Nurse practitioners must retain clinical focus: if the role of nurse practitioner is to retain its integrity and remain true to the reason for its inception, those endorsed as nurse practitioners must remain grounded in clinical practice. Three of the country's nurse practitioners outline why.

HOW CAN we ensure nurse practitioners (NP) retain a clinical focus in their work? This article, by three of this country's practising NPs, addresses that question.

The NP was created to develop an expert clinical role within nursing. (1) However, one of the potential dangers is that the role becomes "owned" not by clinicians, but by academia or management. This can be inferred from the focus of someone's role, ie whether that focus is predominantly academic, managerial or clinical. To maintain the integrity of the NP role, it needs to have a clinical focus.

In order to develop this argument, this article will provide a brief background to the development of the NP in New Zealand; review the current situation; review the criteria for registration as an NP; and raise a number of questions for discussion and debate connected with retaining a clinical focus.

The development of the NP role in New Zealand has come in the wake of overseas evidence that such roles can make a significant contribution to health provision. The Nursing Council developed the regulatory framework and Deborah Harris was registered as the first NP in 2001.

There were a number of motivating reasons for introducing the role: lack of a clinical career pathway for nurses, difficulty in retaining experienced nurses; and the evidence that these roles could improve client outcomes.

In order to become an NP, nurses need a minimum of four years working in their specialty area and a clinical master's degree (or equivalent). They are required to submit a portfolio to Nursing Council evidencing their advanced practice, as well as attend an interview and be assessed against the six competencies for NPs. (2)

At the time of writing, there were nine NPs registered in New Zealand. They specialise in many different areas including neonates, mental health, wound care, and child and family health. The authors of this article are all employed by Waikato District Health Board (DHB), the only DHB to have NPs in its three divisions--acute, community and mental health services. Not all registered NPs in New Zealand are currently in clinical practice.

The competencies that need to be demonstrated for registration as a NP are:

(i) Articulates scope of nursing practice and its advancement.

(ii) Shows expert practice working collaboratively across settings and within interdisciplinary environments.

(iii) Shows effective nursing leadership and consultancy.

(iv) Develops and influences health/socioeconomic policies and nursing practice at a local and national level.

(v) Shows scholarly research enquiry into nursing practice.

(vi) Prescribes interventions, appliances, treatments and authorised medicines within the scope of practice. This competency only needs to be demonstrated by those NPs applying for prescribing rights.

As outlined by Nursing Council, these competencies are seen as equally important and all need to be an integral part of the NP's practice. Clearly an NP does require skills in understanding and conducting research, as well as teaching and providing clinical leadership, but these skills need to be applied on a strong foundation of clinical expertise. In other words, competency two--shows expert practice working collaboratively across settings and within interdisciplinary environments--needs to be seen as the foundation competency on which the remaining competencies are built.

The danger of not acknowledging competency two as the foundation competency, is that nurses who are currently in academic or managerial roles who potentially meet the competencies of the NP and who may successfully attain NP status, will, by doing so, undermine the clinical essence of the NP role, as anticipated at its inception. The role was developed not only to provide advanced clinical expertise at the bedside, but also a career structure that encourages nurses to remain in clinical settings. If those who are not in clinical practice successfully attain NP status, it creates a greater possibility that the NP role will develop a non-clinical focus. Acknowledging competency two as the foundation of the NP's role and practice, on which the remaining competencies are built, ensures the focus and integrity of the role will remain intact.

How do we ensure the clinical focus of the NP role? We want to raise six issues connected with retaining a clinical focus which we consider matters of central importance.

How much time should NPs spend delivering patient/client care? There are no clear guidelines oil this, but in order to retain clinical expertise we believe NPs need to spend at least 40 to 50 percent of their time in direct patient/Client care.

What is the self-perception of the NP? Do they see themselves first and foremost as a clinician or as an academic or as a manager? Many will argue that it is indeed possible to be both. But the philosophy of the NP must be based in clinical practice in order to reflect the real issues of health care delivery and gain. It will serve no useful purpose for nursing or the public to create another senior nursing role that does not nurse. Clearly we believe NPs need to see themselves as clinicians.

What should be the academic and research capability of NPs? Nursing is a contextual profession. Nursing only happens when a nurse meets a patient or client. Nurse practitioners need to be able to demonstrate they can perform and use re search and that they are evidence-based when there is evidence available. They need to be able to identify the holes or gaps in the research and evidence, and direct inquiry to answer the questions raised from and in clinical practice.

When is an NP not an NP? We would argue that an NP is only an NP when they are actually practising in the role. The very title NP strongly suggests this and perhaps individuals need to take responsibility for calling themselves something else when they leave clinical practice.

What is the responsibility of NPs in providing nursing leadership? Clinical leadership is fundamental to the role of the NP. Leadership has many definitions but it is essentially about change. Clinical leadership is therefore about change that makes a difference for the patient and clients by improving the service provided, or simply by getting the health care to the patient in the best way or time. (4)

Over the past few decades there have been significant health care reforms in New Zealand. The reforms have been driven by ideas such as managed competition, managed care, public/private partnerships and integrated care. These health care reforms have been introduced by policy makers and managers of health care services faced with funding pressures on one hand and failures of health care service delivery on the other. These changes to health care delivery have been driven by good intentions, ie the aim of improving services to the people of New Zealand in a cost effective way. However, in reality these reforms have had little positive impact on clinical practice.

Improvements in health care depend first and foremost on making a difference to the experience of people who use the services we provide. In the application process to the Nursing Council, the applicant is required to demonstrate clinical leadership in their practice. It is essential the NP continues with this, for it is clinical leadership and vision that will contribute to future health gain and develop models of care that will provide the platforms for improved access to care.

Is the clinical role of NP happening anywhere in New Zealand? Waikato DHB has NPs employed in both hospital and community settings. This organisation is currently leading the way in supporting the role of the NP in clinical practice.

Nurse practitioners must be clinicians. Competency two of the NP competencies must be the foundational competency. The questions raised here are important to ensure the new and exciting rote of NP retains the clinical focus originally intended.

(*) These three nurse practitioners intend continuing the dialogue on the evolution of the NP and hope to contribute further to this debate in the future.

REFERENCES

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

2) Nursing Council of New Zealand (2002) Nurse Practitioner Endorsement. Wellington: Author.

3) Nursing Council of New Zealand (2002) The Nurse Practitioner. Wellington: Author.

4) Ham, C. (2003) Improving the performance of health services: the role of clinical leadership. Lancet; 361, p1978-1980.

--Deborah Harris, RCpN, PGDip Nsg, NP, is employed as a NP in neonatalogy at Waikato District Health Board (DHB).

--Mark Smith, RPN, MSc, BHSc, PGDipPsych, NP is employed as an NP in mental health at Waikato DHB and is a senior clinical lecturer at the University of Auckland.

--Julie Betts, RCpN, ADN, PGDip HSc, NP, is a wound resource nurse in community services, Waikato DHB.