With the development of more advanced ways to deliver consumer centered quality health care services the traditional professional roles of nurse and doctor are being transformed. The shift from provider driven to consumer driven health care system anticipated a change in traditional ethical, cultural, and structural doctrine of professions in the system.
As such, there is distinct shift in organization and culture of nursing profession, which includes the way nurses are educated, development of new nursing competencies, Code of Ethics, and a Code of Conduct, influences of human rights movement, opportunity policy, and legislation.
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There have been quite a number of speculations and criticism behind the establishment of advanced nursing practice but generally a lot of potential and promises have been seen from this profession. Proof of this is that States such as Kansas have since revised their laws concerning the practice since 1999, and has generated positive responses thus far (“Nurse Practice Act changes to be introduced in 1999”, 1999).
Similar cases in which there was an increase in the number of advanced nursing Practitioners has also been noted in States like Connecticut, where a community of APNs started their own discussion group until they found that their population has increase since they were established in the late 1990’s (Capobianco, 1999).
Definition of Advanced Nursing Practice
Advanced nursing practice at its simplest, is the attainment of further education, caring skills and field of practice of registered nurses. Those who are undergoing advanced nursing practice posses a master’s or even a doctorate degree in nursing, and in doing so may entitle themselves to additional certification examinations.
The practitioners of Advanced Nursing Practice are called Advanced Practice Nurses or APNs may also take the task of Certified Nurse Midwife (CNM), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS) or Certified Registered Nurse Anesthetist (CRNA) whenever required. They may also administer primary health care, perform mental health services, diagnose and prescribe medicine, do some scientific research and finally they can also teach in medical and nursing schools.
As with other professions, examinations are conducted to earn and maintain licenses which some professionals claim as almost like trying to acquire a medical practice license (“Advanced Practice Nursing”, 2006).
Another definition of advanced nursing practice comes from Jeffrey Bauer, one of the authors of Telemedicine and the Reinvention of Healthcare: The Seventh Revolution in Medicine. He defines advanced practice nursing as not just the attainment of higher education and training of a nurse but also the pursuit of excellence through the six foundations of professional autonomy.
Bauer also noted that APNs can manage their own clinical practice and that they are probably the solution for the country’s ever present shortage of health care practitioners (Sharp, 2000).
Brown (2003) in the position statement defines advanced practice nursing as “an umbrella term appropriate for a licensed registered nurse prepared at the graduate degree level ... with specialized knowledge and skills that are applied within a broad range of patient populations in a variety of practice settings.
The competencies of specialists include the ability to assess, conceptualize, diagnose, and analyze complex problems related to health. Credentials for a specialist require current licensure as a registered nurse, at least a master's degree in nursing, current national certification in the advanced practice area, and approval by the board of nursing,” (Brown, 2003, p. 391).
As such, even though there is a variety of definitions that are used by scholars to define advanced nursing practice, there are three crucial features that distinguish advanced practice nursing from a regular registered nurse: graduate level advanced education, strong relevant and specific theoretical base, professional application of theoretical knowledge in a day to day practice.
Definition and Roles of a Nurse Practitioner
A nurse practitioner (NP) is an advanced practicing nurse, whose practice is focused on services that meet the general needs of community, individuals, families and groups. NP is one of the four types of dances practicing nurses, the other three - certified nurse midwife, certified registered nurse anesthetist, and clinical nurse specialist normally concentrate on a specific area of health, such as cancer care, gerontology, mental or national health (Hickey, 2000).
High level of demand for nurse practitioners that is caused by economic efficiency of these specialists as compared with doctors is a factor of the roles and focus of services provided by NP.
When it comes to speaking about the scope of roles attributed to a nurse practitioner, they are broad. Earlier definitions address health promotion and disease prevention as well as involve diagnosis and management of common illnesses alongside with stable chronic diseases.
Nurse practitioner’s roles also include ordering, conducting, and interpreting laboratory tests alongside with prescriptions, treatments, and therapies. The general roles must then be matched with the specific theoretical background of a nurse practitioner and the field of practice (Raingruber, 2003).
As such, the focus of the nursing practitioners’ roles is on chronic health care treatment, performance of parental, child care, well-woman and adult care check ups, and, finally, health promotion and teaching alongside with disease prevention.
Primary attention is given lately to patient – nurse practitioner relationships and the scope of NP roles in a given situation. Firstly, scholars emphasize advocacy relationships between the two, as there is a conflict between NP’s freedom to practice and patients’ rights and interests in health care settings.
Ellen W. Bernal (2002) emphasizes the importance of friendly relationships between patients and medical personnel and the role of a nurse practitioner as a patients’ advocate. Under this view, NPs are to identify unsafe and unethical practices and at the same time maintain own autonomy in order to be able to openly stand up to moral and ethical dilemmas.
At the same time, the need to maintain treatment boundaries within the nurse client relationship is also one of the roles of nurse practitioners. As nurse find themselves working in different therapeutic settings working on his/her own or as a member of a team, the boundaries of client relationships are often a subject to testing (Peternelj-Taylor, & Yonge, 2003).
As such, one of the roles of NP is to adequately respond to the testing within the boundaries of professional integrity. Even though there is a large amount of literature addressing therapeutic treatment boundaries for nurse practitioners, it is impossible to address every situation and the issue still remains to be up to nurses’ consent, whereas the role of NP is to establish and maintain working boundaries in patient relationships.
Professional Issues Surrounding Advanced Nursing Practice
Perhaps, the hottest issue surrounding current ANP is the blurring line between being a doctor and ANP. To be more specific, ANPs feel as though their “territory” is slowly being intruded by APNs, which they believe is outrageously unfair for them who have the “proper” and “real” right to administer medical attention to patients.
A drastically increasing number of ANPs in the United States, which doubled within the past 10 years and, under the most modest predictions, is likely to double within the next 4 years. The scope of the issue is broad, as in more then half of the states ANPs are allowed to practice without any distinct requirement for physician supervision or collaboration (Mccabe & Burman, 2006).
Going even further then this, as nurses have authority to prescribe some drugs and are eligible for Medicaid reimbursement in every state – it is economically unreasonable for patients, whose focus shifted towards sustaining medicine and health care, to pay for considerably more expensive medical services provided by a physician. As such, there is a conflict between the roles of physicians and APNs, which leads to uncertainty and deprives medical students to pursue additional education.
Thus, a way in which this matter can be solved is by putting a limit on what an APN can and cannot do by setting-up a set of guidelines and regulations that will clearly state the roles of the physician and APN so that arguments like these would be avoided (Edmunds, 1999).
It should be further pointed out, that the issue is very challenging, as there is a need to issue federal level guidelines and, perhaps, even regulates market economically in order to resolve the current argument.
Other professional issues surrounding Advanced Nursing Practice are related to patient-nursing roles, Ethical Code of Ethics and a Code of Conduct that define nursing behavior in a given situation. Being complicated and complex previously, they become a subject to even wider interpretation as a result of blurring difference between the roles of physician and APN, as they question the current hierarchy in health organizations and current reimbursement policy in health institutions.
Nurses are the backbone of the industry and thus it should be equated that a strong backbone is required for the integrity of the industry. Unfortunately, inability of government to establish in a timely manner guidelines for advanced nursing practice results in a conflict between the roles of a physician and a nurse practitioner, which leads to uncertainty and potential misconduct.
And still, it is clear that the advantages and benefits of advanced nursing practices far outweigh its consequences. It should also be noted that there are boundaries and limits that are established between the two professions and that any argument regarding these should be settled in a much rather mild-mannered and professional way. After all, professionalism is all about work and anything that is taken personally should be shrugged off.
Advanced nursing practice update. (1999). Kansas State Nurses Association. Retrieved July 31, 2006 from http://www.findarticles.com/p/articles/mi_qa3940/is_199906/ai_n8877228/print
Advanced Practice Nursing. (15 July 2006). Retrieved July 31, 2006 from http://en.wikipedia.org/wiki/Advanced_Practice_Nurse
Bernal, E. W. (2002). The Nurse as Patient Advocate. The Hastings Center Report, 22(4), 18.
Brown, M.A., & Draye, M.A. (2003). Experiences of pioneer nurse practitioners in establishing advanced practice roles. Journal of Nursing Scholarship, 35(4), 391-397.
Capobianco, M. (1999). Advanced practice nursing in the northwest: "There's a lot happening in our little corner of the state”. Connecticut Nursing News. Sept/Nov. Retrieved July 31, 2006 from http://www.findarticles.com/p/articles/mi_qa3902/is_199909/ai_n8853925/print
Edmunds, Marilyn W. (1999). Increasing professional tension limits NP opportunities. Springhouse Corporation. Retrieved July 31, 2006 from http://www.findarticles.com/p/articles/mi_qa3958/is_199905/ai_n8851221/print
Hickey, J. V. (2000). ANCC Responds. Perspectives in Psychiatric Care, 36(1), 33.
Mccabe, S., & Burman, M. E. (2006). A Tale of Two APNs: Addressing Blurred Practice Boundaries in APN Practice. Perspectives in Psychiatric Care, 42(1), 3.
Nurse Practice Act changes to be introduced in 1999. Kansas Nurses. Jan. 1999.
Peternelj-Taylor, C. A., & Yonge, O. (2003). Exploring Boundaries in the Nurse-Client Relationship: Professional Roles and Responsibilities. Perspectives in Psychiatric Care, 39(2), 55.
Raingruber, B. (2003). Nurture: The Fundamental Significance of Relationship as a Paradigm for Mental Health Nursing. Perspectives in Psychiatric Care, 39(3), 104.
Sharp, Nancy. (2000). “The 21st century belongs to nurse practitioners”. Nurse Practitioner, April, 2000.
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