Advanced Nursing Practice

Advanced practice is where nurses incorporate professional leadership, education, research and support of systems into their practice. Their practice includes relevant expertise, critical thinking, complex decision-making, autonomous practice and is effective and safe. They work within a generalist or specialist context and they are responsible and accountable in managing people who have complex healthcare requirements. Advanced practice in nursing is demonstrated by a level of practice and not by a job title or level of remuneration. Advanced practice for the purpose of the nurse practitioner endorsement requires 5,000 hours clinically-based advanced practice in the past six years.

Generalist practice encompasses a comprehensive spectrum of activities. It is directed towards a diversity of people with different health needs, takes place in a wide range of health care settings, and it is reflective of a broad range of knowledge and skills. Generalist practice may occur at any point on a continuum from novice to advanced. (Figure 1).

Specialist practice The term ‘specialist’ defines roles focused within a specific context, for example, a particular population or skill set. Specialist practice follows and builds on a base of generalist preparation. Nurse specialists demonstrate in-depth knowledge, skills and expertise in their area of specialised nursing practice. Expertise in a particular specialty may be developed by undertaking formal education, exposure to relevant clinical experience in the practice area and continuing professional development. There are many nurse specialist roles at the advanced practice level, however, specialisation alone does not characterise an advanced level of practice. Specialist practice may also occur at any point on a continuum from beginning to advanced and is on one pole of the ‘specialist-generalist’ continuum, rather than on the developmental continuum from ‘novice’ to ‘advanced.'

Advanced Nursing Practice - Guidelines for the Australian Context by Chief Nursing & Midwifery Officers Australia 2020

Advanced Nursing Practice - Guidelines for the Australian Context by Chief Nursing & Midwifery Officers Australia 2020

Advanced Nursing Practice Domains

Education

Uses knowledge and skills to educate those receiving care, peers and colleagues.

Nurse practitioner standards for practice - Effective from 1 March 2021

Activities that contribute to improving health literacy and to supporting self-management of illness. Activities also develop and educate self and others across the health care community.

Evidence of meeting requirements in this area may include:

Advocates for and contributes to a culture of continuous professional development and evidence-based practice
Identifies learning needs of various populations and contributes to the development of education programs/resources
Demonstrates active involvement in the development of educational activities at a regional or broader level
Participates in the delivery of postgraduate education programs
Demonstrates reflective practice and develops this practice in others
Conducts in-service education for senior nurses/ junior doctors/ management
Evaluate education programs and recommend revision
Serve as a clinical preceptor for other nurses/medical doctors
Identify learning needs of various populations and contribute to the development of educational resources
Serves as an informal educator to staff whilst providing direct care activities
Provides patient and family education

Advanced Nursing Practice- Guidelines for the Australian context by Chief Nursing and Midwifery Officers 2020 Australia Department of Health

The Australian Advanced Practice Nursing self-appraisal tool QUT

Research

Research includes the creation of new knowledge and/or the use of existing knowledge in a new and creative way so as to generate new concepts, methodologies, inventions and understandings. This could include synthesis and analysis of previous research to the extent that it is new and creative: (Australian Code for the Responsible Conduct of Research, 2018, p.5)

Activities that support a culture of inquiry and innovative problem solving to improve health outcomes and health care delivery systems. This includes conducting clinical research and translating evidence into clinical practice and policy development.

Evidence of meeting requirements in this area may include:

Evidence of active participation in research projects
Publications
Active participation/ leadership regarding quality audits
Translating evidence into clinical practice and policy development
Leads investigations to monitor and improve the quality of patient care practices
Recommends policy changes when integrating theory into practice

Advanced Nursing Practice- Guidelines for the Australian context by Chief Nursing and Midwifery Officers 2020 Australia Department of Health

The Australian Advanced Practice Nursing self-appraisal tool QUT

Leadership

Uses clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health service.

Nurse practitioner standards for practice - Effective from 1 March 2021

Activities that promote sharing and dissemination of knowledge, promote the profession and disseminate nursing knowledge. Demonstrate leadership in the role of consultant within and external to the profession and across health care settings.

Evidence of meeting requirements in this area may include:

Demonstrates high-level communication skills in disseminating nursing knowledge through presentations or publication at local, regional, national or international levels
Serves as a resource or committee member in a professional organisation
Demonstrates professional judgement and leadership in managing clinical care in complex clinical environments or across multiple service or patient populations
Evaluating or initiating new patient services
Initiating or introducing new clinical practices
Clinical practice guidelines development, review and implementation

Advanced Nursing Practice- Guidelines for the Australian context by Chief Nursing and Midwifery Officers 2020 Australia Department of Health

The Australian Advanced Practice Nursing self-appraisal tool QUT

Clinical

Standard 1: Assess using diagnostic capasity

Statement 1.1 NPs demonstrate complex and critical thinking to conduct comprehensive, relevant and holistic health assessments

1.1.1 demonstrates extensive knowledge of human sciences and health assessment

1.1.2 demonstrates comprehensive and systematic skill in obtaining relevant, appropriate and accurate data that inform differential diagnoses

1.1.3 assesses the complex and/or unstable healthcare needs of the person receiving care through synthesis and prioritisation of historical and available data

1.1.4 assesses the impact of comorbidities, including the effects of co-existing, multiple pathologies and prior treatments in the assessment of the person receiving care

1.1.5 demonstrates comprehensive skill in clinical examination including physical, mental health, social, ethnic and cultural dimensions

1.1.6 consistently and accurately synthesises and interprets assessment information specifically history, including prior treatment outcomes, physical findings and diagnostic data to identify normal, at risk and abnormal states of health, and

1.1.7 critically evaluates the impact of social determinants of health on both the individual person and the population.

Statement 1.2: NPs demonstrate accountability in the timely and considered use of diagnostic investigations to inform clinical decision making

1.2.1 makes decisions about the use of person-focused diagnostic investigations that are informed by clinical findings and research evidence

1.2.2 demonstrates accountability in considering access, cost, clinical efficacy and the informed decision of the person receiving care when requesting diagnostic investigations

1.2.3 requests and/or performs selected screening and diagnostic investigations

1.2.4 is responsible and accountable for the interpretation of results and for following-up the appropriate course of action, and

1.2.5 uses effective communication strategies to inform the person receiving care and relevant health professionals of the health assessment findings and diagnoses.

Statement 1.3: NPs integrate theoretical and practical knowledge to apply diagnostic reasoning to formulate diagnoses

1.3.1 synthesises knowledge of developmental and life stages, epidemiology, pathophysiology, behavioural sciences, psychopathology, environmental risks, demographics and societal processes when making a diagnosis

1.3.2 considers the person’s expectations of assessment, diagnosis and cost of healthcare

1.3.3 acts to prevent and/or diagnose urgent, emergent and life-threatening situations, and

1.3.4 determines clinical significance in the formulation of an accurate diagnosis from an informed set of differential diagnoses through the integration of the person’s history and best available evidence.

Standard2: Plans care and engages others

Statement 2.1: NPs critically and ethically translate and integrate evidence-based knowledge into planning care

2.1.1 takes personal responsibility to critically evaluate and integrate relevant research findings into decision making about healthcare management and interventions

2.1.2 ethically explores therapeutic options considering implications for care through the integration of assessment information, the person’s informed decision and best available evidence, and

2.1.3 is proactive and analytical in acquiring new knowledge related to NP practice

Statement 2.2: NPs educate and support others to enable their active participation in care

The NP:

2.2.1 respects the rights of the person to make informed decisions throughout their health/illness experience or episode, whilst ensuring access to accurate and appropriately interpreted information

2.2.2 uses appropriate teaching/learning strategies to provide diagnostic information that is relevant, theory-based and evidence-informed

2.2.3 communicates about health assessment findings and/or diagnoses, including outcomes and prognosis, and

2.2.4 works to meet identified needs for educating others regarding clinical and ongoing care.

Statement 2.3: NPs consider quality use of medicines and therapeutic interventions using their comprehensive knowledge when planning care

2.3.1 develops an individual plan of care and communicates this to appropriate members of the healthcare team and relevant agencies

2.3.2 exhibits a comprehensive knowledge of pharmacology and pharmacokinetics related to NP scope of practice

2.3.3 works in partnership with the person receiving care to determine therapeutic goals and options

2.3.4 verifies the suitability of evidence-based treatment options including medicines, in regard to commencing, maintaining/titrating or ceasing interventions, and

2.3.5 demonstrates accountability in considering access, cost and clinical efficacy when planning treatment.

Statement 2.4: NPs collaborate and consult for care decisions to obtain optimal outcomes for the person receiving care

2.4.1 collaborates with other health professionals to make and accept referrals as appropriate, and

2.4.2 consults with and/or refers to other health services, disability services, maternity services, aged-care providers and community agencies at any point in the care continuum.

Standard 3: Prescribes and implaments therapeutic interventions

Statement 3.1: NPs use professional knowledge when prescribing indicated non-pharmacological and pharmacological interventions

3.1.1 contributes to health literacy by sharing knowledge with the person receiving care to achieve evidence-informed management plans

3.1.2 safely prescribes therapeutic interventions based on accurate knowledge of the characteristics and concurrent therapies of the person receiving care

3.1.3 demonstrates professional integrity and ethical conduct in relation to therapeutic product manufacturers and pharmaceutical organisations

3.1.4 safely and effectively performs evidence-informed invasive/non-invasive interventions for the clinical management and/or prevention of illness, disease, injuries, disorders or conditions, and

3.1.5 interprets and follows-up the findings of screening and diagnostic investigations in an appropriate time frame during the implementation of care.

Statement 3.2: NPs manage episodes of care, establishing and maintaining respectful relationships with people at the centre of care

3.2.1 supports, educates, coaches and counsels the person receiving care regarding diagnoses, prognoses and self-management, including their personal responses to illness, injuries, risk factors and therapeutic interventions

3.2.2 advises the person receiving care on therapeutic interventions including benefits, potential side effects, unexpected effects, interactions, importance of compliance and recommended follow-up

3.2.3 shares information with others in consultation with the person receiving care

3.2.4 discloses the facts of adverse events to the person receiving care and other health professionals; mitigates harm, and reports adverse events to appropriate authorities in keeping with relevant legislation and organisational policy

3.2.5 advocates for improved access to healthcare, the healthcare system and policy decisions that affect health and quality of life

3.2.6 practises without the discrimination that may be associated with race, age, disability, sexuality, gender identity, relationship status, power relations and/or social disadvantage

3.2.7 practises in a way that respects that family and community underpin the health of Aboriginal and/or Torres Strait Islander people, and

3.2.8 conducts relationships within a context of collaboration, mutual trust, respect and cultural safety.

Statement 3.3: NPs recognise their duty of care and practise in accordance with federal, state and territory legislation and professional regulation governing NP practice

3.3.1 defines duty of care in accordance with relevant legislation and regulation

3.3.2 remains informed of changes to legislation and professional regulations, and implements appropriate alterations to practice in response to such changes, and

3.3.3contributes to the development of policy and procedures appropriate to context and specialty.

Standard 4: Supports health systems

Statement 4.1: NPs engage in reflective practice and evaluate the outcomes of their practice

4.1.1 monitors, evaluates and documents treatments/interventions in accordance with person- determined goals and healthcare system outcomes

4.1.2 develops plans for appropriately ceasing and/or modifying treatment in consultation with the person receiving care and, when needed, other members of the healthcare team

4.1.3 applies the best available evidence to identify and select appropriate outcomes measures of practice

4.1.4 uses quality indicators to monitor and measure the effectiveness of strategies, services and interventions to promote safe practice

4.1.5 participates in clinical supervision and clinical practice review

4.1.6 implements research-based innovations for improving care, and

4.1.7 contributes to research that addresses identified gaps in the provision of care and/or services.

Statement 4.2: NPs advocate for, participate in, or lead systems that support safe care, partnership and professional growth

4.2.1 advocates and provides evidence for expansion to NP service where it is believed that such an expansion will improve access to quality and cost-effective healthcare for populations in all locations and contexts, including those in regional and remote communities

4.2.2 demonstrates clinical leadership in the design and evaluation of services for individuals and communities in health promotion, health protection or the prevention of injury and/or illness

4.2.3 articulates and promotes the NP role in clinical, political and professional contexts

4.2.4 acts as an educator and/or mentor to students, nursing colleagues and others in the healthcare team

4.2.5 critiques healthcare policies for their implications on the NP role and the populations for whom they care, and

4.2.6 influences health, disability and aged-care policy and practice through leadership and active participation in workplace and professional organisations.

Support of systems is a practice domain of the Strong Model of Advanced Practice and is a contemporary feature of advanced practice. It is described as activities that promote quality and safe patient care and facilitate the optimal progression of patients through the healthcare system. NPs demonstrate the advanced practice activities in this domain that include:

actively participate in the assessment, development, implementation, and evaluation of quality improvement programs in collaboration with healthcare teams
provide clinical leadership in the development, implementation, and evaluation of standards of practice, policies and procedures
serve as a mentor
advocate the role of the nurse, and
serve as a spokesperson for nursing and the health system when interacting with other professionals, patients, families, and the public.

Nurse practitioner standards for practice - Effective from 1 March 2021

Activities that contribute to the optimal performance of health systems including advocacy and mentorship, developing and implementing innovative models of care and improving access to high quality health care and health outcomes

Evidence of meeting requirements in this area may include:

Contribute to, consult or collaborate with other health care personnel on recruitment and retention activities
Participant in strategic planning for the service, department or hospital
Provide direction for and participate in unit/service quality improvement programs
Provide leadership in the development, implementation, and evaluation of standards of practice, policies and procedures
Serve as a mentor
Serve as a spokesperson for nursing and the health facility when interacting with other professionals, patients, families and the public
Demonstrates leadership in strategic planning for the service, department or hospital
Manages complex projects or leads projects relating to significant practice change within the service or organisation
Develops and undertakes quality activities to advocate for and demonstrate the contribution of advanced nursing practice roles to the healthcare team and the health system more broadly

Advanced Nursing Practice- Guidelines for the Australian context by Chief Nursing and Midwifery Officers 2020 Australia Department of Health

The Australian Advanced Practice Nursing self-appraisal tool QUT

What is the difference between RN1, RN2, RN3 and Advanced Practice?

Registered nurse—level 1 (RN1)

(a) An employee at this level performs their duties:

(i) according to their level of competence; and

(ii) under the general guidance of, or with general access to a more competent registered nurse (RN) who provides work related support and direction.

(b) An employee at this level is required to perform general nursing duties which include substantially, but are not confined to:

• delivering direct and comprehensive nursing care and individual case management to patients or clients within the practice setting;

• coordinating services, including those of other disciplines or agencies, to individual patients or clients within the practice setting;

• providing education, counselling and group work services orientated towards the promotion of health status improvement of patients and clients within the practice setting;

• providing support, direction and education to newer or less experienced staff, including EN’s, and student EN’s and student nurses;

• accepting accountability for the employee’s own standards of nursing care and service delivery; and

• participating in action research and policy development within the practice setting

Registered nurse—level 2 (RN2)

(a) An employee at this level:

(i) holds any other qualification required for working in the employee’s particular practice setting; and

(ii) is appointed as such by a selection process or by reclassification from a lower level when the employee is required to perform the duties detailed in this subclause on a continuing basis. An employee at this level may also be known as a Clinical nurse.

(b) In addition to the duties of an RN1, an employee at this level is required, to perform duties delegated by a Clinical nurse consultant or any higher level classification. Duties of a Clinical nurse will substantially include, but are not confined to:

• delivering direct and comprehensive nursing care and individual case management to a specific group of patients or clients in a particular area of nursing practice within the practice setting;

• providing support, direction, orientation and education to RN1’s, EN’s, student nurses and student EN’s;

• being responsible for planning and coordinating services relating to a particular group of clients or patients in the practice setting, as delegated by the Clinical nurse consultant;

• acting as a role model in the provision of holistic care to patients or clients in the practice setting; and

• assisting in the management of action research projects, and participating in quality assurance programs and policy development within the practice setting.

Registered nurse—level 3 (RN3)

(a) An employee at this level:

(i) holds any other qualification required for working in the employee’s particular practice setting; and

(ii) is appointed as such by a selection process or by reclassification from a lower level when that the employee is required to perform the duties detailed in this subclause on a continuing basis. An employee at this level may also be known as a Clinical nurse consultant, Nurse manager or Nurse educator.

(b) In addition to the duties of an RN2, an employee at this level will perform the following duties in accordance with practice settings and patient or client groups:

(i) Duties of a Clinical Nurse Consultant will substantially include, but are not confined to:

• providing leadership and role modelling, in collaboration with others including the Nurse manager and the Nurse educator, particularly in the areas of action research and quality assurance programs;

• staff and patient/client education;

• staff selection, management, development and appraisal;

• participating in policy development and implementation;

• acting as a consultant on request in the employee’s own area of proficiency; for the purpose of facilitating the provision of quality nursing care;

• delivering direct and comprehensive nursing care to a specific group of patients or clients with complex nursing care needs, in a particular area of nursing practice within a practice setting;

• coordinating, and ensuring the maintenance of standards of the nursing care of a specific group or population of patients or clients within a practice setting; and

• coordinating or managing nursing or multidisciplinary service teams providing acute nursing and community services.

(ii) Duties of a Nurse Manager will substantially include, but are not confined to:

• providing leadership and role modelling, in collaboration with others including the Clinical nurse consultant and the Nurse educator, particularly in the areas of action research and quality assurance programs;

• staff selection and education;

• allocation and rostering of staff;

• occupational health;

• initiation and evaluation of research related to staff and resource management;

• participating in policy development and implementation;

• acting as a consultant on request in the employee’s own area of proficiency (for the purpose of facilitating the provision of quality nursing care);

• being accountable for the management of human and material resources within a specified span of control, including the development and evaluation of staffing methodologies; and

• managing financial matters, budget preparation and cost control in respect of nursing within that span of control.

(iii) Duties of a Nurse Educator will substantially include, but are not confined to:

• providing leadership and role modelling, in collaboration with others including the Clinical nurse consultant and the Nurse manager, particularly in the areas of action research;

• implementation and evaluation of staff education and development programs;

• staff selection;

• implementation and evaluation of patient or client education programs;

• participating in policy development and implementation;

• acting as a consultant on request in the employee’s own area of proficiency (for the purpose of facilitating the provision of quality nursing care); and

• being accountable for the assessment, planning, implementation and evaluation of nursing education and staff development programs for a specified population.

(Nurses Award, 2010)

Advanced Practice Registered Nurse

Advanced practice is not an employment classification or pay schedule, and is demonstrated though post graduate education, training and clinical experience allowing registered nurses to work to their full scope of practice within their clinical context. Advanced practice nurses possess the required skills, knowledge and experience to commence the Master of Nurse Practitioner program and work towards endorsement as a Nurse Practitioner.

(Fact sheet: Advanced nursing practice and specialty areas within nursing)

NATIONAL PRACTICE STANDARDS Australian Nursing and Midwifery Federation Standards funded by the Australian Government Department of Health 2014

This document was mapped against the National competency standards for the registered nurse 2006 and is now replaced by Fact sheet: Advanced nursing practice and specialty areas within nursing. However may still be useful in providing examples on how to contextualise Advanced Practice in General Practice Nursing.

How do I become Advanced Practice to prepare for Nurse Practitioner Endorsement?

The Registration standard: Endorsement as a nurse practitioner (the registration standard) state that a nurse seeking endorsement as an NP must be able to demonstrate the following:

Current general registration as an RN in Australia with no conditions or undertakings on their registration relating to unsatisfactory professional performance or unprofessional conduct.
The equivalent of three years’ (5,000 hours) full-time experience at an advanced practice level, within the past six years, from the date when the application seeking endorsement as an NP is received by the NMBA. (Note: Advanced practice hours that are part of an NMBA-approved program of study cannot be included as evidence towards the 5,000 hours of advanced practice
Successful completion of:
- Pathway 1: an NMBA-approved program of study leading to endorsement as an NP, or
- Pathway 2: a program that is substantially equivalent to an NMBA-approved program of study leading to endorsement as an NP, as determined by the NMBA.
Compliance with the NMBA Nurse practitioner standards for practice.

Continum of Novice to Advanced Practice (recommendation):

Bachelor of Nursing or registered as a Division 1 Nurse on AHPRA
12 months TPPP (recommended, not mandatory)
2 years in a specialty field (can include TPP)
Graduate Certificate/Diploma in your specialty field or education and/or study relevant to specialist area of practice (target area for endorsement)
2-3 years Advanced practice in this specialty field (target area for endorsement)
Master of Nurse Practitioner (target area for endorsement)
5000+ hours of Advanced Practice in the same specialty field (target area for endorsement)

Common Specialty fields include:

Ageing and Palliative Care
Chronic and Complex Care
Child and Family Health Care
Emergency and Acute Care
Mental Health Care
Primary Health Care (General Practice, Prision, Dermatology, Womens/Sexual Health, Diabetes, etc)

(ACNP)

A 'Generalist' Advanced Practice Nurse or Nurse Practitioner may work across all specialty fields, levels of healthcare including primary, secondary and tertiary care and different settings (GP, specialist, OPD, aged care, acute care). The most common type of 'Generalist' Advanced Practice Nurse or Nurse Practitioner is categorised as 'Remote and Rural'.

The 'Generalist' Nurse Practitioner scope and definition is not currently clear and has no exact criteria for endorsement. This 'Generalist' Nurse Practitioner endorsement process has been a struggle for many nurses attempting to receive endorsement.

'Generalist practice encompasses a comprehensive spectrum of activities. It is directed towards a diversity of people with different health needs, takes place in a wide range of health care settings, and it is reflective of a broad range of knowledge and skills. Generalist practice may occur at any point on a continuum from novice to advanced.'

Currently ther is a governmental push towards Generalist Nurse Practitioners in Primary Health Care to improve access to care and reduce the burdon on the hospital systems. For Nurse Practitioners to provide comprehensive care to patients they require a broad 'Generalist' scope of practice especially for Nurse Practitioners working in General Practice or Nurse Led Clinics.

'South Australians will have more options for free primary health care as part of a new pilot program expanding the number of nurse practitioners working in GP clinics, which will also help ease pressure on busy emergency departments.'

- The Hon Mark Butler MP

"To allow NPs to best address these health needs, research highlights the need for Australian NP education to pivot toward a more generalist focus. This allows a broader scope of practice rather than a narrow and specialised skillset."

- Nurse Practitioner Workforce Plan

Some other helpful resources in understanding the Advanced Practice Generalist Nurse and Generalist Nurse Practitioner include;

The National Rural and Remote Nursing Generalist Framework 2023-2027 Rural Nurse Practitioners A framework for services and training in NSW Health

QUT: the australian advanced practice nursing self-appraisal tool

APNA: A framework for Advancing general practice nursing (Novice - Advanced RN in General Practice - Nurse Practitioner)