A clinical internship model for the nurse practitioner programme

Introduction 

Nurse practitioners (NPs) have been working in Canada, the United States of America (USA), and United Kingdom (UK) hospitals for a considerable length of time. The numbers of NPs in Canada is approaching 1000 (Canadian Institute for Health Information, 2006). In the UK, the number is close to 38,000 (NMC, 2006) and in the USA, there are 106,000 NPs (American Academy of Nurse Practitioners, 2006).

The role of the NP in Australia is relatively new but the numbers are increasing with approximately 140 NPs. These numbers are expected to increase as health service providers acknowledge the benefits of NPs. In the state of Victoria there are to date only 36 nurses NPs endorsed by the Nurses Board of Victoria (NBV website, 2006). In Victoria a nurse practitioner is defined as “… a registered nurse educated for advanced practice who is an essential member of an interdependent health care team and whose role is determined by the context in which s/he practices” (NBV website, 2006). An important issue from a curriculum development aspect is: what is the most appropriate method for preparing nurses for these types of advanced clinical practice roles? One approach is to develop a curriculum that incorporates clinical internship that will best prepare nurses for these advanced roles.

Literature 

The introduction of the NP was a specific strategy aimed at increasing the number of health care providers who could provide a quality service that was able to meet the increasing healthcare delivery needs of the community in a cost-effective manner (McMullan et al., 2001). NPs provide a unique blend of nursing and medical care. In Australia, the main areas that health service providers have employed NPs are primary healthcare, emergency and more recently acute care. In one study, NPs have contributed to a 39% increase in the number of patients presenting to rural and community hospitals (Bergeron et al., 1999). Most of the literature reports that NPs are highly skilled, cost-effective and are able to provide a high-level of care with better documentation than their medical counterparts (Barr et al., 2000, Bryant and Graham, 2002, Byrne et al., 2000, Cooper et al., 2002, Moser et al., 2004, Pinkerton and Bush, 2000, Roblin et al., 2004, Sakr et al., 1999, Hylka and Beschle, 1995). A Cochrane Review (Laurant et al., 2005) reported that nurses can provide a high quality of care and achieve good health outcomes for patients but their findings were limited to primary healthcare.

A review of the literature highlights the difference in approach to NP curricula. Gardner et al. (2004) outlined three board areas of study: clinical practice, clinical sciences and nursing studies. They highlighted the importance of the clinical environment and the essential role of a clinical mentor. From earlier work, NP competency standards have been formulated and adapted by the Australian Nursing and Midwifery Council (ANMC) for NPs (Gardner et al., 2006).

In Australia, there are a range of approaches to the education of NPs. Some universities focus on providing only the specialist perquisite subjects required for registration as a NP such as pharmacology, while others provide a Master degree in Nurse Practitioner that aims to prepare nurses for the advanced practice role. These programmes all offer a form of advanced clinical skills development but how they do this varies from supervised clinical practice to a designated clinical internship programme.

Clinical internship is usually associated with physician training programmes but the concept of internships for nursing is growing as research has shown benefits in staff recruitment and retention (Murphy et al., 2004, Alvarado et al., 2003). One paper has examined the use of internship for NPs and clinical nurse specialists in a Canadian hospital (Alvarado et al., 2003) and the authors report positively on the idea of a clinical internship model for preparing nurse practitioners but make the point that its success is tied to the degree that a supportive infrastructure is provided. Murphy et al. (2004) have reported the clinical benefits of an internship and they describe a four month internship for NPs to enhance clinical practice. One could question whether four months is long enough for a clinical internship.

The idea of nurses acting as mentors of each other in the clinical setting and the development of formalised mentorship programmes in nursing is well established (Lloyd and Bristol, 2006). Mentoring has been defined as ‘providing guidance and support within a personal relationship’ (Heartfield and Gibson, 2005, p. 18). It is considered to be a complex interactive process that involves the nurturing and empowering of the learner in order to promote confidence in their abilities that fosters their professional and personal growth (Allen, 2005). Heartfield and Gibson (2005) claim that for a mentorship experience to be positive, the mentor and the mentee relationship needs to be based on shared values and professional respect for each other. Successful mentoring relationships are often based on professional friendship and relationships established over time through working alongside each other (Allen, 2005, Heartfield and Gibson, 2005). Much work has been done in the UK to develop mentoring programmes as part of a professional development pathway for nurses (English National Board for Nursing, Midwifery and Health Visiting and Department of Health 2001, Firtko et al., 2005).

Given the issues of ensuring nurses are clinically and academically prepared for NP roles and the limited resources available to universities and hospitals, the challenge is to offer a Masters course which incorporates both these aspects and also satisfies the nationally used competencies for NPs. Prior to outlining the clinical internship, it is necessary to outline the Nurses Board requirements before proceeding to outline the academic requirements for NP courses.

Professional body and academic requirements 

Academic programme 

From the university perspective, the challenge was to develop a Master’s degree programme that was clinically relevant to NPCs and also took the endorsement process into consideration. The La Trobe Nurse Practitioner Master’s degree has three core units which NPCs complete prior to undertaking the clinical internship: health assessment and diagnostics, therapeutic medication management and evidence-based guideline development. These three units prepare NPCs for the clinical internship where they develop their assessment and diagnostic knowledge and skills, medication formulary and guidelines for clinical practice.

The entire course is aimed at preparing NPCs for endorsement in their field of specialty practice and include developing a detailed understanding of related physiology, pharmacology, psychological impact and contemporary interventions for their patient cohort, which integrates theory and practice through the core units and the clinical internship. Recently the Australian Nursing and Midwifery Council (ANMC) has endorsed the National Competency Standards for the NP (ANMC 2006). These competencies have been incorporated into an assessment tool (see Table 1). The advantage of using the assessment tool is that NPCs can identify their clinical learning needs related to their specialty while also fulfilling the nationally recognised NP competencies.

Table 1. ANMC competencies for nurse practitioner competency framework

	Standard 1: Dynamic practice that incorporates application of high-level knowledge and skills in extended practice across stable, unpredictable and complex situations
	Competency 1.1: Conducts advanced, comprehensive and holistic health assessment relevant to a specialist field of nursing practice
	Competency 1.2: Demonstrates a high-level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence-based and informed by specialist knowledge
	Competency 1.3: Has the capacity to use the knowledge and skills of extended practice competencies in complex and unfamiliar environments
	Competency 1.4: Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences, and the application of this knowledge to patient care and the education of others
	Standard 2: Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy and accountability
	Competency 2.1: Applies extended practice competencies within a nursing model of practice
	Competency 2.2: Establishes therapeutic links with the patient/client/community that recognise and respect cultural identity and lifestyle choices
	Competency 2.3: Is proactive in conducting clinical service that is enhanced and extended by autonomous and accountable practice
	Standard 3: Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health service
	Competency 3.1: Engages in and leads clinical collaboration that optimize outcomes for patients/clients/communities
	Competency 3.2: Engages in and leads informed critique and influence at the systems level of health care

The clinical internship model reported on here requires NPCs to complete clinical objectives in three main areas: clinical, leadership and research (see Table 2).

Table 2. Clinical objectives for the clinical internship

	Clinical
	1.Interdependently practice advanced health assessment and diagnostic skills in the specialty area 2.Develop and apply advanced clinical knowledge and decision making skills related to patient/client group 3.Select, perform and interpret appropriate diagnostic and other laboratory tests 4.Individualize the use of the clinical decision making process as the framework for gathering and organizing medication information, planning, prescribing, administering, documenting and evaluation to suit their practice needs. 5.Apply pharmacological interventions appropriately including therapeutic effects and adverse events 6.Compile and complete clinical practice portfolio 7.Integrate data from existing standardized screening tests into care management
	Evidence-based
	1.Trial and further develop clinical guidelines for advanced nursing practice for a range of conditions in a specialty area of clinical practice
	Leadership
	1.Demonstrate clinical leadership in practice development and clinical care whilst working as part of a multidisciplinary team. 2.Develop professional relationships within the multidisciplinary team 3.Undertake continuous quality evaluation of the care given (including patient/client satisfaction and auditing of role) 4.Identify and utilize the appropriate hospital and community resources and support groups 5.Provide clinical and educational support to nursing staff for patients/clients 6.Provide the relevant health education and health promotion to the patient/client group 7.Provide clinical audit of workload of patient/client group

The clinical internship model 

The description of the internship programme will be presented followed by the students’ comments on the model. For the clinical internship to succeed, it is of paramount importance that the mentor has a clear understanding of the NP role within the clinical specialty. The role of the mentor will be outlined before the students’ evaluation of the model is presented. The role of the mentor is to assist the NPC to develop and apply advanced assessment, diagnostic and pharmacological skills to become a NP. Accordingly, the mentor is required to be an expert in the specialty and is usually a physician or endorsed NP nominated by the mentee after consultation with senior nurses in that specialty area.

The programme quite clearly stipulates the mentorship plan for each semester and a formal weekly 1-h meeting between the NPC and mentor is compulsory during the semester. These meetings are aimed at providing a structured approach to clinical learning. The internship requires that the mentor and NPC to develop and maintain a clinical learning plan, keep a log of the meetings that shows how the objectives have been achieved that includes the content of all self-directed learning activities. As well as generic objectives, NPCs can develop specialty specific objectives.

On a day-to-day basis in the clinical environment, the NPC works with their mentor. During this time the NPC is required to complete clinical case presentations of six different patients in their care. The presentations provide evidence that the NPC is performing in their extended scope of practice (limited prescribing, initiation and interpretation of diagnostics, referral to medical specialists, admitting and discharging privileges and approval of absence of work certificates) and is using and developing the clinical practice guidelines appropriately. The patient log records all patients seen by the NPC along with their assessment findings, tests ordered, diagnosis, mentor evaluation and the plan of care.

For the clinical case presentations, as well as using the patient log, there is a clinical case presentation assessment tool, which incorporates the ANMC NP competencies and also uses an adapted version of the Bondy scale, which assists the mentor to document the level of NPC performance. This scale allows the NPC and mentors to identify the level of practice from independent practice to dependent. This information can also be used in framing the ongoing learning objectives during the weekly meetings. The clinical internship programme includes 450h of clinical practice in the candidates’ specialty area, which can be completed in either one or two semesters of enrolment.

The NPC, mentor and unit co-ordinator meet twice per semester. The purpose of this meeting is to ensure that the unit objectives that are specific to the NPC’s area of specialty clinical practice are being achieved and provide a forum to raise clinical or theoretical issues. Equally, it provides a mechanism for ongoing evaluation of the internship programme that enables changes to be made as necessary.

Initial student evaluations 

The overall feedback on the clinical internship programme that incorporates mentorship from NPCs has been positive. In total, four students have been enrolled in the internship: three from Emergency Departments (ED) and one midwife from an antenatal clinic. Three students provided feedback on the internship. The students were asked to give their opinions on the internship, in terms of did it work for them, any issues they had, what they would change about the model, did having one mentor work and any other comments they wished to make. The responses were obtained via email responses and numbered to maintain confidentiality. Some of their comments are quoted below.

The other part of the course that the NPCs valued was the case presentations (both the clinical case presentations with the mentor and the case presentations presented to their peers on study days):

One of the comments from one of the NPCs was the flexibility needed for mentoring to work:“The mentor model needs to be flexible which we were able to do. I used face to face meetings along with the availability of telephone advice/contact where needed”.

One of the NPCs who worked in a rural environment found that mentorship did not work:

This NPC suggested that maybe more than one mentor is required. This is certainly something that is being considered for the course. Equally the above comment points to the fact that within the clinical internship model the programme of mentorship established needs to be individually tailored for that setting and must be flexible enough to be changed at any given point in time.

Discussion 

This discussion paper highlights the importance in developing and delivering a programme that meets the academic and clinical requirements for NPCs. We have highlighted the importance of a mentorship programme and have demonstrated the importance of NPCs keeping a clinical log and presenting clinical cases within the clinical environment. Secondly, the feedback from NPCs has been positive. There is no doubt that for the mentorship experience to be successful and productive, a collaborative approach is necessary.

Although the assessment tool has not been formally assessed for validity and reliability, it appears to be successful. An evaluation tool will be developed and a formal study will examine the tool in the next 12 months. It is clear to see from previous research, that authors have concentrated on comparing NPs to physicians in terms of care provided (Cooper et al., 2002, Moser et al., 2004, Pinkerton and Bush, 2000) rather than on curriculum development and the importance of preparing NPs for advanced clinical roles.

From previous work on piloting competencies, the benefits are substantial to the NP and the process works well (Mason et al., 2005).

The mentorship approach appears to be successful from the students’ perspectives and is suitable for this clinically oriented Masters programme. A high degree of support was observed from the mentors in most cases, a finding previously reported by Heartfield and Gibson (2005). The complexity of mentorship cannot be overlooked and problems such as poor communication and poor objective identification for NPs are highlighted by Barker (2006). The importance of the clinical internship cannot be underestimated and previous studies have highlighted its importance (Gardner et al., 2004). Also from a managerial perspective, the written support and approval of the NP’s manager is essential as issues can arise with relocation of tasks and changes to the working relationships with the new NP role (Reay et al., 2003). This perspective is also highlighted by Marsden et al. (2003) who examined NP deployment and in particular organizational and cultural issues.

What becomes apparent is the amount of time and effort required to ensure a successful NP mentorship programme and as identified by others; programmes require adequate resource allocation including time and technology and flexible communication methods to ensure the coordination of information and advice (Heartfield and Gibson, 2005). The literature suggests that the idea of collegial mentorship, incorporated into a clinical internship, can result in a positive learning experience for the learner. Evaluating the impact of NPs on staff retention and the development of endorsed NPs as mentors to new NPCs would be the next step in this process.

This discussion paper outlines the mentorship programme developed in response to clinical and academic needs and could be applied to any setting both nationally and internationally in line with local competency and clinical requirements. Although each country has their own professional body that regulates nursing, there is the International Council of Nursing definition of a NP which makes this model attractive and potentially applicable to any setting.

Conclusion 

The clinical internship model appears to be a suitable method of assessment and allows NPCs to develop their scope of practice whilst integrating the theory with their specialist clinical practice. Important to the success of such a programme of clinical learning is the establishment of a flexible mentor–mentee relation that enables NP role development that is role specific. Equally, the benefits of a clinical internship within a Master degree course that focuses specifically on the acquisition of theoretical knowledge, clinical skills needed to perform in the role of NP, and a programme of learning that enables the accumulation of evidence for endorsement with the registering authority, have been welcomed by industry.