Developing the Advanced Practice Nurse in Catalonia

The development of advanced practice nurses (APN) has proved a challenge for nurses in countries such as the USA, Canada, Great Britain, and Australia among others. It is only in recent years that the system has been considered in Catalonia and Spain as a way to develop new roles to bring effectiveness and effi ciency to the health system. From the standpoint of training and implementation of the above-mentioned new nursing roles, the following article aims to conceptualise APN and its reference models, as well as to contextualise and refl ect on APN in Catalonia in order to assimilate them into advanced practice. Descriptors: Advanced Practice Nursing, Nurse’s Role, Clinical Competence, Professional Practice, Nursing. RESUMEN El desarrollo de la enfermera de práctica avanzada (EPA) ha supuesto un reto para las enfermeras en países como EE.UU., Canadá, Gran Bretaña y Australia, entre otros, y desde hace escasos años está siendo considerada en Catalunya y España como un sistema para desarrollar nuevos roles que aporten efi cacia y efi ciencia al sistema sanitario. El presente artículo pretende conceptualizar la EPA y los modelos de referencia así como contextualizar y refl exionar sobre la EPA en Catalunya, desde el punto de vista de formación y de la implantación de los denominados nuevos roles de enfermería, asimilándolos a la práctica avanzada. Descriptores: Enfermería de Práctica Avanzada; Rol de la Enfermera; Competencia Clínica; Práctica Profesional; Enfermería. RESUMO O desenvolvimento da prática de enfermagem avançada (PEA) constitui um desafi o para enfermeiras de países como os Estados Unidos da América, do Canadá, Reino Unido e da Austrália. Sendo na Espanha e na Catalunha, desde alguns anos, um sistema que permite a formação de novas competências na enfermagem em prol da efi ciência e efi cácia do sistema sanitário. O presente artigo pretende defi nir a PEA e seus modelos de referência, da mesma forma que espera contextualizar e refl etir em relação a PEA na Catalunha, enquanto processo de formação e inserção das novas competências e responsabilidades da prática de enfermagem avançada. Descritores: Prática Avançada Enfermagen; Papel do Profi ssional de Enfermagem; Competência Clínica; Prática Profi ssional; Enfermagem. Developing the Advanced Practice Nurse in Catalonia Construcción de la enfermera de práctica avanzada en Catalunya (España) A construção da Prática de Enfermagem Avançada da Catalunha (Espanha) REFLECTION Montserrat Comellas-Oliva E-mail: montsecomellas@euit.fdsll.cat CORRESPONDING AUTHOR


INTRODUCTION
The nursing profession in developed countries is currently going through an important change, not only in standards and training programmes, but also in clinical practice.New roles and competences are being developed in the nursing field due to population changes and the need to readjust the approach to healthcare, as well as the need to make healthcare services more efficient.These make up just some of the reasons as to why the nursing profession must readjust to population needs and healthcare system objectives.
Drawing from models that encourage focused practice, knowledge, and clinical skills in specific care fields, for many years various countries such as the USA, Canada, the United Kingdom, and Australia, among others, have firmly backed the development of advanced practice nurses (APN).In this context, advanced practice (AP) has given a helping hand to new roles, contributed to quality service and at the same time is more cost effective for the health service as a whole.
Catalonia is an autonomous region in Spain which in recent years has begun to generate and adapt new roles and competences in nursing in such a way that they aid in the creation of a more cost-effective system.This requires us not only to expand upon competences, training, independence, authority, and leadership, but it also requires a firm commitment, adapted to the legislative and training framework for AP nursing.
This reflective article has been achieved using the framework for a study that is being carried out in order to understand APN competences in the context of Catalonian healthcare, the aim of which is, from the standpoint of training and implementation of the above-mentioned new nursing roles, to conceptualise APN and its reference models, as well as contextualise and reflect on APN in Catalonia in order to assimilate these models into advanced practice.

CONCEPTUALISATION OF ADVANCED PRACTICE
According to a review by Mantzoukas and Watkinson (1) , the APN concept came to light at the beginning of the twentieth century in the United States due to socio-political and professional forces, and began as a form of specialisation.
Patterson and Haddad (2) state that the APN concept emerged at the end of the Sixties in the USA, followed by Canada and the United Kingdom at the beginning of the Eighties.From the 1980s it began to be published in journals, and since then an increasing amount of scientific literature has followed, including almost 8,000 articles and various books on the subject (3) .
The American Nurses Association (ANA) (4) defines APN as having specialised clinical knowledge and skills through completing a master's or doctoral degree, which prepares students for specialisation and increased knowledge and progress within the profession.The specialisation is limited to or concentrated within one area of nursing.An increased knowledge refers to gaining new expertise and practical skills.This includes gaining the knowledge and skills to be able to work independently within the increasingly stretched limits of the traditional medical profession.Progress in this part of postgraduate nursing training includes both specialising and an increase in knowledge.This is categorised by internalising theoretical and practical knowledge that is based on investigation.
The Canadian Nurses Association (CNA) (5) , defines APN as a generic term to describe an advanced level of nursing practice in which the use of postgraduate education as well as experience and a profound knowledge is maximised to address individual, family, group, and community health needs.
CNA (5) believes that advanced practice nurses have the training, clinical experience, leadership skills, and understanding of organisations.These nurses play an important role in healthcare policy and make decisions that affect the results of both the system and patient healthcare.Building upon a nurse's knowledge helps advance the nursing profession, which broadly and effectively contributes to the healthcare system.APN nurses improve healthcare in a timely, accessible, cost-effective, and high-quality manner for all Canadians.
The International Council of Nurses (ICN) (6) , on their part, defines nurse practitioners/advances nurse practitioners as: Specialist nurses who have acquired the beginnings of expert knowledge, the skill to make complex decisions and the necessary clinical skills to carry out the profession.These characteristics result from context and the country in which the nurse is accredited to practice.To enter into the profession an intermediate-level university qualification is recommended.

REFERENCE MODELS
Various proposals have been put forward to explain the conceptual model of APN in order to place it firmly within the general nursing context.One of the forerunners to explain this was Patricia Benner from the University of California, who in 1984 published her book, From Novice to Expert (7) .As a result of her research, she describes the conduct nurses acquire in clinical practice, starting from the role of apprentice.A nurse may or may not achieve different levels before achieving the highest level, which Benner name as "expert".However, the knowledge and skills that nurses must obtain to qualify as experts come from clinical practice, dealing with many different clinical situations, and through reflective reasoning and analysis.
From the authors who have followed Benner's progressive practice principles, and those who have defined an AP model, both the Oberle and Allen and Ann B. Hamric models will be highlighted throughout this article, due to their importance in this reflection.
In the Oberle and Allen model, AP is an extension of expert practice and is characterised by having a higher practical knowledge, meaning that a nurse is highly skilled at individualising care.The inherent difference between an expert by experience and an APN nurse is primarily that a nurse must already be an expert and have a good practical knowledge and skills in order to later achieve further theoretical and integrated knowledge through theory and practice by completing postgraduate studies.
Hamric (8) , has summarised an integrated AP model published in 1996 and updated it with subsequent publications.In it a conceptual definition of APN is proposed and includes: Developing the Advanced Practice Nurse in Catalonia Comellas-Oliva M.
1) Primary Criteria: those criteria that must be fulfilled before a nurse can be considered an APN (the attainment of a master's degree in advanced practice nursing in a specific specialisation, possession of a specialised national advanced practice certificate, and complete work experience focusing on the patient and family) 2) Nuclear Skills: in which clinical practice is considered the "core competence" and includes six characteristics: using a holistic perspective; education in therapeutic patient cooperation; using expert clinical thinking; using reflective practice; using evidence as a guide to practice; and using diverse theoretical approaches for health and illness management.The other "additional competences" are: to be an expert in coaching, at the same time as guiding patients, families and other healthcare providers; to be interested in research; fulfil clinical leadership; take part in collaborative practice and put making ethical decisions into practice 3) Finally, Hamric, exposes the critical elements that are not specifically part of the definition of practice but, however, have a large impact on the daily progress and management of APN.These are related to health policies, management and organisation, and performance improvement.

TRAINING AND LEGISLATIVE FRAMEWORK FOR NURSING IN CATALONIA
Nurses' training in Spain has gone through a curriculum change due to the Ley Orgánica de Universidades (The Spanish Organic Law for Universities [LOU]) (9) .This change was made adapt to the European Higher Education Area, meaning that the three-year university diploma in nursing changed to the current four-year undergraduate degree in nursing, achieving a high-competence level in clinical nursing as well as developing competences in research and methodology.
In the last few decades, postgraduate or master's university studies have been the most important for specialisation and acquiring area-specific clinical competences.With the curriculum change in place, nurses nowadays can easily access master's and doctorate studies.
Furthermore, in 2005 the Real Decreto (Royal Decree) on Nursing Specialisations (10) stated the following seven specialities: Obstetrician/Gynaecologist; Paediatric; Mental Health; Primary and Community Nursing; Geriatric; Medical-Surgical; and Work-Related healthcare nursing.These specialities are regulated by the Ministerio de Sanidad (Healthcare Ministry) and are achieved by taking part in a two-year residence in a multi-professional teaching centre.Once the specialisation has been completed it is possible to directly access a doctorate programme.
This legislative framework, which enlarges basic training, has some limitations in order to develop AP nursing, such as the prohibition of nurses from prescribing (drugs and healthcare material) as well as the lack of legislation surrounding the allowance of hospital discharges by nurses.
Despite the efforts by nurses to allow nursing professionals to write prescriptions, the Real Decreto (Royal Decree) of October 2015 (11) , leaves prescriptions out of nursing competences and only recognises the competence of explaining or dispensing medicines if previously accredited.This can be done after the person prescribing has performed a medical diagnosis, which then leaves out the very competence for explaining or dispensing medicines after issuing a nursing diagnosis.On the other hand, in 2009 El Sistema Sanitario Público de la Comunidad Autónoma de Andalucía (the Public Healthcare Services of the Autonomous Region of Andalusia) approved a regulation that allowed Andalusian nurses to individually and collaboratively prescribe pharmacological treatments when linked to healthcare cases (12) .In the same way, in Catalonia in July 2015, the Departament de Salut de la Generalitat de Catalunya (the Healthcare Department of the Catalonian Government) and Els Collegis Oficials d'Infermeres i Infermersde Barcelona, Tarragona, Lleida i Girona (the Nursing Colleges of Barcelona, Tarragona, Lleida, and Girona) laid the foundations so that nursing professionals could prescribe medication and committed to allowing nursing prescription-writing in the following months (13) .

ADVANCED PRACTICE AND NURSING ROLES
The concept of "role" is used to better explain the AP of the nurse.Authors such as Reveley and Walsh (14) , argue for the need to develop new roles and prepare nurses to work at the absolute limit, at higher levels than in traditional practice.
The role is the main way to identify AP nurses in Catalonia, assimilating AP professionals into "new roles" that, up until now, were not easily identified in the professional nursing arena.
For many years, roles that could be considered AP roles have existed and were developed by the so-called "clinical nurses".These nurses are dedicated to specific fields of care, such as nosocomial/hospital-acquired infection nurses, pressure sore nurses, ostomy, or diabetes nurses, and are characterised by having a high level of theoretical knowledge and practical skills.These roles were implemented in a vast majority of hospitals.According to Ridao (15) , these nurses act in the clinical process of hospitalisation and out-patient care by performing initial and continued evaluation, proactive intervention, assessment of the attending nurse, complex care, patient education, discharge preparation, and continued healthcare.
Along with the new roles and associated with the case management model, roles aimed at answering the needs of the ageing population are also emerging.A forerunner role for case management was the so-called "liaison nurse" who worked with a wide selection of patients before hospital discharge and who worked and coordinated well in different areas, institutions, and departments (16) .
In 2010 a document calling for the application of case management in primary care was published by the Institut Català de la Salut (Catalan Health Institute [ICS]) (17) , and from 2011-2015 the Pla de Salut (Healthcare Plan) (18) proposed a more integrated system for chronic patients, responding to population needs and making the healthcare system more efficient.In order to do this, the Programa de prevenció i atenció a la cronicitat (19) (Programme for the Prevention of and Support for Chronicity) has been developed and implemented.This guides the casemanagement model to detect and assist high-dependence and/ or complex-case patients, as well as high-risk home situations, and pinpoints the nursing case-management professional on the map of healthcare resources (20) .
There are many experiments that are being carried out through the case-management perspective, from experiments on primary/community care, to nurses exhaustively following chronic patients with advanced illnesses and managing all of their care to avoid flare-ups, overlaps, transfers, and hospital admittances, as well as case-management nurses who work in emergency services in hospitals, going over cases and forwarding them to the most appropriate unit.They also work in day-surgery and conventional hospitals, proactively acting to avoid complications, and educate patients and families, all whilst coordinating discharges with other units.
The main responsibility of case-management nurses is to, as the name states, "manage care," although they do also take part in clinical practice; as they usually care for a specific type of patient, they are very well prepared to evaluate and treat them.From specialising in a certain group of patients, they may receive various names such as management nurse for patients with cardiac insufficiency, management nurse for patients with chronic obstructive pulmonary disease, nurse for frail patients, and management nurse for patients with complex chronic illnesses, among others.
Other roles in the "transition role" are those which were traditionally carried out by doctors but which have begun to be done by nurses.This is the case for perianaesthesia nurses who carry out the preoperative anaesthetic consultation and, although they have been trained for the competences to do it, this role is often difficult because role conflicts can arise between doctors and nurses.
In that case, are these all AP roles?If we consider the definitions by ANA and CNA, these nurses have knowledge and clinical skills that are specialised to a specific area of care or type of patient.Therefore, does knowledge assimilation happen through scientific evidence or research?In reality it is nurses with specific postgraduate training and with a high level of clinical expertise who, along with team-leadership recognition, have been able to access these positions.
If we consider the definition of the ICN, it is specialist nurses, "specialist" meaning those who have theoretical and practical knowledge of a specific patient type, which enables complex decision-making and the ability to go further than what is possible in the traditional nursing role.
On the other hand, looking at the above-mentioned models, it seems to be clear that they draw from a proficient or expert level that can be seen in Benner's model (7) , from which nurses can concentrate on a specific area of knowledge and patient-type by undertaking postgraduate training, where they can develop specific clinical competences.From there, according to Oberle and Allen's model (3) , it is possible to note that these types of nurses do take part in AP.They form an extension of expert practice, thanks to the integration of theoretical knowledge, practice, and the ability to individualise care.Looking at Hamric's model (8) we can conclude that AP nurses in Catalonia do carry out the core competence -direct clinical practice -although the additional competences and surrounding elements do need to be further studied.

FINAL CONSIDERATIONS
Although there is a political and professional interest in having nursing advance and take on new professional roles, the AP concept goes even further than the current implementations that are being produced.Some of the differentiating elements are: Postgraduate training, whilst considering specialities, it does not include sufficient competences and the learning results as described in AP models, such as reflective analysis, coaching, decision-making, and professional leadership, among others.
Whilst a certification or accreditation system for external or organisational AP nurses does not exist, it would be difficult to assure that nurses who choose health organisations for AP truly meet the required criteria.
In this way, the implementation of these competences in the daily clinical practice by case-management nurses shows that they have high clinical leadership skills in interdisciplinary teams, but do they reflectively analyse their cases?To what extent do they empower patients and families to help them advance in self-care?Do they make the correct decisions and make them by cooperating with other professional team members?Do they use evidence to improve care?Do they take part in and conduct research to improve nursing science?What results do their efforts have?
The barriers nurses face when they carry out these types of roles are of a different type; the most frequent barrier is the fact that prescribing is impossible due to the law.On top of that, on many occasions nurses are unable to make final decisions on their patients' healthcare, which in itself causes a continuous awkwardness between nursing staff and patients.
It is also true that nurses have traditionally carried out collaborative roles and very rarely or in fact never at all carried out roles in an autonomous manner.If it were not that way, we would probably not be discussing new competences or advanced competence.What is occurring is that new professional duties are being gained which up until now were unimaginable.Despite all the setbacks, nursing in Catalonia is advancing.