Editorial
Looking to the future of Advanced Practice Nursing in Spain
Mirando al futuro de la Enfermería de Práctica Avanzada en España
a Profesor de la Escuela Universitaria de Enfermería y Fisioterapia San Juan de Dios, Universidad Pontificia de Comillas, Madrid, Spain
b Associate Lecturer of Advanced Practice, Nursing and Midwifery School of Oxford, Oxford Brookes University, Advanced Critical Care Practitioner (ACCP), Plymouth University Oxford, United Kingdom
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This variability has created a complex landscape due to disparate initiatives that have generated a broad catalogue of titles and functions,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and due to the lack of consensus on the meaning of APN. There is a vast volume of research articles, argument, and academic debate in the literature related to APN, which reflects the great interest in the scientific community and the search for evidence to support implementation of the role.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–6</span></a> Paradoxically, this body of international literature also generates confusion regarding the role by presenting profiles that are labelled as advanced practice which vary greatly. The continued uncritical use of advanced practice nursing as a label to cover and capture the diversity of nursing practice and nursing roles that differ from the generalist nurse is at the root of this confusion.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An area on which there is great consensus among professionals at the political and social level (legislators, managers, educators, service users), is the need to reach a consensus and support the new advanced practice roles in order to implement them successfully.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> Initiatives can be developed within this debate to meet the real demands of service users.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This process should include, as fundamental aspects of the role, a description of the specific competencies to be acquired during postgraduate training, accreditation, registration and protection of the title, professional licensing and performance evaluation and revalidation, which also implies explicit recognition by the healthcare system itself.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In countries where APN is firmly established, the process by which a generalist nurse becomes an advanced practice nurse involves a series of phases. Among the requirements for advanced practice is to have successfully completed university training at master’s level or higher, to acquire APN competencies<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and subsequent certification. On completion of their university training, the nurse proceeds to registration. Registration involves the inclusion of their name in the professional list of an official or regulatory institution. These institutions keep and update a file of nurses who have obtained their certification, and are also responsible for protecting the title of APN, which means that only nurses who have been certified by academic institutions and who are officially registered can use this title to practice their profession. The professional licence is the decision by the competent administration authorising a professional to conduct a certain activity. This licensing process only applies to people who, having acquired their certification and having registered, are allowed to use the officially protected title of APN.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a> To enter the workforce, the accredited professional, registered and officially licensed to practice, must pass a selection process by the employer, which, in most cases, is a health institution. A document that details the training and clinical experience requirements, competencies required, functions, portfolio of services, responsibilities, and rights of the job (job description) guides this process. This document, which must be approved by the care centre management as a result of the process of implementing the role, provides continuity and implies explicit recognition of the role, as opposed to positions created specifically for a particular person, which are usually eliminated when that professional leaves the position. However, incorporation into an APN position does not mean that the profile is complete. Manley<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> defines continuous professional development as the continuous acquisition, maintenance, improvement and reinforcement of knowledge, skills, and competences during professional practice. This continuous professional development ensures not only individual learning but also satisfaction with health service delivery, according to the changing needs of service users. Thus, the clinical performance of healthcare practitioners must be regularly assessed by their health institution managers and by regulatory institutions (revalidation) to ensure quality provision of services.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Studying the APN implementation processes in countries where the role has been present for decades and how it has been adapted in our setting helps us draw an adapted roadmap. There is sufficient evidence available to show that developing the APN role requires designing and implementing specific university training in advanced postgraduate practice at master's degree level, to train and equip the nurse with the necessary competencies to assess, diagnose, and autonomously treat patients with chronic or acute diseases, including prescribing medicines and medical devices within their area of competence.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> The UK has one of the most extensive prescribing programmes in the world, providing professionals who undergo the training the most extensive independent rights to prescribe. These "prescribers" are recognised as having the ability to independently prescribe any medicine within their area of competence to patients with diagnosed or undiagnosed conditions.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It is important to bear in mind that the priority objectives of APN include addressing a care gap, responding to a demand from system users, increasing the capacity to respond, or implementing a resource that improves the quality of care through the acquisition of specific competencies. Advanced practice, as a tool for addressing an underserved area of care, requires a break with the current model and with the barriers it presents given the rigid limits of the traditional professions. Breaking down the barriers implies broadening the scope of clinical practice with the sole objective of responding effectively and efficiently to the requirements and needs of service users, as active subjects. Concepts such as "skill-mix" or "boundary-spanning" help to redefine the relationship between roles and multidisciplinary work.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The situation in terms of advanced practice in Spain is multi-faceted. The newness of the role in our country means we can take advantage of the experience of other countries and collaboratively design an adapted profile from scratch. However, this very newness involves us in a debate about the professional space that APN should occupy, in which resistance and interests divert attention from the primary objective, which is just to meet the needs of service users. APN was born under this premise alone, and has developed and expanded with this sole objective. There is no doubt that unmet or insufficiently met needs exist and will continue to arise as a result of the natural process of socio-demographic and cultural change in the population. This puts health systems in a critical position and forces them to develop strategies and adapt, or disappear to make way for other models. Nurses can be part of the solution if they respond quickly, flexibly, effectively, and efficiently to these changes, otherwise the opportunity to demonstrate their full potential will be lost. The development and growth of the profession, the expansion of competencies and functions, and improved working conditions are very desirable consequences of developing this role, but they lose all meaning if the first and only mission of APN is not to respond to the care needs of the community.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The International Council of Nurses (ICN), in an effort to delineate the APN role, includes only two types: the Clinical Nurse Specialist (CNS) and the Nurse Practitioner (NP). Both are registered advanced practice nurses who have completed advanced education and training beyond the generalist nursing level. Although both roles share similarities, there are important differences between the NP and the CNS in terms of their area of practice, specialisation, and responsibilities.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In the Spanish context, the fact that nursing specialties exist with their current training and regulatory design, raises the debate as to whether they could be considered advanced practice roles. In principle, the term "Nurse Specialist", purely for reasons of similarity, could have some equivalence with "Clinical Nurse Specialist", in a more detailed analysis, however, where the level of competence would have to be defined so that the roles can be complementary within the system without controversy. Although analysis of the similarities and differences between nursing specialties and advanced practice profiles is too important for us to deal with in this article, we should point out the need to open the debate, to be inclusive, opting for the design of alternatives where both models can coexist, and existing and emerging profiles can be fully developed.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The development and implementation of the role requires dialogue between healthcare institutions, academia, scientific societies, and service users themselves, in which healthcare needs are analysed, options adapted to these needs are explored and, if one of these options is to create an APN profile, the competency profile, curricular pathway, accreditation, registration, and professional career are designed. In initiatives that have not included any of these elements or have not had this prior debate, gaps have arisen between the competences developed during training, clinical needs, or the national, regional, or healthcare centres' own strategic plans, resulting in considerable disenchantment among professionals and, in most cases, delay in the implementation and growth, or even the disappearance, of the role.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Again, using the UK as an example of a country where APN is firmly established, one of the roles that stands out for its exemplary implementation process is that of the Advanced Critical Care Practitioner (ACCP). The Faculty of Intensive Care (FICM), which comprises anaesthetists as the UK's medical lead in intensive care units, has designed a training curriculum together with advanced practice nurses, healthcare institutions, and the universities involved in the development of the role.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> A two-year training period begins after a selection process to access the master's programme (performed jointly by the hospital offering the training programme and the university), which includes aspects such as previous training and experience. Competencies common to other APN professionals such as assessment and taking of clinical history, physical examination, diagnosis, clinical reasoning, and pharmacological prescription and specific critical care competencies (airway management, central venous access, critical patient transport, etc.) including clinical rotation, are included in this document. It is mandatory that clinical rotation hours are protected during the two years of training, in other words, the ACCP trainee does not assume clinical responsibilities and entirely focusses on their training, they are supernumerary, just as students can be during their undergraduate studies. The training process concludes with accreditation followed by registration as a member of the Faculty of Intensive Care.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> ACCPs also remain members of the National College of Nursing and Midwifery Council (NMC) if their previous training was as nurses, or members of their particular regulatory body in other cases (physiotherapists, pharmacists, etc.). Throughout their career, ACCPs can continue to grow and develop, moving into more senior positions depending on the context of each hospital. FICM has also developed job description models for the different levels of ACCPs that guide both the selection of ACCPs by the hospital and the assessment of the clinical impact of the role.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Countries where APN roles are already firmly established have systematic processes for implementing the role, with service users or patients at their centre. These APN implementation models aim to improve advanced clinical practice and healthcare by defining roles and responsibilities, identifying competencies and skills, and providing guidance on education, training, leadership, and research. Each model is designed to be applied in specific contexts and has its own particularities and unique characteristics making it appropriate for use in different settings and health systems. Countries such as England,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Scotland,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> the United States,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Australia,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and Canada<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> publish and regularly update their national plans.</p><p id="par0050" class="elsevierStylePara elsevierViewall">There is evidence of the need to establish state plans to develop APN<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>; however Spain lacks this type of national strategy, yet there are initiatives at regional level. In Andalusia, for example, there is a long history in implementing an APN model, where a series of specific profiles have been defined and prioritised with their own competency manual and portfolio of services (from the nurse case manager who focusses on the approach to complex chronic patients with more than twenty years of experience to the most recent APN profiles in the care of people with complex chronic wounds, APN in complex oncological processes, APN in the care of people with complex diabetes treatments, and APN in the care of people with ostomies, with a certification programme through the Andalusian Health Quality Agency.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27–28</span></a> A proposal for an advanced practice nurse model was also recently published in Catalonia.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> This model, developed with the participation of representatives of professional nursing associations in Catalonia, focuses on key aspects such as defining the role, standards of practice, a regulatory framework that guarantees valid and reliable training and certification based on internationally recognised and accepted standards, proposing standard recommendations and characteristics for the recognition of the new APN role.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Nevertheless, the absence in Spain of a national implementation framework for APN is a major constraint to development of the role. Initiatives are presented in a fragmented way, attempting to meet specific needs or gaps in care in each setting. This is consistent with the evolutionary process of advanced practice in other countries and could be viewed as the initial or nascent phase. To respond to this need for coordination, there is a Framework Initiative on Care in the Ministry of Health which aims to address the regulatory aspects of APN with the autonomous regions. However, national regulation of APN should not be the only strategy to definitively resolve a variability that is the consequence of both the newness of the role and the country's own political structure, since the autonomous communities (ACs) are responsible for regulating, modifying and adapting to their contexts the aspects legislated at national level, the State being responsible for health service coordination and communication between the different regions and with the national government. Competences relating to health are also devolved in countries where APN is firmly established, as is the case of the National Health Service (NHS) in the United Kingdom, where competences are devolved to Scotland, Wales, and Northern Ireland, England being the main reference point, or Canada, with a federal political structure, where health is the responsibility of the provinces, equivalent to the ACs in Spain. This shows how coordination, cooperation, and effective communication between regions, practitioners, educational institutions, scientific societies, and service users constitute the most effective tool for guaranteeing the right of citizens to access resources as valuable as APN, while each setting maintains its specific characteristics.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Although in Spain we still have some way to go to achieve a nationally consolidated APN model, the experience of some autonomous communities is already a major endorsement. Moreover, evidence from other countries shows that defining the training and professional profile in a multidisciplinary and collaborative way is not only possible, but seems to be the only way to successfully develop an effective tool such as APN, overcoming potential differences and corporate interests.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The structure of nursing: a national examination of titles and practice profiles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Gardner" 1 => "C. Duffield" 2 => "A. Doubrovsky" 3 => "U.T. Bui" 4 => "M. 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