Professional Documents
Culture Documents
Advanced Practice Nursing
Advanced Practice Nursing
Assistant Professor, School of Nursing, McMaster University; Clinical Nurse Specialist, Juravinski Cancer Centre, Hamilton, Ontario; and Canadian Health Services Research Foundation, Postdoctoral Fellow, Canada
Alba DiCenso
PhD RN
Professor, School of and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario; and Chair in Advanced Practice Nursing, Canadian Health Services Research Foundation/Canadian Institute of Health Research, Canada
Gina Browne
PhD RN
Professor, School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario; and Director, Systems Linked Research Unit for Health and Social Service Utilization, Canada
Janet Pinelli
PhD RNC
Professor, School of Nursing and Department of Pediatrics, McMaster University, Hamilton, Ontario; and Clinical Nurse Specialist/Neonatal Nurse Practitioner, McMaster Childrens Hospital, Canada
Submitted for publication 5 January 2004 Accepted for publication 14 March 2004
Correspondence: Denise Bryant-Lukosius, Room 3H48 Faculty of Health Sciences, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5. E-mail: [email protected]
B R Y A N T - L U K O S I U S D . , D I C E N S O A . , B R O W N E G . & P I N E L L I J . ( 2 0 0 4 ) Journal of Advanced Nursing 48(5), 519529 Advanced practice nursing roles: development, implementation and evaluation Aim. The aim of this paper is to discuss six issues inuencing the introduction of advanced practice nursing (APN) roles: confusion about APN terminology, failure to dene clearly the roles and goals, role emphasis on physician replacement/support, underutilization of all APN role domains, failure to address environmental factors that undermine the roles, and limited use of evidence-based approaches to guide their development, implementation and evaluation. Background. Health care restructuring in many countries has led to substantial increases in the different types and number of APN roles. The extent to which these roles truly reect advanced nursing practice is often unclear. The misuse of APN terminology, inconsistent titling and educational preparation, and misguided interpretations regarding the purpose of these roles pose barriers to realizing their full potential and impact on health. Role conict, role overload, and variable stakeholder acceptance are frequently reported problems associated with the introduction of APN roles. Discussion. Challenges associated with the introduction of APN roles suggests that greater attention to and consistent use of the terms of the terms advanced nursing practice, advancement and advanced practice nursing is required. Advanced nursing practice refers to the work or what nurses do in the role and is important for dening the specic nature and goals for introducing new APN roles. The concept of advancement further denes the multi-dimensional scope and mandate of advanced nursing practice and distinguishes differences from other types of nursing roles.
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Advanced practice nursing refers to the whole eld, involving a variety of such roles and the environments in which they exist. Many barriers to realizing the full potential of these roles could be avoided through better planning and efforts to address environmental factors, structures, and resources that are necessary for advanced nursing practice to take place. Conclusions. Recommendations for the future introduction of APN roles can be drawn from this paper. These include the need for a collaborative, systematic and evidence-based process designed to provide data to support the need and goals for a clearly dened APN role, support a nursing orientation to advanced practice, promote full utilization of all the role domains, create environments that support role development, and provide ongoing evaluation of these roles related to predetermined goals. Keywords: advanced nursing practice, advanced practice nursing, nursing, role barriers, role implementation, role evaluation
Introduction
Advanced practice nursing (APN) represents the future frontier for nursing practice and professional development. It is a way of viewing the world that enables questioning of current practices, creation of new nursing knowledge, and improved delivery of nursing and health care services (Patterson & Haddad 1992, Davies & Hughes 1995, Elliott 1995, Sutton & Smith 1995). Therefore, continued development of APN is of paramount importance for society and the nursing profession. In this paper, six issues inuencing APN role development, implementation and evaluation are described, and recommendations for the future introduction of APN roles are proposed. Confusion about the roles is evident in misuse of terms, inconsistent titling and educational preparation, and varied interpretations about the purpose of APN roles (Dunn & Nicklin 1995, Woods 1997, Brown 1998, Styles & Lewis 2000, Chang & Wong 2001). In addressing this issue, the terms advanced nursing practice and advanced practice nursing are distinguished, and this provides the basis for examining ve other issues: lack of clearly dened APN roles and goal expectations, role emphasis on physician replacement and support, underutilization of the full scope of APN role domains, environmental factors that undermine APN roles, and the limited use of research and evidence-based approaches to guide the introduction of new APN roles.
practitioners (Keane & Richmond 1993, Elliott 1995, Alcock 1996, Dillon & George 1997, Pinelli 1997, Offredy 2000, Chang & Wong 2001, Chen 2001, Pulcini & Wagner 2001, White 2001). New APN roles have occurred predominantly in acute care settings. Increasing demand for APN is expected to continue well into the 21st century, with expansion of such roles in ambulatory and community settings. Despite the need for this higher level of nursing practice, there are many challenges to the successful implementation of APN roles (Dunn & Nicklin 1995, Beal et al. 1997, Woods 1998, Irvine et al. 2000, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001, Guest et al. 2001, Seymour et al. 2002). Preliminary results of an international survey of the roles indicate variability in legislative and regulatory mechanisms, titling, role autonomy, prescriptive authority, role functions, educational preparation, and extent to which these roles have been evaluated (ICN 2001). Thus, it is unclear which roles truly reect advanced practice.
Nursing and health care management and policy Table 1 Denition of terms relevant to advanced practice nursing (APN) roles Term Advanced nursing practice or advanced practice Denition
What nurses do in the role Involves multiple interacting role domains broadly related to clinical practice, education, research, professional development and organizational leadership (CANO 2001) Distinguished from basic practice through specialization, expansion and advancement (ANA 1995b) Clinical care or direct nurseclient interaction (Brown 1998) Specialization and expansion of knowledge, skills and role autonomy (ANA 1995b) Professional activities that lead to innovation and improved nursing care (McGee & Castledine 2003, Davies & Hughes 1995) Commitment to a nursing orientation to practice Synthesis Integration of practical, theoretical and research knowledge (ANA 1995b) Purposeful integration and application of role competencies related to clinical practice, education, research, leadership and professional development to improve patient health (Davies & Hughes 1995, Hamric 2000) The whole eld of a specic type of nursing, namely advanced nursing practice (Brown 1998, RCNA 2000, Styles & Lewis 2000) Includes APN roles, APN environments and environmental factors affecting role development, implementation and evaluation A variety of roles in which nurses function at an advanced level of practice Roles that include all domains of advanced nursing practice Require graduate education, practice experience, licensure and certication Local conditions: organizational structures and culture of the work environment Society: values, expectations, demands and needs for health care Health care system: workforce, practice trends and economy Government: funding, health care policies, legislation Nursing profession: knowledge production, education, practice, regulatory and credentialing mechanisms and political activities Advanced practice nursing community: advanced practice nurses, educational institutions, specialty organizations and social networks (Roy & Martinez 1983, Brown 1998, Read 1999, Hamric 2000, Styles & Lewis 2000)
Ackerman et al. 1996, Dunphy & Winland-Brown 1998, Hamric 2000). Advanced nursing practice includes other role domains broadly related to education, research, professional development and organizational leadership (CANO 2001). How role domains are dened varies among advanced nursing practice models. Manley (1997) identied four integrated subroles related to direct and indirect expert practice, education, research, and consultation for the advanced practitioner/ consultant nurse. Knowledge and skills related to transformational leadership, collaboration, and organizational development were required to operationalize the sub-roles. The Synergy Model identies eight domains of practice for clinical nurse specialists (Moloney-Harmon 1999). Role domains related to clinical judgement, clinical inquiry, teaching/learning, collaboration, systems thinking, advocacy/moral agency, caring practices, and response to diversity impact on three spheres of inuence (patient/family, nursing,
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health systems). The Strong Model denes ve domains for acute care nurse practitioner roles, including direct comprehensive care, support of systems, education, research, publication, and professional leadership (Ackerman et al. 1996). Specic aspects of role domains reect patient, practitioner, academic, and systems needs unique to practice settings. The concept of advancement Three characteristics distinguish advanced nursing practice from basic nursing practice: specialization or provision of care for a specic population of patients with complex, unpredictable, and/or intensive health needs; expansion or acquisition of new knowledge and skills and role autonomy extending beyond traditional scopes of nursing practice; and advancement, which includes specialization and expansion (ANA 1995b). Advancement is broadly dened as the integration of theoretical, research-based, and practical knowledge that occurs as part of graduate nursing education (ANA 1995b, p. 14). Implicit characteristics include innovation, orientation to practice, and synthesis of knowledge and skills (Table 1). Innovation involves professional activity that promotes development of new nursing knowledge (McGee & Castledine 2003) or improves nursing care (Davies & Hughes 1995). Professional activities include evaluating nursing interventions, enhancing the nursing role in new models of care delivery, or facilitating change in health care policies and practices. Innovation or the advancement of nursing practice cannot occur without commitment to the fundamental values of the profession. These values involve a nursing orientation to practice that is patient-centred, health-focused and holistic (McMahon 1992, Watson 1995, Chinn & Kramer 1999). Advancement involves purposeful actions to improve patient health through integration of knowledge and skills related to clinical practice, education, research, professional development, and organizational leadership (Calkin 1984, Ackerman et al. 1996, Moloney-Harmon 1999). Davies and Hughes (1995, p. 160) refer to this integration of role domains as the synthesis of competencies. The ability to synthesize and apply this depth and breadth of knowledge suggests that advancement involves more than expertise developed through experience, and also requires high levels of critical thinking and analysis (McGee & Castledine 2003). Advancement also occurs when advanced nursing practice role domains function synergistically to produce a whole that is greater than the sum of its parts (Hamric 2000, p. 58). As such, advanced clinical practice does not occur in isolation from other role domains. Acquisition of specialty or expanded clinical knowledge and skills is not indicative of advanced practice unless clinical practice directs and is
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guided by the knowledge and activities of other role domains to improve patient care. Therefore, roles extending beyond traditional boundaries of nursing practice, but designed only to provide clinical care, represent expanded but not advanced nursing practice.
structures, and culture of the employer and local health care system (Brown 1998, Hamric 2000). Organizational structures include contracts, policies and procedures that dene and support role autonomy, scope of practice, role responsibilities and accountability; outline work schedules and workload; provide mechanisms for re-imbursement; document provision of resources and support; and facilitate collaboration, referral and consultation with other health care providers (Brown 1998, Read 1999, Hamric 2000, Guest et al. 2001). The development, acceptability, and demand for APN roles are driven by societal values, expectations, and needs for nursing and health care services. For example, greater social acceptance of women in the workforce and heightened demands for care providers during military conicts enabled expansion of nursing roles and education for nurse midwives, nurse anaesthetists, and clinical nurse specialists (Komnenich 1998). Nurse practitioner roles have also developed in response to health needs in under-serviced, rural, and remote populations (Komnenich 1998, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001, Duffy 2001). The health care system inuences APN roles through uctuations in the supply and demand of care providers, new practice trends, and economic pressures affecting the delivery of health services. For example, the need for cost containment through shorter hospital stays and improved medical treatment and technology to support outpatient care contributed to the shift from hospital to community care, and has led to the introduction of APN roles in ambulatory and community settings (Read 1999, Whyte 2000, Wilson-Barnet 2001). Competition among health care providers for nite health care resources also affects the introduction and re-imbursement of APN roles (Brown 1998, Mundinger 1999, Cameron & Masterson 2000, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001). Government health care priorities inuence the development of new APN roles through allocation of funds and policies that require changes in health care delivery. For example, government polices in the United Kingdom to restrict junior doctors working hours and improve primary care and palliative care services necessitated the introduction of new APN roles in various settings (Read 1999, Seymour et al. 2002). The nursing profession is responsible for dening APN roles, establishing standards for practice and education, and regulating and monitoring advanced practice nurses to ensure the safety, effectiveness and quality of practice. The legitimacy of APN is determined by the professions support of prerequisites for advanced practice, such as graduate educa-
tion, licensure and certication for specialty-based practice (Brown 1998, Hamric 2000, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001) and is dependent on research to justify the need, document the effectiveness, and promote the development of APN roles (Roy & Martinez 1983, Kleinpell 2001). Dening and clarifying APN roles within and external to the profession is important for role consistency and promoting the effective use of APN roles (Dunn & Nicklin 1995, Read 1999). Role development also depends on the nursing professions strength in lobbying for laws and regulations that support APN (Roy & Martinez 1983). The APN community includes advanced practice nurses, educational institutions, specialty organizations and social networks that inuence APN role development (Roy & Martinez 1983, Brown 1998). For example, the Nurse Practitioner/Advanced Practice Network established by the International Council of Nurses (ICN 2001) connects advanced practice nurses and provides resources and evidence-based data to support the global development of APN roles.
Failure to dene APN roles based on systematic identication of needs and goals
Organizations often initiate new APN roles as a solution to a specic health care issue, rather than with well-dened goals resulting from systematic need assessments and clear understanding of APN roles (Dunn & Nicklin 1995, Alcock 1996, Cameron & Masterson 2000, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001). Evaluations of national initiatives suggest that many organizations fail to assess local health care needs in order to clearly dene new APN roles and how they will achieve government priorities for improving health care (Guest et al. 2001, Read et al. 2001). In the absence of clearly-dened goals, APN roles become shaped by the expectations of stakeholders such as managers, health care providers, and nurses in the role, resulting in wide variations in how APN roles are interpreted and used. Lack of role clarity and inconsistent expectations contribute to problems such as role conict, role overload, and variable stakeholder acceptance of APN roles (Beal et al. 1997, Knaus et al. 1997, Woods 1998, Kleinpell-Nowell 1999, Irvine et al. 2000, Sidani et al. 2000, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001). Inexperience with APN by those involved in introducing the roles can lead to misinterpretation, under-use of the role and inconsistency among APN roles related to purpose, titling, scope of practice, education, funding, and reporting mechanisms (Dunn & Nicklin 1995, Alcock 1996, Dillon & George 1997, Cameron & Masterson 2000).
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with disability and psychological distress (Corner et al. 1995, 1996, Bredin et al. 1999). When compared with patients randomized to traditional supportive care, patients in the APN group demonstrated fewer problems with depression, improved physical symptoms, decreased breathlessness, and enhanced performance status. These studies suggest that the value added component of APN roles involves a nursing orientation to practice characterized by coordinated, integrated, holistic, and patientcentred care designed to maximize health, quality of life and functional capacity. Opportunities for innovation and improved patient and health care systems outcomes occur when the introduction of APN roles represent a complementary addition to the model of care rather than a transfer of role functions between care providers.
time (Guest et al. 2001). This suggests that the issue is not that the multi-dimensional nature of APN roles is too broad, but that insufcient attention is paid to dening and communicating role priorities and achievable goals for how components of the APN role will meet patient and health care systems needs. Role overload occurs when APNs lack direction to address competing, excessive and unexpected role demands. Clearlydened goals are important for establishing realistic role expectations within the health care team and enabling effective decision-making to manage workload conicts. Clearly-dened goals are also important for identifying strategies to support the implementation of role priorities. Research is often the most underutilized aspect of APN roles. Nurses often lack the knowledge, skills, experience and resources to participate in research activities and even evaluate the impact of their APN role (Bamford & Gibson 2000, Sidani et al. 2000, Guest et al. 2001, Read et al. 2001). In the absence of administrative and practical supports to develop the research component of APN roles, a critical feature of advancement and opportunities to develop new nursing knowledge are lost.
The APN roles by their nature represent innovation and continuously challenge the boundaries of nursing practice and existing modes of health care delivery. Yet, the implementation of health care policies to support the introduction of APN roles, such as realignment of health care providers roles and authority and reallocation of resources, is politically difcult and more likely to occur in incremental stages (Alford 1975, Hutchinson et al. 2001). Thus, it is not surprising that policies and regulations to support role autonomy and legitimize expanded practice related to diagnostic and prescriptive authority, patient referrals, hospital privileges and re-imbursement often lag behind the introduction of new APN roles (Martin & Hutchinson 1999, Sidani et al. 2000, Lynch et al. 2001; Marsden et al. 2003). The absence of government policies, regulations, and stable funding to support APN has contributed to the ad hoc introduction of roles, inconsistent role development, inadequate resources and limited opportunities for planned change and innovation, and has implications for the safety and quality of patient care (Cameron & Masterson 2000, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001, Guest et al. 2001). Lack in planning and preparation for introducing APN roles is also evident within local environments. Nurses report feelings of isolation and lack of support in pioneering the introduction of their roles in health care systems not yet designed to accommodate APN (Dillon & George 1997, Bamford & Gibson 2000, Guest et al. 2001, Seymour et al. 2002). Lack of ofce space, clerical support, communication technology, and educational opportunities are common role barriers, and inattention to these basic resources marginalizes the purpose and legitimacy of APN roles (McFadden & Miller 1994, Sanchez et al. 1996, Martin & Hutchinson 1999, Irvine et al. 2000, Guest et al. 2001, Read et al. 2001). Role acceptance and the support of physicians, nurses and other care providers are associated with role satisfaction and extent to which APN roles can be implemented (McFadden & Miller 1994, Beal et al. 1997, Dillon & George 1997, Irvine et al. 2000, Read et al. 2001). These stakeholders are often unfamiliar with APN and are not included in planning new APN roles. As a result, APNs expend considerable effort overcoming role conicts and resistance by educating stakeholders about APN and negotiating implementation of their roles (Martin & Hutchinson 1997, Woods 1998, Bamford & Gibson 2000, Irvine et al. 2000, Seymour et al. 2002). Resistance to change and bureaucratic health systems limit the extent to which APNs can negotiate organizational polices to support role autonomy and expanded practice. The need for strong administrative support to facilitate organizational change required for the introduction of APN
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roles cannot be understated. Administrative support is associated with APN role satisfaction, role autonomy, role clarity, role innovation and fewer problems related to role conict and role overload (McFadden & Miller 1994, Sanchez et al. 1996, Read 1999, Guest et al. 2001). Nurse administrators are also important for promoting role clarity, nurturing a nursing orientation to practice, and addressing nursing practice issues (Beal et al. 1997, Cameron & Masterson 2000, Irvine et al. 2000, Marsden et al. 2003).
Limited use of research and evidence-based approaches to guide the systematic development, implementation, and evaluation of APN roles
Similar to new health interventions, the introduction of new health care provider roles, including advanced practice nurses, should be based on evidence documenting the need and effectiveness of the role (Spitzer 1978). Only a few reports of the wide-scale introduction of primary care and neonatal nurse practitioners document a systematic process using rigorous research methods to establish the need, dene the role, and evaluate and monitor the implementation, effectiveness and integration of the role (Spitzer 1978, Mitchell et al. 1995, Mitchell-DiCenso et al. 1996a, Sidani et al. 2000). At organizational levels, evaluating new APN roles is often an afterthought. Failure to collect baseline data prior to the introduction of the APN and to dene performance indicators has made it difcult to evaluate the impact of new nursing roles (Guest et al. 2001, Read et al. 2001). Evaluations of the roles should also consider the responsibilities of other health care team members and environmental factors that affect role implementation. Formative evaluations examining the impact of environmental factors such as educational preparation, organizational structures and government policies on APN roles have been useful for identifying role barriers and needs for additional support (Woods 1998, Kleinpell-Nowell 1999, Irvine et al. 2000, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001, Guest et al. 2001, Read et al. 2001, Marsden et al. 2003). Advanced practice nursing roles may improve patient and health care systems outcomes related to health status, functional status, quality of life, satisfaction with care and cost efciency (Spitzer 1978, Mitchell-DiCenso et al. 1996a, Brown 1998). Outcome evaluations have mostly compared APNs with physicians in their ability to improve patient outcomes associated with medical care (Spitzer et al. 1974, Mitchell-DiCenso et al. 1996b, Mundinger et al. 2000, Horrocks et al. 2002). As a result, less is known about the impact of nursing care and non-clinical aspects of APN roles.
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provide ongoing and rigorous evaluation of APN roles related to predetermined outcome-based goals. A framework for developing, implementing and evaluating APN roles the PEPPA framework is discussed in BryantLukosius (2004).
Conclusion
Denitions of advanced nursing practice and APN have provided the foundation for describing six issues inuencing the introduction APN roles and proposing recommendations to improve the future introduction of APN roles. The introduction of these roles is as complex and dynamic as the roles themselves. Their ad hoc introduction is a barrier to their optimal utilization. Developing and evaluating the effectiveness of strategies to overcome systemic barriers to the implementation of APN roles will be important for the continued development of APN and efforts to move forward the nursing care provided to society (Davies & Hughes 1995, p. 160).
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