Manual Nursing leadership and management: the advanced practice role

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From the authors who have followed Benner's progressive practice principles, and those who have defined an AP model, both the Oberle and Allen and Ann B. Hamric models will be highlighted throughout this article, due to their importance in this reflection. In the Oberle and Allen model, AP is an extension of expert practice and is characterised by having a higher practical knowledge, meaning that a nurse is highly skilled at individualising care.

The inherent difference between an expert by experience and an APN nurse is primarily that a nurse must already be an expert and have a good practical knowledge and skills in order to later achieve further theoretical and integrated knowledge through theory and practice by completing postgraduate studies.

Hamric 8 , has summarised an integrated AP model published in and updated it with subsequent publications. In it a conceptual definition of APN is proposed and includes:. Primary Criteria: those criteria that must be fulfilled before a nurse can be considered an APN the attainment of a master's degree in advanced practice nursing in a specific specialisation, possession of a specialised national advanced practice certificate, and complete work experience focusing on the patient and family.

Nuclear Skills: in which clinical practice is considered the "core competence" and includes six characteristics: using a holistic perspective; education in therapeutic patient cooperation; using expert clinical thinking; using reflective practice; using evidence as a guide to practice; and using diverse theoretical approaches for health and illness management. The other "additional competences" are: to be an expert in coaching, at the same time as guiding patients, families and other healthcare providers; to be interested in research; fulfil clinical leadership; take part in collaborative practice and put making ethical decisions into practice.

Finally, Hamric, exposes the critical elements that are not specifically part of the definition of practice but, however, have a large impact on the daily progress and management of APN. These are related to health policies, management and organisation, and performance improvement. This change was made to adapt to the European Higher Education Area, meaning that the three-year university diploma in nursing changed to the current four-year undergraduate degree in nursing, achieving a high-competence level in clinical nursing as well as developing competences in research and methodology.

In the last few decades, postgraduate or master's university studies have been the most important for specialisation and acquiring area-specific clinical competences. With the curriculum change in place, nurses nowadays can easily access master's and doctorate studies. These specialities are regulated by the Ministerio de Sanidad Healthcare Ministry and are achieved by taking part in a two-year residence in a multi-professional teaching centre. Once the specialisation has been completed it is possible to directly access a doctorate programme.

This legislative framework, which enlarges basic training, has some limitations in order to develop AP nursing, such as the prohibition of nurses from prescribing drugs and healthcare material as well as the lack of legislation surrounding the allowance of hospital discharges by nurses. Despite the efforts by nurses to allow nursing professionals to write prescriptions, the Real Decreto Royal Decree of October 11 , leaves prescriptions out of nursing competences and only recognises the competence of explaining or dispensing medicines if previously accredited. This can be done after the person prescribing has performed a medical diagnosis, which then leaves out the very competence for explaining or dispensing medicines after issuing a nursing diagnosis.

In the same way, in Catalonia in July , the Departament de Salut de la Generalitat de Catalunya the Healthcare Department of the Catalonian Government and Els Collegis Oficials d'Infermeres i Infermersde Barcelona, Tarragona, Lleida i Girona the Nursing Colleges of Barcelona, Tarragona, Lleida, and Girona laid the foundations so that nursing professionals could prescribe medication and committed to allowing nursing prescription-writing in the following months The concept of "role" is used to better explain the AP of the nurse. Authors such as Reveley and Walsh 14 , argue for the need to develop new roles and prepare nurses to work at the absolute limit, at higher levels than in traditional practice.

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The role is the main way to identify AP nurses in Catalonia, assimilating AP professionals into "new roles" that, up until now, were not easily identified in the professional nursing arena. For many years, roles that could be considered AP roles have existed and were developed by the so-called "clinical nurses". These roles were implemented in a vast majority of hospitals.

According to Ridao 15 , these nurses act in the clinical process of hospitalisation and out-patient care by performing initial and continued evaluation, proactive intervention, assessment of the attending nurse, complex care, patient education, discharge preparation, and continued healthcare. Along with the new roles and associated with the case management model, roles aimed at answering the needs of the ageing population are also emerging. A forerunner role for case management was the so-called "liaison nurse" who worked with a wide selection of patients before hospital discharge and who worked and coordinated well in different areas, institutions, and departments They also work in day-surgery and conventional hospitals, proactively acting to avoid complications, and educate patients and families, all whilst coordinating discharges with other units.

The main responsibility of case-management nurses is to, as the name states, "manage care," although they do also take part in clinical practice; as they usually care for a specific type of patient, they are very well prepared to evaluate and treat them. From specialising in a certain group of patients, they may receive various names such as management nurse for patients with cardiac insufficiency, management nurse for patients with chronic obstructive pulmonary disease, nurse for frail patients, and management nurse for patients with complex chronic illnesses, among others.

Other roles in the "transition role" are those which were traditionally carried out by doctors but which have begun to be done by nurses. This is the case for perianaesthesia nurses who carry out the preoperative anaesthetic consultation and, although they have been trained for the competences to do it, this role is often difficult because role conflicts can arise between doctors and nurses.

In that case, are these all AP roles? If we consider the definitions by ANA and CNA, these nurses have knowledge and clinical skills that are specialised to a specific area of care or type of patient. Therefore, does knowledge assimilation happen through scientific evidence or research? In reality it is nurses with specific postgraduate training and with a high level of clinical expertise who, along with team-leadership recognition, have been able to access these positions.

If we consider the definition of the ICN, it is specialist nurses, "specialist" meaning those who have theoretical and practical knowledge of a specific patient type, which enables complex decision-making and the ability to go further than what is possible in the traditional nursing role. On the other hand, looking at the above-mentioned models, it seems to be clear that they draw from a proficient or expert level that can be seen in Benner's model 7 , from which nurses can concentrate on a specific area of knowledge and patient-type by undertaking postgraduate training, where they can develop specific clinical competences.

From there, according to Oberle and Allen's model 3 , it is possible to note that these types of nurses do take part in AP. They form an extension of expert practice, thanks to the integration of theoretical knowledge, practice, and the ability to individualise care. Looking at Hamric's model 8 we can conclude that AP nurses in Catalonia do carry out the core competence - direct clinical practice - although the additional competences and surrounding elements do need to be further studied.

Although there is a political and professional interest in having nursing advance and take on new professional roles, the AP concept goes even further than the current implementations that are being produced. Some of the differentiating elements are:. Postgraduate training, whilst considering specialities, it does not include sufficient competences and the learning results as described in AP models, such as reflective analysis, coaching, decision-making, and professional leadership, among others.

Whilst a certification or accreditation system for external or organisational AP nurses does not exist, it would be difficult to assure that nurses who choose health organisations for AP truly meet the required criteria. In this way, the implementation of these competences in the daily clinical practice by case-management nurses shows that they have high clinical leadership skills in interdisciplinary teams, but do they reflectively analyse their cases?

To what extent do they empower patients and families to help them advance in self-care? Do they make the correct decisions and make them by cooperating with other professional team members?

Specialized Knowledge of Leaders in Nursing

Do they use evidence to improve care? Do they take part in and conduct research to improve nursing science? What results do their efforts have? The barriers nurses face when they carry out these types of roles are of a different type; the most frequent barrier is the fact that prescribing is impossible due to the law. On top of that, on many occasions nurses are unable to make final decisions on their patients' healthcare, which in itself causes a continuous awkwardness between nursing staff and patients. It is also true that nurses have traditionally carried out collaborative roles and very rarely or in fact never at all carried out roles in an autonomous manner.

If it were not that way, we would probably not be discussing new competences or advanced competence. What is occurring is that new professional duties are being gained which up until now were unimaginable. Despite all the setbacks, nursing in Catalonia is advancing. Review of advanced nursing practice: the international literature and developing the generic features. J Clin Nurs [Internet].

The advanced nurse practitioner: common attributes. Can J Nurs Adm.

The nature of advanced practice nursing. When you're looking at the integration of the CNS and the NP, there needs to be support from a government level in terms of funding.

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Leadership and Management Competence in Nursing Practice

There needs to be support from an administrative level in terms of support for the development of new roles and responsibilities and the implementation, and that implementation needs to involve support and evaluation. There needs to be support from other healthcare professionals, particularly physicians in terms of the collaboration.

That support is critical because if you don't get that support then your ability to implement needs a lot more tenacity in order to make it work, to make it successful. When you've got the support and funding, then you have the opportunity to show what you can do. The multidisciplinary roundtable convened by CHSRF to formulate evidence-informed policy and practice recommendations based on the synthesis findings recommended that advanced practice nursing positions and funding support should be protected. Most administrator participants commented on the insufficient infrastructure resources, as the following two quotes from an administrator and an APN demonstrate.

Nursing Leadership

It's a slow and steady approach to implementation. We need to keep thinking about it and have those infrastructures in place to make sure we are setting them up for success and not setting them up to fail.

Job Opportunities in Nursing Leadership

The system needs to be prepared to support them [CNSs] in that you need an office; you need a phone; you need a pager. I've seen CNSs hired and then it comes time for them to fill out an annual report and they don't have a file folder to put it in. You know you need space. It is very hard to put six CNSs in an office the size of a closet and think they can work there.

Inattention to basic resources such as office space, clerical support, communication and technology marginalizes the purpose and legitimacy of CNS and NP roles. Participants also noted a lack of supportive policies that would allow APNs to function to their full scope. Cummings and McLennan suggest that nursing leaders in healthcare settings can influence policy change and shape the healthcare system by facilitating changes in the workplace that continually improve quality of care and meet fiscal realities.

CNSs and NPs value the non-clinical aspects of their role, and these activities contribute to role satisfaction Bryant Lukosius et al. However, insufficient administrative support and competing time demands associated with clinical practice are frequently reported barriers to participating in education, research and leadership activities Bryant-Lukosius et al.

Role of research, leadership and management in nursing

This is particularly problematic for NPs in acute care, who usually report to both a nursing and a medical director. In our interviews, we learned that physicians wanted the NPs' time devoted mainly or exclusively to clinical practice, whereas nursing administrators wanted the NPs to also have some protected time to engage in leadership, research and education activities.

A nursing administrator stated:. They are delivering excellence in clinical care, personally working well with the team, with other interdisciplinary team members as well, but they have not been making as strong a contribution to the science of nursing, or to the development of the practice of nursing and certainly not to the development of the system. Role expectations can be enhanced and negotiated by strong leadership from healthcare managers who can communicate a clear vision for the multiple dimensions of the role to team members and support the role within the organization Reay et al.

The development of detailed written job descriptions Cummings et al. As shown in the following quote from an APN, a key strategy to protect the various dimensions of the role is administrative support. Structuring the role [is needed] so that they're actually successful in allowing individuals the time to do the research, to do the education, to go to the conferences, to do the learning that needs to be done so that they can come back and mentor other individuals.

It's not just about seeing a hundred patients in a month. Actively shaping roles allows fulfillment of advanced practice nursing role dimensions in addition to patient care, and this in turn contributes to successful integration as well as advancement of the nursing profession. Nursing leaders raised concern about the lack of awareness of advanced practice nursing roles within healthcare organizations.


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Administrators reported regularly articulating information about advanced practice nursing to physicians, healthcare team members and other administrators to increase awareness. Inadequate healthcare team awareness of the CNS and NP roles has been identified as a barrier to advanced practice nursing role integration for example, Bailey et al.


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