Additional education has been through university and polytechnic papers, attendance at conferences and seminars and also from personal readings and experience. Reflective writing, with evidence of incorporation of the new-found knowledge into practice, is a valid form of portfolio evidence and one I used in my portfolio.

Competency Three: Shows effective nursing leadership and consultancy.

While there are specific nursing roles based predominantly on leadership and consultancy which have leadership titles, eg nurse director, nurse consultant, clinical nurse specialist, clinical charge nurse etc, leadership is by no means exclusive to these roles. Leadership and consultancy are common in many nursing roles, but are generally unrecognised. Some of the difficulty is that leadership and consultancy tend to get framed as something else, partly because they overlap with other aspects of our role, eg the nurse as "teacher". When we are asked for advice because of our specialist knowledge and skills, it is important to recognise that, at times, this is occurring within the context of an advisory/consultancy and/or leadership role and has moved beyond the teaching role. The following are some of the ways I show evidence of leadership and consultancy in my practice:

Team: Being available to members of the multidisciplinary team to advise them in their clinical work, often with more complex cases; mentoring other community nurses; taking an active leadership/adviser rote in clinical, service, registered nurse and quality meetings.

New staff and students: Having a session with new staff during the induction programme; providing input into the undergraduate nursing students on placement; teaching in Otago Polytechnic's mental health new graduate programme.

Community: Providing consultancy and supervision to community service providers, families and GPs.

Local and national involvement: Participating in a national dual diagnosis group; involvement in local ministerial working groups for the ongoing development of services for people with mental illness and intellectual disability; supporting local community agencies with ongoing service improvements and development.

Education and meetings: Contributing advanced nursing knowledge in education, in-service and quality programmes focused on enhancing practice and service provision.

Active involvement in working parties, service reviews, service development, consultation papers and writing submissions all involve an element of leadership.

Competency Four: Develops and influences health/socio-economic policies and practice at o local and national level.

Competency Five: Shows scholarly research inquiry into nursing practice.

As I undertook additional study aimed at extending my clinical practice, this in turn brought numerous opportunities for meeting the advanced practice competencies, particularly competencies four and five. I have embraced these opportunities to disseminate my specialist knowledge in a way that not only improves patient care and outcomes, but also shows evidence of meeting the advanced competencies. I have been involved in service planning and project groups on issues related to intellectual disability; I have commented on policies and practice standards; and I have shared my knowledge with those in the community who would benefit from it, eg community intellectual disability and mental health providers.

A more tangible way in which I have shown evidence of meeting these competencies and have demonstrated incorporation of evidence into practice, is the development of a series of teaching packages for community support organisations. These teaching packages explain how common mental illnesses affect people with intellectual disability. I have also developed a series of brochures and pamphlets to accompany these teaching packages. Included are medication pamphlets written for people with mild intellectual disability, so they can better understand the medication they are taking.

Every teaching opportunity has been important, whether formal teaching as a guest lecturer at polytechnic, or on formalised NGO education programmes, or teaching as part of Otago District Health Board's (DHB) education or in-service programme. Participation in journal clubs and case studies/reviews, which are designed to be reflective and in turn change practice, have also provided me with evidence for "developing and influencing health practice".

I must ensure my practice is up-to-date and evidence based. Regular access to two journals specific to my scope of practice, regular participation in the mental health and intellectual disability services' monthly education and research forum, and reading Mental Health Headliners--a website that keeps me up-to-date with national mental health happenings and which is based on best-practice guidelines--are all ways of ensuring my practice is current and evidence-based. In relation to medication knowledge, I access the New Ethicals on-line data base, (2) use the Medsafe website and gain access to pharmacology and psychiatry journals through a medical colleague. Complementing these sources is the knowledge of expert clinicians in the field.

Another way of meeting these competencies is to put pen to paper, instead of just talking. Today there are numerous opportunities to comment formally on issues relevant to practice. Over the last few years I have written submissions to parliament about legislation pertaining to my area of practice; provided a written response to a newspaper article; submitted a proposal in response to the restructuring of the DHB's mental health and intellectual disability service; and recently I wrote a submission on a document looking at clinical accountability in the mental health service. There are suggested formats for writing submissions and responding to consultation documents, which makes what might seem an arduous task easier. Although the thought is daunting and many nurses shy away from it, writing submissions is a skill that, with guidance and practice, can be gained without too much difficulty. A good starting point for me was to write a joint submission with a colleague who was experienced and who gave me guidance.

There was not enough time in my working day to embrace the opportunities necessary to advance my practice and gain the competencies required for NP endorsement. However, just as I have used my own time to gain the necessary education to advance my practice, it has sometimes been necessary to use my own time to achieve some of the skills required, eg writing a submission, giving a talk at a primary health organisation, developing a brochure or pamphlet or being part of a health promotion group. Gaining the necessary knowledge and skills has taken time, but it has been achievable. I never thought "this is impossible, I can't do it". And working as an NP has been more exciting and rewarding than I had imagined. This advanced clinical rote offers an exciting pathway for many nurses who are passionate about clinical work and who want a high degree of autonomy. I would encourage nurses now working in advanced practice roles to give serious consideration to the very real possibility of becoming NPs. The role for me has increased my professional satisfaction, enhanced patient care and improved patient outcomes.

References

(1) Ministry of Health (2002) Nurse Practitioners in New Zealand. Wellington: Ministry of Health.

(2) http://www.mims.co.nz/mims_cd/mimscd_index.htm

Bernadette Forde, RN, NP, works as an NP in Otago District Health Board's mental health and intellectual disability services.