Demonstrating advanced nursing capabilities.

The focus for this month's Kai Tiaki Nursing New Zealand is advanced and extended practice. But just how do nurses in New Zealand understand the term? In my experience, understandings and interpretations can be many and varied, to some degree this may reflect changes in the range of nursing practice and nursing roles.

I believe the term nurse practitioner (NP) identifies the advanced nursing knowledge and skills of the individual nurse, while the term "advanced practice" can be broadly understood to encompass an individual nurse's capacities, whether as an NP or registered nurse (RN).

When the International Council of Nurses (ICN) interviewed key nursing leaders from 24 countries on the subject, it found a diversity of views. (1) However, the term "advanced practice" itself was commonly linked to NP roles. The ICN advanced practice nurse/NP definition is :

"[a] registered nurse that has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practise. A master's degree is recommended for entry level." (1)

ICN quotes the Nursing Council of New Zealand (NCNZ) as defining advanced practice as:

"Advanced nursing practice reflects a range of highly developed clinical skills and judgements acquired through a combination of nursing experience and education. Essentially, advanced nursing practice requires the application of advanced nursing knowledge, with practitioners drawing not only on their clinical experience, but also on the experience of the profession as a whole." (2)

In its position statement, NZNO states:

"The scope of advanced nursing practice is distinguished by autonomy to practise at the edges of the expanding boundaries of nursing. It is firmly grounded in the unique body of knowledge that is nursing. In advanced nursing practice the nurse makes use of scientific theories drawn from nursing and other disciplines, as well as current research which enables articulation of sound rationale for the selection of nursing actions." (3)

White these key nursing bodies describe distinctive working definitions of the concept, I question advanced practice being tightly linked to the NP title.

In my rote at Canterbury District Health Board (DHB), I work alongside, support, and provide a means of endorsement for staff who wish to participate in our professional development recognition programme (PDRP). I feet humbled by the talent, knowledge and innovation I observe and often ponder how to showcase these nurses to the rest of the health community, and how to demonstrate their contribution to the advancement of nursing practice. None of these nurses are NPs, some are senior nurses and others are staff nurses.

Jenny Gardner, for example, is an RN working in Christchurch Women's Hospital's neonatal unit. As well as working as a neonatal nurse, Jenny is involved in neonatal research projects, locally, nationally and internationally, frequently in a co-ordinating role. As the local co-ordinator for the newborn hearing screening programme, she is currently trialling new hearing machines, with feedback to be provided to Ministry of Health for the national hearing screening programme. She is a member of the neonatal multidisciplinary research group and journal club. She has completed her diploma of health science and is preparing to submit her thesis for a masters of health. She is also an active member of NZNO and a member of two NZNO sections. Although employed as an RN, I consider her to be working at an advanced level of nursing practice. She has been endorsed as an expert RN on our PDRP programme.

A clinical nurse specialist (CNS) recently asked me: "What is the difference between my rote as a CNS and nurse 'M' [an RN who has achieved expert level on the PDRP]?" The only difference, I said, was that the CNS held the designated senior role. The RN had the capability to perform effectively in the CNS role; however, the position was not vacant. "M" has a masters degree and demonstrates autonomous and collaborative practice, regularly incorporating research findings into daily practice. She has the same types of skills and attributes as the CNS. The main difference is she has chosen to work as a staff nurse.

Advanced practice roles are a relatively recent development in New Zealand when compared to other countries such as the United States. To achieve NP status, a relatively prescriptive approach has been taken. This was necessary to enable the introduction of an extension to traditional nursing rotes, especially around the area of prescribing rights.

There is no doubt nursing is in a state of transition when it comes to a standardised understanding of advanced practice. On the one hand, this gives the profession an exciting opportunity to discuss what exactly this means. Is it limited to defined roles such as CNS or NP? Does being in one of these roles define you as a nurse working at an advanced practice level? We must also recognise that, due to this transitional stage, some nurses employed in senior and advanced rotes do not necessarily demonstrate "advanced practice", using the ICN, NCNZ and NZNO definitions. For example, at a national level, I am aware that some senior nursing staff have obtained these positions through entitlement, ie from years of service within an organisation, and not necessarily because of their advanced practice characteristics.

Throughout its history, nursing has continued to extend and advance its practice in order to meet patients' needs, taking the best of resources, knowledge and technology available. Further discussion and debate on this topic is needed as we begin to look more deeply at defining advanced practice. I believe we need to look at advanced practice as two different issues--NP/advanced practice nurse as a specific title and advanced practice as a channel for development within the nursing profession.

My thanks to colleagues Jo Greenlees-Rae, Sarah Brophy and Michael McIlhone for valuable discussions in preparing this editorial.

References

(1) Schober, M. & Affara, F.A. (2006) Advanced Nursing Practice. Geneva. Oxford: Blackwell Publishing, pp 2-13.

(2) International Council of Nurses website. http://www.icn.ch/Flash/Regulation_Terminology.swf. Retrieved 10/01/07.

(3) NZNO (2000) Advanced nursing practice position statement, Wellington: author.

Rebecca Hickmott, RN, is professional practice and practice facilitator at Canterbury District Health Board.