Keywords

The Caring advanced practice nursing model has been developed from the International Council of Nurse’s principles on advanced practice nursing (Schober and Affara 2006) and Hamric’s (2009) Model of Advanced Nursing Practice and has been inspired by the Nordic theory of caritative caring (Eriksson 2018; Lindström et al. 2018) and a person-centered perspective on nursing (Fagerström 2011, 2019a, b). The nurse-patient relationship is the core of the Caring advanced practice nursing model, which is and has been a core concept in Nordic nursing research since the beginning of nursing science. The Caring advanced practice nursing model includes eight competency domains, of which the most important is direct clinical practice. In the model, central theoretical perspectives, i.e., a holistic view of human beings, a person-centered fundamental ethical approach (ethos), caring, and health, are considered to characterize and be determinative for the quality and outcomes of nursing. Understanding of the model is deepened by relating it to an interpretative framework on patients’ need for nursing and care, i.e., “the basis of good care” (Fagerström 1999, 2000; Fagerström and Bergbom 2010).

5.1 The Caring Advanced Practice Nursing Model

In this chapter, a conceptual model of advanced practice nursing is presented, i.e., an abstract description of selected advanced practice nursing characteristics. The model emanates from a caritative perspective developed by the Nordic caring theorist Katie Eriksson (2018) and is based on theoretical studies and international research on knowledge of clinical reality in advanced practice nursing and experiences of different models of advanced practice nursing. The Caring advanced practice nursing model should not be considered a normative or final model but is instead intended to provide a simplified picture of reality, which is what a theoretical model normally represents. The theoretical perspectives part of the Caring advanced practice nursing model form a philosophical approach to nursing and the patient and therefore influence the provision of clinical practice.

The model was originally developed for the Nordic setting and is a conceptual model built on a modified version of the International Council of Nurse’s principles on advanced practice nursing and Hamric’s Model of Advanced Nursing Practice (see Fig. 5.1). The model encompasses central advanced practice nursing competency areas, critical contextual factors, and descriptions of central theoretical perspectives, presented in more detail in Chap. 6. The epistemological view employed in the model is based on a three-dimensional view of knowledge (see Chap. 4; Fagerström 2011, 2019a).

Fig. 5.1
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The Caring advanced practice nursing model. A schematic description of core competency domains and central nursing science perspectives (Fagerström 2011, 2019a, p. 63). The central theoretical perspectives—holistic view, ethos, caring, and health—are represented by four stars in the middle of the figure. The critical contextual factors that influence advanced practice nursing are represented by points on the outer edges of the circle

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Eight core competency domains are delineated in the Caring advanced practice nursing model:

  1. 1.

    Direct clinical practice

  2. 2.

    Ethical decision-making

  3. 3.

    Coaching and guidance

  4. 4.

    Consultation

  5. 5.

    Cooperation

  6. 6.

    Case management

  7. 7.

    Research and development

  8. 8.

    Leadership

For a schematic illustration of the model, see Fig. 5.1.

5.2 The Nurse-Patient Relationship

The mutual and dynamic nurse-patient relationship lies at the core of the Caring advanced practice nursing model. In each moment and during all phases of the nursing process, the mutual nurse-patient relationship and clinical practice are characterized by the nurse’s view of knowledge and theoretical perspectives. Both the nurse’s view of knowledge and theoretical nursing perspectives influence the nurse’s thoughts, feelings, decisions, and actions and therefore the quality and outcome of the nursing he/she provides.

The nurse-patient relationship, seen in the middle of Fig. 5.1, is an area of research that has been of a great interest throughout the history of nursing. In an etymological analysis of the concept “relationship,” one sees that the term is derived from the Latin word relatio, which means to carry or turn back, narration (story), or relations (Kasén 2002). Semantic analysis reveals that the concept encompasses important dimensions such as “story,” “touch,” and “connection.” In the nurse-patient relationship, which is based on mutual trust, the patient’s message about his/her health needs and suffering are expressed and emerge (Eriksson 1994; Fagerström et al. 1998). For the nurse, this entails being able to interpret and understand the patient’s message. Through nurse-patient conversations and dialogue, the common goals for the health process are formulated. Through both action (doing) and approach (being), the nurse meets the patient’s health needs.

5.3 Central Theoretical Perspectives

The central theoretical perspectives in the Caring advanced practice nursing model (see “stars”; Fig. 5.1) can be understood as philosophical “common denominators” that influence how phenomena and situations in nursing are perceived, interpreted, and understood (Fagerström 2011, 2019b). The theoretical perspectives considered important in advanced practice nursing are listed below and described in more detail in Chap. 6. They are:

  • A holistic view of mankind and human beings, related to life context

  • Ethos as a person-centered fundamental ethical approach

  • Caring as the core of advanced practice nursing

  • Health as the primary focus of all nursing

In the schematic description of the Caring advanced practice nursing model (see Fig. 5.1), the dynamic nursing process that occurs in advanced practice nursing is illustrated. The state of each individual human being’s health/unhealth and suffering are constantly changing, which can be illustrated using a description of a boat engine (the total clinical competence of the nurse) with several propeller blades (nursing competency areas). The nurse-patient relationship and theoretical perspectives form the primary axis of the actual motor. Advanced practice nursing is realized in various guises and forms, depending on both nurse and patient factors as well as factors related to the patient’s environment and current living situation. An advanced practice nurse’s competency is constantly changing and evolving, in accordance with a patient’s care and nursing needs and societal and organizational requirements and needs. In actual clinical situations, different demands are made on an advanced practice nurse’s competence, and subsequently the type of competence needed varies in accordance with each patient’s needs and desires. This means that different advanced practice nurses develop different areas of competency, depending on the role they have. For example, an advanced practice nurse in an emergency/acute care unit more often develops competency in systematic (“top to toe”) clinical examination, whereas an advanced practice nurse who works with asthma or diabetes-related patient follow-up more often develops competency in coaching, guidance, and motivating patients with chronic conditions to change their lifestyles.

5.4 Contextual Factors

In accordance with Hamric (2009), the development of advanced practice nursing is influenced by critical factors in one’s environment (see outer edges of Fig. 5.1). For example, managerial support, organizational attitudes, legislation, professional cultures, the knowledge that one’s colleagues possess, and the general public’s awareness people’s awareness of what advanced clinical nursing is have clearly influenced the development of advanced practice nursing models, also in the Nordic countries (Altersved et al. 2011; Bergman et al. 2013; Lindblad et al. 2010; Wisur-Hokkanen et al. 2015; Jokiniemi et al. 2015a, b). Note that the use of the term “environment” here refers to the various clinical contexts where the advanced practice nurse role has been introduced, encompassing also the surrounding culture and society. The following contextual factors are considered critical to the development of advanced practice nursing:

  • Organizational structure and culture

  • Legislation, certification, and registration

  • Leadership

  • Continuous evaluation

  • Marketing

5.5 “The Foundation for Caritative Caring” for Nursing on the Generalist, Specialist, and Advanced Levels

The model of “the foundation for caritative caring” has been developed over the course of several years and is based on research on how patients’ need for nursing and care can be measured and understood on the generalist, specialist, and advanced levels. The overall objective has been to achieve deeper understanding of patients’ need for nursing and care in relation to the suffering he/she experiences. The nurse’s understanding of the patient’s care needs and suffering can be related to three different levels, i.e., the personal, in relation to actual life context, and organizational (see Fig. 5.2). The model for “the foundation for caritative caring” encompasses elements that are considered to be important for good nursing practice: the patient’s message of suffering, comfort and well-being, caring, competence, life context, “the caring moment,” and time and place. See Fig. 5.2 for an illustration of the most central elements of the model of “the foundation for caritative caring” (Fagerström et al. 1998; Fagerström 2011, 2019a; Fagerström and Bergbom 2010).

Fig. 5.2
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The model of “the foundation for caritative caring” on the personal level, in relation to the actual life context and on the organizational level. (Modified after Fagerström 1999, 2019a, p. 67)

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On the personal level, it is important that nurses truly attempt to interpret and understand a patient’s health needs as well as his/her message of suffering (Eriksson 1994; Arman 2012). That a patient perceives health and well-being despite illness, poor health, discomfort, and/or pain is a vital objective for both nurses and patients. Such understanding is closely linked to the concept of care, which for the patient is about what is important and really matters to him/her. The patient’s need for health and care emerges which is for the patient an important and determinative concept: concern. That nurses understand a patient’s “why” is the key to understanding the patient’s needs, i.e., what each unique patient perceives to be his/her problems, needs, and desires. For nurses, this is about demonstrating care. The patient needs both the nurse’s and the entire care team’s competence. Patients today still continue to have great faith in professional staff’s competence.

Both patients and nurses exist in a cultural and historical context. A person’s current life context is shaped by concrete and abstract others, e.g., family members, friends, social networks in one’s close environment, and, for some, belief in a higher power or god (person-dependent). In a cultural context, phenomena and events perceived in the same manner are assigned common meaning, e.g., what a patient is or how a patient should act (Benner and Wrubel 1989). In a cultural context, important values and attitudes toward and experiences of mankind and life in general exist. Both nurses and patients carry their own life history, which includes experiences from one’s past and which is something that influences both the now and thoughts about the future (Fagerström et al. 1998; Fagerström 2000).

In the caring moment, when a nurse meets a patient, a variety of different factors affect the situation. All the elements mentioned above affect the nursing process, even organizational factors. A central question is whether the time and place for “the good nursing and caritative caring” exist. If one seeks to preserve patient safety while achieving good treatment outcomes, human resources composed of both qualitative (skills and competence) and quantitative (nursing intensity and nursing resources) should be in balance with what the patient needs. Leadership for an organization and the prevalent organizational culture are of great importance to whether “the good nursing and caritative caring” can be realized (Fagerström and Salmela 2010; Salmela et al. 2011).

5.6 Advanced Practice Nursing in the Dialectical Tension Between the General and the Specific

All nursing is composed of complex wholes and realized in complex contexts. Models and theories cannot fully describe the complexity and variation of clinical reality. Awareness of this fact does not make nursing as a subject area less interesting; on the contrary, it challenges and encourages the investigation of those factors that influence nursing in the clinical context.

Knowledge as scientifically tested theories (knowing why) and the expressions and patterns that a patient reveals (knowing what) together with practical knowledge (knowing how) can often be considered general knowledge (cf. Oberle and Allen 2001). Conversely, having personal competence, where one’s general knowledge is integrated into and can be discerned in concrete patient situations, and having knowledge of each unique patient’s need for care and treatment can be considered specific knowledge. To understand why a situation is the way it is and know how one’s practical knowledge can best be used in a concrete patient situation, a nurse must use his/her personal competence and practical wisdom. For an advanced practice nurse to be able to interpret and understand all the information that a patient reveals, the complexity of a situation as a whole, a person-centered ethical approach, and inner wisdom of what can be good for the individual patient are needed. Specific, scientific knowledge and practical intelligence and wisdom must be joined into a whole (synthesis). Consequently, the nursing process can be understood as the creation of a synthesis between general and specific knowledge. This process can thus be described as a dialectical tension between the thesis (the general) and the anthesis (the specific) (see Fig. 5.3).

Fig. 5.3
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Advanced practice nursing in the dialectical tension between the general and the specific. (Fagerström 2019a, p. 68)

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