Southeast Missouri State University



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The Nature of Advanced Practice Nursing

Kathleen Oberle, PhD, RN

Marion Allen, PhD, RN

In attempting to define "advanced practice," we argue that nursing as such is teleological or goal directed with those goals being defined by the patient or client in interaction with the nurse. In helping the patient meet identified goals, the nurse requires 2 kinds of knowledge-general and particular. General includes theory (know what/why), pattern recognition (know what), and practical knowledge (know how). Particular (know who) is personal knowledge about the patient. The advanced practice nurse, by virtue of graduate education, is able to move beyond the familiar and experientially learned. He or she makes a deliberate attempt to situate self in a dialectic between general and particular knowledge in such a way that the interplay opens possibilities. Knowing when a particular action would be most helpful is defined as practical wisdom. We argue that a highly developed sense of practical wisdom is the hallmark of advanced practice.

DEFINING THE ISSUE

The term "advanced practice nursing" first appeared in nursing indexes in the 1980s. Since that time, there has been a growing amount of literature on the subject, with more than 8000 articles and numerous books devoted to it. l-3 Nonetheless, as faculty members teaching in master's programs that purport to prepare advanced practice nurses (APNs), we wondered about the adequacy of our reply when students ask about the defining features of advanced practice. In our view, definitions offered in the literature fall somewhat short of capturing its essence and often fail to distinguish it from expert practice. Instead, most of the extant literature deals with roles of the APN such as clinical nurse specialist and nurse practitioner, detailing elements of those roles, and the characteristics of the nurses who will fill the roles,45 rather than defining characteristics of the practice itself. This lack of clarity and definition is reflected in Styles' call for further work "to clarify and harmonize the conceptual basis of advanced nursing practice."6

Kathleen Oberle is an associate professor for the Faculty of Nursing, University of Calgary Alberta, Canada.

Marion Allen is a professor for the Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.

Nurs Outlook 2001;49:148-53.

Copyright © 2001 by Mosby, Inc.

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148 Oberle and Allen

Other confusion arises from the movement in curricula and conceptualizations about nursingg-12 away from an "expert model." The suggestion is that thinking of the nurse as an expert leads to objectification and oppression of clients. Instead, nurses and students are encouraged to think of the client as expert in his or her own experience, and as equal partner in the health/illness experience, which leads to questions about whether one ought to talk about such a thing as expert nursing practice. Much of this literature seems to suggest that nursing expertise unfolds primarily in relational communication. Yet when one examines the literature on advanced practice, most of the descriptors appear to reflect skills acquisition and critical thinking abilities. Thus students find themselves confused by an apparent conflict. Also, conceptualizations of nursing as such are scarce in the description of advanced practice, which raises yet another issue for students. They question the relationship between conceptual frameworks and advanced practice, and whether such frameworks can and should inform that practice in some meaningful way.

The purposes of this article are to explore some of the issues raised above and to present a model of advanced practice nursing that may prove useful in addressing these issues. In addition to helping students and faculty derive responses to conceptual conundrums, the model may help those persons in advanced practice roles to articulate the unique characteristics of their work and provide nursing administrators and members of other disciplines with a framework for understanding what is to be expected from an APN.

DIRECTIONS IN THE LITERATURE

In seeking an articulation of advanced practice nursing it seemed reasonable to expect that writings in nursing theory and nursing philosophy would be helpful. However, with the myriad of conceptual frameworks13n4 and evidence of considerable debate among nursing scholars as to the nature, object, and scope of nursing,15 this literature served more to confuse than to clarify. Controversies dominating the literature include whether nursing is an art or a science (or neither, or both),1G what syntactical structures (research methodologies and "truth" criteria used within the discipline) are most appropriate for generating nursing knowledge, l ~~ 18 the relationship between theory and practice, 19 and ontological and epistemological considerations.2o-25 Many of these debates seem to have spun out of recent developments in nursing theory and the

schism between what have been dubbed the "totality" and "simultaneity" paradigms. Parse8 characterized the differences between the 2 paradigms as follows:

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...totality paradigm frameworks and theories are more closely aligned with the medical model tradition ...concerned with ...promotion and maintenance of health and prevention of illness. They have specific regimes and goals to bring about change that they believe to be best for the people they serve ...the simultaneity paradigm holds as primary, persons' perspectives of their health situations and their ...desires to change. Thus, there are no specific regimes and goals established to meet societal norms.

Such apparently different world views naturally lead to questions about the nature of practice and the kinds of knowledge needed to inform practice, which leaves open to debate questions of what the APN needs to do and know.

There is a strong theme running through the simultaneity literature that "nurse as expert" is a paternalistic notions carried over from the totality paradigm and as such should be eliminated from nursing thought. At first this seems incompatible with notions of nursing expertise. According to Parses

since nursing is not to involve "specific regimes and goals," nursing knowledge is instead about "bearing witness as persons ...choose ways of changing health patterns." Again, notions of levels of practice are absent from this conceptualization. Moreover, there is almost no discussion in the simultaneity literature on practical skills or the importance of biologic nursing knowledge.26-28 One could presume that advanced practice, if such a thing exists, entails knowing how to more effectively contact and share the patient's experience or to facilitate interaction with the environment.

In reviewing those conceptualizations designated by Parses as belonging to the totality paradigm, we discovered some evidence of consideration of advanced practice. Orem,29 for example, used the term "advanced nursing practitioner" to designate nurses who work in governing and leadership roles and to differentiate nurses prepared at a university level from those nurses prepared at the associate degree or diploma level. She noted that nurses, after experience in nursing practice situations, can, through graduate education, move to an expert level of clinical nursing practice and to specialization, but did not specify the knowledge and skills required. One can infer from her writing about professional education that she would expect advanced level nurses not only to have up-to-date knowledge of scientific, technologic, and nursing practice developments, but also to contribute to the growth of nursing knowledge.

Despite the limited dialogue about practice levels in the philosophic and theoretical work described above, there is a considerable body of literature on nursing expertise, and there seems to be some agreement as to the kinds of characteristics expert nurses should possess. According to Benner et al^30 expert practice is experientially learned and characterized by excellent practical reasoning, pattern recognition, embodied know-how, skill of involvement with patients, the ability to manage technology, and the ability to work with and through patients. Jasper^31 defined an expert nurse as one who "has developed the capacity for pattern recognition through a high level of knowledge and skill, and extensive experience in a specialist field, and who is identified as such by her [sic] peers." The ability to work from an intuitive base has also been seen as a characteristic of an

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expert nurse,30,32,33 although English34 suggested that what has been thought of as intuition is simply an ability, derived from experience and sound clinical and scientific knowledge, to respond to cues obtained through careful observation. This ability, he contends, is the hallmark of nursing expertise. Expert nurses have been described as being at the "pinnacle of performance in their discipline," 35 demonstrating quality decision making, adept psychomotor skills, intuition, knowledge, experience, and clinical specialization. Deliberative action, artful problem solving, ability to make inferences from a knowledge base, ability to separate relevant from irrelevant data, and ability to rapidly select relevant knowledge for problem solving have also been used as descriptors of expert practice.36

If expert nurses are at the "pinnacle of performance," how then does one differentiate advanced practice? Descriptors have been said to include knowledge and expertise, clinical judgment, skilled and self-initiated care, scholarly inquiry,6 comprehensive assessment and diagnostic skills, ability to critically analyze research, cooperation and collaboration with others, leadership, autonomous assessment skills, ability to make clinical decisions, ability to mesh theory and practice in a comprehensive and expert manner, collaboration with multidisciplinary teams, and leadership in research, education, and practice.^4 These descriptors sound very similar to those of expert practice, and one might ask whether advanced practice nursing is greater than, or distinct from, expert practice. In fact, some authors, such as Benner et al,30 have not distinguished between the two. Others have suggested that there are qualitative differences, and most have agreed that advanced practice entails, and thus subsumes, nursing expertise. In fact, competencies defined by Hamric^37 as necessary for advanced practice include the term "expert." These competencies include expert clinical practice, expert guidance and coaching skills, consultation, research skills including utilization, evaluation, and conduct, clinical and professional leadership, collaboration, change agent skills, and ethical decision-making skills. Thus, in Hamric's view, expertise is a necessary, but not sufficient, condition for advanced practice. She suggested the following definition:

Advanced practice is the application of an extended range of practical, theoretical, and research-based therapeutics to the phenomena experienced by patients within a specialized clinical area of the larger discipline of nursing.

To distinguish further between the 2 levels of practice, authors have pointed to such things as the kinds of knowledge possessed, role definition, and the types of problems with which nurses deal. Davies and Hughes^38 claimed that the difference is entailed in the depth and range of knowledge, anticipation of patient responses, judgment about nonclinical variables, clarity of clinical decisions, and the ability to articulate the rationale for practice. Calkin39 suggested that APNs can manage the fullest range of human responses that is closest to the range of potential responses, and that APNs rely less on intuition than do expert nurses, using instead more deliberation and conscious reasoning.

These distinctions are helpful, but they leave some questions unanswered. For example, are there essential differences

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in the way APNs relate to patients and approach and solve problems? How does expert knowledge differ from the knowledge of advanced practitioners, and is it used differently? How does one reconcile notions of "nurse as expert" with extant nursing philosophic and scientific theory, and how can advanced practice be informed by theory? There is general agreement that graduate education is a defining feature of advanced practice, 1,3 which begs the question, what is it that a student must learn in such a program to enable the transition from expert to advanced practitioner?

In attempting to address these issues, we will first present our understanding of the nature of nursing practice in general, as this provides the grounding for our ideas of advanced practice. Following that, we expand on and extend our ideas into a conceptualization of advanced practice. Our argument is grounded in a postpositivist, critical realist perspective that says that there is a real world driven by natural causes, but that it is not possible for humans truly to perceive it with their imperfect sensory and intellectual capabilities. However, one can arrive at probable truths through a variety of approaches.^40 These modest knowledge claims gain warrant through their correspondence with what is known of reality and perceptions of stakeholders about their usefulness as a basis for actionthat is, when they are supported by objective evidence, and when their argument is credible, coherent, and consensual.4o,41 Within this perspective we take the position that nursing is a societally mandated, socially constructed practice profession existing to serve a public that has certain expectations of nurses and nursing actions.

CONCEPTUALIZING NURSING PRACTICE

We believe that patients present to nurses seeking the kind of assistance that they, by virtue of disciplinary and experiential knowledge, can provide. Thus, clients are goal-oriented, and nursing is, by necessity, teleological, with the purpose of assisting others to reach their goals. Lauder,42 borrowing from Aristotle, suggested that the proper object of nursing ought to be "human flourishing," which goes beyond health; indeed, health becomes a resource for human flourishing. Accepting this notion, we submit that patient goals are related to human flourishing, of which health is an important part. Note that accepting human flourishing as the goal of nursing makes room for the kinds of care provided in the broadest sense to individuals, families, and communities.

Clients may have in mind specific objectives related to human flourishing when they seek nursing care, or they may require assistance in establishing particular goals. They look to nursing expertise (and experts) because of the knowledge base from which the nurse works, with the expectation that the nurse will assist them in moving toward their goals in the most expedient and effective way. That is not to say that nurses unthinkingly follow "specific regimes and goals established to meet societal norms"8; rather, they use nursing knowledge and expertise (which may include knowledge of particular regimes) to identify and implement processes that have a reasonable expectation of success. Actions are chosen, to the extent possible, with input from the patient or client. Certainly the nurse may assist

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patients in the particulars of goal definition and the direction that could be taken, since they may not have sufficient knowledge of what outcomes are probable, given certain actions. If they are unable to express their goals or needs (eg, in situations involving cognitive, impairment) and input from family or other' proxy decision makers is absent, the nurse will base actions on common understandings of what the patient would probably want if he or she could express a preference.

An important element in our understanding of nursing is the notion of praxis, which Chinn and Kramer43 defined as "thoughtful reflection and action that occur in synchrony." This they suggested is different from "practice" in that it is more creative and value grounded. Praxis requires a more selfconscious awareness of values and puts a greater emphasis on reflection. Another useful addition to our argument is supplied by Lauder,42 who wants us to distinguish between technical and practical questions in nursing. In his view, "technical question[s] force the nurse to judge the most effective and efficient actions that are likely to attain [human flourishing] . ...Practical question [s] ask how the nurse ought to act in relation to the client." The former are skills questions, the latter, ethics questions. We submit that both must be asked (and answered) by nurses proposing nursing actions. Thus, the notion of praxis speaks to the need to address simultaneously the technical and practical questions.

Nursing knowledge, then, is that which leads to answers to practical and technical questions, and must, of necessity, be about what matters to people, and must also enable human flourishing. Such knowledge can be general or particular. By general knowledge we mean shared patterns, as identified through experience and theory. By particular knowledge we mean personal knowledge of the individual or group for whom we are providing nursing care. General and particular knowledge of the sort needed by nurses is represented by these familiar terms: know how, know what, know why, know who, know that, and know when. All of these elements are present to some extent in every nursing encounter.

To elaborate, we believe that the client presents to the nurse with a problem or potential problem. On the basis of general knowledge, the nurse will, at that point, have a kind of understanding of the goal to be reached and will be able to generate 1 or more possible options for action that are recognized as having a probability of leading to that goal. The kinds of general knowledge brought to the encounter by the nurse include practical knowledge (or know how43), which includes psychomotor and procedural knowledge and skills as well as relational and communication skills; and pattern recognition (or know what), which enables the nurse to identify particular problems. Know how and know what are informed to some extent by theory, which is the form of general knowledge that provides descriptive and prescriptive information and enables the nurse to recognize universal patterns (descriptive theory) and to know why (prescriptive theory). However, given the lack of empirical support for much of nursing practice, a good deal of know how and pattern recognition must by necessity be experiential.

However, general knowledge alone is not enough if the needs of the client are to be met. Some particular knowledge

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Theory < General

(know whit why (Thesis)

Pattern Recognition

(know AN-11M)

Fr actical Kowledge

(know how)

Patient Client

Presenting

(_' oncern

Particular

(k1101\' who)

(Antithesis)

Figure 1. A conceptualization of advanced practice.

is required; otherwise the nurse is working exclusively from his or her own perspective rather than that of the client and might wrongly or incompletely define the goals and actions that are feasible and appropriate. Hence, the nurse needs, to some extent, to know who. This means having an understanding of meanings attached by the patient to the particular problem, the kinds of outcomes desired, and the kinds of actions that would be acceptable. Access to the particular is obtained through methods of connecting,44 such as gaining trust, establishing rapport, and the like. Communication skills are key.

Once the nurse has a clearer idea of what the client's goals might be, possibilities for action can be generated. The choice of action will be determined by the nurse's understanding of the situation, his or her range of available skills, and, to, varying extents, the patient's preference. This is the element we have termed "know that," to denote the nurse's knowing that a particular intervention is called for in this instance.

Here we employ another concept of Aristotle's as articulated by Lauder43-that of practical wisdom, which he says can be understood as follows:

[It] is a form of knowledge that can be claimed by those who purport to deal with human good...[it] ends ...in the actual performing of some action designed to produce good for fellow humans. These actions are taken only after the practically wise person decides, consciously or unconsciously, the most effective and morally right option.

From this we conclude that practical wisdom is that which informs nursing action and can be characterized as knowing when a particular action ought to be taken. It must be informed by praxis, that is, "thoughtful reflection and action," and nursing expertise entails the development of practical wisdom such that nursing actions are increasingly likely to lead to human good, defined in this case as human flourishing.

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Practical wisdom

(know when)

Telo

(human

flour ishing

'

As a nurse moves through levels of practice from novice to expert30 changes are seen in the degree of practical wisdom the nurse possesses. We agree with Lauder's42 position that practical wisdom cannot be gained only through theoretical knowledge; instead, it requires a link between thinking and doing, and, as such, practical knowledge and pattern recognition are foundational. Both are increased through experience such that the execution of interventions becomes more skillful, and the range of possible options for intervention (know that) is increased. In addition, with increased practical knowledge the nurse becomes more skillful at accessing personal or particular knowledge, enhancing goal definition, and increasing the probability that goals will be met. Thus expert practice is characterized by increasing practical wisdom as evidenced by considerable know how and pattern recognition, as well as the ability to link particular knowledge with general knowledge, which results in nursing care that is consistent with the descriptors of expertise outlined earlier in this article.

CONCEPTUALIZING ADVANCED PRACTICE

We now come to our argument about advanced practice. We take the position that advanced practice is essentially an extension of expert practice and is characterized by the highest level of practical wisdom. Thus the APN must first be an expert practitioner with well-developed practical knowledge and pattern recognition skills. The inherent difference between expert and advanced practice is that the expert nurse's knowledge base is largely experientially acquired, whereas the APN has a greater store of theoretical knowledge acquired through graduate study. Also, through senior clinical practica the APN has developed skills that increase access to the particular, namely, communication and relational skills.

To this point, then, one might understand that advanced practice is reflected primarily in enhanced theoretical and practice

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The Nature of Advanced Practice Nursing

Transforming

elf

Oberle and Allen

APN Trails, form aft ve

Education Practice

Ti-an;forllling

Practice

Figure 2. The transformative process.

ular knowledge, but there are additional elements. What characterizes the APN, and must be cultivated in advanced practice programs, is a disposition to situate oneself in a dialectic between the general and the particular. That is, the APN makes a deliberate attempt to bring theoretical, practical, and particular knowledge together such that the interplay opens possibilities. As well, by attending to the personal, by knowing who, the nurse at once becomes aware of, and assists clients to become aware of and to construct meaning in their experience. Thus the APN is able to move beyond the familiar and experientially learned. Goals can be more clearly defined, and more (and/or potentially more effective) options for intervention can be generated. The result, then, is a more refined sense of know that. Once the options have been generated, the nurse (and patient) must choose those options which seem most likely to lead to the patient's preferred outcome. The nurse must know when a particular action would be most appropriate and helpful, that is, he or she must demonstrate practical wisdom, the possession of which is a necessity in provision of the kind of care that is most likely to lead to human flourishing. Although all nurses have some amount of practical wisdom, it is accumulated and honed through clinical experience and enriched through the interplay of general and particular knowledge, that is, understanding of theory and awareness of the other. Development of the skills, knowledge, and attitude that lead to greater practical wisdom is thus the focus of advanced practice programs, and well-developed practical wisdom is hallmark of the advanced practice nurse (Figure 1).

How, then, is practical wisdom achieved in the context of a graduate program? Certainly, it requires development of a strong theoretical knowledge base and considerable practical experience to encourage integration of theory with practice (that is, to encourage praxis). It also involves reflection, not just on particular nursing actions and activities, but on nursing as a whole. Thus, the APN must develop and be able to articulate a conceptual framework that provides a kind of structure for reflection. Students have suggested that this movement into the dialectic leads to personal transformation as the nurse becomes increasingly aware of the possibilities that can be generated, and, by extension, the potential of nursing action. Personal growth and increasing awareness lead to a transformation of practice throughout the program. The ultimate result is what we have termed "transformative practice" (Figure 2), a practice that is generative and creative and transforms problems into possibilities.

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In summary, it is our contention that advanced practice in nursing is characterized by well-developed know how and know what (clinical expertise), extensive know why (theory base) and enhanced ability to access the theory base, and an enhanced ability (and intent) to access the know who (particular knowledge). The nurse's deliberate intent to situate self within the dialectic between the general and the particular, and the willingness and ability to be informed by that dialectic, results in an exquisite sense of know that. Finally, advanced practice is distinguished by well-developed practical wisdom, shaped by experience, and informed by supervised clinical practice and a theory base, which is best developed through a graduate program.

CONCLUSION

Earlier in this article we raised several questions about advanced practice nursing. Are there essential differences in the way APNs relate to clients and approach and solve problems? How does expert knowledge differ from the knowledge of advanced practitioners, and is it used differently? How does one reconcile notions of "nurse as expert" with extant nursing theory? And how can advanced practice be informed by nursing theory? We have argued that these is, indeed, a qualitative difference between expert and advanced practice that is realized in a dialectic between general and particular knowledge. The APN brings together these 2 kinds of knowledge in a synthesis that is deliberative, generative, and transformative. The ability to create such a synthesis requires expert knowledge but goes beyond the known to create new possibilities. Thus it requires active reflection that yields action, characterized as praxis. Praxis involves choice; knowing when a particular choice is best is the practical wisdom that typifies advanced practice. Problem solving and critical thinking in advanced practice, as compared with expert practice, demand a greater access to both theoretical knowledge and knowledge of the particular, the knowing

who. Constructed and expressed meanings form a basis for much of the critical reflection that leads to action.

What conceptualizations of nursing, as philosophic theo

ries,45 offer advanced practice is a clearer understanding, not of the specifics of such practice, but of its nature, object,' and scope. Thus, in adopting a particular conceptualization as a

I basis for practice the APN must have a clear idea of how these

3 aspects are defined within that conceptualization. We have argued in this article that the nature of advanced practice teleologic and that its object is human flourishing. The $60 is related to health and illness. These notions could be cons' T,4

is v

ale'

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tent .with many of the extent conceptualizations of nursing, but they might be inconsistent with some. For example, our ideas diverge from many of those in the simultaneity paradigm because we suggest a direct relationship between thinking and doing: the notion of acting to produce universal good (telos). Note, however, that the dialectic in our model predicates against means-end relationships of the sort to which the simultaneity theorist objects. Instead, particular goals evolve and develop as the nurse and patient reflect, consider, and construct new meanings. Thus, one might find congruencies between our model and the simultaneity paradigm. We leave it to the judicious reader to explore further the relationships between our ideas and any one of the many conceptualizations of nursing. Perhaps a more important question is whether our model of advanced practice is consistent with the reality of clinical nursing. Ours is a critical realist approach, and inherent in such an approach is the necessity of putting one's ideas forward for public scrutiny. It is only through dialogue that the claims of our ideas can be examined and challenged. We invite the reader to construct such a challenge.

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