Nurse Education in Practice (2008) 8, 397–404

Nurse

www.elsevier.com/nepr

Educationin Practice

A clinical internship model for the nursepractitioner programme

Geraldine A. Lee a,*, Les Fitzgerald b

a La Trobe University, Alfred Clinical School of Nursing, The Alfred Hospital, Prahran,Melbourne 3004, Australiab School of Nursing and Midwifery, La Trobe University, Bundoora, Melbourne 3086, Australia

Accepted 16 March 2008

14do

39

KEYWORDSClinical internship;Nurse practitioner;Curriculum

71-5953/$ - see front mattei:10.1016/j.nepr.2008.03.00

* Corresponding author. Tel.38.E-mail address: g.lee@latr

r �c 2002

: +61 3 9

obe.edu

Summary Nurse practitioners in Victoria, Australia must be prepared to Masterslevel before seeking nurse practitioner (NP) endorsement. The challenge from a uni-versity curriculum development perspective was to develop a programme that pre-pares the NP theoretically and clinically for their advanced practice role.The aim of this discussion paper is to outline how the internship model was devel-

oped and report the students’ opinions on the model.The NP students complete the internship with a suitably qualified mentor which

requires them to work together to develop and maintain a clinical learning plan,keep a log of the weekly meetings that shows how the objectives have beenachieved. The internship includes advanced clinical assessment, prescribing, diag-nostic and treatment skills and knowledge related to the nurse’s specialty. The clin-ical assessment tool incorporates the National Competency Standards for the NursePractitioner and allows students and mentors to identify the level of practice andset clinical objectives.Students were asked to give feedback on the clinical internship and overall their

comments were favourable, reporting benefits of a clinical mentor in their work andthe clinical case presentations. The clinical internship allows the acquisition ofknowledge and clinical skills in the clinical specialty with an expert clinical mentorin this innovative programme.

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076 3933; fax: +61 3 9076

.au

Introduction

Nurse practitioners (NPs) have been working inCanada, the United States of America (USA), andUnited Kingdom (UK) hospitals for a considerablelength of time. The numbers of NPs in Canada is

rved.

398 G.A. Lee, L. Fitzgerald

approaching 1000 (Canadian Institute for HealthInformation, 2006). In the UK, the number is closeto 38,000 (NMC, 2006) and in the USA, there are106,000 NPs (American Academy of Nurse Practitio-ners, 2006).

The role of the NP in Australia is relatively newbut the numbers are increasing with approximately140 NPs. These numbers are expected to increaseas health service providers acknowledge the bene-fits of NPs. In the state of Victoria there are to dateonly 36 nurses NPs endorsed by the Nurses Board ofVictoria (NBV website, 2006). In Victoria a nursepractitioner is defined as ‘‘. . . a registered nurseeducated for advanced practice who is an essentialmember of an interdependent health care teamand whose role is determined by the context inwhich s/he practices’’ (NBV website, 2006). Animportant issue from a curriculum development as-pect is: what is the most appropriate method forpreparing nurses for these types of advanced clini-cal practice roles? One approach is to develop acurriculum that incorporates clinical internshipthat will best prepare nurses for these advancedroles.

Literature

The introduction of the NP was a specific strategyaimed at increasing the number of health care pro-viders who could provide a quality service that wasable to meet the increasing healthcare deliveryneeds of the community in a cost-effective manner(McMullan et al., 2001). NPs provide a unique blendof nursing and medical care. In Australia, the mainareas that health service providers have employedNPs are primary healthcare, emergency and morerecently acute care. In one study, NPs have con-tributed to a 39% increase in the number of pa-tients presenting to rural and communityhospitals (Bergeron et al., 1999). Most of the liter-ature reports that NPs are highly skilled, cost-effective and are able to provide a high-level ofcare with better documentation than their medicalcounterparts (Barr et al., 2000; Bryant and Gra-ham, 2002; Byrne et al., 2000; Cooper et al.,2002; Moser et al., 2004; Pinkerton and Bush,2000; Roblin et al., 2004; Sakr et al., 1999; Hylkaand Beschle, 1995). A Cochrane Review (Laurantet al., 2005) reported that nurses can provide ahigh quality of care and achieve good health out-comes for patients but their findings were limitedto primary healthcare.

A review of the literature highlights the differ-ence in approach to NP curricula. Gardner et al.(2004) outlined three board areas of study: clinical

practice, clinical sciences and nursing studies.They highlighted the importance of the clinicalenvironment and the essential role of a clinicalmentor. From earlier work, NP competency stan-dards have been formulated and adapted by theAustralian Nursing and Midwifery Council (ANMC)for NPs (Gardner et al., 2006).

In Australia, there are a range of approaches tothe education of NPs. Some universities focus onproviding only the specialist perquisite subjects re-quired for registration as a NP such as pharmacol-ogy, while others provide a Master degree inNurse Practitioner that aims to prepare nurses forthe advanced practice role. These programmes alloffer a form of advanced clinical skills develop-ment but how they do this varies from supervisedclinical practice to a designated clinical internshipprogramme.

Clinical internship is usually associated with phy-sician training programmes but the concept ofinternships for nursing is growing as research hasshown benefits in staff recruitment and retention(Murphy et al., 2004; Alvarado et al., 2003). Onepaper has examined the use of internship for NPsand clinical nurse specialists in a Canadian hospital(Alvarado et al., 2003) and the authors report pos-itively on the idea of a clinical internship model forpreparing nurse practitioners but make the pointthat its success is tied to the degree that a support-ive infrastructure is provided. Murphy et al. (2004)have reported the clinical benefits of an internshipand they describe a four month internship for NPsto enhance clinical practice. One could questionwhether four months is long enough for a clinicalinternship.

The idea of nurses acting as mentors of eachother in the clinical setting and the developmentof formalised mentorship programmes in nursing iswell established (Lloyd and Bristol, 2006). Mentor-ing has been defined as ‘providing guidance and sup-port within a personal relationship’ (Heartfield andGibson, 2005, p. 18). It is considered to be a com-plex interactive process that involves the nurturingand empowering of the learner in order to promoteconfidence in their abilities that fosters their pro-fessional and personal growth (Allen, 2005). Heart-field and Gibson (2005) claim that for a mentorshipexperience to be positive, the mentor and the men-tee relationship needs to be based on shared valuesand professional respect for each other. Successfulmentoring relationships are often based on profes-sional friendship and relationships established overtime through working alongside each other (Allen,2005; Heartfield and Gibson, 2005). Much work hasbeen done in the UK to develop mentoring pro-grammes as part of a professional development

A clinical internship model for the nurse practitioner programme 399

pathway for nurses (English National Board for Nurs-ing, Midwifery and Health Visiting and Departmentof Health 2001, Firtko et al., 2005).

Given the issues of ensuring nurses are clinicallyand academically prepared for NP roles and thelimited resources available to universities and hos-pitals, the challenge is to offer a Masters coursewhich incorporates both these aspects and also sat-isfies the nationally used competencies for NPs.Prior to outlining the clinical internship, it is neces-sary to outline the Nurses Board requirementsbefore proceeding to outline the academic require-ments for NP courses.

Professional body and academicrequirements

Nurses board requirements

Those who wish to become NPs must fulfil certaincriteria. In most instances nurses enrol in a Mas-ter’s degree programme and also seek employmentas a nurse practitioner candidate (NPC). As the NPtitle is protected, a nurse cannot use the title with-out formal endorsement with the relevant Nurses’Boards in Australia. The focus of the NP role is onhealth promotion, education, and the complemen-tary nature of the advanced nursing role with fiveextended practice areas: limited prescribing, initi-ation and interpretation of diagnostics, referral tomedical specialists, admitting and discharging priv-ileges and approval of absence of work certificates.(NBV website, 2006).

Nurses and midwives interested in becoming aNP must have at least three years post graduate di-ploma experience in their specialty. In this clinicalinternship model, NPCs must have a letter of clini-cal support from their manager and co-director ofnursing because the clinical internship model relieson establishing a clinical internship programmewithin the health care setting. The internship pro-gramme centres on students working with theirmentor and other colleagues in the role of NPC.As all the Masters students enrolled in the courseare NP candidates, for the remainder of the paperthey will be referred to as NPCs.

NPCs need to complete a set of clinical practiceguidelines relating to their specialty area of clinicalpractice. These guidelines outline different presen-tations and seek to provide a high-level of evidencefor the relevant treatment. The guidelines are‘signed off’ by the relevant personnel: radiologist,pharmacist, medical consultant, Director of Nursingand relevant specialist medical consultant (ortho-paedics for example). A formulary of all themedica-

tions the NP is able to prescribe must also besubmitted to the Nurses Board as part of theendorsement process. Together the guidelines andmedication formulary define their scope of clinicalpractice. A NPC may also vary their scope of prac-tice at any time by further application to the NursesBoard. In addition to this NPCs must demonstrateadvanced health assessment and diagnostic skillsand be a leader in clinical practice and research togain endorsement as NP. The benefits of a clinicalinternship model are that it enables the NPC to gainthe knowledge and skills necessary to manage pa-tients within their specialty area of clinical practiceprior to Nurses Board endorsement.

The aim of this discussion paper is twofold; tooutline the clinical internship and report feedbackand opinions from the NPC students on the pro-gramme. Ethics approval was not sought as thiswas deemed an evaluation of the internship. Anemail was sent to all NPCs requesting their feed-back on the model and confidentiality was assured.Only the authors had access to the students’ com-ments and all comments were de-identified.

Academic programme

From the university perspective, the challenge wasto develop a Master’s degree programme that wasclinically relevant to NPCs and also took theendorsement process into consideration. The LaTrobe Nurse Practitioner Master’s degree has threecore units which NPCs complete prior to undertak-ing the clinical internship: health assessment anddiagnostics, therapeutic medication managementand evidence-based guideline development. Thesethree units prepare NPCs for the clinical internshipwhere they develop their assessment and diagnos-tic knowledge and skills, medication formularyand guidelines for clinical practice.

The entire course is aimed at preparing NPCs forendorsement in their field of specialty practice andinclude developing a detailed understanding of re-lated physiology, pharmacology, psychological im-pact and contemporary interventions for theirpatient cohort, which integrates theory and prac-tice through the core units and the clinical intern-ship. Recently the Australian Nursing and MidwiferyCouncil (ANMC) has endorsed the National Compe-tency Standards for the NP (ANMC 2006). Thesecompetencies have been incorporated into anassessment tool (see Table 1). The advantage ofusing the assessment tool is that NPCs can identifytheir clinical learning needs related to their spe-cialty while also fulfilling the nationally recognisedNP competencies.

Table 1 ANMC competencies for nurse practitioner competency framework

Standard 1: Dynamic practice that incorporates application of high-level knowledge and skills in extended practiceacross stable, unpredictable and complex situationsCompetency 1.1: Conducts advanced, comprehensive and holistic health assessment relevant to a specialist field ofnursing practiceCompetency 1.2: Demonstrates a high-level of confidence and clinical proficiency in carrying out a range ofprocedures, treatments and interventions that are evidence-based and informed by specialist knowledgeCompetency 1.3: Has the capacity to use the knowledge and skills of extended practice competencies in complexand unfamiliar environmentsCompetency 1.4: Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences,and the application of this knowledge to patient care and the education of others

Standard 2: Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy andaccountabilityCompetency 2.1: Applies extended practice competencies within a nursing model of practiceCompetency 2.2: Establishes therapeutic links with the patient/client/community that recognise and respectcultural identity and lifestyle choicesCompetency 2.3: Is proactive in conducting clinical service that is enhanced and extended by autonomous andaccountable practice

Standard 3: Clinical leadership that influences and progresses clinical care, policy and collaboration through alllevels of health serviceCompetency 3.1: Engages in and leads clinical collaboration that optimize outcomes for patients/clients/communitiesCompetency 3.2: Engages in and leads informed critique and influence at the systems level of health care

Table 2 Clinical objectives for the clinical internship

Clinical1. Interdependently practice advanced health assessment and diagnostic skills in the specialty area2. Develop and apply advanced clinical knowledge and decision making skills related to patient/client group3. Select, perform and interpret appropriate diagnostic and other laboratory tests4. Individualize the use of the clinical decision making process as the framework for gathering and organizing

medication information, planning, prescribing, administering, documenting and evaluation to suit their prac-tice needs.

5. Apply pharmacological interventions appropriately including therapeutic effects and adverse events6. Compile and complete clinical practice portfolio7. Integrate data from existing standardized screening tests into care management

Evidence-based1. Trial and further develop clinical guidelines for advanced nursing practice for a range of conditions in a spe-

cialty area of clinical practiceLeadership

1. Demonstrate clinical leadership in practice development and clinical care whilst working as part of a multidis-ciplinary team.

2. Develop professional relationships within the multidisciplinary team3. Undertake continuous quality evaluation of the care given (including patient/client satisfaction and auditing of

role)4. Identify and utilize the appropriate hospital and community resources and support groups5. Provide clinical and educational support to nursing staff for patients/clients6. Provide the relevant health education and health promotion to the patient/client group7. Provide clinical audit of workload of patient/client group

400 G.A. Lee, L. Fitzgerald

The clinical internship model reported on hererequires NPCs to complete clinical objectives inthree main areas: clinical, leadership and research(see Table 2).

Clinical mentorship

Given that the primary focus of the internship isthe clinical aspect, the student is required to work

A clinical internship model for the nurse practitioner programme 401

with a nominated mentor (usually a physician orendorsed NP in the specialty). The NPC should iden-tify a suitable mentor within their work environ-ment and the mentorship process must beapproved by the co-director/director of nursingand the consultant physician before the internshipcommences. The rationale for this is that hospitalor clinical agency need to be supportive of theirstaff members who are engaging in the course gi-ven the impact on health care resources. While itis important that the NPC chooses their mentor,the hospital or health care agency and also the unitco-ordinator must input and will have final ap-proval. Once a health professional has agreed tobe a mentor a formal agreement between theNPC, mentor and University will be established.

The mentor should be:

� Up-to-date and have clinical expertise in theNPC’s specialty.� Available during clinical placement and committo being a mentor for the duration of theinternship.� Accessible within the clinical environment forteaching and reviewing patients seen by theNPC.� Have a good understanding of the NP model andthe extended scope of practice of the role.� Able to provide clinical supervision.� Able to observe the NPC working clinically andprovide thorough critical feedback on their per-formance in the role.� Have at least a Masters in a relevant field.

The clinical internship model

The description of the internship programme will bepresented followed by the students’ comments onthe model. For the clinical internship to succeed,it is of paramount importance that the mentor hasa clear understanding of the NP role within the clin-ical specialty. The role of thementorwill beoutlinedbefore the students’ evaluation of the model is pre-sented. The role of thementor is to assist the NPC todevelop and apply advanced assessment, diagnosticand pharmacological skills to become a NP. Accord-ingly, the mentor is required to be an expert in thespecialty and is usually a physician or endorsed NPnominated by thementee after consultationwith se-nior nurses in that specialty area.

The programme quite clearly stipulates thementorship plan for each semester and a formalweekly 1-h meeting between the NPC and mentoris compulsory during the semester. These meetings

are aimed at providing a structured approach toclinical learning. The internship requires that thementor and NPC to develop and maintain a clinicallearning plan, keep a log of the meetings thatshows how the objectives have been achieved thatincludes the content of all self-directed learningactivities. As well as generic objectives, NPCs candevelop specialty specific objectives.

On a day-to-day basis in the clinical environ-ment, the NPC works with their mentor. During thistime the NPC is required to complete clinical casepresentations of six different patients in their care.The presentations provide evidence that the NPC isperforming in their extended scope of practice(limited prescribing, initiation and interpretationof diagnostics, referral to medical specialists,admitting and discharging privileges and approvalof absence of work certificates) and is using anddeveloping the clinical practice guidelines appro-priately. The patient log records all patients seenby the NPC along with their assessment findings,tests ordered, diagnosis, mentor evaluation andthe plan of care.

For the clinical case presentations, as well asusing the patient log, there is a clinical case presen-tation assessment tool, which incorporates theANMC NP competencies and also uses an adaptedversion of the Bondy scale, which assists the mentorto document the level of NPC performance. Thisscale allows the NPC and mentors to identify the le-vel of practice from independent practice to depen-dent. This information can also be used in framingthe ongoing learning objectives during the weeklymeetings. The clinical internship programme in-cludes 450 h of clinical practice in the candidates’specialty area, which can be completed in eitherone or two semesters of enrolment.

The NPC, mentor and unit co-ordinator meettwice per semester. The purpose of this meetingis to ensure that the unit objectives that are spe-cific to the NPC’s area of specialty clinical practiceare being achieved and provide a forum to raiseclinical or theoretical issues. Equally, it providesa mechanism for ongoing evaluation of the intern-ship programme that enables changes to be madeas necessary.

Initial student evaluations

The overall feedback on the clinical internship pro-gramme that incorporates mentorship from NPCshas been positive. In total, four students have beenenrolled in the internship: three from EmergencyDepartments (ED) and one midwife from an antena-tal clinic. Three students provided feedback on the

402 G.A. Lee, L. Fitzgerald

internship. The students were asked to give theiropinions on the internship, in terms of did it workfor them, any issues they had, what they wouldchange about the model, did having one mentorwork and any other comments they wished tomake. The responses were obtained via email re-sponses and numbered to maintain confidentiality.Some of their comments are quoted below.

Student 1: ‘‘Having mentor in my environmentwas great, not only in a clinical sense but alsoas a sound board/buddy in an ED with mixedopinions on NP role anyway’’.Student 2: ‘‘Personally I found the intern timethe most interesting and appropriate part ofthe course as I was able to look at what I doday to day and how it fits into the NP role. Iwas able to easily meet my objectives due tomy fulltime status so time is obviously nee-ded.. . .It is also good to be able to use a mentorfor support and advice during the unit as theyknow where you are coming from and whereyou are going. By far the most appropriate andinteresting part of the course for me’’.

The other part of the course that the NPCs val-ued was the case presentations (both the clinicalcase presentations with the mentor and the casepresentations presented to their peers on studydays):

Student 1: ‘‘I learn more from doing case stud-ies then any other assessment and it pays off inthe future’’.Student 2: ‘‘I enjoyed doing my own and listen-ing to others when it came to the case studies. Agood method of reflection’’.Student 3: ‘‘The case presentations were greatand I found these very valuable’’.

One of the comments from one of the NPCs wasthe flexibility needed for mentoring to work:‘‘Thementor model needs to be flexible which we wereable to do. I used face to face meetings along withthe availability of telephone advice/contactwhere needed’’.

One of the NPCs who worked in a rural environ-ment found that mentorship did not work:

Student 3: ‘‘The mentor aspect of the clinicalinternship didn’t really work for me. I thinkthe weekly meetings are to some extentunachievable. Having a couple of mentors hasbeen vital for my leaving/backup/support -but it was not really a formal process forme.’’

This NPC suggested that maybe more than onementor is required. This is certainly something thatis being considered for the course. Equally theabove comment points to the fact that within theclinical internship model the programme of men-torship established needs to be individually tai-lored for that setting and must be flexible enoughto be changed at any given point in time.

Discussion

This discussion paper highlights the importance indeveloping and delivering a programme that meetsthe academic and clinical requirements for NPCs.We have highlighted the importance of a mentor-ship programme and have demonstrated the impor-tance of NPCs keeping a clinical log and presentingclinical cases within the clinical environment. Sec-ondly, the feedback from NPCs has been positive.There is no doubt that for the mentorship experi-ence to be successful and productive, a collabora-tive approach is necessary.

Although the assessment tool has not been for-mally assessed for validity and reliability, it ap-pears to be successful. An evaluation tool will bedeveloped and a formal study will examine the toolin the next 12 months. It is clear to see from previ-ous research, that authors have concentrated oncomparing NPs to physicians in terms of care pro-vided (Cooper et al., 2002; Moser et al., 2004; Pink-erton and Bush, 2000) rather than on curriculumdevelopment and the importance of preparingNPs for advanced clinical roles.

From previous work on piloting competencies,the benefits are substantial to the NP and the pro-cess works well (Mason et al., 2005).

The mentorship approach appears to be success-ful from the students’ perspectives and is suitablefor this clinically oriented Masters programme. Ahigh degree of support was observed from the men-tors in most cases, a finding previously reported byHeartfield and Gibson (2005). The complexity ofmentorship cannot be overlooked and problemssuch as poor communication and poor objectiveidentification for NPs are highlighted by Barker(2006). The importance of the clinical internshipcannot be underestimated and previous studieshave highlighted its importance (Gardner et al.,2004). Also from a managerial perspective, thewritten support and approval of the NP’s manageris essential as issues can arise with relocation oftasks and changes to the working relationships withthe new NP role (Reay et al., 2003). This perspec-tive is also highlighted by Marsden et al. (2003)

A clinical internship model for the nurse practitioner programme 403

who examined NP deployment and in particularorganizational and cultural issues.

What becomes apparent is the amount of timeand effort required to ensure a successful NP men-torship programme and as identified by others; pro-grammes require adequate resource allocationincluding time and technology and flexible commu-nication methods to ensure the coordination ofinformation and advice (Heartfield and Gibson,2005). The literature suggests that the idea of col-legial mentorship, incorporated into a clinicalinternship, can result in a positive learning experi-ence for the learner. Evaluating the impact of NPson staff retention and the development of en-dorsed NPs as mentors to new NPCs would be thenext step in this process.

This discussion paper outlines the mentorshipprogramme developed in response to clinical andacademic needs and could be applied to any settingboth nationally and internationally in line with lo-cal competency and clinical requirements.Although each country has their own professionalbody that regulates nursing, there is the Interna-tional Council of Nursing definition of a NP whichmakes this model attractive and potentially appli-cable to any setting.

Conclusion

The clinical internship model appears to be a suit-able method of assessment and allows NPCs to de-velop their scope of practice whilst integrating thetheory with their specialist clinical practice.Important to the success of such a programme ofclinical learning is the establishment of a flexiblementor–mentee relation that enables NP roledevelopment that is role specific. Equally, the ben-efits of a clinical internship within a Master degreecourse that focuses specifically on the acquisitionof theoretical knowledge, clinical skills needed toperform in the role of NP, and a programme oflearning that enables the accumulation of evidencefor endorsement with the registering authority,have been welcomed by industry.

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