不要忘记高级护理实践中的领导力

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With an increasingly growing ageing population who require assessment and ongoing management of their complex health care needs, nursing as a profession has grown and evolved to meet these demands. Part of the changes in the nursing workforce include the development of advanced practice and the nurse practitioner role. The advanced practice role is now well established with evidence to demonstrate its effectiveness (Aitkenhead & Lee, 2019; Jennings, Lee, Chao, & Keating, 2009; Jennings et al., 2008; Lee et al., 2014, 2018). Advanced practice roles require advanced clinical assessment skills and the application of complex reasoning and critical thinking. Advanced practitioners make complex clinical decisions by applying the advanced knowledge and skills for each patient consultation, and they work closely in collaboration with colleagues, including physicians and allied health professionals. One study across 39 countries highlighted the movement of tasks from physicians to nurse practitioners in primary care; however, despite reforms in policy, the authors noted a lack of homogeneity in the tasks and the role with practice varying widely (Maier & Aiken, 2016). With this shift in roles in the workforce and the changing roles of nurses, there are now many nurse-led clinics managing patients and demonstrating the positive clinical outcomes that are comparable to medical colleagues (Connolly et al., 2017; Hendriks, Vrijhoef, Crijns, & Brunner-La Rocca, 2014; Qvist et al., 2016; Zhu, Liu, Hu, & Wang, 2015). Advanced practice roles are one of the largest expanding workforces, and no doubt, further development of the role will emerge over the next decade (Maier, Barnes, Aiken, & Busse, 2016).

Although the advanced practice role primarily focuses on delivering the clinical aspects of patient care, the other pillars of advanced practice (research, education and leadership/management) should not be overlooked as they are key to the success of the advanced practice role. Interestingly, the International Council of Nursing definition of nurse practitioners includes the importance of certain characteristics, ‘expert knowledge base, complex decision-making skills and clinical competencies’, but does not include the other pillars of advanced practice (International Council of Nurses, 2020).

The advanced practice role requires the application of relevant research and management knowledge and skills in order to provide efficient optimal clinical care and ensure implementation of evidence-based practice. What probably is not as well known or recognized is that advanced practice nurses often work at higher organisational levels acting as practice leaders, managing their own workload and working across professional, organisational, agency and system boundaries to improve services and develop practice. These management skills may be required for them to be able to effectively perform their role but may not be formally recognized as an important skill set. In a recent survey of registered nurses, the advanced practice role was valued by respondents; however, less than one third wished to become advanced practitioners (Woo, Zhou, Lim, & Tam, 2020). Within our university, we undertook focus groups with our master's advanced practice students examining whether they felt prepared for their role. The exploratory study revealed concerns about competence and confidence, and students proposed that a transitional period would ensure that they were adequately prepared for the role (Bench et al., 2018).

This finding was reiterated in our recent rapid review examining the educational preparedness of advanced clinical practitioners (Dover et al., 2019). The results from the reviewed literature noted the need for appropriate education and clinical supervision during the master's advanced practice programme and the need for a clinically focused consolidation period following the completion of the master's degree to enable practitioners to develop their skills under supervision in the clinical environment. This research demonstrates that the development of clinical skills and knowledge is only one aspect of advanced practice education.

The multiple aspects of the advanced practice role are now clear, and the need for the development of the four pillars, including leadership, appears paramount for nurse practitioners to be successful in their practice. Research and experience suggest that master's advanced practice programmes need to ensure all pillars of advanced practice are integrated into education and leadership needs to be an overt component. Its importance is highlighted in the United Kingdom with the development of the Advanced Clinical Practice definition and framework.

‘Advanced Clinical Practice is delivered by experienced registered healthcare practitioners. It is a level of practice characterised by a high level of autonomy and complex decision-making. This is underpinned by a masters level award or equivalent that encompasses the four pillars of clinical practice, management and leadership, education and research, with demonstration of care and area specific clinical competence’ (Health Education England, 2017).

Clearly, nurse practitioners are an essential part of the workforce and advanced practice roles are expanding across the globe to deal with the significant workforce shortages. No doubt, after the current COVID-19 pandemic, there will be further evidence supporting advanced practice roles and acknowledging the skills and knowledge of these practitioners working across professional, organisational, agency and system boundaries in managing and working in the current health crisis. The year 2020 will be remembered for the coronavirus but also, hopefully, as the year that advanced practice nursing came into its own.

全文翻译（仅供参考）

随着越来越多的老龄化人口需要对其复杂的医疗保健需求进行评估和持续管理，护理作为一种职业已经发展壮大，以满足这些需求。护理人员队伍的部分变化包括高级实践的发展和执业护士的角色。高级实践的作用现已得到充分确立，并有证据证明其有效性（Aitkenhead & Lee，2019 年；Jennings、Lee、Chao 和 Keating，2009 年；Jennings 等人，2008 年；Lee 等人，2014、2018 年）。高级实践角色需要高级临床评估技能以及复杂推理和批判性思维的应用。高级从业人员通过将先进的知识和技能应用于每次患者咨询，做出复杂的临床决策，并与包括医生和专职医疗专业人员在内的同事密切合作。一项跨越 39 个国家的研究强调了初级保健中从医生到执业护士的任务转移；然而，尽管进行了政策改革，但作者指出，任务和作用缺乏同质性，实践差异很大（Maier & Aiken，2016 年）。随着劳动力角色的这种转变和护士角色的变化，现在有许多护士主导的诊所管理患者并展示了与医学同事相当的积极临床结果（Connolly 等人，2017 年；Hendriks、Vrijhoef、Crijns , & Brunner-La Rocca, 2014; Qvist 等人, 2016; Zhu, Liu, Hu, & Wang, 2015)。高级实践角色是规模最大的劳动力队伍之一，毫无疑问，未来十年该角色将进一步发展（Maier、Barnes、Aiken 和 Busse，2016 年）。

尽管高级实践角色主要侧重于提供患者护理的临床方面，但不应忽视高级实践的其他支柱（研究、教育和领导/管理），因为它们是高级实践角色成功的关键。有趣的是，国际护理理事会对执业护士的定义包括某些特征的重要性、“专家知识库、复杂的决策技能和临床能力”，但不包括高级实践的其他支柱（国际护士理事会，2020 ）。

高级实践角色需要应用相关的研究和管理知识和技能，以提供有效的最佳临床护理并确保实施循证实践。可能不太为人所知或公认的是，高级执业护士通常在更高的组织级别上担任实践领导者，管理自己的工作量并跨越专业、组织、机构和系统边界工作，以改善服务和发展实践。他们可能需要这些管理技能才能有效地履行其职责，但可能不会被正式认可为重要的技能组合。在最近对注册护士的一项调查中，受访者重视高级实践角色；然而，只有不到三分之一的人希望成为高级从业者（Woo、Zhou、Lim 和 Tam，2020 年）。在我们大学内，我们与硕士高级实践学生进行了焦点小组讨论，以检查他们是否为自己的角色做好了准备。探索性研究揭示了对能力和信心的担忧，学生提出过渡期将确保他们为该角色做好充分准备（Bench 等人，2018 年）。

我们最近在检查高级临床从业者的教育准备情况的快速审查中重申了这一发现（Dover 等人，2019 年）。审查文献的结果指出，在硕士高级实践计划期间需要适当的教育和临床监督，并且需要在完成硕士学位后进行以临床为重点的巩固期，以使从业者能够在临床环境的监督下发展他们的技能.本研究表明，临床技能和知识的发展只是高级实践教育的一个方面。

高级实践角色的多个方面现在很清楚，发展包括领导力在内的四大支柱的必要性对于执业护士在实践中取得成功似乎至关重要。研究和经验表明，硕士高级实践课程需要确保高级实践的所有支柱都融入教育，领导力需要成为一个明显的组成部分。随着高级临床实践定义和框架的发展，它的重要性在英国得到了强调。

“高级临床实践由经验丰富的注册医疗保健从业者提供。它是一种以高度自治和复杂决策为特征的实践水平。这是由硕士水平的奖项或同等学历支撑的，其中包括临床实践、管理和领导、教育和研究的四大支柱，并展示了护理和特定领域的临床能力”（英国健康教育，2017 年）。

显然，执业护士是劳动力的重要组成部分，高级实践角色正在全球范围内扩大，以应对严重的劳动力短缺问题。毫无疑问，在当前的 COVID-19 大流行之后，将有进一步的证据支持高级实践角色，并承认这些从业者在管理和应对当前健康危机方面跨越专业、组织、机构和系统界限工作的技能和知识。2020 年将因冠状病毒而被人们铭记，但也有望成为高级实践护理诞生的一年。

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