Clarification of advanced nursing practice: characteristics and competencies

Advanced Practice Nursing in Chile and the Role of the Registered Nurse: Integrating 2 Realities Through Continuous Education

PURPOSE/AIMS

The aim of this study was to explore the perceptions that experienced and highly specialized nurses have of the clinical nurse specialist (CNS) role through description of the registered nurses' (RNs') experiences.

DESIGN

This study used a qualitative descriptive design.

METHODS

Interviews were conducted with 6 RNs (2 managers, 1 chief nursing officer, 2 educators, and 1 clinician) and 32 RNs who participated in 5 focus groups. Participants were purposively sampled from intensive care units and emergency departments from 4 public and private hospitals. The analysis of the narratives and field notes used thematic content analysis.

RESULTS

Common aspects of the CNS competencies and the experienced RN were recognized. These included direct patient care, assessment, and mentoring, with important differences in management, research, and coaching competencies.

CONCLUSION

The findings could facilitate the development of a master's program for the CNS in Chile. Formally recognizing the skills and clinical experiences of expert RNs may motivate nurses to pursue a master's degree that prepares them for advanced practice.

Nurse practitioner-led multidisciplinary teams to improve chronic illness care: the unique strengths of nurse practitioners applied to shared medical appointments/group visits

PURPOSE

To describe the roles of nurse practitioners (NPs) in a novel model of healthcare delivery for patients with chronic disease: shared medical appointments (SMAs)/group visits based on the chronic care model (CCM). To map the specific skills of NPs to the six elements of the CCM: self-management, decision support, delivery system design, clinical information systems, community resources, and organizational support.

DATA SOURCES

Case studies of three disease-specific multidisciplinary SMAs (diabetes, heart failure, and hypertension) in which NPs played a leadership role.

CONCLUSIONS

NPs have multiple roles in development, implementation, and sustainability of SMAs as quality improvement interventions. Although the specific skills of NPs map out all six elements of the CCM, in our context, they had the greatest role in self-management, decision support, and delivery system design.

IMPLICATIONS FOR PRACTICE

With the increasing numbers of patients with chronic illnesses, healthcare systems are increasingly challenged to provide necessary care and empower patients to participate in that care. NPs can play a key role in helping to meet these challenges.

Perioperative Clinical Nurse Specialist Role Delineation: A Systematic Review

A CLEARLY DEFINED ROLE for the perioperative clinical nurse specialist (CNS) has not been identified or established. USING ROLE THEORY as a framework, a systematic review of the literature was conducted to provide recommendations for a delineated CNS role and to compare this role with other nursing roles. SEVERAL FACTORS CONTRIBUTE to CNS role confusion, including the versatility of the position, lack of certification examinations, and variance of state recognition. FUTURE RESEARCH should investigate merging of CNS and nurse practitioner titles, perioperative CNS functions, spheres of influence, and patient outcomes.

Advanced Practice Nursing: Unification Through a Common Identity

Despite the wide variety of advanced practice roles in nursing and the well-documented differences among them [Hamric, A. (2000). A definition of advanced nursing practice. In A. Hamric, J. Spross, & C. Hanson (Eds.), Advanced nursing practice: An integrative approach (pp. 53-73). Philadelphia, PA: W. B. Saunders], the authors suggest that nurses in these roles should adopt a common identity, that of an "advanced practice nurse" (APN). The authors outline the development of advanced practice nursing in Canada and the United States, tracking historical influences and highlighting current issues facing APNs. The authors explore elements that constitute the definable and describable core of advanced practice nursing-knowledge, education, scope of practice, regulatory issues, and outcomes. They conclude that adoption of a common identity for all advanced practice nursing roles may clarify role confusion (which is currently experienced within and outside the profession), reinforce links between knowledge development and nursing practice, and ensure that advanced nursing practice is responsive to the needs of society.

Approaches to teaching: current opinions and related research

Three approaches to teaching and learning are introduced. Each approach has its relative merits and disadvantages. Ideally, each approach should not be used in isolation. The use of facilitatory approaches to teaching and learning should be encouraged to assist the development of problem solving, decision making skills and creative and critical thinking in nurses, particularly those studying on competency-based education and training courses and programmes.

A Survey of Nurses Who Practice in Infertility Settings

DESIGN

A nonrandom convenience sample was used to obtain information about the educational level, clinical activities, knowledge base, and skills of nurses involved with in vitro fertilization.

PARTICIPANTS

Three hundred thirty-six returned surveys.

RESULTS

The Wilcox rank sum test compared nurses in the private practice setting with those in hospital-based services. No differences were found with regard to educational level or perceived level of proficiency with regard to the practice setting or geographic location in the United States. Seventy-three percent of the respondents indicated their primary role was in direct patient care; 31% stated they had been active in artificial reproductive nursing less than 5 years. Graduate level education was not correlated with perceived level of expertise but did correlate with length of clinical experience in assisted reproductive nursing and with certification.

CONCLUSION

Assisted reproductive nursing currently does not meet the standards for classification as an advanced practice nursing group. Action to further the area of reproductive nursing to a specialty in nursing or an advanced practice level is worth consideration for this highly specialized and unique group of nurses.

Advanced practice nursing roles: development, implementation and evaluation

AIM

The aim of this paper is to discuss six issues influencing the introduction of advanced practice nursing (APN) roles: confusion about APN terminology, failure to define clearly the roles and goals, role emphasis on physician replacement/support, underutilization of all APN role domains, failure to address environmental factors that undermine the roles, and limited use of evidence-based approaches to guide their development, implementation and evaluation.

BACKGROUND

Health care restructuring in many countries has led to substantial increases in the different types and number of APN roles. The extent to which these roles truly reflect advanced nursing practice is often unclear. The misuse of APN terminology, inconsistent titling and educational preparation, and misguided interpretations regarding the purpose of these roles pose barriers to realizing their full potential and impact on health. Role conflict, role overload, and variable stakeholder acceptance are frequently reported problems associated with the introduction of APN roles.

DISCUSSION

Challenges associated with the introduction of APN roles suggests that greater attention to and consistent use of the terms of the terms advanced nursing practice, advancement and advanced practice nursing is required. Advanced nursing practice refers to the work or what nurses do in the role and is important for defining the specific nature and goals for introducing new APN roles. The concept of advancement further defines the multi-dimensional scope and mandate of advanced nursing practice and distinguishes differences from other types of nursing roles. Advanced practice nursing refers to the whole field, involving a variety of such roles and the environments in which they exist. Many barriers to realizing the full potential of these roles could be avoided through better planning and efforts to address environmental factors, structures, and resources that are necessary for advanced nursing practice to take place.

CONCLUSIONS

Recommendations for the future introduction of APN roles can be drawn from this paper. These include the need for a collaborative, systematic and evidence-based process designed to provide data to support the need and goals for a clearly defined APN role, support a nursing orientation to advanced practice, promote full utilization of all the role domains, create environments that support role development, and provide ongoing evaluation of these roles related to predetermined goals.

The changing landscape of doctoral education: Introducing the professional doctorate for nurses

The last decade has heralded the introduction of an alternative form of doctoral education for nurses in the United Kingdom, the professional or taught doctorate. First introduced in 1995 in the UK the number of professional doctorates for nurses has steadily increased totalling more than 23 programmes in 2004, a trend that seems set to continue. This paper presents those factors leading to the introduction of the professional doctorate in mainstream higher education generally and those leading to its adoption by the profession nursing. Professional doctorates are defined variously and these are considered relative to the traditional PhD. It will be some time before the full benefits of these programmes are realised and an empirical basis established. Meantime this paper highlights some of the potential benefits and some concerns whilst advocating recommendations that include the longitudinal evaluation of such programmes.

Knowing the nurse practitioner: dominant discourses shaping our horizons

The purpose of this paper is to examine the various discourses, particularly the dominant instrumental and economic discourses that have brought the phenomena of the nurse practitioner (NP) into being. It is proposed that NPs have been constituted as an object of nature and therefore understood metaphorically as a tool or instrument within the health care system to be used efficiently and effectively. Heidegger's philosophical analysis of the question concerning technology is used to argue that our current ways of knowing the NP through these discourses, with their emphasis on calculative logic, have resulted from our modern view of the essence of technology. It is also argued that there is now a need to shape our horizons concerning the NP in new and different ways. There is a need to engage in dialogical forms of research in order to evoke the richness and depth of what it means to be an NP, that is, to reveal the other modes of expression by which we define ourselves, understand others and nursing.

[The nursing labour market in Canada (1985-1999)]

This literature review analysed both published and unpublished scientific and professional studies on the nursing labour market in Canada within the period of 1985 to 1999. The goal was to conduct a situational analysis utilising statistical data and canvassing all concerned parties to extract their points of view. The analysis revealed significant cyclical variations in the evolution of the workforce, particularly with respect to auxiliary nurses, such as the perceived existence of major problems in recruiting new professionals in the field and retaining existing professionals in their organisations, the lack of homogeneity in educational training programmes, and the co-existence of several operational structures for organising nursing care, of which there is a lack of evaluation on their effectiveness. The results of the literature review identify the necessity to further develop the knowledge base on such a relevant dimension of the nursing labour market.

Educating advanced practice nurses for practice reality

The complexity of the current health care environment ethically mandates advanced practice nursing (APN) educators to prepare graduates with a clear understanding of APN roles and professional and regulatory issues for them to make a reasonable transition to the marketplace. Integrating both clinical content needed for APN practice and APN role issues can be a difficult balance. This article describes critical role content needed in APN programs and offers a variety of teaching strategies. Recommendations regarding the timing and placement of role content in the graduate curriculum also are offered. Although there is no one right way to build APN role content into graduate coursework, some approaches are preferable to others.

Developing a neonatal workforce: role evolution and retention of advanced neonatal nurse practitioners

BACKGROUND

Over the past decade more than 120 advanced neonatal nurse practitioners (ANNPs) have graduated from the Southampton based ANNP programme.

OBJECTIVES

To determine the scope of practice and evolving role of ANNPs and to identify factors that may affect future recruitment and retention.

METHOD

An open ended structured questionnaire on clinical role, working arrangements, retention and attrition, continuing education, and professional development was sent to 95 ANNPs.

RESULTS

A response rate of 83% was achieved. There was an attrition rate of 14%, with most ANNPs remaining in their original seconding unit. Factors considered to be important for role satisfaction included a well defined role, working within a team of ANNPs, appropriate remuneration, and evidence of unit support for both role definition and continuing professional development.

CONCLUSIONS

Although ANNPs are expensive to both train and employ, this evidence suggests that there is a good return on the investment in terms of retention to the unit and the specialty. Their role incorporates many features of advanced nursing practice as well as providing "value added" neonatal care by merging traditional medical and nursing roles and crossing professional boundaries. In 2004 the manpower challenges for neonatal units will be even more acute; these data confirm that there are effective options available but they require long term strategic planning and investment.

Pharmacology education: a theoretical framework of applied pharmacology and therapeutics

United Kingdom Government initiatives such as The NHS Plan (DoH 2000) identified the need for nurses to undertake multi-skilled professional roles. In the United Kingdom, the transition to a larger graduate nurse workforce continues, as Universities offer nurse pre-registration courses at diploma and degree levels. Concomitant with the change in educational standard is the need to teach student nurses the theoretical principles of medication management and to develop skills in clinical reasoning skills. Both elements are limited in current educational pre-registration nurse programmes, in order to develop the future, multi-skilled workforce such courses should incorporate the theory and skills of health assessment, physical examination, applied pharmacology and clinical reasoning. This paper aims to examine how knowledge of applied pharmacology and therapeutics can be integrated into an undergraduate pre-registration nursing programme. Discussion focuses on how this generic framework can provide educators with an outline of the theoretical constructs, their application, the teaching strategies involved and instruction on how to prepare nurses to clinically reason with regard to medication management issues. This framework can be adapted to accommodate nurses studying for all parts of the register.

Informatics competencies for nurse practitioners

Informatics knowledge and skills are essential if clinicians are to master the large volume of information generated in healthcare today. Thus, it is vital that informatics competencies be defined for nursing and incorporated into both curricula and practice. Staggers, Gassert, and Curran have defined informatics competencies for four general levels of nursing practice. However, informatics competencies by role (eg, those specific for advanced practice nursing) have not been defined and validated. This article presents an initial proposed list of informatics competencies essential for nurse practitioner education and practice. To this list, derived from the work of Staggers et al., 1 has been added informatics competencies related to evidence-based practice. Two nurse informaticists and six nurse practitioners, who are program directors, were involved in the development of the proposed competencies. The next step will be to validate these competencies via research.

Clinical nurse specialist participation on a collaborative research project. Barriers and benefits

Clinical nurse specialists are expected to contribute to the development of new nursing knowledge through research activities. Competing demands require constant juggling of time and priorities, and activities, such as research, often do not receive the attention they deserve. Research requires specific skills and knowledge and significant time expenditure. Collaborative research is an appropriate way for the clinical nurse specialist to both contribute to research and improve his or her research skills. This article discusses two pediatric critical care clinical nurse specialists' participation in a collaborative research team led by university faculty. The study was designed to reduce family uncertainty and stress and to increase staff nurse competency in providing family care. The ability of the clinical nurse specialists to contribute to the research team was enhanced by knowledge of the research process, good communication skills, and clinical expertise in the specific population of interest. Challenges for the clinical nurse specialists included limited experience in conducting clinical research and balancing clinical and research priorities. Both clinical nurse specialists and the university faculty benefited from this collaboration. The clinical nurse specialist, with expertise in a clinical specialty, is able to bridge the gap between the academic and clinical sites, making clinical research more likely. At the same time, working with expert researchers allows the clinical nurse specialist to increase his or her research skills.

Clinical competence assessment in nursing: a systematic review of the literature

BACKGROUND

The assessment of clinical competence has returned to centre stage of nurse education. However, there is little evidence to support the use of clinical competence and a wide variety of methods for its use.

RESEARCH QUESTION

The present study was designed to investigate the evidence for the use of clinical competence assessment in nursing.

DESIGN

A review using systematic methods of literature pertaining to clinical competence in nursing was conducted using defined dates, databases and search terms.

RESULTS

There is still considerable confusion about the definition of clinical competence and most of the methods in use to define or measure competence have not been developed systematically and issues of reliability and validity have barely been addressed.

CONCLUSION

The assessment of clinical competence remains almost universally accepted in the nurse education literature as a laudable pursuit yet there are aspects of it that remain at odds with the higher education of nurses.

Use of competencies in training fertility nurses in clinical practice

In this article, the value of clinical competencies in the role development of fertility nurses is discussed using the example of the Oxford Fertility Programme. Clinical competencies are incorporated into the training programme within the Oxford Fertility Unit to enable new staff to demonstrate their clinical ability and undergo assessment while learning new and expanded skills. New staff are required to explore both the theoretical and practical foundations that underpin clinical practice. Competencies are used in a structured programme in which staff have to provide evidence of the appropriate knowledge to perform new and expanded procedures. New staff work with a senior nurse, who is their lecturer and who assesses both their clinical and theoretical development. The new staff are also assigned a preceptor with whom they work on a daily basis to consolidate the practice explored with the lecturer. The Scope of Professional Practice produced by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC, 1992) places the emphasis on professional development for individual practitioners. Within the Oxford Fertility Unit, the nurses work collectively and as autonomous practitioners, which enables them to provide a specialized and personal service to their patients. Professional profiles are an integral element of an individual's professional development and are used in the training programme. They provide an accurate record of a nurse's abilities and knowledge and how he or she relates them to practice.

Urban outpost nursing: the nature of the nurses' work in the AIDS prevention street nurse program

The AIDS Prevention Street Nurse Program in Vancouver, Canada focuses on HIV and sexually transmitted diseases (STD) prevention within a context of harm reduction and health promotion targeted at marginalized, hard to reach, high-risk populations. As part of a large evaluation project that included interviews with street nurses, clients, and other service providers together with document analysis, the nature of the street nurses' work and its fit within the provision of health care were described. The street nurses' work reflected the following themes: reaching the marginalized high-risk populations for HIV/STDs; building and maintaining trust, respect, and acceptance; doing HIV/AIDS and STD prevention, early detection, and treatment work; helping clients connect with and negotiate the health care system; and influencing the system and colleagues to be responsive. The findings and their implications for community health nursing practice are examined.

The nature of advanced practice nursing

In attempting to define "advanced practice," we argue that nursing as such is teleological or goal-directed with those goals being defined by the patient or client in interaction with the nurse. In helping the patient meet identified goals, the nurse requires 2 kinds of knowledge-general and particular. General includes theory (know what/why), pattern recognition (know what), and practical knowledge (know how). Particular (know who) is personal knowledge about the patient. The advanced practice nurse, by virtue of graduate education, is able to move beyond the familiar and experientially learned. He or she makes a deliberate attempt to situate self in a dialectic between general and particular knowledge in such a way that the interplay opens possibilities. Knowing when a particular action would be most helpful is defined as practical wisdom. We argue that a highly developed sense of practical wisdom is the hallmark of advanced practice.

Education for advanced nursing practice: an evolving framework

This paper presents and critiques a framework for advanced health care practice. The framework is a set of professional attributes which underpin the delivery of an inter-disciplinary postgraduate course in the United Kingdom (UK). It enables students to review and develop knowledge and skills required to lead and advance nursing and health care practice. The framework is reviewed in relation to UK policy discussion on advanced or higher levels of practice. Brief comparisons are made with international concepts and literature on advanced nursing practice. The potential contribution of this framework to nursing practice and education is discussed. In particular, the framework provides a degree of clarity and coherence in specifying the nature and scope of advanced and higher level practice in the UK.

The role of the clinical nurse specialist in the development of a domestic violence program

In the demanding and ever-changing world of healthcare, CNSs are constantly challenged to define their practice and contributions to the organization. This article describes the multifaceted role of the CNS in the development of an innovative hospital-wide domestic violence program. The strategic use of the CNS, primarily as an organizational consultant, illustrates how nursing practice is improved when the organization is the primary focus.

Oncology decision tree

Financial cutbacks and budgetary constraints continue to be a part of government policy, and impact deeply on many aspects of daily life in Australia in the late 90s. Health care is not immune from these measures, and nurses and other allied health professionals are having to manage increasingly complex patient care with less funding and resources. Patients undergoing chemotherapy and radiotherapy can usually be managed on an outpatient basis, but need round the clock specialist nursing care at home following treatment which can have unpleasant side effects. Home nursing is an expensive option, but it has been shown in the US that a specialist nurse can triage by telephone, providing expert and timely advice and care to this vulnerable group, preventing admission to hospital and providing family support. The purpose of this paper is to demonstrate that, despite budget constraints, an improved cost effective service can offer clients expert care at a fraction of the cost of alternative services. By Sally Koodiaroff.

Specialist nurse: an investigation of common and distinct aspects of practice

Over the past decade the discipline of nursing has been reviewing its practice, especially in relation to specialty areas. There has been an appreciation by nursing leaders that specialisation brings with it concerns related to a disuniting effect on the discipline and a fragmentation of nursing's traditional generalist practice. Accompanying these concerns is a debate over what is a specialty and how to define a specialist. This qualitative study drew upon a constructivist methodology, to explore how nurses, working in specialty areas, define and give meaning to their practice. Three groups of nurses (n=20) from the specialty of critical care were interviewed using a focus group technique. The data were analysed to build constructions of specialty practice. A distinct and qualitative difference was recognised in the practice behaviours of nurses working in the specialty area. The qualitatively different practice behaviours have been identified as 'nursing-in-a-specialty' and 'specialist nurse'. Two constructions emerged to differentiate the skill behaviours, these were 'practice' and 'knowledge'. The specialist nurse practices were based on two distinct types of practice, that of 'discretion' and 'incorporation'. 'Knowledge' was constructed as a synthesis of propositional and practice knowledge. By Carrie Fairweather and Glenn Gardner.

The Scope of Professional Practice: A literature review to determine the document's impact on nurses' role

Following the UKCC's publication of The Scope of Professional Practice (Scope) in 1992, it commissioned a study to investigate the document's impact. As part of the study, a review of the literature relating to Scope and its application was undertaken. Given the association of expanded practice using Scope, with new nursing roles and titles, the British and American literature relating to clinical nurse specialists and advanced practice was included in the review. This was undertaken because of the considerable influence from America on developments in this area in Britain.

Advanced practice nursing: parameters for successful integration

This article analyzes advanced practice nursing roles through a literature review and a pilot stakeholder survey in relation to five strategic areas: (1) definitions and scope of practice; (2) education, credentialing and regulation; (3) new roles in healthcare; (4) costs and benefits in health reform; and (5) implementation and relationships. The Canadian health services environment is best served by a multifaceted APN role, defined by a nursing paradigm that invokes collaborative relationships with physicians, and education and credentialing that is based on national standardization.

Core competencies for clinical nurse specialists: a usable framework

This article describes a framework of generic core competencies for assessing the role of the Clinical Nurse Specialist (CNS). It was devised by a group of CNSs at Kingston Hospital NHS Trust, over a two year period. Currently, there is considerable confusion surrounding the role of the CNS. The UKCC is in the process of clarifying what is meant by specialist practice, with the aim of formally recognizing its status on the register. There does not seem to be a consensus opinion on the standards of competence required to practise as a CNS. This article seeks to address this issue by demonstrating a means of competency-based assessment for the role of the CNS.

Advanced nursing practice from a cross-cultural perspective

This article describes the perceptions of a visiting lecturer exchange experience between Wolverhampton University, School of Nursing and Midwifery, and the University of Kentucky, Lexington, in the American state of Kentucky. The major goal of the visit was to learn health assessment skills to bring back to future advanced practice programmes within the university. The opportunity to work with a variety of nurse practitioners culminated in a unique review of the training development and evolution of advanced nursing practice in Kentucky. Some of the conceptual confusions of advanced nursing practice are explored, together with the features of a new blended role which combines the practice of two traditional positions: the medical skills of nurse practitioners and the expertise of clinical nurse specialists.

Revealing higher levels of nursing practice

The following discussion describes the early findings of a doctoral study, due for completion in 2001. The findings represent data collected in the USA, Australia, New Zealand and the UK, from nurses deemed to be engaged in advanced nursing practice. The paper will review the need for the study and provide a brief overview of the methodology employed. The current status of the findings, utilizing open coding, is presented. Major categories identified thus far are enhancing patient stay, improving patient outcome, promoting the role, trustworthiness, tenacity and survival in the role. The categories identified clarify current understanding of the concept, advanced nursing practice.

Factors influencing tissue viability nurse specialists in the UK: 2

The literature review presented in the first part of this article (Vol 7(11): 648-57) revealed a lack of empirical data on specific contextual issues concerning the current practice of tissue viability clinical nurse specialists (CNSs) in the UK. This descriptive study utilizes focus groups to explore the experiences of tissue viability CNSs. It highlights the development of a facilitative style of expert practice within this group of nurse specialists and makes recommendations for successful role implementation. The findings suggest that specialist nurses are evolving a style of practice in congruence with the UKCC's vision of specialist practice (UKCC, 1994) and that these characteristics are likely to become more apparent over the next decade.

A framework for advanced practice nursing

The empirical and expository literatures about advanced nursing practice have lacked a broad, comprehensive, conceptual framework to organize and guide substantive work. Such a framework is needed during the development of health care policy, educational curricula, role descriptions, and research agendas for this arena of practice. The framework proposed in this article represents an integrative synthesis of previous work on advanced nursing practice. The proposed framework is based on the definition of advanced practice nursing as professional health care activities that (1) focus on clinical services rendered at the nurse-client interface, (2) use a nursing orientation, (3) have a defined but dynamic and evolving scope, and (4) are based on competencies that are acquired through graduate nursing education. Advanced practice nursing is comprised of activities in the domains of advanced clinical practice, health care systems management, and professional involvement in broad health care discourse.

Role of the clinical nurse specialist: an integrative review of the literature

This review of the literature related to the role of the clinical nurse specialist was commissioned by the AACN in order to provide a comprehensive resource for advanced practice nurses. This review provides a historical overview of clinical nurse specialists and some of the gaps or barriers to practice that have been experienced. A summary of these gaps shows that many have repeated themselves over the years. Also provided are potential solutions to facilitate the progression of this role in the future.

Preparing for prescriptive privileges: a CNS-physician collaborative model. Expanding the scope of the psychiatric-mental health clinical nurse specialist

Advanced practice nurses throughout the United States have been successful in securing prescriptive privileges and the related accountability for independent practice. As their authority for the medication management of patients increases, opportunities for practice in expanded nursing roles also increase. When the clinical nurse specialist (CNS) is able to undertake medication management of patients in addition to providing specialized nursing care, continuity is enhanced and cost is reduced. Assuring that the CNS is prepared to provide comprehensive patient services and has the competence to efficiently assess the need for medication, prescribe specific drugs, implement patient teaching, and monitor patients' responses to the medication regimen are key factors if this extended role is to be successful. This article focuses on the CNS in psychiatric mental health nursing. It outlines a collaborative CNS-physician model that addresses the challenges of developing the necessary knowledge and skills to manage patients' medication.

Working together: the advanced rural nurse practitioner and the rural doctor

This paper discusses the complex and interrelated roles of the rural nurse and doctor. These roles are viewed as being complementary to each other in any healthcare setting, but more so within the context of rural Australia. The current move towards the development of advanced nurse practitioner roles is often clouded by unnecessary medical fears that nurses are attempting to displace doctors. In contrast, this paper argues that the development of new rural nursing roles identifies rural nursing as a major specialist area within the wider profession of nursing and, at the same time, recognises the reality of practice for many rural nurses. Individual public figures may perceive the solution to the shortage of rural doctors to lie in their replacement with nurses. The nursing profession, however, will resist this approach. Nursing is not the first rung on the ladder to a career in medicine. Nurses are educated and acknowledged to focus their practice on the clients' responses to healthcare problems and not the practice of medicine. The primary role of the nurse is to provide care. The primacy of care should not be set aside by those nurses seeking to develop their practice, not should advanced practice be defined in terms of taking on tasks previously carried out by other healthcare professionals.

Development of specialist and advanced practice in North America

North American literature provides interesting ideas about the nature of specialist and advanced practice which are useful in informing British thinking on these subjects. However, the two roles do not have the same meanings as their British counterparts. Clarification of the terminology used and the roles described are essential if we are to understand the concepts. This article presents an overview of the literature about clinical nurse specialist and advanced practitioner roles within North America and identifies differences and similarities between the two.

Palliative care: new challenges for advanced practice nursing

The terminally ill are emerging as a specialized patient population that needs the expanded skills and knowledge of advanced practice nurses. These nurses can follow patients across a variety of settings in an integrated system of health care and over the continuum of living and dying. This paper addresses the concept of palliative care and the advantages of advanced practice nurse leadership in this area. Four major criteria for the establishment of a new advanced practice nursing area (American Nurses Association, 1995) serve as a framework. These criteria are: the area lies within the scope of nursing practice; a documented need exists; there is a body of knowledge upon which to base the practice; and the field of nursing would be diminished if the need were ignored. The author maintains that there is sufficient evidence for the creation of a new role: advanced practice nurse in palliative care.

Consultant nurse: an appropriate title for the advanced nurse practitioner?

The term 'consultant nurse' has been offered as an appropriate title for the 'advanced nurse practitioner'. Although both share similar roles and functions the way that each will perform within these roles will differ. Many of the principles and processes involved in consultancy may be viewed by nurses as incongruent with nursing practice, including the relationship between the consultant and the consultee and the view that the consultant nurse should not have a direct care role. The title itself has medical connotations and therefore is viewed negatively by many nurses as it conjures up a view of an aloof, elitist practitioner. Nursing is unique, and although many of the processes involved in consultancy are appropriate to nursing they should only be used in a way that keeps the patient at the centre of care. The title is therefore seen as inappropriate for the advanced nurse practitioner.

The changing role of advanced practice nursing in a managed care environment

Advanced practice nursing in a managed care environment--is this an oxymoron? Can these two phrases exist together? Do advanced practice nurses have a role in a managed care environment? As health-care systems continue to merge and managed care impacts the bottom line, advanced practice nurses are challenged to show their worth. In this article, the author reviews the impact managed care has had on the roles of two master's-prepared traditional clinical nurse specialists. Included are examples of how the roles were adapted to fit in the managed care setting. The current role of the advanced practitioners is reviewed, using the common subroles as a basis for discussion. The impact of managed care on each component of the clinical nurse specialist role is identified. The author also demonstrates that advanced practice nurses can have a valuable role in the managed care environment.