Toronto Canada September 17-20

Approximately 650 delegates from 31 countries travelled to the Westin Harbour Castle in Toronto, Canada late in September 2008 for the 5th International Council of Nurses International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) Conference.

Although different countries describe the role of advance practice nurses (APN) differently: ranging from Clinical Nurse Specialist to Nurse Practitioner, there is a universal definition of what the role is:

An umbrella term describing an advanced level of nursing practice that maximises the use of graduate educational preparation, in-depth nursing knowledge and expertise in meeting the health care needs of individuals, families, groups, communities and populations.

With this in mind, the conference was an opportunity for celebrating nursing achievements and unifying a belief in our profession that we can build on for the future.

The most significant features/papers of the conference

This conference highlighted the political framework that has the potential to enhance and impede the progression of advanced nursing practice if not managed well. It was an amazing experience to listen to so many highly passionate and motivated nurses forging ahead with their commitment to primary health care.

Many of the presentations espoused the importance of prevention and early identification for commencing treatment. This role is clearly well suited to Nurse Practitioners who have a strong understanding and knowledge in illness, psychosocial issues and recovery. Many of the presentations on clinical matters were guided by evidence based practice. Advance practice nurses and Nurse Practitioners demonstrated their clinical expertise through a structured evaluation process such as the PEPPA (Participatory, Evidencebased, Patient-centred Process for the Advanced practice nursing role) framework, or through randomised control trials relating to a treatment intervention.

It was quite a challenge not to become overwhelmed as speakers described the torture and trauma experienced by women in Africa. Hearing how terminology such as "vaginal destruction" has been introduced into our language, and how often the damage is irreparable; the despair that the HIV-infected women of Zimbabwe experience and the ethical dilemmas faced by the nurses was very moving.

The opening and closing address by the keynote speakers were outstanding. Their inspirational address stressed the importance of collaboration and mentorship so those patient outcomes can be optimised.

The conference highlighted the rapid expansion of APN roles over the last decade. The experiences in different countries portrayed how APN roles emerged as a result of the need to contain costs, improve access to care, decrease waiting times, serve the underprivileged and maintain health across various specialties.

Comparing the development of APN roles between countries was very interesting. It seemed that developing roles is easier where postgraduate nursing education exist such as Hong Kong, Singapore, Australia, United Kingdom and the USA. Although Africa has APNs, it was clear listening to presenters that the demand for such experienced nurses is significantly greater than what is available.

Although the evolution of APN/NP roles differs in each country, strong similarities exist: a focus on primary health care, roles in the community, hospital and longterm settings, caring for people who are disenfranchised, poor, elderly and those with chronic illness. It became clear as the conference progressed that the current global crisis provides an opportunity for APN/NPs to develop policy, clinical expertise and educational programs aimed at meeting the needs of the health care system.

I attended a workshop on how to evaluate advanced nursing practice that I found quite useful. The workshop described the PEPPA framework. This is a methodical 8-step process to guide role with a collaborative approach. I have provided the algorithm of the process as Appendix A for your interest.

The workshop described the benefits of a systematic approach and highlighted some limitations. It is interesting to note that while collaboration is highlighted, the need for stakeholder support is also seen as a limitation, particularly if the stakeholder has a particular biased or prejudiced view of the role. It suggests that nursing roles can only be developed if other health disciplines are in agreement. However, I think it signifies how respectful nurses are of how their role fits in with the entire health service delivery and how we see our role within the structure.

As such, I think this approach provides the opportunity for nurses to articulate and showcase their potential and expertise, so that the other health disciplines understand they need advance practice nurses/Nurse Practitioners on their team.

Nursing clinics

There were a number of papers and posters on the area of nursing clinics. I got the impression that the USA lead the way in this area. There was one interesting paper on retail clinics. I was quite curious as to what the term meant, and soon discovered that some retail centres have a health clinic staffed by APN/NPs who are able to conduct a primary health care check during the person's shopping day.

Nurse Practitioners with primary health care focus in medical centres.

The role of collaboration was highly emphasised throughout the conference. Having a primary health care model within multidisciplinary centres has demonstrated how NPs are utilised to their full scope of practice. The limitations of hospital settings with prescribing limitations and restrictions placed upon the role from other disciplines did not sound apparent in the multidisciplinary centres where there was a mutual respect for the role of each member.

Benefits of informal interchanges with other participants at the conference

Sharing views on approaches to care, interventions, how the role is utilised and received within different health care systems and cultures was quite interesting. I am surprised by the similarity of impediments and resistance from other health disciplines, particularly around the areas of nurse prescribing.

I feel that I have a better understanding of healthcare delivery in disadvantaged countries. Also, I believe that I have developed a greater appreciation of our educational opportunities and clinical standards in NSW and Australia.

Evaluation of the experiences derived from the conference

Overall, the conference was an extraordinary experience. Being a member of a highly qualified and highly skilled network is very rewarding. There were many positive experiences as outlined in this document.

There was very little to be critical of. There was a good balance of educational frameworks, policy direction, clinical papers and discussion panels that made the conference both informative and worthwhile. I am now much more aware of the global
network with is working very hard to improve standards of care, and demonstrate the role of APN/ NPs in that structure.

The most senior mental health clinicians in attendance were from Australia. Nevertheless, educators and researchers from other specialty areas were present and this was very productive as I could listen to their views on the future of nursing and transfer these ideas to the mental health specialty.

Summary

There is a unity forming within the nursing profession in developing APN/NP roles internationally. I believe that I have a better understanding of three key areas. Firstly, how the various professional nursing organisations internationally collaborate and liaise with World Health Organisation. Secondly, how the educators, policy writers, clinicians work together in each country to improve standards of service delivery. Lastly, how the clinician themselves demonstrates their expertise has fostered an optimism that the future of nursing can continue to evolve to meet the needs of our patients.

Elaine Ford
Nurse Practitioner, Mental Health
Consultation-Liaison Psychiatry, Westmead Hospital
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