The Role of the Clinical Nurse Specialist in Cancer Care E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The Role of the Clinical Nurse Specialist in Cancer Care Gain a fresh and insightful perspective on the evolving role of the Clinical Nurse Specialist in the delivery of cancer services. The Role of the Clinical Nurse Specialist in Cancer Care explores the dynamic and essential world of the Clinical Nurse Specialist (CNS) in cancer care, covering both foundational and advanced topics and rooted in robust research and evidence-based practice. * Trace the historical development of the CNS role while gaining invaluable patient and carer perspectives that provide essential guidance for professionals in this field * Examine key aspects such as symptom management and non-medical prescribing, gaining a deeper understanding of the multifaceted responsibilities of Clinical Nurse Specialists * Find vital subjects like leadership and multidisciplinary teamwork supplemented with practical tools to excel in your role * Explore comprehensive coverage of specialised areas within clinical nursing, including the unique challenges of caring for young adults with cancer, navigating the complexities of COVID-19, and utilising digital tools for enhanced patient care Whether you are a registered nurse aspiring to become a clinical nurse specialist or an established CNS seeking professional growth, The Role of the Clinical Nurse Specialist in Cancer Care provides invaluable insights and development opportunities. This engaging resource is also an excellent companion for advanced practitioners specialising in cancer care, ensuring they stay up-to-date with the latest advancements in this vital field.
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Veröffentlichungsjahr: 2023
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Dedication Page
List of Contributors
Foreword
Introduction
References
About the Companion Website
1 Evolvement of Advanced Nursing Practice
1.1 Introduction
1.2 Evolvement of Nursing as a Profession
1.3 Advanced Nursing Practice
1.4 Conclusion
References
2 Emergence and Evolvement of the Clinical Nurse Specialist Role in Cancer Care
2.1 Introduction
2.2 Advanced Nursing Practice
2.3 Historical Context
2.4 Specialists vs. Generalists
2.5 Definition of a CNS
2.6 Components of the Clinical Nurse Specialist Role
2.7 Professional Standards
2.8 Education Requirements
2.9 Outcomes of the Clinical Nurse Specialist Role
2.10 Specialist Practice in Cancer Care
2.11 Future Direction of the CNS
2.12 Conclusion
References
3 Patient Perspective
References
4 Carer's Perspective
5 Key Worker Role
5.1 Introduction
5.2 The Key Worker
5.3 Key Worker/Clinical Nurse Specialist Impact on Direct and Indirect Patient Care
5.4 Challenges in Practice
5.5 ‘First Impressions Count’
5.6 Example of Change in Practice
5.7 Conclusion
References
6 Psychological Support
6.1 Introduction
6.2 Part One: The Impact of a Cancer Diagnosis
6.3 Part Two: Self‐Care and the Clinical Nurse Specialist
6.4 Conclusion
References
7 Integrating Research and Evidence‐Based Practice
7.1 Introduction
7.2 Evidence‐Based Practice
7.3 Barriers to the Implementation of Evidence‐Based Practice in the Clinical Setting
7.4 Role of Evidence‐Based Practice in Caring for Patients with Cancer and Their Carers
7.5 Providing Evidence‐Based Care as a Clinical Nurse Specialist
7.6 Clinical Application of Evidence‐Based Practice by Clinical Nurse Specialists
7.7 Cancer Research and Clinical Trials
7.8 Cancer Clinical Trials, Research Nurses and the Role of the Clinical Nurse Specialist
7.9 The Role of the Clinical Nurse Specialist Along the Cancer Clinical Trial Patient Pathway
7.10 Conclusion
References
8 Symptom Management
8.1 Introduction
8.6 Conclusion
References
9 Multidisciplinary Teamworking
9.1 Introduction
9.4 Conclusion
References
10 Leadership and the Clinical Nurse Specialist
10.1 Introduction
10.2 Leadership
10.3 Self‐Recognition of the Clinical Nurse Specialist as a Leader
10.4 Leadership in the Context of the Clinical Nurse Specialist
10.5 Conclusion
References
11 Nurse‐Led Clinics
11.1 Introduction
11.2 Nurse‐Led Care and the Launch of Nurse‐Led Clinics in Healthcare
11.3 Components of a Nurse‐Led Clinic
11.4 Introducing a Nurse‐Led Clinic
11.5 Nursing Skills Required to Introduce and Establish a Nurse‐Led Clinic
11.6 Approaches to Delivering a Nurse‐Led Clinic
11.7 Patient Outcomes Related to Nurse‐Led Clinics
11.8 Benefits of Nurse‐Led Clinics for the Registered Nurse
11.9 Benefits of Nurse‐Led Clinics for the Healthcare Organisation
11.10 Challenges to Implementing Nurse‐Led Clinics
11.11 Nurse‐Led Clinic Service Evaluation
11.12 Future of Nurse‐Led Clinics
11.13 Reflection on the Role as a Uro‐Oncology CNS Undertaking Nurse‐Led Clinics
11.14 Conclusion
References
12 Non‐Medical Prescribing
12.1 Introduction
12.2 Background
12.3 Developments in Nursing Practice and the Role of Prescribing
12.4 Preparing to Prescribe
12.5 Benefits and Challenges of Non‐Medical Prescribing
12.6 Deciding to Become a Non‐Medical Prescriber
12.7 Conclusion
References
13 Cancer in the Adolescent and Young Adult
13.1 Introduction
13.2 Background to Adolescent and Young Adult Cancer Services
13.3 Person‐Centred Adolescent and Young Adult Care
13.4 Support for Family and Significant Others
13.5 Holistic Care
13.6 Multidisciplinary Working
13.7 Healthcare Professional Knowledge
13.8 Adolescent and Young Adult Clinical Nurse Specialist Leadership Skills
13.9 Communication with Adolescents and Young Adults
13.10 Age‐Appropriate Environments
13.11 Adolescent and Young Adult Peer Support
13.12 Adolescent and Young Adult Treatment Priorities
13.13 Transitional Adolescent and Young Adult Care
13.14 Living With and Beyond Cancer
13.15 Late Effects of Cancer Treatment
13.16 Palliative Adolescent and Young Adult Care
13.17 Co‐production
13.18 Conclusion
References
14 COVID‐19 and the Clinical Nurse Specialist
14.1 Introduction
14.8 Conclusion
References
15 Digital Health
15.1 Introduction
15.2 The Role of the Informatics Nurse/Chief Nursing Information Officer
15.3 Electronic Observations
15.4 Electronic Health Records
15.5 Digitalisation of Blood Glucose Monitoring
15.6 Electronic Nurse Prescribing
15.7 Nurse Digitally Requesting Bloods
15.8 Remote Consultations
15.9 Virtual Wards
15.10 Electronic Patient‐Reported Outcome Measures
15.11 Mobile Cancer Applications
15.12 Home Blood Monitoring
15.13 Artificial Intelligence
15.14 Barriers to Digital Health
15.15 Conclusion
References
16 Future Direction of the Clinical Nurse Specialist in Cancer Care
16.1 Introduction
16.2 The Role of Caring and the Clinical Nurse Specialist
16.3 Developing Skills for Today and the Future
16.4 Leadership
16.5 Equality, Diversity and Inclusion in the Role of the Clinical Nurse Specialist
16.6 New Ways of Working
16.7 Self‐Reflection
16.8 Conclusion
References
Index
End User License Agreement
List of Tables
Chapter 6
Table 6.1 Categories of psychological support.
Table 6.2 SPIKES framework.
Chapter 12
Table 12.1 The clinical management plan.
Table 12.2 Prescribing in practice.
Table 12.3 Principles of professional nursing.
Chapter 16
Table 16.1 Compassion in healthcare.
Table 16.2 Clinical and humanity based skills.
Table 16.3 Quality and skills for leadership.
Table 16.4 Equity, diversity and inclusion.
Table 16.5 The role of the clinical nurse specialist in a changing world....
List of Illustrations
Chapter 7
Figure 7.1 The patient clinical trial pathway and potential CNS role interfa...
Guide
Cover Page
Title Page
Copyright Page
Dedication Page
List of Contributors
Foreword
Introduction
About the Companion Website
Table of Contents
Begin Reading
Index
Wiley End User License Agreement
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The Role of the Clinical Nurse Specialist in Cancer Care
Edited by
Dr Helen Kerr PhD, RN
Queen’s University Belfast
Foreword by
Johan De Munter
President of the European Oncology Nursing Society
This edition first published 2024© 2024 John Wiley & Sons Ltd
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Library of Congress Cataloging‐in‐Publication DataNames: Kerr, Helen, editor.Title: The role of the clinical nurse specialist in cancer care / edited by Helen Kerr.Description: Hoboken, NJ : Wiley‐Blackwell, 2023. | Includes bibliographical references and index.Identifiers: LCCN 2023023154 (print) | LCCN 2023023155 (ebook) | ISBN 9781119866992 (paperback) | ISBN 9781119867005 (adobe pdf) | ISBN 9781119867012 (epub)Subjects: MESH: Neoplasms–nursing | Nurse Clinicians | Nurse’s RoleClassification: LCC RC266 (print) | LCC RC266 (ebook) | NLM WY 156 | DDC 616.99/40231–dc23/eng/20230626LC record available at https://lccn.loc.gov/2023023154LC ebook record available at https://lccn.loc.gov/2023023155
Cover Design: WileyCover Image: © Israel Sebastian/Getty Images
To my mother, Meta Bell, whose career as a Marie Curie nurse inspired me and many others to compassionately care for others.
To my partner, Sharon Kerr, who believes in me.
Helen Kerr
List of Contributors
Karen Armstrong, BSc (Hons), PGDip, RNNorthern Ireland Cancer CentreBelfast, Northern IrelandUnited Kingdom
Edel Aughey, MSc, BSc, PGCE, RNBelfast City Hospital and School of Nursing and MidwiferyQueen's University BelfastBelfast, Northern IrelandUnited Kingdom
Ruth Boyd, MSc, BN, RGN, DNNorthern Ireland Cancer Trials NetworkBelfast Health and Social Care TrustBelfast, Northern IrelandUnited Kingdom
Laura Croan, MSc, RNHaematologyBelfast Health and Social Care TrustBelfast, Northern IrelandUnited Kingdom
Monica Donovan, MSc, RNSchool of Nursing and MidwiferyQueen's University BelfastBelfast, Northern IrelandUnited Kingdom
Sarah Hanbridge, RN, RNT, FNF Digital Scholar, MA, PCGE, BA (Hons) Dip NursingDigital Informatics TeamLeeds Teaching HospitalYorkshire, EnglandUnited Kingdom
Michelle Keenan, MSc, BSc, RNBelfast Health and Social Care TrustBelfast, Northern IrelandUnited Kingdom
Helen Kerr, PhD, RN, Dip CounsellingSchool of Nursing and MidwiferyQueen's UniversityBelfast, Northern IrelandUnited Kingdom
Caroline McCaughey, MSc, PGCE, RNSchool of Nursing and MidwiferyQueen's University Belfast and Oncology/HaematologyBelfast City HospitalLisburn RoadBelfast, Northern IrelandUnited Kingdom
Johanna McMullan, RN, MSc, MEdSchool of Nursing and Midwifery Queen’s UniversityBelfast, Northern IrelandUnited Kingdom
Oonagh McSorley, PhD, RNSchool of Nursing and MidwiferyQueen's University BelfastBelfast, Northern IrelandUnited Kingdom
Clare McVeigh, PhD, RNSchool of Nursing and MidwiferyQueen's University BelfastBelfast, Northern IrelandUnited Kingdom
Shelley Mooney, MSc, RNBelfast Health and Social Care TrustBelfast, Northern IrelandUnited Kingdom
Adrina O'Donnell, MSc, BSc (Hons) RN, DipNNorthern Ireland Cancer CentreBelfast Health and Social Care TrustBelfast, Northern IrelandUnited Kingdom
Hinal Patel, MSc, RNUniversity College LondonHospitals NHS Foundation TrustLondon, EnglandUnited Kingdom
Barry Quinn, PhD, RNSchool of Nursing and MidwiferyQueen’s University BelfastBelfast, Northern IrelandUnited Kingdom
Susan Smyth, MSc, RNMacmillan UnitUlster HospitalUpper Newtownards RoadBelfast, Northern IrelandUnited Kingdom
Kerrie SweeneyCancer ServicesAntrim Area HospitalNorthern Health and Social Care TrustNorthern IrelandUnited Kingdom
Ruth Thompson, MSc, RNNursing Policy and PracticeRoyal College of NursingBelfast, Northern IrelandUnited Kingdom
Stephanie Todd, BSc(Hons) Postgrad Dip, RNBelfast Health and Social Care TrustBelfast, Northern IrelandUnited Kingdom
Amy Vercell, MSc, RNDigital ServicesThe Christie NHS Foundation TrustManchester, EnglandUnited Kingdom
Trevor WightmanNorthern IrelandUnited Kingdom
Foreword
Today, it is recognised that the burden of cancer in the population lies across the whole lifespan and that innovation in cancer care is crucial to tackling the cancer burden across the globe. Apart from the imperative of ensuring that every person with cancer has the best possible chance to receive treatment and survive cancer, the potential for the best outcome demands an interprofessional collaboration among all stakeholders in cancer care. Cancer nurses are key healthcare providers who contribute to innovative, qualitative and safe cancer care, from prevention to survivorship and end‐of‐life care. As forefront healthcare providers, they have a great responsibility and, at the same time, a great opportunity to contribute to the success of the provided care. However, developments in healthcare are not remaining constant, as great leaps continue to be taken to meet the current needs of those who need care.
To meet this modern standard of care, the development and implementation of lead roles such as clinical nurse specialists (CNS) are crucial in supporting person‐centred care and health outcomes. CNS are advanced practice nurses who have completed advanced education programmes and clinical training in a specific area of healthcare. In the field of cancer care, the CNS plays a vital role in improving patient outcomes and providing high‐quality care. A CNS works closely with patients, families and other healthcare professionals to coordinate and deliver cancer care that is tailored to the unique holistic needs of each individual. They are skilled in conducting comprehensive assessments, developing care plans, and providing education and support to patients and families.
The CNS also has a strong understanding of the various innovative cancer treatment modalities, including chemotherapy, radiation therapy, immunotherapy, hormonal therapies and surgery and is able to provide expert guidance and support to patients undergoing these treatments. They often care for patients throughout all stages of cancer, from diagnosis and treatment to post‐treatment follow‐up and survivorship.
In addition to their direct patient care responsibilities, CNS also serve as leaders within the healthcare community. They may act as consultants to other healthcare professionals, providing expert advice and guidance on cancer care and treatment. CNS may also serve as educators, teaching other healthcare professionals about the latest research and best practices in cancer care. Next to education is research, an important aspect of the work of a CNS in cancer care. The CNS may conduct research studies or participate in clinical trials to advance the field of cancer care and improve patient outcomes. They may also work to identify and address care gaps, developing innovative treatments, care and support approaches.
As advocates for patients, CNS work to ensure that individuals with cancer and their families and carers receive the best possible care and support. They may also advocate for policies and practices that promote cancer prevention and early detection, contributing to reducing the burden of cancer on individuals and society as a whole. Overall, the work of a CNS in cancer care is multifaceted and vital in improving the lives of patients and their families affected by cancer.
For those interested in pursuing a career as a CNS in cancer care, it is important to have a strong foundation in nursing and a passion for cancer care. CNS must also be willing to continue learning and staying up‐to‐date on the latest research and best practices in cancer care.
If you are a CNS, a nurse seeking to specialise in cancer care, or simply interested in learning more about this important area of cancer nursing, this book is an invaluable resource. It provides a comprehensive look at the work of CNS in cancer care and their vital role in improving patient outcomes and advancing the field. As a cancer nurse whose own ventures into cancer care were encouraged and supported by talented and inspirational national and international nursing colleagues, I warmly welcome this book. Finally, to all readers, I want to thank you for recognising the important role of the CNS. When going through this book, you will notice that many chapters are written by clinical nurse specialists for clinical nurse specialists. As a result of this comprehensive collaboration, the book provides important, reflective depth with an honest and current perspective of the CNS role. We hope that you will enjoy reading this book and that it will inspire you to embrace the full potential of the CNS role in cancer care.
Johan De Munter
Cancer Nurse Manager
Cancer Center, University Hospital Ghent, Belgium
President, European Oncology Nursing Society
Introduction
Helen Kerr
From nursing's inception as a profession, there has been a continual evaluation of the profession in response to changing health and societal needs (International Council of Nursing 2020). One aspect of this relates to the growing global interest in extending nursing practice beyond the level of initial registration (East et al. 2015) in response to changing demographics (Holloway et al. 2009), greater user involvement and rising expectations (Por 2008). One component of advanced nursing practice is advanced nursing roles, with up to 52 different roles in 26 countries reported in one study (Heale and Buckley 2015). The clinical nurse specialist (CNS) is one advanced nursing role.
The CNS's role within cancer services significantly contributes to providing high‐quality care delivery. In cancer care, the role is reported to contribute to improvements in psychological outcomes for patients; increased patient satisfaction; improvements in patient knowledge; enhanced clinical outcomes, particularly in relation to symptom management; and enhanced service delivery outcomes, such as increased access to services (Kerr et al. 2021). Understanding and appreciating the specific components of the role has been outlined by various authors and includes broad categories of direct patient care and other aspects such as administration, research, education and leadership. This book further delineates the various components of the CNS role to provide clear insights into the contribution of this role in improving patient outcomes and supporting the development of these aspects within current roles.
This book is in four sections. The first section has two chapters that relate to the emergence and evolvement of advanced nursing practice with a focus on one specific component: advanced nursing roles. Chapter 1 focuses on the historical context of advancing nursing practice and advanced practice nurse roles. Chapter 2 outlines the historical and current context of the CNS role, providing a background for the book.
Section two has two chapters that provide a patient and carer perspective of the CNS role. Chapter 3 is written by Johanna, who shares her experiences of being diagnosed with breast cancer and reflects on the CNS's role in her care. Chapter 4 is written by Trevor, a carer of an individual who had cancer; he shares his experience of being a carer and the impact the CNS had in their care.
The third section has nine chapters, and each is co‐authored by a CNS along with an academic with a clinical background in cancer services. Each chapter focuses on a different component of the CNS role. Chapter 5 provides an overview of the operationalisation of the key worker role and a discussion of how challenges associated with this role could be effectively managed. Chapter 6 focuses on the skills required by the CNS in providing psychological support to individuals with a cancer diagnosis and their carers. There is also a discussion of the importance of self‐care for nurses working in cancer services. Chapter 7 focuses on how research and evidence‐based practice must be integrated into the CNS role, discussing the importance of cancer clinical trials. Chapter 8 focuses on symptom management. There is an outline of the presentation, assessment and management of gastro‐intestinal symptoms associated with a diagnosis of cancer and treatment interventions, along with a focus on pain assessment and management. Chapter 9 focuses on the CNS's important contribution to the multi‐disciplinary team and how to integrate this role within an established interdisciplinary team. Chapter 10 provides a clinical approach to developing the leadership aspect of the CNS role in managing patient care to optimise services. Chapter 11 focuses on the steps involved in introducing and establishing nurse‐led clinics in cancer services. Chapter 12 outlines the historical context of the non‐medical prescribing role and the contribution this role has for the CNS in enhancing patient care. Chapter 13 focuses specifically on the role of the CNS for adolescents and young adults with cancer, identifying the skills required to provide care for these individuals and their families and carers.
Section four considers the future direction of the CNS role and has three chapters. Chapter 14 explores the impact the COVID‐19 global pandemic had on the role of the CNS in cancer services, including a discussion on the introduction and evolvement of approaches adopted for patient safety. There is an exploration of how the CNS can contribute to reviewing the sustainability of some of these approaches. This is followed by Chapter 15, which provides an overview of the historical evolvement of digital health and how the CNS can contribute to addressing the challenges of moving aspects of care delivery to a virtual environment, particularly in the context of the COVID‐19 global pandemic. Chapter 16, the final chapter, examines the future direction and possible trends in practice and care delivery for CNS working in cancer services. There is an emphasis on the continuing central role of delivering person‐centred care within this specialist role.
The book should be of interest to nurses considering the CNS role as part of their career trajectory, as it delineates some of the various components of the role. The book will also be of interest to those currently in CNS roles, as it identifies aspects of the role that could be developed, such as nurse‐led clinics and non‐medical prescribing. Finally, those who work alongside CNS or are in strategic leadership roles will appreciate the significant contribution the CNS role makes to improving patient outcomes and delivering healthcare in the cancer context.
Twenty‐two authors contributed to this book, providing their perspectives on the significant and valuable contribution the CNS role makes to enhancing patient care. We invite you to explore, reflect on and enjoy engaging with this book and consider how you and others can develop the CNS role so as to improve outcomes for individuals with cancer and their families and carers.
References
East, L., Knowles, K., Pettman, M., and Fisher, L. (2015). Advanced level nursing in England: organisation challenges and opportunities.
Journal of Nursing Management
23: 1011–1019.
Heale, R. and Buckley, C. (2015). An international perspective of advanced practice nursing regulation.
International Nursing Review
62: 421–429.
Holloway, K., Baker, J., and Lumby, J. (2009). Specialist nursing framework for New Zealand: a missing link in workforce planning.
Policy Politics and Nursing Practice
10 (4): 269–275.
International Council of Nurses (ICN) (2020).
Guidelines on Advanced Practice Nursing
. Geneva: ICN.
Kerr, H., Donovan, M., and McSorley, O. (2021). Evaluation of the role of the clinical Nurse Specialist in cancer care: an integrative literature review.
European Journal of Cancer Care
30 (3): 1–13.
Por, J. (2008). A critical engagement with the concept of advanced nursing practice.
Journal of Nursing Management
16: 84–90.
About the Companion Website
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1Evolvement of Advanced Nursing Practice
Helen Kerr
Abstract
This chapter will focus on the emergence and evolvement of advanced nursing practice. The historical context of the inauguration of nursing as a profession and the subsequent regulation of nursing will be outlined. The rationale for the development of advanced nursing practice will be explored, leading to a focus on one component of this concept: advanced practice nurse roles. The nomenclature associated with advanced practice nurse roles will be outlined, leading to an introduction to the emergence of the specialist nursing workforce, specifically the clinical nurse specialist, which will be the focus of Chapter 2.
1.1 Introduction
This chapter will focus on the emergence and evolvement of advanced nursing practice. The historical context of the inauguration of nursing as a profession and the subsequent regulation of nursing will be outlined. The rationale for the development of advanced nursing practice will be explored, leading to a focus on one component of this concept: advanced practice nurse (APN) roles. The nomenclature associated with APN roles will be outlined, leading to an introduction to the emergence of the specialist nursing workforce, the focus of Chapter 2.
1.2 Evolvement of Nursing as a Profession
It is well‐recognised that modern nursing, as it is currently delivered, is accredited to the influence of Florence Nightingale (World Health Organization [WHO] 2020), who introduced the idea that nursing was a profession that required education (Wilson 2005). Glasper and Carpenter (2019) report that prior to these influences, nurses were considered incompetent. In the 1850s, when Florence Nightingale was in her 30s, she was internationally renowned for her services in Turkey as part of the British Army's employment of female nurses during the Crimean War (National Council of State Boards of Nursing 2020). Florence Nightingale subsequently developed a Nightingale Training School on the grounds of St Thomas's Hospital, London, United Kingdom (UK), in the 1860s. Despite reports that medicine was unsupportive of Nightingale's attempts to introduce formal education and training for nursing, training schools were developed across England (Glasper and Carpenter 2019).
In the late nineteenth and early twentieth centuries, Ethel Bedford Fenwick lobbied for a nursing register and, in December 1921, became the first nurse to register with the newly formed General Nursing Council (GNC) (Glasper and Carpenter 2019). In 1943, the responsibilities of the GNC were extended by a Nurses Act to include assistant nurses, renamed state enrolled nurses by the Nurses (Amendment) Act in 1961 (Glasper and Carpenter 2019). The Nurses, Midwives and Health Visitors Act was passed in 1979, effective from 1983, and replaced the GNC with the United Kingdom Central Council (UKCC) and four national boards for nursing, midwifery, and health visitors in each of the four countries of the UK: England, Northern Ireland, Scotland and Wales.
Project 2000 was introduced in the late 1980s and moved nurse education and training into higher education. In 2001, under the Nursing and Midwifery Order, the Nursing and Midwifery Council (NMC) was established in the context of the UK. In many countries across the globe, a similar trajectory regarding the professionalisation and regulation of nursing emerged, albeit on a different timeline, with most countries around the world now regulating and governing nursing practice through regulatory bodies (National Council of State Boards of Nursing 2020). The WHO (2020) reported that 86% of countries now have a body responsible for the regulation of nursing, and most countries also have a statute of law that regulates nurses (National Council of State Boards of Nursing 2020).
Nursing has evolved to become the largest staff group in healthcare globally, accounting for approximately 59% of the workforce and a reported 27.9 million nurses worldwide, of which 19.3 million are categorised as professional nurses (WHO 2020). Nursing does not have a set of international standards, which means nurses are educated, regulated and disciplined in a variety of ways across the globe (Stievano et al. 2019). Despite these geographical variations, a series of recommendations for nursing for all countries was published by the WHO in 2020. These relate to increasing funding to educate and employ nurses, establishing leadership positions, equipping nurses in primary healthcare to work to their full potential including prevention and management of noncommunicable disease, implementing gender‐sensitive workforce policies and modernising nursing regulation by harmonising education and practice standards (WHO 2020). The WHO recommendations demonstrate the continuing development of the nursing profession at a time when the regulation of nursing marked a centenary in the UK in December 2021.
1.3 Advanced Nursing Practice
From nursing's inception as a profession, the profession has been continually evaluated in response to health, societal and person‐centred care challenges (International Council of Nurses (ICN) 2020). One aspect of the evaluation is the growing global interest in extending nursing practice beyond the level of initial registration (East et al. 2015). The need to extend nursing practice is attributed to multiple rationales. There has been an increasing demand for healthcare due to changing demographics and new government strategies (Holloway et al. 2009). Nursing has also evolved in response to greater user involvement and rising expectations, with service users requiring greater choice (Por 2008). There has also been a suggestion that nurses advancing their practice was due to changes in the field of medicine, such as shortages in physicians (Por 2008); however, this is refuted by Hamric and Tracy (2019), who state that advanced nursing practice is not a substitute for medical practice. Although the origins of advanced nursing practice date back about a century (Hamric and Tracy 2019), advanced practice nursing has only existed in the United States of America (USA) since the 1960s and the UK since the 1980s (Callaghan 2008). This supports Barton's (2012) assertion that the evolution of advancing nursing practice has been protracted.
There is contention about the accepted terminology for nurses developing their practice beyond the level of registration. In general, the literature reports two similar terms: advanced practice nursing and advanced nursing practice. Although these terms are used interchangeably in the literature, Hamric and Tracy (2019) argue that they are different, so it is important to explore the differences.
Although Jamieson (2002) stated that there is no singular definition for advanced practice nursing, there have been recent attempts to clarify this concept. The ICN (2020, p. 6) states that advanced practice nursing ‘is viewed as advanced nursing interventions that influence clinical healthcare outcomes for individuals, families, and diverse populations’. This highlights a definition with a narrower emphasis on nursing interventions rather than a broader focus on expanded practice. In contrast, Sheer and Wong (2008) argue that advanced practice nursing is an umbrella term for nurses practising at a higher level. ‘Advanced practice nursing is the patient‐focused application of an expanded range of competencies to improve health outcomes for patients and populations in a specialised clinical area of the larger discipline of nursing’ (Hamric and Tracy 2019, p. 213).
The second term, advanced nursing practice, appears to be used more frequently in the literature with a definition similar to that of advanced practice nursing previously outlined by Hamric and Tracy (2019). Advanced nursing practice is ‘an umbrella term describing an advanced level of clinical nursing practice that maximises the use of graduate educational preparation, in‐depth nursing knowledge and expertise in meeting the health needs of individuals, families, groups, communities and populations. It involves analysing and synthesising knowledge, understanding, interpreting, and applying nursing theory and research; and developing and advancing nursing knowledge and the profession as a whole’ (Canadian Nurses Association 2010, p. 14). Por (2008) states that advancing nursing practice is an ‘ongoing process in nursing practice using expanded knowledge, clinical expertise and research to further the scope of nursing practice’ (p. 84). The Registered Nurses Association of British Columbia Policy Statement (2001, cited in ICN 2020, p. 6) provides a similar definition, stating that ‘advanced nursing practice is a field of nursing that extends and expands the boundaries of nursing's scope of practice, contributes to nursing knowledge and promotes advancement of the profession’. The American Association of Colleges of Nursing (2004, p. 3, cited in Hamric and Tracy 2019) provide an alternative definition for advanced nursing practice as ‘any form of nursing intervention that influences healthcare outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and healthcare organisations and the development and implementation of health policy’. These terms appear to be used interchangeably, so the confusion and debates continue. This book will use the term advanced nursing practice and borrow the definition published by the ICN in 2020, outlined in the previous paragraph.
A further area of confusion regarding this concept relates to the criteria associated with advanced nursing practice. Understanding how advanced nursing practice differs from a registered nurse at the point of initial registration regarding the broad skills, attributes and competencies will help to demystify advanced nursing practice. A simple distinction made by Calkin (1984) between basic or advanced practitioners relates to the latter associated with expertise being gained through education and experience. However, there is no universal understanding of the attributes or competencies associated with advanced nursing practice.
1.3.1 Criteria Associated with Advanced Nursing Practice
In attempting to delineate the criteria related to advanced nursing practice, which may include identifying the level of skills, attributes and competencies, it is important to recognise the geographical variations that have an impact, such as policy development, regulation and healthcare demands, as the evolution of advanced practice nursing has differed in each nation (Sheer and Wong 2008). Two decades ago, Castledine (2001) suggested the introduction of levels of nursing, with level one commencing at registration, recognising the anticipated development of expertise as nurses develop through experience and education. A starting point to understanding the criteria associated with advanced nursing practice is the recognition that advanced nursing practice involves advanced nursing knowledge and skills (Hamric and Tracy 2019). This identifies the higher platform of expertise in both knowledge and skills related to advanced nursing practice. Dowling et al. (2013) identify what they describe as four attributes related to advanced nursing practice, which include clinical expertise, leadership, autonomy and role development. These overarching components identify the areas in which advanced knowledge and skills should be demonstrated.
Hamric and Tracy (2019) state that there is a growing consensus on the core competencies related to advanced practice nursing (these authors use this terminology rather than advanced nursing practice). This work significantly contributes to understanding the competencies related to advanced nursing practice by identifying seven core competencies. The first competency is central and relates to providing direct clinical practice. The additional six competencies are guidance and coaching, consultation, evidence‐based practice, leadership, collaboration and ethical decision‐making. An enhanced level of knowledge, skill, and expertise should be exercised within the seven competencies when practising at an advanced level. Although there have been attempts to provide transparency, practices related to advanced nursing are often invisible (Por 2008), providing a strong argument for the need for further clarification.
There have been attempts to clarify advanced nursing practice in different geographical locations from a policy and strategic perspective. In the context of Northern Ireland, an Advanced Nursing Practice Framework Department of Health, Social Services and Public Safety (2016) identifies four core competencies and also four components associated with advanced nursing practice. The four competencies are direct clinical practice, leadership and collaborative practice, education and learning, and research and evidence‐based practice. The first of the four components relates to clinical practice and the scope of the role. This includes an ability to work autonomously, undertaking comprehensive health assessments; an ability to diagnosis, prescribing care and treatment; providing complex care; acting as an educator, leader and innovator; and contributing to research. The second component is a supervision requirement relevant to the area of practice. The third component is service improvement and an ability to influence policy development and lead service improvement initiatives. The final component relates to an education requirement: a masters‐level qualification and completion of the Nursing and Midwifery recordable Non‐Medical Prescribing V300 qualification.
Although these competencies and components are a very useful attempt at delineating advanced nursing practice, the specific level at which the nurse should demonstrate the four components is unclear. The identification of a specific level in this continuum in each of the components outlined by the Department of Health, Social Services and Public Safety (2016) would provide some further guidance on a flexible threshold for advanced nursing practice. Jamieson (2002) states that advanced practice could be considered part of a continuum with the development of expertise. This aligns with Benner's seminal work on the development of a taxonomy, first published in 1982 which is a model related to the stages of clinical competence. Five levels are identified, from level one, novice, to advanced beginner, competent, proficient and finally level five, expert (Benner 1984). This also supports Calkin's (1984) philosophy that nurses become experts through experience.
Despite the progression in achieving a level of clarity on the terminology of advanced nursing practice and the associated attributes and competencies, it continues to be poorly articulated (MacDonald et al. 2006), and conceptual confusion remains (Arslanian‐Engoren 2019). Hamric and Tracy (2019) argue that full clarity on advanced practice nursing is yet to be achieved. Advanced nursing practice is a broad concept that captures nurses extending their practice through an expanded range of attributes and competencies with an advanced level of skills and knowledge. Advanced‐level nursing is generic in that it applies to all clinical nurses working at an advanced level regardless of area of practice, setting or client group. It describes a level of practice, not a specialty or role that should be evident as being beyond that of first‐level registration (Department of Health 2010; Hamric and Tracy 2019). In practice, this means nurses can demonstrate advanced nursing practice but not be in an APN role. The APN role will be explored in the next part of this chapter.
1.3.2 Advanced Practice Nurse Roles
Reviewing roles and responsibilities has provided opportunities for the nursing profession to create new roles (Por 2008) and improve efficiency in healthcare delivery (Delamaire and Lafortune 2010). ‘An Advanced Practice Nurse (APN) is one who has acquired, through additional education, the expert knowledge base, complex decision‐making skills and clinical competencies for expanded nursing practice, the characteristics of which are shaped by the context in which they are credentialed to practice’ (ICN 2008, cited in ICN 2020, p. 9).
Similar to the rationale for the development of advanced nursing practice as a concept, the rationale for the development of advanced practice nursing roles includes changes in the developing health needs of society, advances in healthcare systems, government policy, workforce supply and advances in nurse education (Canada Nurses Association 2010). Chang et al. (2011) suggest that the APN role initially emerged to meet the evolving needs of healthcare. Delamaire and Lafortune (2010) suggest that the rationale includes improving access to care, promoting higher quality of care, improvements in costs and enhancing career prospects. Woo et al. (2017) state that the APN role was introduced as a solution to the lack of primary care physicians and subsequently extended into other healthcare settings.
An estimated 40 countries have now established or are in the process of developing APN roles, with different timelines for the emergence of APN roles globally. These countries include Canada, the USA, Australia, New Zealand, the UK, Switzerland, Japan, Spain and Botswana (Oulton and Cardwell 2016). In the USA, APN roles emerged in the 1940s and are now well‐established (MacDonald et al. 2006). These roles include nurse anaesthetists and nurse midwives. The first APN programme commenced in Australia in 1990 (Sheer and Wong 2008), and the development of advanced practice in the UK was pioneered in 1970s. However, it was 1990 when Barbara Stilwell led the establishment of the first advanced nursing practice course at the Royal College of Nursing Institute (Leary and MacLaine 2019).
Although APN roles have provided opportunities for nurses to develop their practice and improve patient care, there is confusion about the nomenclature related to advanced practice nursing roles (Gardner et al. 2009). Stasa et al. (2014) state that there is a lack of clarity on key terms related to advanced nursing positions, with Jokiniemi et al. (2021) stating ‘the common feature in international literature on advanced practice nursing and its subroles, is ambiguity!’ (p. 422). Internationally, a range of terms are used to describe advanced practice nursing roles, which is argued to have hindered developments in the roles (Dowling et al. 2013). There is an assumption that the term advanced practice nurse is homogenous, but in reality, it covers multiple roles (Ketefian et al. 2001).
Advanced practice nursing is associated with a range of titles (Por 2008). One study identified 13 titles beyond basic registered nurse titles (Pulcini et al. 2010); and an international study identified 52 different advanced practice nursing roles in 26 countries (Heale and Buckley 2015). WHO (2020) reported that 53% of countries that provided data for a report had advanced practice nursing roles, with the number of nurses holding advanced practice nursing positions increasing (Stasa et al. 2014). APNs can be generalists or specialists (Sheer and Wong 2008), as reflected in some of the following advanced practice nursing role titles: clinical nurse specialist, advanced nurse practitioner, nurse practitioner, higher level practitioner, nurse consultant, specialist practitioner, nurse therapist and physician's assistant (Daly and Carnwell 2003). There are four established advanced practice roles in the USA: certified registered nurse anaesthetist, certified nurse midwife, nurse practitioner and clinical nurse specialist (Hamric and Tracy 2019). Dowling et al. (2013) state that the two most common advanced practice roles are the clinical nurse specialist and nurse practitioner.
1.3.3 Regulation
There is wide variation in the regulation of APN roles globally (Heale and Buckley 2015). In the USA, an educational and regulatory framework is administered by the American Association of Nurse Practitioners (Leary and MacLaine 2019). A similar framework exists in Australia (Leary and MacLaine 2019). Guidance has been developed, but as yet there is no regulatory or legal framework for advanced practice in the UK (Leary and MacLaine 2019). As an example, the advanced nurse practitioner role is currently not regulated in the UK by the NMC, but this is currently under review (NMC 2020–2025 ). Although nursing is a regulated profession, advanced practice is not regulated in most countries globally, with the Republic of Ireland being in the minority in regulating advanced practice at a national level (Carney 2016).
1.3.4 Components of Advanced Practice Nurse Roles
Although the role responsibilities and components for each APN role vary, there is also a common identity (MacDonald et al. 2006). One commonality is that most APN roles involve direct patient care. Direct care in APN roles includes assessment, investigations, procedures, and counselling patients and families (Chang et al. 2011). Kleinpell et al. (2014) suggest eight global characteristics of an APN role: the right to diagnose, authority to prescribe medication, authority to prescribe treatment, authority to refer clients to other professionals, authority to admit patients to hospital, legislation to promote the role title, legislation or other forms of regulation mechanism specific to the role and recognition of the APN role. These universal components are a useful template for various countries in developing advanced nurse practice roles regarding education and clinical standards.
1.3.5 Education Requirements
Education is a crucial component in developing knowledge and skills related to APN roles and is often linked to regulation (Heale and Buckley 2015). In an international survey, 42 of 52 APN roles had a minimum level of education requirement; education requirements for each role varied widely (Heale and Buckley 2015) and differed across the globe. Hamric and Tracy (2019) state that all advanced practice registered nurse roles should require at least a master's education, and this is a requirement in many (but not all) countries. In Canada and the USA, each province or state is a separate jurisdiction for the regulation of nursing, resulting in a patchwork of legislations and regulations related to advanced nursing practice (MacDonald et al. 2006). The American Academy of Nurse Practitioners (2019) state that the entry‐level qualification for nurse practitioners is the master's, post‐master's or doctoral level. In the USA and Canada, nursing leaders have proposed a doctor of nursing practice as the entry level for APN roles (Apold 2008). In the UK, the Royal College of Nursing (RCN) state that advanced nurse practitioners should be educated to the masters level (RCN 2018). In summary, there appears to be a consensus that the minimum level of education required for an APN roles is a master's qualification; however, as countries are at different levels of development, this is currently not applied globally.
1.3.6 Outcomes Associated with Advanced Practice Nurse Roles
There are reported benefits associated with APNs in terms of safety, quality and efficiency to patients and services (Leary and MacLaine 2019). Engaging APN roles has the potential to improve access to care, promote higher quality of care and reduce waiting times (Delamaire and Lafortune 2010). Htay and Whitehead (2021) found that advanced nurse practitioners were associated with improved service provision outcomes such as improved patient satisfaction and reductions in waiting times and costs. Nurses in advanced practice in emergency and critical care improved the length of stay, time to consultation/treatment, mortality, patient satisfaction and cost savings (Woo et al. 2017).
A range of studies report on the outcomes associated with individual advanced nurse practice roles, such as an integrative review related to the role of the clinical nurse specialist in cancer care (Kerr et al. 2021). Positive outcomes were reported related to this role, including improvements in psychological support, information provision, symptom management, service coordination and patient satisfaction. However, there are challenges in measuring the outcomes associated with APN roles. This is due to team‐based care being provided and collaborative models of care (Kapu et al. 2017), resulting in challenges in determining if the outcomes are attributed specifically to the APN role. A wide range of outcomes may potentially be impacted by the input of an APN role, and some of these outcome metrics measure patient's length of stay, costs of care, adverse events, patient and family knowledge, staff nurse knowledge, readmission rates and hand hygiene compliance (Kapu et al. 2017). It is the responsibility of organisations to ensure that these outcomes are measured and disseminated, as doing so will enhance public confidence in the investment in advanced nurse practice roles.
1.3.7 Barriers to Advanced Practice Nursing Roles
It is well‐recognised that barriers exist to APNs practising to their full extent (Kleinpell et al. 2014). Heale and Buckley (2015) report on findings from an international survey of 38 countries, with most countries not reporting any barriers. However, for those that did report barriers, they related to physicians and medical organisations, legislative limitations, low nursing representation in policy development and lack of regulation. Delamaire and Lafortune (2010) report on four barriers that can also act as facilitators, which relate to professional interests such as potential opposition by the medical profession regarding the development of advanced nursing practice, the organisation of care and funding mechanisms, the impact of legislation and regulation of health professional activities on the development of new roles and the capacity of the education and training system to provide nurses with higher skills. Barriers to APNs practising to their full potential can have a significant negative impact on health services (Heale and Buckley 2015). Kleinpell et al. (2014) suggest approaches to overcoming barriers that include communicating the value of the role to stakeholders, including patients; media campaigns on the role in patient care; lobbying to change restrictive APN role regulations; demonstrating the outcomes related to the role; and disseminating exemplars of collaborative models of quality and safety improvements.
1.3.8 Recommendations for Advanced Practice Nurse Roles
There have been attempts to develop a universal standard for advanced practice nursing roles; however, doing so is challenging due to the geographical variations that influence these roles, such as policy development, legislation, regulation and healthcare demands. Chang et al. (2011) identify that a contextually appropriate framework for APNs should be the goal of healthcare organisations. Bryant‐Lukosius and DiCenso (2004) provide a useful participatory, evidence‐informed, patient‐centred process for advanced nursing practice role development, implementation and evaluation (the PEPPA framework). This framework aims to overcome barriers to role implementation through knowledge and understanding of the roles and environments and outlines nine steps to assess, prepare, introduce and evaluate advanced nursing practice roles. A universal framework such as PEPPA can be modified to incorporate contextual variations.
1.4 Conclusion
Healthcare demands will continue to rise due to the ageing population and global epidemic of chronic disease. To respond to the changing health needs of the population, the demand for nursing will likely require a range of generic and specialist skills (Holloway et al. 2009). There continues to be support for nurses advancing their practice beyond initial registration (Dowling et al. 2013) and a growing demand for advanced practice nursing roles (Bryant‐Lukosius and DiCenso 2004). This is due to the need for expert nurses working at an advanced level of practice (Kleinpell et al. 2014). APNs can add value, increase access to healthcare and strengthen the workforce (Woo et al. 2017).
The emergence of advanced nursing practice worldwide and the introduction of APN roles such as the clinical nurse specialist and nurse practitioner have resulted in robust discussions attempting to identify the distinguishing characteristics of these new roles and levels of nursing practice (ICN 2020). There is abundant literature on advancing nursing practice, much of which highlights the ongoing confusion regarding the definitions and terminologies used. Despite the plethora of literature, the debate continues on clarifying advancing nursing practice and APN roles. Calkin (1984) stated almost 40 years ago that there was a lack of a simple definition for advanced practice nursing, and only in 2020 did the ICN provided guidelines for advanced practice nursing to unlock this stalemate.
There has been debate on the key issues related to advanced nursing practice, such as minimum education requirements and levels of practice; however, it is recognised that geographical variations must be considered, so a universal template may not be appropriate. The guidelines published by the ICN (2020) provide standards for advanced nursing practice, offering a universal guide for countries to consider. This will take time and involve an investment in the nursing profession with regard to developing nurses to a higher level of skills and knowledge and an advanced level of practice and autonomy. APN roles elevate the level of care provided to patients and can improve patient outcomes. They also provides opportunities for career progression for nurses. One of the valuable APN roles that contributes is the clinical nurse specialist role, which is the focus of Chapter 2.
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