Developing Advanced Nurse Practitioner Role

In Oman, nursing functions in the primary health care centres are restricted to traditional nursing tasks that are normally performed in secondary and tertiary health settings. The directorate of nursing and midwifery affairs (DNMA) at the ministry of health In Oman (MOH) stressed that currently nurses working in primary health care, particularly those in small health centres are functioning in an advanced practice role without any formal educational preparation and often in the absence of medical supervision during the evening shifts and the weekends(DNMA, 2012). There is no regulatory mechanism to protect these nurses and the public when they function in this advanced role. In 2011 World Health Organization (WHO) consultants have done a partial situational analysis in Oman of the issue and have suggested that these nurses need to be provided with appropriate educational preparation and advanced skills in order to function in this advanced practice role (DNMA, 2012)

The need to develop the role of advanced nursing practitioner in Oman is top of the agenda, clarity around the role is needed hence it was studied extensively worldwide (MOH, 2011). Therefore this assignment will discuss the development of ANP, definition, roles development taking into consideration other countries experience, the benefits of ANP and the international council for nurses (ICN) recommendations.

Discussion

The number of advanced nurse practice (ANP) has been growing worldwide and in recent years increased interest has been seen. The NP was introduced to meet health service gaps, with the literature describing the first reported NP role in the US in the mid-1960s (McIntosh, et al., 2003 and Driscoll, et al., 2005 cited in Lowe, et al., 2011, p.679). Additionally, the development of advanced nursing practice has become a global trend in the last few decades and stated that the first APN roles in the US were nurse anaesthetist and nurse midwives; both emerged in the 1940s and the first clinical nurse specialist (CNS) program in psychiatric nursing was established in 1954 (Sheer and Wong, 2008). However, there is worldwide variation of when the ANP was adopted but clearly stated in the literature that United States of America was the first leading in developing this role.

Throughout 1990s, the nursing literature demonstrated an almost undisputed desire to develop a nurse practitioner intended to function at an advanced level (Mantzoukas and Watkinson, 2007). The development of advanced nurse practice (ANP), an important milestone in the professional development of the nursing discipline in the 20th century (Lewandowski & Adamle, 2009), has become a global trend in the 21st century (Sheer & Wong, 2008; Lewis, et al., 2009 and Pulcini, et al., 2010). However, ANP encompasses multiple types of nurses in advanced roles; these roles include nurse practitioners (NPs), certified nurse midwives, nurse anaesthetists and clinical nurse specialists (CNS) (Ketefian, et al., 2001).

The International Council of Nursing (ICN) define an advance nurse practitioner as: “a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which she/he is credentialed to practice” (Pulcini, et al., 2010, P.31 and ICN, 2008, p.29).

The need to develop the ANP roles were as a result of the need to contain costs, improve access to care, reduce waiting time, serve the deprived, and maintain health among specific groups (Sheer and Wong, 2008). In addition to that, advanced nursing practice was implemented due to an international climate of financial austerity, together with emergent technology, ageing populations and issues with sustaining work forces, efficient and cost-effective health care (Lowe, et al., 2011). It seems reasonable to assume that one of the introductions of NP services would be the reduction of cost, but cost reduction seemed difficult to proof.

However, Paez (2006) stated In one study that nurse practitioner in tertiary service prescribe more expensive drugs compared with a Physician prescribing resulting in higher drug cost in the treatment and another studies have proven that NP’s prescriptions led to a reduction of the drug-cost. Several other studies have proven the cost effectiveness of starting a NP program in their organizations (Chen, 2009 and Chenoweth, 2008). On the other hand, a study in the Netherlands of NP cost effectiveness did reveal the complexity of cost calculation of NP’s related work and its possible reduction (Dierick-van Daele, 2011).

In addition to that, Lowe et al (2011) emphasized that It is dif¬cult to provide evidence of ef¬ciency and cost effectiveness of ANP without clarity and consistency of roles and this is only possible when de¬nitions clearly articulate the advanced roles and functions, indicating how they make differences thus clear de¬nition then leads to standardized measures that can provide verification of efficiency, cost effectiveness and realization of patient outcomes with respect to health care.

On the other hand, studies have shown that APNs are able to bring about positive health outcomes, contain health costs, and enhance care satisfaction (Wong and Chung, 2006). Also Advanced nurse practitioners (ANPs) are considered to play an important role in helping to alleviate the shortage of human resources in health care in both developed and developing countries (Horrocks, et al., 2002 cited in Pulcini, et al., 2010, p.31).

It is clearly stated that introduction of NP and ANP in most of research findings suggest a reduction of cost, but more randomised controlled trials should be conducted to support this idea and attention must be given to what drugs are prescribed by NP’s. However, the developing of ANPs roles brings positive health outcomes, enhance care satisfaction, reduce cost and help in shortage of human resources.

On the other hand, Ketefian et al (2001) mentioned that advanced practitioner is beyond basic practice within the clinical domain, also requires higher levels of clinical skill and knowledge, which are acquired through graduate level education and/or certi¬cation in a clinical specialty. This advanced preparation equips the professional nurse for an expanded range of theoretical and research-based interventions.

Advanced practice nursing roles such as clinical nurse specialist (CNS) and clinical nurse consultant (CNC) have evolved globally in a variety of specialty clinical areas (Dunphy, et al., 2009 cited in Lowe, et al., 2011, p 678) both roles were predominantly developed around a consultancy type position, with some indirect patient care being maintained (Ackerman, et al., 1996 cited in Lowe, et al., 2011, p 678). On the other hand, Lowe et al (2011) outlined that although definition and clarity of NP and CNC is reported differently in the literature both are falling under ANP umbrella. Furthermore, Lincoln (2000) supported the idea that both NP and CNC should fall under the scope of ANP despite their differences and the impact on healthcare delivery system. On the other hand, Mick and Ackerman (2002) emphasized that both the CNC and the NP roles are pathways to advanced nursing practice.

It is clearly stated in the literature that both NP and CNS/CNC falls under one umbrella, but both roles should be differentiated a point noticeably supported by Dunn (1997) and Roberts-Davis and Read (2001) who mentioned that the direct care of the NP includes provision of care by way of initial assessment of problems/concerns, establishment of diagnosis following appropriate diagnostic testing if required and formulation of a management plan, which may include prescription of medicines. On the other hand, the CNS/CNC provides the on-going improvement of patient care through management/case management of a patient group with differentiated problems.

Noticeably there are three concepts in developing ANPs roles; one concept supported by Laurent (2000) and Lewis (2002) which both emphasized that the development of advanced nursing practice role needs to be associated with the concept of a clinically specialized nurse possessing a degree of expertise in a specific area of practice and being primarily involved in managerial and task management responsibilities. This concept views the advanced nursing practice as a result of practice specialization considering that there is an opportunity held by nurses for the substitution of other professional’s roles with specialized nurses practising at advanced level (Pearson & Peels, 2002, Daly & Carnwell, 2003). Such specialist nurses will have more control and autonomy in carrying out activities such as diagnosing, assessing (e.g. tissue viability), intervening (e.g. prescribing) and referring to other professionals based on their clinical judgement (Daly & Carnwell, 2003).

A second concept that consider the development of advanced nursing practice roles need to be an exclusive domain of the ANP title protected by governmental and statutory legislations under a newly developed clinical posts. These ANPs are viewed as the extension of nursing into the domains of other health professions, rather than the development or expansion of the nursing discipline (Daly & Carnwell, 2003; Loftus & Weston, 2001). This concept considers that this role ought to be extended in new environments, such as those of Nurse Developing Units or Nurse-led clinics or Nursing triage, where again nurses will have greater degree of autonomy and professional decision making. These ANPs, in contrast to specialist nurses, are considered to be primarily nursing-focused and -orientated practitioners that avoid fragmentation of nursing care. Moreover, such ANPs will have to acquire and implement further knowledge and skills emerging from other disciplines, such as technical skills, and management and educative capabilities. Therefore, these ANPs will have to combine nursing knowledge with other types of knowledge functioning at a higher level of practice and will be acting as the interface between medical and nursing care (Carnwell&Daly, 2003, Loftus&Weston 2003).

A third concept views the advanced nursing practice to be neither a result of specialization, nor attained by virtue of being bestowed with the relevant title. Instead, they view the concept as a generic or an umbrella term that includes elements of advanced practice within the discipline of nursing (Reveley & Walsh, 2000). Some of these elements of advanced practice are the ability to discover, modernize and grow the nursing profession by utilizing multiple types of knowledge and skills along with research evidence and academic thinking processes. Hence, a Master’s degree is recommended for entry level (ICN, 2008, p.29). Furthermore, these characteristics would enable the ANP to collaborate confidently with the multidisciplinary team and offer leadership and expert coaching that would allow motivation, empowerment and dissemination of competent practice, thus clearly demonstrating the contribution of nursing to the health care of society (Hamric & Hanson, 2003).

In summary, the author supports the concept of advanced nursing practice and specialist nurse being two distinctive roles and the ANP roles should be developed as a part of the nursing discipline in Oman with research evidences and academic thinking processes. The author did not find any evidence that support the idea of the need of specialist nurses in order to develop ANPs roles, but the author believe that nurses in Oman should develop from functioning at basic level to function as specialist nurses and develop more at advanced nurse practitioner role, hence DNMA (2012) outlined that the nurses in Oman health services function at basic level. However, specialist nurse roles and advanced nurse practitioner roles are needed in the current climate of health services in Oman.

However, the risk of equating advanced nursing practice with the specialist nurse is the medicalization of the nursing profession and nurses acting as a replacement or a substitute for medical personnel rather than providing advanced nursing care (Pearson & Peels 2002). On the other hand, if advanced nursing practice is associated with a defined title and consequently with prescriptive roles of practice, such as those of nursing development units, nurse-led units and nursing triage, then the advanced nurse practice role it will run the risk of becoming just another type of medical specialization, this is what Pearson and Peels (2002) caution when they outline that, “in the process of expanding nursing roles and removing existing barriers, some things might be lost … and general nursing roles [will become] denigrated” (p. 3).

However, the divergence from the traditional registered nurse role and subsequent professional autonomy has drawn some concern from the medical fraternity, worried that they may lose their patient’s to ANPs (Wilson & Bunnell, 2007), their power (Appel & Malcolm, 2002) and posing a challenge to the existing and dominant medical discourse(Kilpatrick, 2008). Furthermore, such a process may well provide the reason why ANPs are often reported as assisting the co-ordinated approach of the multi-disciplinary team (van Soeren & Micevski, 2001). However, ANPs might better deliver care due to the very nature of an integrated approach to practice through the application of nursing knowledge and experience and the ability of the ANP to intersect professional boundaries in their clinical practice should serve to provide a better understanding of patient needs (Kilpatrick, 2008).

However, Davies and Huges (2002) argued in order to develop ANPs roles; ANP should be flexible in their approach to care, be able to lead, and be prepared to take risks. Furthermore, there have been more recent claims that the ANP needs to be able to use both experiential as well as theoretical knowledge, demonstrate expertise, show the ability to research and think critically (Mantzoukas and Watkinson, 2007). However, developing the role of ANP in Oman requires the nurses to function at advanced level focusing on developing the specialist nurses and subsequently develop to ANP roles with appropriate education level as DNMA (2012) emphasized on the need of ANP study at least at masters level and the need to move away from diploma based nurse’s program to baccalaureate level.

On the other hand, several commonalities have emerged on the attributes of ANPs. Person-centred care appears to be at the forefront of the vision for nurses. Sutton and Smith (1995) are advocates of this, and claim that ANPs spend their time focusing upon the patient, placing them at the centre of their role in order to provide the highest standard of care. They have a desire to “push the boundaries” and strive to provide holistic and innovative patient-centred care (Shiu, et al., 2012). The author believes that ANPs would be needed to fulfil the vision of ministry of health in Oman (DNMA, 2012).

Clarity around what each of the advanced nursing roles offer is paramount to take advantage of this opportunity to improve healthcare delivery (Lowe, et al., 2011). Despite there being evidence to support the idea that recognition of the ANP role can improve patient safety and service development (Cerinus, 2009), we have to ask the question of whether ANPs will ever be fully accepted by the very people in Oman. In other countries nurse-led chronic disease management clinics have been very well received, and the patients are very grateful to be able to “avoid” having to see the doctor. The culture in Oman is predominantly medical oriented, the population are tribal and less educated than in the western world, accepting the role of ANP will need a coordinated efforts from all disciplines. However, the success of developing ANP roles in Oman depend on the consistencies in de¬ning the explicit nature of the ANP role, protection of the ANP title, its scope of practice and the credentialing processes required (Lowe, et al., 2011).

On the other hand, Lowe et al (2011) argued that the title of NP in the UK is not protected, or under any regulatory governance, unlike the role in other countries such as Australia, Canada, Ireland and the US. However In June 2005 the UK Nursing and Midwifery Council (NMC) decided to finally define what constituted ‘advanced nursing practice’ and agreed the title should be protected. They concluded advanced nursing practise is an umbrella term, which is used to describe a number of specialist roles including clinical nurse specialist and nurse practitioner (NMC, 2010). The ministry of health in Oman need to overcome these issues around the initial phase of developing the role of ANP in United Kingdom by clearly defining and protecting the role.

On the other hand, the regulatory nursing body and the educational institutes in Oman need to consider the steps in developing the ANP role that had been implemented in the United Kingdom as the nursing and midwifery council (NMC) and the Royal College of Nursing (RCN) developed a formal ANP programs to be taught in higher education institutes (HEI). On successful completion candidates gain accreditation from the RCN and is then recognised as an ANP. Both the RCN and NMC have since been in opposition to individuals and institutes who continue using the title ANP without the adequate training and education (RCN, 2012).

The establishment of the AANPE (Association of Advanced Nursing Practice Educators) sought to bring together all the HEIs in the UK who teach and run the ANP programs. On the other hand, there is a lack of consistency about the skills required by a NP in the UK clinical setting, the educational preparation required before licensure/endorsement and in the subsequent measures for maintenance of competence to practice and regulation (Wilson & Bunnell, 2007). The author believes that the definition of the role, protecting the title of ANP, develop a formal ANP programs, accreditation, set the skills and competencies and develop an association of advanced nursing practice is important to develop the role of ANP in Oman.

However, Sheer and Wong (2008) outlined that the speed of developing ANP role internationally varies and factors influences development are; first the readiness of the nursing profession itself to advance to a higher level. The readiness refers to the presence of a substantial general-nurse population and well-developed nursing education at the baccalaureate level to allow further development of the discipline. Second the nursing educations exist at the postgraduate level and have reasonable nurse to population ratios. Recently the education system in Oman introduced the post graduate studies for critical care (adult, neonate and accident and emergency) primary health care, psychiatry, administration and nephrology and developed the baccalaureate science of nursing, but most of the nurses have a diploma (three years program) in nursing.

Conclusion

The author discussed in this assignment that the advanced nurse practitioner initially was developed in United States of America, supported the need for ANP development in Oman, outlined the different roles of ANP that the NP and CNS/ CNC are under one umbrella, discussed the different concepts of developing the role and support the advantages of developing the ANP role in reducing cost, bringing better health outcomes and helping in shortage of human resources.

The author emphasized that in order to develop ANP role within Oman; the practicing nurses in primary, secondary and tertiary health settings should be advanced toward extended nursing roles (specialist nurses) and ANP role. In addition to that defining the role of ANP, protecting the title of ANP, develop a formal ANP programs, accreditation, set the skills and competencies and develop an association of advanced nursing practice is important to develop the role of ANP in Oman. Furthermore, regulatory body and legal framework need to be established and the need for medical and public acceptance of the role.

Moreover, there is a need to develop the existing diploma degree in the nursing health institutes to baccalaureate degree level (BSN) as the number of graduate at BSN is very low and develop an education program at master’s level as education at masters’ level does not exist in Oman. Lastly, there is a need to establish a regulatory body for ANPs in Oman.