advanced nursing practice, advanced practice nurse, clinical expertise, clinical nurse specialist, nurse practitioner
G Donnelly. The Essence of Advanced Nursing Practice. The Internet Journal of Advanced Nursing Practice. 2005 Volume 8 Number 1.
The purpose of this research was to gain a deeper understanding of the clinical expertise of advanced practice nurses that develops as a result of the integration of advanced theoretical concepts, added elements of practice from other disciplines and clinical practice into a nursing framework. A hermeneutics phenomenological method was used to study eight advanced practice nurses using an open ended interview format.
This study highlighted three themes that characterize advanced practice nursing. Advanced practice nurses are leaders in developing nursing practice through providing clinical leadership by maintaining a commitment to develop nursing practice, using their authority and power to influence clinical and policy decisions; and providing clinical development. Nursing values and perspectives that ground advanced practice nursing include advocacy, holism, nursing experience, integration of theory into practice, and added medical functions in a nursing framework. The creation and use of research to drive nursing practice was clearly evident in this study.
Based on doctoral dissertation research completed at Faculty of Graduate Studies, University of Regina, Regina, Saskatchewan, Canada
Supported by University of Regina Graduate Studies Scholarship &
The Saskatchewan Nurses Foundation
A long recognized fact is that nurses are underutilized despite the fact that they have been receiving sophisticated educational preparation1. In the 1990s, the delivery of health care taxed the economic foundation of the Canadian universal health care system. The political and administrative response to this situation has been to downsize and examine more efficient ways of delivering health services. A renewed interest has emerged in advanced nursing practice, specifically the nurse practitioner role, as this role is seen by government, health authorities, the nursing profession and others as an opportunity to provide cost effective high quality health care, and an opportunity for nurses to develop professionally 2,3.
In 2000, the Canadian Nurses Association developed a framework for advanced nursing practice which serves as a basis for the development of the role in Canada. Advanced nursing practice is the maximal use of nursing's expertise and competencies in meeting health needs of a population of patients. The profession is characterized by the deliberate, purposeful and integrated use of expanded nursing knowledge, research and clinical practice expertise, grounded in the values of holistic, patient-centered-care. Advanced nursing practice can only be realized if there is capacity to expand the boundaries of nursing practice, which, in turn can effect changes in health care. Advanced practice nurses will best be able to fulfill this role if they are prepared in university graduate programs in nursing4 .
Central to the development of advanced nursing practice is the need to achieve sufficient conceptual clarity about the nature of advanced practice As clinical practice in advanced practice has not been articulated clearly, this researcher asked the question: What is the lived experience of working as an advanced practice nurse in the clinical context to provide holistic patient care?
This study was grounded in hermeneutic phenomenology that seeks to both understand and ascribe meaning to human phenomena. This approach, is a descriptive method that is attentive to how things appear or letting things speak for themselves and interpretation of the data in which the “facts of the experience need to be captured in language.” The methodology allows the study of lived experience, explication of phenomena as they present themselves to consciousness, a description of the experiential meaning as we live them and is the attentive practice of thoughtfulness. Fundamental to this research is the writing or linguistic approach involving reflection on the text which attends to the meanings and significance of the phenomena of everyday life5.
A purposive selection strategy was used to identify participants who could share their practice experience as advanced practice nurses. Eight participants in this study are practicing advanced practice nurses, either in the role of Nurse Practitioner or Clinical Nurse Specialist, and all hold a Master's degree in advanced practice nursing.
Participants were involved in taped conversational interviews with the researcher. The focus of the interview was to gain increased insight into how advanced practice nurses conduct nursing practice, given their theoretical background, nursing perspective and expanded scope of practice. Data collection was conducted using open-ended interview techniques.
The data analysis approach used in this research was the discovery-orientated approach advocated by Van Manen 5, which avoids a predetermined set of procedures. This approach involved interpretation through the deliberate act of describing aspects of the participants' experience in a textual form and is grounded in a body of knowledge and insights that constitutes both a source and a methodological ground for present human science research practice.
Transcriptions were initially read to gain an understanding of the data. It is recognized that the understanding of the data was influenced by the researcher's own advanced practice background and theoretical understanding of the nature of the advanced practice role gained from the literature. Frequent re-examination of the transcriptions and subsequent reflection on the conversations led to the emergence of a number of categories of data. Explanation of these categories, in an effort to attach meaning, frequently resulted in moving data from one category to
Development of themes involved a lengthy period of re-examination and reflection upon the categories of data. Thematic development involved a fluid process of combining and re-creating some data categories as well as moving data from one category to another. These processes resulted distillation of three overarching themes that described the lived experience of the clinical practice of advanced practice nurses.
Category 1: Developing Nursing Practice
A common belief is that advanced practice nurses provide services quite differently and somewhat independently of the mainstream of nursing practice. Participants in the study have indicated otherwise. These advanced practice nurses clearly understood that their role as developing practice by capitalizing on opportunities to move nursing staff to a higher level of functioning. One participant expressed this notion, saying:
We need to advance nursing practice, we need to take it beyond what is known and we should be leaders in saying this is the clinical question. Our goal really is to develop practice, so that eventually we can work ourselves out of a job' this really is development work.
Category 2: Having Clinical Experience
Participants emphasized the critical importance of experience in the clinical field in addition to their graduate degrees, in order to function as an advanced practice nurse. The limits of formal education were clearly stated by the participants as exemplified by this acute care nurse practitioner.
You need a bank of experience to apply your thinking skills to-I don't think a textbook approach will work. You won't know that a patient's colour is off, unless you have seen other patients whose colour is off-you can't just say there's something wrong here—that comes from experience. You just won't have the same quality of practice when you are done no matter how well your thinking skills and your theoretical ideas are developed because you have no context to put it around. Your previous experience allows look back and search for options and make a decision.
Category 3: Using Clinical Judgment & Reasoning
The depth and breadth of knowledge that underpins advanced practice includes the ability to link theoretical concepts to practice, make complex clinical decisions and choose from a wider range of alternatives for patient care. The transcripts clearly revealed that these advanced practice nurses use intellectually disciplined processes to guide nursing practice. A neonatal nurse practitioner shares her experience:
Nurse Practitioners are taught how to critically think-think through what to do for a patient and then do the right thing. With a broader background you take into account a broader more holistic assessment and use a wider range of interventions rather than just the skills that you were taught. I don't think people who rely on a recipe approach or rely heavily on protocols would not probably do that well... you have to be able to think beyond this. They do what they do in these situations without taking into account the extraneous factors that might complicate the recipe.
Category 4: Blending Care & Cure
Advanced practice nurses perform a wider range of skills, and have more highly developed competencies and they approach the care of patients differently. One of the nurse practitioner described her practice this way:
The advanced practice nurse is a bridge between medicine and nursing. It is kind of a nice way to think about it Somedays you aren't sure which side of the bridge you are on or if you are in the middle. We are always very conscious of the fact that we are nurses and we can't emphasize the medical part too much!
Advanced practice nurses with their wider range of competencies face the dilemma of having to function within this system where they take on some of the curing functions; yet, at the same time, because of their intensive grounding in nursing values, trying to preserve the “caring” functions that are associated with nursing.
Category 5: Preservation of Caring
Participants talked about holism becoming increasingly significant in advanced nursing practice because a perception is created that nurse practitioners are mini-physicians or physician substitutes. The nursing perspective is articulated by this neonatal nurse practitioner:
Things are getting assessed on doctor's rounds now that didn't get assessed before we [nurse practitioners] took over this role. Now when we are doing the medical plan of care we project when this baby is going to go home, then we can start talking early about things like: Is the mom able to breast feed ? Does she have enough milk? How does she feel about a supplement? We look at the whole picture in trying to decide how well the baby is doing. I think we bring all of our nursing practice - and now we are nurse practitioners we have authority - and we bring important nursing things to patient management.
When life changes occur, the advanced practice nurse works with patients and families to maximize their ability to integrate the consequences of their condition or situation into their life so that they can carry on meaningful activities. Continuity of care is simply more than discharge from hospital and admission to community services.
Category 6: Advocating
Often the health care system becomes very organizationally focused and fails to deal adequately with patients who have needs outside the norm. The advanced practice nurses in this study clearly indicate that their role in advocacy for individual patients and groups of patients is increasingly important. A clinical nurse specialist describes her role in advocating:
Advocating for clients is a big part of the role. Sometimes it is just a matter of being with them [patients] when they need someone to talk to about an issue-or being a sounding board. A lot of times it is a matter of getting the staff together and saying are we doing what is in the best interests of the client or are we doing what is in the best interests of the staff? I suppose I am doing those things that most times the manager and staff are not able to do... or it means that they cannot go and spend as much time as I do. I need to be able to advocate for better nursing practice.
The data provided by the participants confirms that advanced practice nurses advocate at various levels for patients. They work for and with individual patients or groups of patients to achieve better health care services.
Category 7: Embracing Research
Consistently, participants in this study expressed a clear vision of how research is central to practice development. Research from this perspective becomes more fundamental in driving the clinical practice of advanced practice nurses. The integration of research findings, or evidence, and conducting research, appears to be a central component of the work of advanced practice nurses. A cardiovascular clinical nurse specialist/nurse practitioner explains it this way:
Nurses question all the time, but they don't have the background, skill or time to take those questions to the next level. I think it is important to have a masters degree and the reason I think it's important is because you need to have a research background and with this type of training you can actually move practice forward. We need to be leaders in helping formulate research questions that address problems that will assist our frontline nurses in doing a better job of what they do. I think it is the clinical nursing research that sets us apart from most of the nursing staff.
Even though advanced practice nurses will often identify a lack of time and resources to actually conduct research3, the participants in this study clearly talk of the centrality of research either in terms of using or conducting research in their nursing practice.
Category 8: Having Power
The relative powerlessness, real or perceived, of nurses in general practice is contrasted with the power and authority of advanced practice nurses. Advanced practice nurses armed with their advanced knowledge and clinical expertise, and the power and authority inherent in the nature of their roles are able to definitively practice nursing. The autonomy and independence associated with their role functioning is clearly identified as a theme by the participants. One participant, who is a neonatal nurse practitioner expressed this point of view:
Nurses have always had a lot of responsibility and no authority. I think advanced practice nursing gives nursing some authority to actually change institutional practices. In my advanced practice, I continue to have a lot of hands on nursing care however, now I do it with more authority, and at more advanced levels. I can apply more advanced pathophysiology, interpret more tests, and can plan elements of care. It is a matter of developing some credibility with the doctors. I think we are beginning to get that from asking a lot of questions and making a point of sharing our ideas.
A clear sense is evident from the conversations with these advanced practice nurses that the role provided them with authority to practice not only those added functions previously held by physicians, but the authority to practice nursing autonomously.
Themes Pervasive in Advanced Practice Nursing
The data categories presented narrative data of the experiences of the daily practice of advanced practice nurses. This inquiry uncovered practices supported in the extant literature and practices that have not yet been described. This section identifies the taken-for-granted meanings and practices associated with advanced nursing practice and illustrates how this inquiry confirmed or challenged some extant knowledge.
Theme l: Leading the Development of Nursing Practice
Advanced practice nurses are leaders in developing nursing practice. They practice at the edges of the expanding boundaries of nursing's scope of practice. Their commitment to nursing practice through leadership, mentoring, and role-modeling serves as a catalyst for further development because the general nursing population does not have the background and orientation to do so. They have been successful in changing the traditional power relationships and have broadened professional boundaries to become central players as expert clinicians and decision-makers. Advanced practice nurses who have sound clinical expertise are able to use evidenced-based practice guidelines, participatory methods and demonstrate a nursing perspective in clinical mentoring and teaching. At this juncture their ability to provide clinical leadership becomes evident.
Theme 2: Grounding Practice in Nursing Values and Perspectives
Advanced nursing practice is grounded in the values and perspectives in which caring, health promotion, involvement with people in helping to deal with their reality, and an understanding of context and a broad range of factors that influence health and illness are stressed. The conscious awareness of the advanced practice nurses in this inquiry helped to alleviate concerns that the importance of nursing practice will be lost by the movement to take on medical functions. The participants in this study demonstrated clearly how they take on their added medical functions and place them within the context of patient-focused care.
While an assumption is that all nurses do advocacy work to a certain extent, advanced practice nurses are particularly well positioned because of the depth and breadth of their knowledge base about specific health problems and their ability to clearly articulate issues of concern. Advocacy extends beyond individual patients to systems of care through the surveillance of care practices and systems management.
Van Manen5 describes three levels of reflection where the first and second levels of reflection include technical aspects and understanding practice; while the third level involves exploration of the underpinnings of practice, including the moral-ethical aspects. The data from this inquiry are consistent with this description of advanced practice nurses in that the understanding and technical aspects are learned through the interplay of theory and practice, but are followed with a spirit of inquiry and exploration of theory and practice in nursing's values and perspectives. These advanced practice nurses seem to have gained from their vast experience by reflecting on the implications of their actions which, in turn, gives them a deeper understanding of the whole clinical picture.
Developing advanced nursing practice with a sound grounding in nursing's values and perspectives is contingent on a number of factors that include nursing experience. A nursing identity is developed during clinical experience as nurses assimilate and integrate the art, science and spirit of professional nursing. Their thinking processes amplify and transform relevant portions of their nursing experience to guide both present and future practice. This combination becomes the expertise that comes from this deep understanding of clinical practice which according to Benner6 is gained through a hybrid of clinical experience and sophisticated use of knowledge.
The depth and breadth of the theoretical background of the advanced practice nurse allows them to practice from a much different perspective because they have a deep understanding of the rationale and the significance of nursing interventions. The deliberate use of theory or a theoretical framework to drive practice is a clear understanding in the data.
Study participants were able to provide a balanced perspective to medical management and nursing care. Medical care can be better tailored to achieving desired outcomes because of the holistic perspective that nursing brings to clinical situations. This blend translates into better continuity of care, a broader perspective in planning, and improved focus on nursing issues.
Theme 3: Using Emerging Evidence to Guide Practice.
The use of research is a distinguishing characteristic of advanced practice nursing. The drawing of research and practice together is evident as the study participants used appropriate research evidence to deal with specific patient problems, applied the evidence and then evaluated the effects of the research grounded evidence. The research role of the advanced practice nurse includes conducting studies and using existing research for improving nursing practice.
The participants in this inquiry confirm Ingersoll's 7 suggestion that advanced practice nurses are seeking out and using best evidence in their practice. The research-theory-practice linkages serve to drive the development of the clinical practice of these advanced practice nurses. The centrality of these research activities in practice was emphatically stated.
One of the challenges facing the advanced practice nursing education programs is to provide educational opportunities that have a grounding in nursing perspectives and methods to support evidence-based practice The nursing profession and health officials must resist the temptation to provide minimal education which merely adds functions and tasks the nursing role. This approach will undermine the sustainability and development of the advanced practice nursing.
For advanced practice nurses to be effective in initiating and negotiating change they must be placed in organizational contexts which give them the authority and power to affect change. The basis and strength of the advanced practice nursing role lies in its clinical expertise. The multiple sub-roles, such as researcher and educator, need to be placed in a perspective of the primacy of clinical practice.
Nursing experience is a prerequisite to developing clinical expertise. Learning to make good clinical judgments is dependent on experiential learning where the use can one can refine, challenge or disconfirm expectations8. This development is a requirement for establishing credibility essential in the provision of clinical leadership. The findings of this study underline the value in a strong theoretical base which, coupled with the nurses' experience is used to advance nursing practice.
By articulating some of the taken-for-granted practices and meanings associated with advanced practice nursing, this study illuminated some of the aspects of advanced practice nursing which had not been described extensively in the literature. The use of a hermeneutic phenomenological technique provided the researcher with the opportunity to gain insights into how advanced practice nurses maintain nursing values while expanding their scope of practice and develop nursing practice using an evidence-based approach.
The author acknowledges the support and direction provided by Dr. Marlene Taylor, Professor Emeritus, University of Regina, Dr. Cyril Kesten, Professor, Faculty of Education, University of Regina, Dr. Gloria Miller, Associate Professor, Faculty of Administration, University of Regina and Dr. Marlene Smadu, Associate Dean, College of Nursing, University of Saskatchewan. The author also acknowledges the support of the Faculty of Graduate Studies and the Saskatchewan Nurses Foundation for their financial support.
Dr. Glenn Donnelly firstname.lastname@example.org