IMPLEMENTING ADVANCED PRACTICE

NURSINGMARY GRACE F. DAUZ, PhD, RN

Director of Nursing, Angeles University Foundation MEDICAL CENTER

Professor, GRADUATE SCHOOL OF NURSING Angeles University Foundation

Philippines

ADVANCED PRACTICE NURSINGRefers to a broadly defined nursing interventions that influence healthcare outcomes, including the direct care of individual patients, management of care for individuals and populations, administration of nursing health care organizations, and the development and implementation of health policy.

(ACCN Position Paper, 2004)

It is an overarching system of practice which utilizes the application of specialized and expanded roles towards patient care. It encompasses deep knowledge and competence that is based on graduate education and substantial experience.

(Schober, 2008; ICN, 2002)

ADVANCED PRACTICE NURSING

The implementation of Advanced PracticeNursing can be realized and sustained ifsignificant PRACTICE ENVIRONMENTS andLEGISLATIVE FRAMEWORKS can usher its rolerecognition and legitimacy within the healthcare system.

(Bryant-Lukosius, et.al., 2004; Styles & Lewis, 2000;

Walsh & Bernhard, 1998)

RATIONALEVariation in supply and distribution of

health providers, demographic changes among patients, geographical

difficulties, and financial limitations were some of the challenges which

paved the way for the application of Advanced Practice Nursing across

countries.(Schober, 2008; Schreiber et.al., 2003;

Hawke, 2002; White, 2001)

Has emerged as health care systems andgovernments around the world have cometo recognize “that optimizing the nursingcontribution to health care through theirexpanding role is an EFFECTIVE strategyfor IMPROVING health services”.

(Schober and Affara, 2006)

ADVANCED PRACTICE NURSING

The ADVANCED PRACTICE NURSEis a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which he/she is credentialed to practice. A Master’s Degree is recommended for entry level.” (ICN, 2008)

Nurses can choose from a variety of diverse andequally valuable practice opportunities toexpand current roles and create new ones, ofwhich, advanced nursing practice is one.

(Canadian Nurses Association)

Advanced Practice Nurses are viewed asEXPERTS in their respective domains,ENGAGED in activities that EXTEND BEYONDthe narrow application of technicallycomplex procedures. In particular, AdvancedPractice Nursing involves the sophisticateduse of knowledge and skills.

(Daly and Carnwell, 2003)

Evolution of APN

Nurse Midwives and Nurse Anaesthetists

laid the formative foundations of what weknow as Advanced Practice Nursing.

(Hanson & Hamric, 2003)

According to the Organization for Economic Cooperation and Development (OECD)

US and Canada established “NursePractitioners” in the mid 60s

UK and Finland used different forms ofcollaboration between doctors andnurses

Australia and Ireland – more recent; butare active in establishing higher educationprograms and posts for advanced practicenurses

In other countries – formal recognition ofAPN is still in its infancy, althoughunofficial advanced practices may alreadyexist in reality.

(www.oecd.org)

FOUR GROUPS OF APN

Nurse Anaesthetists Nurse Midwives Clinical Nurse Specialists Nurse Practitioners

each has a different focus of practice

NURSE ANAESTHETISTS

In the US, a Certified Registered Nurse Anaesthetist (CRNA) is defined as a registered nurse who is educationally prepared for, and competent to practice nurse anaesthesia.(Faut-Callahan & Kremer, 2000)

The IFNA, formally created in 1989, is governed by a council of national representatives and has developed standards of practice as well as for educational curricula. Currently, there are 32 nations represented by IFNA.

(MacDonald, et.al., CNA, 2005)

NURSE ANAESTHETISTS

NURSE MIDWIVESA Certified Nurse Midwife (CNM) is anindividual educated in two disciplines ofNursing and Midwifery, who possessesevidence of certification according to therequirements of the ACNM, specificallyregistered nurses who have graduatedfrom a midwifery education program bythe CNM Division of Accreditation andhave passed a national certificationexamination administered by the ACNMCertification Council, Inc.

(ACNM, 2004 & American College of OB-Gyne, 2002)

NURSE MIDWIFERY AS APN

The only country that has explicitlyrecognized nurse midwifery as a form ofadvanced nursing practice is the US,where certified nurse midwifery is oneof the four recognized and regulatedAPN roles.

(Hamric, Spross & Hanson, 2005; Joel, 2005)

CLINICAL NURSE SPECIALISTSClinical Nurse Specialists (CNS) areregistered nurses, who have agraduate nursing preparation at theMaster’s or Doctoral level as CNS.They are clinical experts in evidence-based nursing practice within aspecialty area, treating andmanaging the health concerns ofpatients and populations.

(American Nurses Association, 2004)

play a leading role in the development ofclinical guidelines and protocols, promotethe use of evidence, provide expertsupport and consultation, and facilitatesystem change.

(Association of RN of Newfoundland and Labrador, 2007)

Clinical Nurse Specialists

NURSE PRACTITIONERS (NP)provide direct care focusing on healthpromotion and the treatment andmanagement of health condition. They areregistered nurses with additional educationalpreparation and experience who possess anddemonstrate the competencies toautonomously diagnose, order, and interpretdiagnostic tests, prescribe pharmaceuticalsand perform specific procedures within theirlegislated scope of practice.

(CNA, 2006a)

ROLE SUMMARYCRNA – narrow range of services to a

narrow base of patientsCNM – narrow range of services to a

narrow patient baseCNS – medium range of services to a

narrow patient baseNP – wide range of services to a wide

base of patients, depending upon area of certification

(www.jblearning.com)

With a focus on

HEALTH PROMOTION and DISEASE PREVENTION,

both CNS and NP “enhance the provision of

timely, accessible, cost-effective and quality

health care”.(CNA, 2006)

IMPLEMENTING ADVANCED PRACTICE NURSING

Practice EnvironmentsLegislative Frameworks

PRACTICE ENVIRONMENTS

Competencies are the specificknowledge, skills, judgment andpersonal attributes required for aregistered nurse to practicesafely and ethically in adesignated role and setting.

(CNA, 2005)

Core competencies are based on anappropriate depth, breadth, and range ofnursing knowledge, theory and research,enhanced by clinical experience and theeffective and simultaneous blending ofsuch attributes in a variety of practiceenvironments, characterizes AdvancedPractice Nursing.

PRACTICE ENVIRONMENTS

CLINICAL COMPETENCIESThe cornerstone of APN is EXPERTISEin a specialized area where the nurseworks in partnership with the clientand other members of the health careteam in the provision ofcomprehensive care through theholistic and integrated approach.

RESEARCH COMPETENCIES

An APN is able to synthesize and useresearch evidence for improving clientcare, organizations or systems.

The APN is able to conduct and supportresearch that enhances or benefits nursingpractice and contributes this newknowledge through proper channels fordissemination

APNs are LEADERS. They are agentsof change who consistently seekseffective new ways to practice, toimprove the delivery of care, to shapetheir organizations to benefit thepublic and to influence health policy.

LEADERSHIP COMPETENCIES

Effective collaboration and communication with clients and colleagues across sectors and at the organizational, national and international level is a characteristic of an APN.

Collaboration is a complex process requiring knowledge –sharing and joint responsibility for patient care, management and outcomes.

(Sandra Duke, NP)

CONSULTATION and COLLABORATION

A number of research studies have proven thebeneficial role of APNs. The recognition givento advanced practice provides an avenue fornurses to become highly in-demand and valuedin the health care system. In most countrieswhere it is applied, exists with explicit policiesfor practice. These policies govern and supportthe existence of special roles and functions.

(Bryant-Lukosius, et. al.,2004; Canadian Nurses Association, 2008)

LEGISLATIVE FRAMEWORK

The ASEAN Joint CoordinatingCommittee on Nursing(AJCCN) under the HSSWGhas signed the MutualRecognition Arrangements(MRA) on Nursing Services onDecember 6, 2006.

The Nursing MRA will facilitate the mobility of nursing service professionals within the ASEAN to enhance exchange

of information and expertise on standards and qualifications, promote

adoption of best practices for professional nursing services and

provide opportunities for capacity building and training of nurses.

(AJCCN, Nursing Services)

In a meeting on November 10-11, 2009, theAJCCN agreed on the adoption of the 5domains of ASEAN Nursing Common CoreCompetencies:

• Ethics and Legal Practice

• Professional Nursing Practice

• Leadership and Management

• Education and Research

• Professional, Personal and QualityDevelopment

FUTURE DIRECTION OF APN IN THE PHILIPPINES

Advanced Practice Nursing in the Philippinesis partly realized through the NursingSpecialty Certification Program (NCSP)through a BON Resolution in 1999 (BON99-14) which was further enforced throughComprehensive Nursing Specialty Programstipulated under the Philippine Nursing Lawof 2002 (RA 9173).

There are only a few Clinical NurseSpecialists in the Philippines, however,nurses working in specialty areas havemostly been trained by their homeinstitutions through formal and informaleducational trainings leading towards theirspecialty. Some of these nurses haveMaster’s Degree.

(ICN, 2010; Vanessa M. Manila, UP CON)

Currently, there is no policy provision whichformalizes the position of an “Advanced PracticeNurse” in the Philippines; neither are thereexplicit standards of practice for those who maybe working as “advanced nurses”.

These developments provide the impetusto formulate an APN Framework thatwould define systems, scope and standardsof practice, and means to improve thepractice of the profession to ultimatelycontribute to better health outcomes inthe country.

(ICN, 2010; Vanessa M. Manila, UP CON)

The Philippine Senate Committee on Civil Service and Government Reorganization; Health and Demography and Finance proposed an Act providing for a Comprehensive Nursing Law towards Quality Health Care System was proposed in 2015. In Sec 43 and 46 of this proposed Act was Advanced Practice Nursing.

According to Senator Trillanes (co-Author), theenactment of this Bill is intended to complementthe talent and competence of nurses by providingthem with an updated regulatory framework.

However, on June 16,2016, then PresidentBenigno C. Aquino IIIhas vetoed Senate BillNo. 2720 which seeksthe enactment of theComprehensive NursingLaw.

AUF Medical Center

MISSION

AUF Medical Center is committed to provide the highest quality in healthcare services, education and research for the improvement of health and well being of the community.

VISION

AUF Medical Centerenvisions to be the most trusted partner in the delivery of healthcare services.

One of its strategic thrusts is organizationalcapacity where it aims to improve work culture,KNOWLEDGE AND SKILLS, physical facilities andtools and technology through employeeengagement initiatives, performance appraisaland review, IN-SERVICE AND SPECIALIZEDTRAINING INITIATIVES, renovation andreplacement plan, accreditation, licensing andstatutory compliances.

AUFMC endeavours to become the besthospital north of Manila. With its continuousimprovements in facilities and healthcareservices along with monitoring the educationalqualifications and competencies of the nursingservice, AUFMC will be ready once theframework for the APN will commence for itsimplementation in the ASEAN Region.

Advancement in technology, the desire toimprove patient outcomes, and theimprovement of health care access aresome f the notable reasons for launchingthe APN, however, there are notabledifferences on how advanced practicewas implemented globally.

In most countries with APN, the designation of roles necessitated the development of legislative frameworks which went beyond certification. There were those with second licensure, with accreditation programs and institutions and emphasis on the roles of regulatory bodies.(CAN, 2008; Advanced Practice RN Consensus Committee, 2008; Sheer

& Wong, 2008; Stanley & Bednash, 1998)

Advanced Practice Nursing is perceived towiden career options and optimize nurses’contribution to the health care system.

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