Advanced nursing practice is a term that describes an advanced level of nursing practice that maximizes the use of in-depth nursing knowledge and skill in meeting the health needs of clients (individuals, families, groups, populations, or entire communities). In this way, advanced nursing practice extends the boundaries of nursing scope of practice and contributes to nursing knowledge and the development and advancement of the profession.
Currently, the most recognized role of advance practice nurse is that of the clinical nurse specialist. Although the term advanced nursing practice is frequently used to describe the practice of nurses in such a role, until recently, there has not been agreement within the profession about the definition and nature.
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Under the umbrella term of advanced nursing practice, four distinct roles are identified: nurse practitioner, nurse midwife, clinical nurse specialist, and nurse anesthetist.
The cornerstone of advanced nursing practice is expertise in a specialized area of nursing. Clinical experience and additional education equip the nurse with the skill to synthesize from a broad range of nursing, experiential and scientific knowledge in addressing the health concerns of clients along a continuum of care.
Nurse practitioners believe that they and other colleagues should be able to practice in an employment situation which gives equal right and responsibilities, to everyone operating at the same standard.
The advance practice nurses should provide consultation to both colleagues and clients and have a vision for nursing practice within the context of the health care system.
The minimal educational preparation for advance nurse practice is a graduate degree in nursing. A formal graduate degree program in nursing is valued, because it covers the growing theoretical base of nursing, promotes nursing research and the incorporation of new knowledge into the nurse’s practice and evaluates and documents the nurse’s achievements.
The central focus of nursing practice is clinical practice in which there is a direct relationship between nurse and client. Direct care is supported by nursing education, research and administration.
A clinical nurse specialist is a registered nurse who holds a master’s or doctoral degree in nursing with expertise in a clinical nursing specialty. An expert practitioner, the clinical nurse specialist provides direct care, education and consultation to clients, as well as education and consultation to the healthcare.
The United States is the country with the most well developed advanced practice roles and the greatest degree of consensus on the nature and scope of advanced practice. In the U.S., there are four established advance nurse practice roles: nurse practitioner, nurse-midwife, nurse anesthetist, and clinical nurse specialist. All but the nurse-midwife role require graduate education, although the majority of nurse-midwives have masters or doctoral degrees.
All registered nurses are personally and professionally accountable for their actions. Legislation and regulation of advanced practice nurses should be set up using a professional practice model in which practitioners have sole authority for their practice, clear standards of practice, accountability for decision-making, and maintaining skills.
As well, legislation and regulation should protect the titles nurse practitioner, clinical nurse specialist, and advanced practice nurse.
More than 70 percent of the employers surveyed said they already had nurses in advanced practice roles, and 30 percent said they intended to hire more nurses in such roles in the future. Employers reported a need for clinical nurse specialists, particularly in practice areas where gaps in service were reported, such as primary care, geriatrics, and mental health.
Lack of funding was reported as the most common barrier to implementation. Nurse practitioners were seen as most needed in primary care and palliative care.
A nurse practitioner is a registered nurse, who has completed advanced education (a minimum of a master's degree) and training in the diagnosis and management of common medical conditions, including chronic illnesses.
Nurse practitioners provide a broad range of health care services. They provide some of the same care provided by physicians and maintain close working relationships with physicians. A nurse practitioner can serve as a patient's regular health care provider.
In 1965, the profession of nurse practitioner was instituted and required a master's degree. In the late 1960s into the 1970s, predictions of a physician shortage increased funding and attendance in nurse practitioner programs.
During the 1970s, the nurse practitioners requirements relaxed to include continuing education programs, which helped accommodate the demand for NPs. Currently, all three educational options to attain nurse practitioners status are valid.
Nurse practitioners are expert nurses who work within a specific area of practice incorporating advanced knowledge and skills. They practice both independently and in collaboration with other health care professionals to promote health, prevent disease and to diagnose, assess and manage peoples’ health needs.
They provide a wide range of assessment and treatment interventions, including differential diagnoses, ordering, conducting and interpreting diagnostic and laboratory tests and administering therapies for the management of potential and actual health needs. They work in partnership with individuals, families and communities across a wide range of settings. Nurse practitioners may choose to prescribe medicines within their scope of practice.
Nurse practitioners also demonstrate leadership as consultants, educators, managers and researchers and actively participate in professional activities, and in local and national policy development.
Nurse practitioners integrate into their practice elements such as diagnosing and treating health problems and prescribing drugs. Nurse practitioners work autonomously, from initiating the care process to monitoring health outcomes, and they work in collaboration with other health care professionals.
Nurse practice in a variety of community, acute care and long-term care settings. These include, but are not limited to community health centers, nursing outposts, specialty units and clinics, emergency departments and long-term care facilities.
Nurse practitioners can serve as a patient’s regular health care provider and see patients of all ages. The core philosophy of the field is individualized care. Nurse practitioners focus on patients' conditions as well as the effects of illness on the lives of the patients and their families.
A clinical nurse specialist is an advanced practice nurse, usually with a Master of Science in Nursing. A clinical nurse specialist is similar to a nurse practitioner; however they may have less autonomy. A clinical nurse specialist is a masters prepared, advanced practice nurse whose care focuses on a specific patient population, like medical, surgical, diabetic, cardiovascular, operating room, emergency room, critical care, neonatal, etc.
The clinical nurse specialists divide their time into five general areas - clinical practice, teaching, researching, consulting, and management. Their assessment skills tend to be more focused than nurse practitioners, since they focus on a particular area of specialty. But they make up for this by being able to provide more expertise than even an expert level staff nurse.
In any medical facility, registered nurses work with doctors to provide the best patient care possible. But clinical nurse specialists are a little different from the usual registered nurse. Clinical nurse specialists are experts in a specialty area of nursing care and are an important resource for hospital staff members.
They keep abreast of current developments in their specialty, from new drug therapies to new treatments to innovations in patient care and make this knowledge available to other staff members by acting as teachers and advisors.
Many clinical nurse specialists actually run clinics. They have full responsibility for coordinating and making decisions about patient care. Some also prescribe and monitor the effects of patients' medication. They manage research protocols, keep an eye on costs to make sure care is being delivered efficiently and cost-effectively, and develop research projects and clinical studies.
These nurses have developed extensive specialist knowledge about a specific area of medicine. They generally have an undergraduate degree or a Master of Science and work closely with doctors who specialize in the same area of healthcare.
They also help ensure that national healthcare standards are put into practice locally, and may contribute to developing policies that govern how patients should be cared for.
The National Association of clinical nurse specialist is the professional organization that represents clinical nurse specialists, provides career development and networking opportunities, and provides a forum for discussion of issues and trends that affect and shape the evolution of clinical nurse specialist practice.
A clinical nurse specialist must be able to care for individuals, families, groups and systems with complex health needs within a specific clinical area; use theoretical and clinical expertise to assist health care providers and consumers in promoting or achieving optimal health.
Develop and implement standards of nursing practice; serve as consultant or resource person for other health providers; facilitate an interdisciplinary approach to meeting the needs of the patient; use effective utilization of resources in order to provide cost effective care; seek consultations and make referrals as needed; use and promote research to improve clinical nursing practice.
The practice of nursing continues to evolve to meet the changing needs of clients. Trends in the delivery of health care are providing opportunities for nurses to create new roles and expand current roles. Among these trends are: an increased emphasis on primary health care, new models of collaborative practice, the shift from institutional to community care, new developments in technology, and the supply and demand for various health providers with particular skills.
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Mundinger M. (1994). Advanced-practice nursing: Good medicine for physicians? New England Journal of Medicine.
Sutton F., Smith C. (1995). Advanced nursing practice: New ideas and new perspectives. Journal of Advanced Nursing.
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