Identifying the practice characteristics of advanced practitioners in acute and critical care settings

Skills, competencies, and policies for advanced practice critical care nursing in Europe: A scoping review

OBJECTIVES

Management of critically ill patients is changing due a rise in population age, comorbidity and complexity. To accommodate these changes, the demand is increasing for advanced practice nurses. More knowledge is needed regarding the role of advanced practice critical care nurses in European countries. The aim of the study was to review the literature describing skills and competencies required for advanced practice critical care nursing in Europe and to investigate related policy.

REVIEW METHOD

We performed a scoping review including papers published in 1992-2019 targeting policy and the intersection of advanced practice nursing (level of practice), critical care nursing (specialty area) and Europe (geographical origin).

DESIGN AND DATA SOURCES

Main sources of evidence were PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Library, SweMed+, Scopus, ERIC and Social Sciences Citation Index. We also searched grey literature, webpages, reference lists and performed hand-search.

RESULTS

The search identified 11,478 papers/references of which 42 were included. Four levels of practice were identified with unclear boundaries: professional nurse, specialized nurse, advanced practice nurse and advanced critical care practitioner (nurse or other). Most skills and competencies described in the literature were generic to advanced practice and only few were area specific to critical care. Advanced practice critical care nurses were often unable to fulfil their role because education, supportive policy and legislation were lacking.

CONCLUSIONS

This scoping review informs the policy makers and the INACTIC study of existing advanced practice in critical care nursing in Europe. The advanced role in critical care nursing is characterized by inconsistency regarding policy, education, titles, roles, scope of practice, skills and competencies. Levels of practice and areas of specialization need to be clarified. Most skills and competencies identified were generic for advanced practice nursing and many were generic for any profession. Task-shifting from physician to nurse needs to be more clearly defined and patient outcomes described. Given the scarcity of papers in our target area, we believe it might be too early to conduct a systematic review at this time.

Development of a nursing practice based competency model for the Flemish master of nursing and obstetrics degree

The aim was to identify a set of competences for the Flemish academic Master of Nursing and Obstetrics degree that answer perceived needs in health care. The competency model was to demonstrate a degree of consensus among key nurses. The study was conducted in all Flemish hospitals registered to have 400 beds or more. Head nurses of surgery, geriatrics and intensive care units were eligible to participate, as well as one nurse from administration per hospital. A two round Delphi process allowed participants to comment on items identified in an analysis of existing international competency profiles of master level nurses and adapted to the Flemish context. Competences agreed to by 90% of the respondents were considered to have consensus. Fifteen out of 19 eligible hospitals were recruited in the study, 45 nurses participated in the Delphi panel. Consensus was reached on 31 competences that can be assigned to 5 nurse's roles: nursing expert, innovator, researcher, educator and manager. The resulting competency profile is in accordance with published profiles for similar programs. The reported study demonstrates a practical method to develop a consensus competency model for an academic master program based on the input of key individuals in mainstream nursing.

Neonatal nurse practitioner role transition: the process of reattaining expert status

Neonatal nurse practitioners (NNPs) have managed care for high-risk hospitalized infants in the United States for over 30 years. The journey from being expert nurse to being novice NNP and then finally to being expert NNP is fraught with many challenges. This study used a qualitative descriptive design to describe advanced practice role transition among 70 NNPs. The data consisted of participants' written responses to open-ended questions. Four themes emerged that depicted a linear progression of the transition process from school preparation to beginning feelings in the new role and then development into a more confident practice. Theme 1: First impressions emphasized the ambivalence novice NNPs experienced regarding their preparedness for the role during a stressful and exciting adjustment period. Theme 2: The transition demonstrated the overwhelmingly similar feelings of anxiety, insecurity, exhaustion, and lack of confidence that plagued decision making. Theme 3: Making it as a real NNP indicated that the 1-year mark was a consistent, significant timeframe for feeling like a real NNP. Theme 4: The helpers and hinderers revealed the vulnerability of the novice NNPs to harsh criticism as well as the importance of support, especially from nurse colleagues. NNPs are a valuable resource; thus, enhancing transition is a worthy goal.

Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors

AIM

This paper reports a study to determine the attitudes of nurses, doctors and general medical practitioners towards the development of an advanced nurse practitioner service within an emergency department.

BACKGROUND

The role of advanced nurse practitioner in emergency care has emerged in a number of countries, and has brought with it confusion about titles, role boundaries, clinical accountability and educational requirements. Initially, the role resulted from a need for healthcare professionals to provide a service to the increased numbers of patients presenting to hospital with less urgent problems. Since then, the service has evolved to one where nurse practitioners provide high-quality and cost-effective care to persons who seek help for non-urgent, urgent or emergent conditions in a variety of emergency care settings. However, little research could be identified on the attitudes of relevant nursing and medical staff towards the development of this role.

METHODS

A questionnaire survey was carried out, and a 29-item Likert rating scale was developed to measure attitudes. Along with some demographic variables, two open-ended questions were added to allow respondents to elaborate on what they perceived as benefits and difficulties associated with an advanced nurse practitioner service. All general practitioners, emergency nurses and emergency doctors in one health board in the Republic of Ireland were targeted, and 25 emergency nurses, 13 emergency doctors and 69 general practitioners were approached to take part. Data were collected in February 2004.

FINDINGS

An overall response rate of 74.8% was achieved. All respondents were positive towards the development of an advanced nurse practitioner service, with general practitioners being less positive. The principal differences appeared between general practitioners and hospital emergency care staff.

CONCLUSION

There is a need for a multidisciplinary approach to the planning of advanced nurse practitioner services. To achieve multiprofessional acceptance, an accredited and standardized education programme is required, and this must address existing role boundaries.

Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care

AIMS

To describe the actual clinical activities undertaken by a critical care nurse consultant in an eight-bedded adult surgical high dependency unit within a large NHS Teaching Hospitals NHS Trust.

BACKGROUND

In the United Kingdom, the first critical care nurse consultants were approved in 2000 following the Department of Health's (1999) revised career structure for nurses. Expert practice is a core function of the role although the nature of expert practice in the context of critical care is unclear. Expert practice is often deemed to be a feature of advanced practice and although a number of studies have investigated this in context of critical care, there is little insight into the nature of advanced practitioners' clinical practice and how it might influence patient outcome.

DESIGN METHODS

A diary was used by a critical care nurse consultant to record activity during scheduled clinical sessions. Data were collected for four months: 39 sessions were evaluated. Qualitative data were content analysed and coded into categories. Clinical activities were coded, categorized and analysed using SPSS 11.0 for windows (SPSS Inc., Chicago, IL, USA).

FINDINGS

Clinical activities included direct care activities, clinical leadership, education and training. Two main themes emerged from the qualitative data and were categorized as clinical reasoning and clinical instruction. Clinical activities arising from clinical reasoning and clinical instruction were aimed at minimizing risk and the provision of quality care. In doing this, one of the outcomes was the detection and resolution of untoward clinical occurrences.

CONCLUSION

The level of achievement--or end point--of clinical activities was that the patient was established in 'a state free from risk or harm that optimises rehabilitation'. 'A state free from risk or harm that optimizes rehabilitation' might be one outcome reflecting the needs of individual critically ill patients that is sensitive to individual nursing contribution.

RELEVANCE TO CLINICAL PRACTICE

There is increasing pressure on health-care professionals to identify and measure their individual impact on the outcome of patients. This study adds further insight into the complexities associated with evaluating the influence of individual contribution on patient outcome, especially when it is characterized by complex processes involving clinical judgement and decision-making.

Advanced nursing practice: policy, education and role development

AIMS AND OBJECTIVES

This paper aims to explore the critical elements of advanced nursing practice in relation to policy, education and role development in order to highlight an optimal structure for clinical practice.

BACKGROUND

The evolution of advanced nursing practice has been influenced by changes in healthcare delivery, financial constraints and consumer demand. However, there has been wide divergence and variations in the emergence of the advanced nurse practitioner role. For the successful development and implementation of the role, policy, educational and regulatory standards are required.

CONCLUSION

The paper highlights the value of a policy to guide the development of advanced nursing practice. Educational curricula need to be flexible and visionary to prepare the advanced nurse practitioner for practice. The core concepts for the advanced nursing practice role are: autonomy in clinical practice, pioneering professional and clinical leadership, expert practitioner and researcher. To achieve these core concepts the advanced nurse practitioner must develop advanced theoretical and clinical skills, meet the needs of the client, family and the community.

RELEVANCE TO CLINICAL PRACTICE

In a rapidly changing people-centred healthcare environment the advanced nurse practitioner can make an important contribution to healthcare delivery. The challenges ahead are many, as the advanced nurse practitioner requires policy and appropriate educational preparation to practice at advanced level. This will enable the advanced practitioner articulate the role, to provide expert client care and to quantify their contribution to health care in outcomes research.

Discovering the nature of advanced nursing practice in high dependency care: a critical care nurse consultant's experience

This paper describes how a critical care nurse consultant's clinical role has evolved within a surgical high dependency unit (SHDU) in a large teaching hospitals trust. In order to provide some background to role development, an overview of the research exploring the nature of advanced nursing practice in the context of critical care will be presented. From the outset, advanced nursing practice was not perceived as the acquisition and application of technical procedures usually undertaken by doctors, but possibly an integration of medicine and nursing where holistic nursing assessment is combined with symptom-focused physical examination. A reflective account of practical problems encountered relating to role integration, professional autonomy, legal and consent issues, non-medical prescribing, and role evaluation will be presented. A model of working that can be applied to high dependency units, integrating the role of the advanced nurse practitioner within the clinical team, will be described.

Nurse consultants as higher level practitioners: factors perceived to influence role implementation and development in critical care

This paper discusses the main factors perceived to influence higher level practice in critical care drawing upon personal experience as a critical care nurse consultant. Implementation and development of the role towards a higher level of practice has been influenced--both positively and negatively--by policy, legislative, organisational, cultural, professional and individual factors. Discussion focuses on professional, policy and organisational issues because--on reflection--these are the main factors that have facilitated and inhibited role implementation and development towards a higher level practice in the United Kingdom. Relevant research exploring advances in nursing practice in critical care, and how this has influenced the development of higher level practice in relation to the nurse consultant role, will also be discussed.

Teaching nurses psychological support of patients with wounds

Concerns about lack of professional empathy with psychological aspects of wound care provided the springboard for this study. Forty-three qualified nurses who regularly care for patients with wounds recorded in research diaries how they supported patients holistically before and after attending a counselling skills workshop. Thirty-nine nurses then attended focus groups to share their experiences. Participants represented varied practice settings, with 581 patient situations recorded in the diaries. Data analysis identified four themes: reflection sharpens the focus on practice; complex situations; emotional labour; and knowing the patient. While patients' feelings were identified in the first diary period, and reflection sharpened the focus on practice, patients' psychological needs were not attended to fully. Following the workshop there was a major shift in the understanding and provision of psychological support for patients with wounds by some of the nurses. Others were unable or unwilling to embrace counselling skills into care. This highlights the need to address nurses' attitudes and beliefs that might interfere with psychological support for patients with wounds.

Confusion prevails in defining 'advanced' nursing practice

The Australian nursing profession has accepted the challenge to support and encourage advanced nursing practice role development. A critical review of national and international literature highlights that there is no singular definition or understanding of 'advanced' nursing practice. Instead difficulty with nomenclature and clarification of levels of nursing are perpetuated by unclear distinction between 'advanced', 'specialist' and 'expert' nursing practice. This paper presents the findings of a review of the literature and posits that ambiguity and lack of consistency in defining 'advanced' nursing practice is hampering the progression of the profession towards the development of consistent advanced practice roles in Australia. It is proposed that a universally accepted definition would provide a vehicle for future Australian role development so that all advanced practice roles have a common genesis and national consistency results.

Challenges of advanced practice nursing in pediatric acute and critical care: education to practice

The APN role of the future is dependent on our ability to document through research that NPs, CNSs, and the consolidated role of the NP/CNS plays a critical role in the delivery of high quality cost-effective care. Further information is needed regarding how the APN contributes to and enhances the care delivered by the healthcare team. Cost effectiveness and quality outcome studies are needed including those that describe morbidity and mortality rates, patient satisfaction, and cost effectiveness of models of care that includes APNs. Brooten and Naylor suggest the inclusion of sensitive nursing outcomes, including functional status, mental status, stress level, satisfaction with care, caregiver burden, cost of care. Defining and clarifying the APN functions and qualities of scope of practice is imperative. Perhaps there are populations best served by APNs. Contributions such as continuity, consistency of care, attention to issues such as immobility, skin integrity, and health promotion may have a value added effect. Time motion studies and process logs may add to the information about APNs in pediatric acute and critical care. Professional certification validating competence is essential for the practice of APNs caring for sick children and their families. A disparity exists between the primary care examination now available and the practice of NPs in pediatric acute and critical care. A certification examination is needed with content consistent with the practice of pediatric acute care NP. APNs must possess sufficient knowledge and skill to meet the needs of patients and families in the changing healthcare environment. According to Strodtbeck and colleagues, flexibility, ability to be a self directed learner, critical thinking, relationship skills, and leadership skills including interpersonal insight, interpersonal competence, and ability to stimulate group discussion will serve APNs well as they move into the century. Transitioning brings exciting opportunities along with challenges. Using a blend of abilities, the pediatric acute care APN can provide optimal care to sick children and families.