Restriction by advancement - The irony of advanced nursing practice in Ireland.

Abstract

Twenty years ago, a clinical career pathway for Advanced Nurse Practitioner (ANP) was first established in Ireland (Begley et al., 2010). This paved the way for expert nurses to optimize patient care through autonomous practice, professional and clinical leadership, and research. This change was not without its challenges for the profession. The first ANP student candidates began university education in September 2017 which is a welcome development. Time has passed, and more change is underway, particularly in relation to growing a critical mass of ANPs in Ireland which has resonance for the evolution of advanced nursing practitioners and advanced nursing practice worldwide. In a recent literature review, Fealy et al. (2018) identified important issues relating to the sustainability of the ANP role, illuminating barriers and enablers to its evolution. However, a focus group undertaken in Ireland found some different, yet equally contentious issues which we feel need expressing to further inform the debate. In November 2016, we invited a group of 14 stakeholders (ANPs from a variety of settings, nurse managers, MSc students and lecturing staff members, all with an interest in the ANP role) to discuss “where are we now and where are we going” in relation to advanced nursing practice and the ANP role in Ireland. The discussion that emerged was honest, stark and passionate. We were surprised to hear this from ANPs who are clearly at the peak of their career yet were clearly frustrated and restricted by virtue of their role. On the one hand, the enthusiasm for making a difference to practice and patient care was palpable as was the wisdom of those present. We conservatively estimated the collective nursing experience in the room to be at least 120 years. The depth and breadth of nursing experience was evident through the multiplicity of patient care exemplars provided which spanned several decades. Stories of good nursing practice were told passionately and with care. On the other hand, the stark restrictions and challenges voiced by ANPs were evident. We found that three key themes which emerged in the discussion related to: Restrictions, Stasis and Inconsistency, which are a far cry from the idealized notion of “advancement.” In Ireland, successfully completing 4 years of undergraduate training enables a newly Registered Nurse, potentially, to practice nursing around the world. However, ANPs in Ireland who have over a decade of clinical experience in our focus group discussion spoke about not being able to provide cover for an ANP colleague in another nearby hospital. Herein lies restriction by advancement. The immense pressure felt by some existing ANPs about this was strongly expressed. At present, ANPs in Ireland are technically “irreplacable” yet they are clearly “expendable” with one participant mentioning a colleague who left due to the pressure. The theme of “stasis” related to the voiced lack of “succession planning” for the future in areas where ANPs currently provide services. The inception of the ANP role in the late 1990s arose as a response to unrest within the Irish nursing profession where at the time, this was the only workable solution for the profession, service and society. The original “trailblazers” made history, were well supported by medical colleagues and challenged the scope of nursing practice irrevocably. The original group of ANPs are to be commended for initiating the journey of Advanced Nursing Practice. However, the criteria by which ANP career pathways were originally created cannot be replicated for the next generation, resulting in what we have termed “experts in stasis.” The recent initiative (Department of Health, 2017) to develop university trained ANPs (in Ireland this began in September 2017) is most welcome here as it represents a potential means by which ANPs can be produced which may potentially replace and expand the small pool of these valuable experts. Closely linked with stasis, was an expressed sense of insonsistency between meeting service needs (i.e., developing ANP staff members to meet population driven health needs) and meeting individual needs (i.e., desire for enhancement of an excellent nurse working at a high level in a particular area). The means whereby ANPs were recruited were not always clear cut across services either. In some places, it was almost impossible for managers to make a “business case” for an ANP as this would mean losing a medical staff member. Pockets of excellence in ANP service in practice were evident yet this was only in services where there was consultant support, management support, and individual canvassing of a “candidate” for a job. It was noted that candidate ANPs must actually prove that they are working at an ANP level (instead of being promoted into the role) which again can be potentially disempowering for ANPs who appear to continually have to prove themselves. Sensitivity to the evolving health needs of the population (e.g., chronic disease and comorbidity) was notably absent, which is in contrast to recent Irish Policy (Department of Health, 2017) which proposes that future ANP services are evidence-based, flexible and adaptive to the evolving healthcare population needs. Perhaps this was due in part to the “experts in stasis” phenomenon and the original means by which ANPs were appointed. The group also said that there remains disjointed understanding regarding the role of ANPs among nursing, medical, ancillary staff members and patients which is concerning. Although our group discussion was vibrant and illuminating, Ireland, as everyone knows, is a small country. Due to the small community of ANPs, participants became extremely concerned about the potential to be identified, which in itself was revealing of the fear they had of the ramifications of the contentious issues they raised. This led us to decide that an editorial piece, giving voice to the issues (benefitting the ANP community) surpassed our need to write a full article (which would benefit us as academics but cause potential concern to those who participated). It could be argued that perhaps their sheer identifiability (and concern with same) is yet another example of restriction by advancement. Some of the challenges voiced by our group will hopefully not be faced by their future counterparts. We hope that the themes raised by here provide another perspective regarding “on the ground” issues which need consideration in parallel to policy developments. It is hoped that the international readership will benefit from the Irish example realizing the need for continued critical evaluation regarding the creation and sustainability of expert roles among our invaluable nursing resource. Ethical permission for the study was granted by Dublin City University Research Ethics Committee in October 2016.