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Advanced Practice Nursing: A level in its own right

Photo: Advanced Practice Nursing: A level in its own right
A summit of Australian nursing leaders was recently held in Melbourne to discuss the future of advanced practice nursing.

The attendees included officers and representatives from leading colleges, regulatory bodies, chief nursing and midwifery offices, the Council of the Deans of Nursing, the ANMF and state/territory branches and university researchers.

The purpose of the summit was to discuss the potential applications and outputs from the findings from recent ground breaking research that shows advanced practice nursing (APN) can be recognized and described as a level of practice rather than a role or title.

The study’s lead investigator, Professor Glenn Gardner of the Queensland University of Technology presented the findings from two recent Australian studies to the summit.
The first was a national survey of the nursing workforce, funded by the ANMF and QUT. A US model that delineates the practice of nurse practitioners and Clinical Nurse Specialist (CNS) was adapted for the Australian context and used to survey the nursing population. Of the 5,662 RN participants, over half worked in hospitals, one third in the community, and 6% in aged care. Almost one third worked in rural or remote communities. On average, nurses had been registered 22 years, most between 11-33 years. And on average, most had been in their current position for more than six years.

The study showed that in Australia, nurses who worked in clinical nurse consultant roles (CNC) were likely to be practicing at an advanced level.

“APN are those nurses who work at the top of the registered nurse practice scope; they are statistically delineated from both the registered nurse (RN) and nurse practitioner (NP) levels of practice,” Professor Gardner says.

Results showed nurses who practiced at an advanced level had high mean scores across five domains of advanced practice – direct care; support of systems; education; research; and professional leadership.

“We have a much better understanding of the practice profile of the Australian nursing workforce. This allows for standardization of the Australian nursing workforce” says Professor Gardner.

The results of a recently completed Australian Research Council funded study were also presented. Early results showed that data from direct observation of advanced practice nurses provide distinct patterns of practice according to the work context.

“Whilst APNs work across all domains, their work patterns vary according to the practice contexts, this has far-reaching implications,” says co-author and University of Technology Sydney Professor, Christine Duffield.

Where in the country are APNs to be used? And how do we decide what level of nurse we need? These questions were put to the floor of nursing leaders at the summit.

Decisions about the use of an APN depend on the nature of the work, nursing leaders argue: it’s not about the role; it is where and how they are practicing that will decide this. The APN role is about the complexity of what they do and is not dependent on the setting.

There needs to be a focus on meeting the needs of the future, according to nursing leaders. The focus should be on what is needed within healthcare service planning, including aged and community care. The US was cited as an example at the summit of service planning – where an increase in the primary healthcare sector for aged care services has decreased hospitalisations.

“One of the things I think is really exciting about this work is in the future how we can extend this to sectors like aged care, primary care and mental health,” ANMF Federal Secretary Lee Thomas says.

“This is a launching pad for nursing spheres,” the summit proposes. “Nurses can work differently but remain under the same ‘umbrella’.”

Role and work value
The summit raises the issue of nurses currently working as APN however their practice not valued as advanced. Public services roles are strongly tied with pay points/pay structures. It shouldn’t matter what the job is called, what matters is what the individual does, nursing leaders argue. Work value is what is important, not the title.

“I think it’s very important nursing directors and nursing executives and the profession understand the profile,” says ANMF Federal Secretary Lee Thomas.
Employers will now have the knowledge and ability to place NPs and APNs into appropriate services, the summit suggests. “This research provides the nursing (practice profile) domains and demonstrates the importance of research irrespective of sector.”

Career path
The research spans across and builds on all previous knowledge of career structure and advancements, irrespective of the location or area of the nurse.

A clear and measurable definition of APN is essential for nursing graduates to understand career directions, nursing leader surmise.

Historically, education pathways for nurses were clear. There is some confusion of career pathways and career standards which is feeding into low numbers for Masters’ intake. There is also the current issue of having different types of nurses, such as specialists, APNs and NPs in postgraduate studies.

The summit highlights the need for nurse leaders and APNs to be available as role models for undergraduate students.

The research findings have the potential to inform both career pathways and postgraduate curriculum design to support the career structures.

Nursing leaders agree that a clear definition of what is an APN is needed and more support for nursing roles is essential. The research can help develop an evidence informed definition of APN. From it a tool of APN for use by all clinicians could be developed.

The research and findings from the summit provides evidence based definitions, frameworks and tools that have potential to achieve clarity in the discipline and improve utility of service and practice across all areas and levels of nursing.

“In this room are the leaders who need to work together as drivers for change. It is essential that the APN role be legitimized and a proactive and innovative approach with service and design for nurses working within their scope.”

Looking at the bigger picture
Chris Williams


Regional Outreach Nurse Chris Williams juggles multiple roles from clinical and education to support systems management and quality improvement initiatives. A Nurse Consultant with the Paediatric Integrated Cancer Service (PICS) at the Royal Children’s Hospital Melbourne, Chris supports programs in regional outreach shared care.

“I see the impact on families dealing with critical events in their life doing whatever they have to do. Some people travel 25,000 kilometers during their child’s treatment. Some people are willing to relocate to be closer to services.

“Our philosophy is to provide safe care as close to home as possible. A child who is treated for leukemia also have five years’ follow up and will need to continue to travel for surveillance. These are significant trips for families who may come from Port Fairy or Albury-Wodonga for a 5-10 minute appointment or simple chemotherapy. If we can get it done locally with an expert on the other end of the line it’s the best outcome.”

Chris spent ten years with Central Coast Health in Gosford Hospital as a Clinical Nurse Specialist in paediatrics in the ward and rotating through the emergency department.

“I was in the ED asking myself: ‘how do we manage these kids with cancer?’ We had a knowledge gap. We had risk patients as risk of sepsis, kids on chemo: I wanted to learn more about that area.”

“My philosophy is about providing quality care to people to the best of my ability. How can we do that unless we can define what quality care is?”

Chris completed a postgraduate certificate in paediatric oncology and another in acute paediatrics. He completed ten years in general paediatrics before the move into paediatric oncology. He also worked for five years in paediatric oncology at the Women’s And Children’s hospital in Adelaide as an Associate Clinical Service Coordinator.

One of Chris’ roles in PICS is to support the regional outreach shared care program. The Childrens Cancer Centres at the RCH and Monash Children’s participate in a shared model of care with nine regional hospital in Victoria: Ballarat, Bendigo, Albury-Wodonga, Geelong, Warrnambool, Traralgon, Shepparton, Frankston and Wangaratta.

“I spend two to three days a week in a nurse consultant role providing medical and nursing education and support for those centres, both on the wards and in the Emergency.

“We have support systems in place. We set up new chemotherapy standards to do low complexity chemo; risk managing the unwell patient; management of the neutropenic patient; central line training. There’s also a lot of work in the background in management of the service capability.”

The other day or two is spent on service improvement projects for quality care in oncology. “We are developing an optimal care pathway for children with leukemia for the DOH.”

Chris says the work is collaborative. “It’s very much a multidisciplinary approach – doctors, nurses, physiotherapists, pharmacists, social work – it’s making sure all these people are involved and engaged.”

One day a week is allotted to bedside clinical care on the day oncology OPD at the RCH. “A lot of ARNs are based in the office and sometimes there is a disconnect from bedside nursing,” says Chris. “Particularly, as my other work has me engaging in other areas, it’s very valuable to have rapport with colleagues at the clinical bedside. And a day a week keeps me honest. It defines what this is all about – the crux of why we do this work for our patients and their families.”

Chris is part of an international group of nurses involved in a research grant to look at improving the nurses’ ability to assess children with cancer prior to chemotherapy. He is also doing a minor thesis across paediatric oncology centres in Victoria looking at the information provided to families when delivering nurse-led telephone triage and advice. “Looking at what algorithms we should use and if they are across all centres – to get consensus on the approach we use when families call from home. We all have basic clinical guidelines, but we need to make sure we are consistent in what we say.”

A large part of the role is advocacy says Chris. “I really enjoy the outreach. I look at the bigger picture – the time to critically think and get things done.”

Looking for the red herring
Jo Magyar


“As RNs we are good at pattern recognition after we’ve seen things lots of times. APN clinicians look for the odd thing out.”

Emergency paediatric nurse Jo Magyar has been at the Royal Children’s Hospital (RCH) in Melbourne for 11 years. “As an RN in triage I would like to think I had diagnostic skills but it’s not until you make the transition how much more you consider and look for. You are always looking for the red herring.”

“As an APN you take on board more detail and start to think further about what’s wrong with this patient. What else am I missing?”

Jo completed a postgraduate certificate in paediatric nursing ER stream and became a CN Specialist five years ago. She is currently an NP candidate.

“Prior to my candidacy I took on the role of education as the Clinical Support Nurse on the floor for four years. I had my first baby, when I came back to the department I definitely wanted to contribute more and went into education.”

The Clinical Support Nurse, as opposed to an educator within the ED, is designed to be a more clinical role working side by side with staff on the floor and also involves in-service training.

Jo’s APN repertoire also involves research. She has had three papers published, two on debriefing clinical incidents in the ED in 2009. “A colleague and I felt there wasn’t formal support for staff after a large resus, so we sought out funding to explore that.”

Since then there have been several developments in the RCH ED. “It has raised awareness and become an important part of our practice with links to a program we now use in debriefing in the ED – it has become engrained.”

A further paper on psychosocial care for seriously injured children and their families was published in 2014.
Jo says her time in nursing as an APN has been the most enjoyable and largest learning curve of her career.

“Even in post-grad and under-grad study, it’s very hard to see where it fits in until you come across it even years down the track. It’s that ‘you don’t quite know what you don’t know yet’. I think in advanced practice you develop more honed advanced critical thinking skills and diagnostic profiling.

“And I think that’s the point of difference –we do the same sort of things as other clinicians. But what led me to being an APN and becoming an NP is still what drives me as a nurse – a sense of helping and resolving issues for families and patients. The clinical management of the patient and building strong rapport with families and it’s the little details that matter. The work we are doing, I get a lot of satisfaction.

“Those in APN roles tend to stay in those roles, you get that continuity – we are a consistent force – which is of great benefit. The sky’s the limit.”

You need to be Sherlock Holmes
Kara Graser


“Your solutions often have to be creative. You have to be able to negotiate and your management needs to be effective. And you need to have a sixth sense about clinical scenarios.” Says Kara Graser.

Kara is an APN at residential aged care provider BaptistCare in WA which has 14 facilities both metro and remote. She works with older adults in the management of chronic disease and palliative care symptoms across several facilities.

“I deal with people with cognitive impairment, the elderly, dementia and psychological problems of the over 65s. I might care for cancer patients who also suffer multiple other medical symptoms.”

People over 65 experience so many chonicities and co-morbidities and pharmacies and it is about finding out where the problems are. I get referrals to help RNs work out what’s going on.”

“ I had a person with what the staff believed were overt cognitive dementia symptoms, but none of the cognitive tests supported that diagnosis. What was going on? We eventually found out he has a brain tumor – the tumor was contributing to his unusual behaviours. It wasn’t dementia; the symptoms related to where the mass was situated.”

The acuity in RAC is higher now with multiple chronic co-morbidities much more complex than they used to be, says Kara with 27 years nursing experience including in coronary care, medical and rehabilitation.

A key role of the AP is to help by, for example, coordinating the entire multidisciplinary (MD) team so that the right people are in play, says Kara. “I provide comprehensive assessment and coordinate others. This is part of my nursing expertise.

“I might need to get everyone together and I might keep a watching brief – so for the case above, the team included the GP, oncology, palliative care, speech therapy, neurology – that they are all in place; and make sure communication between the boundaries flow nicely for everyone and for better end of life care for the patient.

“What’s important is networking across service sectors – that’s the difference. Networking is about knowing where to go to get the right sort of skills for the patient.

“Sometimes you’ve thought of 20 variables and it’s the 21st that gets you – that’s why you need a MD team to work things through. This is the value of working with rather than working on your own.”

Working as an APN is being in a state of constant learning, says Kara. “You need to understand your scope of practice. Being able to say ‘this is not my area of expertise’ is really important but also to be able to stand firm and equally say ‘this is my area of nursing expertise and I recommend this’ and be heard.”

Author: Natalie Dragon
Republished with permission of the Australian Nursing & Midwifery Federation 

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