The idea of advanced practice in nursing presents a challenge to the general nurse in terms of exploring scope of practice and potential professional development (An Bord Altranais, 2000; Thompson and Watson, 2003). There appears to be a lack of clarity in defining the concept of advanced practice (Thompson and Watson, 2003), with terms such as specialist practice, consultant nursing roles and the like clouding the waters of the debate, suggesting a need to perhaps amalgamate and standardise roles (An Bord Altranais, 2000;) .
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This author, as a Community General Nurse in Ireland, is aware of two advanced practice roles within her own practice area: one within the Accident and Emergency Department, an acute care facility, and one within Education, which straddles the academic/practice divide. However, the changing and developing role of the nurse and rapid changes towards higher levels of practice (NMC, 2002; Thompson and Watson, 2003; Lorentzon and Hooker, 2006) seems to suggest that advanced practice may be an integral part of career progression within nursing (An Bord Altranais, 2000), which leads to a need to clarify the concept and map its components and meanings. Concept analysis and conceptual clarification form an identifiable genre within the nursing literature (Paley, 1996). This essay will follow one model of concept analysis to map the concept and explore the implications for practice through an exemplar model case.
Concepts and theories within science are strongly linked (Paley, 1996), and both seem to be interdependent. Concept analysis enables the definition of a concept and allows the critical reader to differentiate between similar and dissimilar concepts (McKenna, 1997). Achieving conceptual clarity is an important task for both research and practice (Walker, 2006). There are a range of concept analyses that have been used within scientific and nursing literature. Morse (1995) suggests that techniques to map concepts should relate to the maturity of the concept concerned. In this case, Advanced Practice is an extant concept which demands clarification in relation to specific areas of nursing activity. Therefore there is a need to determine a means of concept delineation and clarification (Morse, 1995). There is also a need to identify an appropriate means of clarifying the concept, for example whether or not to utilise qualitative or quantitative methods (Morse et al, 1996.)
In this instance, a qualitative approach based on Rodgers (1989; 1991;1993) model of concept analysis will be utilised. This particular model has been chosen because of its firm grounding in research traditions of sociology and nursing (McKenzie, 2000). The Rodgers’ approach has already been utilised to map evolving phenomena (Walker, 2006) and so is particularly applicable to a still developing topic area. As Rodgers’ approach is an inductive, cyclical approach (Walker, 2006), it is a more creative endeavour suitable to the generation of new ideas and definitions. A literature review will be carried out, in a targeted manner, utilising a structured approach (see Table 1).
Table 1 Framework for concept analysis
- Identify concept of interest
- List published literature relevant to the topic and select papers to be included in the sample
- Identify surrogate terms and relevant uses of the concept.
- Identify and select appropriate sample for data collection.
- Identify the attributes of the concept
- Identify the references, antecedents and consequences of the concept.
- Identify concepts that are related to the concept of interest
- Identify a model case of the concept.
The Process of Analysis.
Concept of interest
McKenna (1997) suggests that when choosing a concept, it is best to select a concept that represents phenomena of interest to the researcher. McKenna and Cutcliffe (2005) also suggest that there should be some confusion or lack of consensus about the concepts’ meaning, but the scope should not be too broad. The concept of interest is advanced nursing practice in community general nursing, which is related to the author’s own area of practice and experience of practice delivery. This concept also meets McKenna’s (1997) stipulation that the concept should also be abstract enough o retain its meaning when removed from specific situations. Therefore, the concept of advanced nursing practice is being analysed, with reference to one specific area of practice but not limited by that practice.
- Higher Level of Practice
- Specialist nursing practice
- Role of the Specialist nurse and consultant nurse
- Professional Development in Nursing
- Community nursing practice
Please see Appendix for the audit trail of sample selection.
Attributes of the Concept
The concept of advanced practice is not a new one (Carroll, 2002). Clinical nurse specialists have been cited since the 1940s (Carroll, 2002). It is a nursing concept (Carroll, 2002) despite being associated with advanced practices traditionally carried out by the medical profession (Mantzoukas and Watkinson, 2007). The literature is in agreement that the concept of advanced nursing practice lacks agreement on the core characteristics and roles of such a practitioner (Mantzoukas and Watkinson, 2007).
The concept is related to specialism (Mantsoukas and Watkinson, 2007) suggesting that the role emerges as a unique expression of need within a distinct area of practice (Gardner and Gardner, 2005). Hamric (1996) links advanced nursing practice to practical, theoretical and research based interventions within a specific clinical area linked to the larger discipline of nursing. However, it can also be a more general theoretical construct of any form of nursing which progresses to an advanced level of practice (Mantzoukas and Watkinson, 2007). Evidence does seem to suggest that similarities between specialist nurses and clinical nurse specialist roles and between nurse practitioner and advanced nursing practice roles (Carnwell and Daly, 2003). Therefore it would appear that an eclectic set of role schema have emerged from the general stew of advances in nursing practice. Bryant-Lukosius et al (2004) further define the term advanced nursing practice as referring to the work, or to what nurses actually do in their roles, but also makes reference to the multi-dimensional scope and mandate of the concept.
Specific attributes of the concept include the ability to discover, innovate and expand the nursing profession by employing multiple types of knowledge and skills, support by research evidence and academic thinking processes (Mantzoukas and Watkinson, 2007). Other attributes are: the use of the knowledge in practice; critical thinking and analytical skills; clinical judgement and decision-making skills; professional leadership and clinical inquiry; research skills; mentoring skills; and the ability to change practice (Mantzoukas and Watkinson, 2007). Furlong and Smith (2005), analysing the edicts of the National Council in Ireland, describe the core concepts of advanced nursing practice as: autonomy in clinical practice; clinical and professional leadership; and expert practitioner and researcher. All of these appear to relate meaningfully to nursing as a profession but do not address the application of the role to patient outcomes and clinical effectiveness. However, Benner et al (1999) relate critical thinking to active thinking in practice, the application here being evident. This would then relate to clinical judgement, but the question arises of acceptability of nurses undertaking clinical decision making in the current NHS climate.
References, antecedents and consequences of the concept
Antecedents or prefixes to the concept include the notion of education and individual roles, historical development of the profession (Carroll, 2002), and advanced roles as part of the development process of the nursing profession (Mantzoukas and Watkinson, 2007). In order for the advanced nursing role to exist, there must be an identified need for such a role in specific areas of nursing practice (Caroll, 2002; Mantzoukas and Watkinson, 2007). In particular, the need to perform specific nursing tasks, interventions and clinical monitoring for individual conditions may be viewed as an antecedent (Gardner et al, 2004). Specialist preparation and legislative/professional evolution are also antecedents (Mantzoukas and Watkinson, 2007). Education for advanced nursing practitioners is linked to research-derived curricula and learning defined by clinical practice (Gardner et al, 2004). However, education and specialist preparation of the advanced practitioner in nursing could also be viewed as a consequence, as specific programmes of education have had to be developed in response to the developments of these nursing roles (Gardner et al, 2004).
Consequences include lack of role clarity (Carroll, 2002; Griffin and Melby, 2006) and the notion of the mini-doctor role which leads to nursing practice being carried out within a medical model rather than the optimal holistic nursing model (Carroll, 2002). This would have an impact on nurses themselves and their professional self concept, and on the client/patient, affecting the type and perhaps quality of their care. It might also lead to the erosion of general nursing roles in favour of specialisation, again following a medical model of professional development (Mantzoukas and Watkinson, 2007). However, other literature sees advanced nursing practitioners as being a result of recent health care policies, the role having developed to meet the complex demands of health care systems (Carnwell and Daly, 2003).
Another professional consequence of the concept is the need for regulation and supervision (NMC, 2002). In relation to this is the development and evolution of professional nursing autonomy (Mantzoukas and Watkinson, 2007). The expansion of advanced roles can also be seen as a consequence of the concept, whereby established areas of advanced practice pave the way for its implementation in a range of specific clinical areas (Mantzoukas and Watkinson, 2007). This may be related to practice development ensuring that nursing remains responsive to the changing needs of patients and clients (Thompson and Watson, 2003). This related to another consequence of advanced practice, ongoing change in clinical practice (Mantzoukas and Watkinson, 2007). However, it could be argued that practice development is an antecedent to the concept of advanced nursing practice as well, echoing the blurred nature of the concept from a range of perspectives. Autonomy could also be viewed as a consequence (Wade, 1999). The fact that advanced nursing practice is valued within the healthcare arena is also an important factor (Dunn, 1997; Griffin and Melby, 2006), and makes its most important consequence improvement in patient outcomes and the associated improvements in healthcare and reduced demand on resources (Coster et al, 2006: Gardner and Gardner, 2005).
Concepts related to the main concept
One concept related to advanced nursing practice is fitness for practice (Thompson and Watson, 2003; NMC, 2002). Another is that of barriers and resistance to advanced practice, particularly in relation to the current NHS climate (Thompson and Watson, 2003). Systems and processes must be in place and be effective for advanced practice to establish itself and its efficacy (Gardner and Gardner, 2005). Policy background and political drive are also related to this particular practice development (Carnwell and Daly, 2003). The international or global scope of the concept is also evident from the literature sampled here (Bryant-Lukosius et al, 2004; Sutton and Smith, 1995). Nurse prescribing and authority in pharmacological intervention is another related concept (Lorentzon and Hooker, 2006).
Patient K, a 65 year old woman had been referred to the author (a community RGN), due to a recurrent, chronic leg ulcer on the left ankle. This ulcer had been treated for some years with topical preparations and dressings, including antibiotic treatment and a variety of therapeutic dressings, and the involvement of other professionals such as dietician and physiotherapist had attempted to address potential underlying causes of failure to heal, such as lack of mobility and poor diet. However, after some deterioration in the condition of the ulcer, increased haemoserous loss and offensive odour, K attended the GP and was referred by the practice nurse to the wound specialist clinic at the local outpatient department.
The clinical wound specialist nurse reviewed K’s case, identified the ulcer as a venous ulcer and prescribed four-layer pressure bandaging to treat the wound, based on her own awareness of the research evidence that demonstrated the efficacy of this intervention. The four-layer bandaging technique improves venous return in the lower extremity by providing a gradient of pressure from the bottom of the lower limb towards the knee.
The specialist nurse engaged K in a degree of learning about her condition and its treatment, in order to ensure compliance. The four-layer bandages are left on for two to three days at a time, then removed to dress the ulcer, then replaced with clean four-layer bandages. They can be uncomfortable, and so patient compliance is important in the success of treatment. The specialist nurse spent time with the client, informed her of the rationale and evidence base, and then further contacted this author, her community general nurse, to ensure that those treating K were fully competent in the four-layer bandaging technique. She also advised K to return to her for regular review of her condition. Within 12 weeks the ulcer was healed, which greatly pleased K and allowed her discharge from nursing care.
This case demonstrates many of the features defined by the concept analysis of advanced nursing practice. The advanced practice developed out of a defined need for a specialist wound clinic staffed by specifically trained and experienced staff. The specialist nurse occupies a senior role with a large degree of autonomy. She has been educated in her specialism, utilises evidence-based practice, and engages in an educative role with clients and with non-specialist nurses, demonstrating the components of expert practice but also advancing the expertise of those around her (Benner, 1994).
Professionalizing forces in nursing, clinical need and extension and changes in primary health care appear to have combined to create new roles for nurses in the NHS (Lorentzon and Hooker, 2006). These roles appear to have functional bases defined by gaps within service provision and focus on client need. Therefore, given this concept analysis, it would appear that advanced nursing practice is a needs-driven development of specialist nursing management to provide optimum clinical outcomes for client and service provider. Such practice is evidence based and provided by a trained, competent clinician with the academic and experiential authority required to implement theory into practice, bridging the theory-practice gap through exemplary implementation of clinical judgement (Upton, 1996). It can also be viewed as a logical outcome of continuing professional development within nursing.
This author’s role within the community nursing team encompasses a range of nursing challenges, one of which has been described here. It is through liaison with such specialists that the community nurse can facilitate evidence-based practice and bridge the theory-practice divide which continues to challenge the achievement of best practice in every clinical situation. However, it is also evident that there is a need for further clarification and consensus around such roles and better awareness of the scope of advanced nursing practice both within individual specialisms and in the wider realm of NHS nursing care. This author can see that the role of the community general nurse itself could be further developed into an advanced nursing role, drawing on the successes of such roles in other areas, but this would need policy, systems and ideological change to achieve. Ultimately, if the results are demonstrable improvements in patient outcomes, it would be well worth the challenge.
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Benner, P. (1984) From Novice to Expert California: Addison-Wesley Publishing Company.
Bryant-Lukosius, D., DiCenso, A., Browne, G. & Pinelli, J. (2004). Advanced practice nursing roles: development, implementation and evaluation. Journal of Advanced Nursing 48 (5) 519-529.
Carnwell, R. & Daly, W.M. (2003) Advanced nursing practitioners in primary care settings: an exploration of the developing roles. Journal of Clinical Nursing 12 (5) 630-642.
Carroll, M. (2002) Advanced Nursing Practice. Nursing Standard 16 (29) 33-35.
Castledine, G. & McGee, P. (eds) (1998) Advanced and Specialist Nursing Practice Oxford: Blackwell Science.
Coster, S., Redfern, S. Wilso-Barnett, J. et al. (2006) Impact of the role of nurse, midwife and health visitor consultant. Journal of Advanced Nursing 55 93) 352-363.
Cutcliffe, J.R. & McKenna, H.P. (13005) The Essential Concepts of Nursing Edinburgh: Churchill Livingstone.
Dunn, L. (1997). A literature review of advanced clinical nursing practice in the United States of America. Journal of Advanced Nursing 25 (4) 814-819.
Furlong, E. and Smith, R. (2005) Advanced nursing practice: policy, education and role development. Journal of Clinical Nursing 14 (9) 1059-1066.
Gardner, A. and Gardner, G. (2005) A trial of nurse practitioner scope of practice. Journal of Advanced Nursing 49 (2) 135-145.
Gardner, G., Gardner, A. & Proctor, M. (2004) Nurse practitioner education: a research-based curriculum structure. Journal of Advanced Nursing 47 (2) 143-152.
Griffin, M. & Melby, V. (2006) Developing and advanced nurse practitioner service in emergency care: attitudes of nurses and doctors. Journal of Advanced Nursing. 56 (3) 292-301.
Hamric, A.B. (1996) A definition of advanced nursing practice. In Hamric, A.B., Spross, J.A. and Handson, C.M. (eds) Advanced Nursing Practice: An Integrated Approach Philadelphia: WB Saunders.
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Sutton, F. & Smith, C. (1995) Advanced nursing practice: new ideas and new perspectives. Journal of Advanced Nursing 21 (6) 1037-1043.
Thompson, D. & Watson, R. (2003) Advanced nursing practice: what is it? International Journal of Nursing Practice 9 (3) 129-130.
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The search engine/gateway British Nursing Index was accessed and searches were carried out utilising the following keywords with their associated hits:
- Advanced Nursing Practice
- Higher Level of Practice
- Specialist nursing practice
- Role of the Specialist nurse and consultant nurse
- Professional Development in Nursing
- Community nursing practice
The list of returned citations was further limited by defining parameters as follows:
- Full text
- English Language
- Original Articles.
The express aim was to review 20% of the returned citations, leaving the author with a targeted sample of articles from a range of nursing journals including Journal of Advanced Nursing; Journal of Clinical Nursing; Advances in Nursing Science; International Journal of Nursing Practice; Dimensions of Critical Care Nursing; International Journal of Nursing Studies; Nursing Standard; Graduate Research in Nursing.
The focus of the concept analysis being Advanced Nursing Practice, only those articles which deal specifically with this concept were included in the sample.
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