A critical analysis of advanced practice nursing and nursing specialties

Dear Editor,

In Spain this century many factors have been responsible for driving the evolution of the nursing profession towards full service development. The imperative of chronicity, towards which all healthcare services will have to redirect their efforts,^1,2 the transformation of the educational system with adaption to the European Higher Education Area, the start-up of nursing specialities (with its ups and downs) and the regulation of some interventions such as nursing prescription (despite deplorable management and legislative development by politicians and professional organisations), has resulted in the Spanish nursing profession confronting the development of new services and new competences.

There is obviously much confusion and ambiguity among the nurses themselves, their managers and all other professionals. The population at large is possibly the least confused in this context, to the extent that what they wish is for their demands and needs to be resolved affordably and safely and maybe what they are least concerned about is which provider does this or their particular status in the organization hierarchy.

Although the initial experiences of advanced practices date back to the previous century in U.S.A. and Canada,³ the implementation of these roles has been uneven with regards to time, geography and content. The driving forces behind them are multifarious, and may include, for example, a response to the scarcity of doctors, transformations and coverage of new healthcare systems demands,^4,5 or the improvement of the professional development of nurses.

The origin of confusion concerns both the “what” (concept of advanced practice) and the “how” (justification and operative structuring of its development into the health services in Spain).

With regards to the latter, the justification for advanced nursing services only has to obey one rule: to offer a response to the population's healthcare needs and demands. Today's service and competence organization does not fully guarantee this in terms of accessibility, coordination, continuity, effectiveness or efficiency. The reason for this given in other countries, which is the scarcity of doctors, is not applicable in Spain since the ratio of doctors per inhabitant is one of the highest in the world.⁶ Advanced practice nursing (APN) is a source of solutions for many pressing health service problems such as cardiovascular diseases and diabetes, where lower mortality rates,^7–9 have even been achieved, together with mental health processes such as depression or severe mental disorder,^10,11 advanced care in cancer and terminal illness,¹² dementia,¹³ primary care demand attention,¹⁴ among many other areas some of which have already been tested in Spain.^15–17 The politicians’ and managers’ continuous ignoring of the obvious facts is merely a demonstration of their perpetually outdated priorities.

It is not, however, easy to apply “decontextualised” to APN since it takes place in organisations which possess their own cultures, roles and status, where the disempowerment of nurses on an organisational level is endemic and APN has become a mere desire to overcome models of practice pertaining to the twentieth century. If a healthcare organization does not make profound changes to its interprofessional practice models and empower its clinical nurses, APN will resolve absolutely nothing and will become a mere anecdote in the portfolio of services, possibly leading to tension between the nurses themselves who see their low prominence in the organisation generally persisting in return for experiences of this type. Nursing executives and managers are vital here to prevent this situation, which would lead to a general sensation that advanced practice nursing is merely a fashionable whim.

With regards to the “what” agreement needs to be reached regarding the criteria to be used to define advanced practice services. The different conceptual proposals of the International Council of Nurses (ICN)¹⁸ or other proposals confirm the need for advanced practice to be founded on the acquisition of expert knowledge by formal means (in the majority of cases with a master's degree level), in order for complex decisions to be taken.

In our environment controversy arises due to the simultaneous presence of nursing specialties and the roles of advanced practice. Some arguments without a solid conceptual base and subject to partial interests have attempted to induce a confrontation but this just increases confusion, and in the broader conceptual scale of things, this problem should not exist. The ICN itself establishes this difference between the specialist nurse and the ANP.¹⁸

These futile debates do nothing but delay the putting into practice and development of services which the population will benefit from and requires. To clarify this debate it may be appropriate to offer the example of how in other disciplines, such as the case of internal medicine, advanced practices were developed in the 1980s and 1990s to deal with a highly serious problem that was challenging the health services at that time: AIDS. Certain professionals decided to develop specific competences in the face of this challenge (in many cases without any formal structured support)¹⁹ and it was precisely because the development of competences was not resolved in its day that this conflict exists now between those who wish Infectology to be a specialty in itself or a training area within the area of internal medicine.

Specialisation covers a broad spectrum of skills in care, above that of the general nurse, in defined areas such as care of women, the child and teenage population, mental health, family and community health, etc. The need for advanced knowledge in global healthcare to these population groups or in certain contexts has meant that specialised skills have been required which our health system has operationalised through the specialized resident doctor system. Advanced practice implies the development of specific services for specific health demands and needs (management of chronic, multi morbidity patients, transitional care in people with oncological processes, the undertaking of colorectal cancer screening tests, etc.). It is also important not to forget that not all advanced practice services have the same reach and depending on their characteristics (acting as an entry or terminal care point or not, the patient portfolio, the level of autonomy, service aim, etc.), there is a gradient of advanced practice and specialized practice.²⁰ It is possible that advanced practice services should be developed within the same professional field of specialist nurses and it is also possible that the ANP should develop in areas in which there is no nursing specialisation (we must not forget the scant development of specialties in Spain) or in those where specialization is a requisite for it.

In Spain, after an in-depth review of the international APN competence map,²¹ and establishing a consensus on these competences in our environment,²² tools have been validated to address these gradients²³ and discern competence levels.

The success of APN service implementation in Spain requires analysis and prioritisation of the health needs which would benefit the APN services, identify the capacity of response to these needs, design a competence transformation project based on an existing model or on justified transformation of some of the existing ones, with an analysis of barriers and facilitators, designing well-defined, financed training plans with formal recognition mechanisms, accreditation and reaccreditations of the APNs.^24,25

Lastly, we propose a change in the name and that we begin to speak of advanced clinical nursing, which is more in keeping with the conceptual and care implications of this professional.