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N U R SI N G A N D H E A L T H C A R E M A N A G E M E N T A N D P O L I C Y

Advanced practice nursing roles: development, implementation and


evaluation
Denise Bryant-Lukosius PhD RN CON(C)
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 Children’s Hospital, Canada

Submitted for publication 5 January 2004


Accepted for publication 14 March 2004

Correspondence: 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


Denise Bryant-Lukosius, of Advanced Nursing 48(5), 519–529
Room 3H48 – Faculty of Health Sciences, Advanced practice nursing roles: development, implementation and evaluation
McMaster University,
Aim. The aim of this paper is to discuss six issues influencing the introduction of
1200 Main Street West,
advanced practice nursing (APN) roles: confusion about APN terminology, failure
Hamilton,
Ontario, to define clearly the roles and goals, role emphasis on physician replacement/sup-
Canada L8N 3Z5. port, underutilization of all APN role domains, failure to address environmental
E-mail: bryantl@mcmaster.ca 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 reflect 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 conflict, 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
defining the specific nature and goals for introducing new APN roles. The concept of
advancement further defines the multi-dimensional scope and mandate of advanced
nursing practice and distinguishes differences from other types of nursing roles.

 2004 Blackwell Publishing Ltd 519


D. Bryant-Lukosius et al.

Advanced practice nursing refers to the whole field, 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 ad-
vanced 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 defined 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 pre-
determined goals.

Keywords: advanced nursing practice, advanced practice nursing, nursing, role


barriers, role implementation, role evaluation

practitioners (Keane & Richmond 1993, Elliott 1995,


Introduction
Alcock 1996, Dillon & George 1997, Pinelli 1997, Offredy
Advanced practice nursing (APN) represents the future frontier 2000, Chang & Wong 2001, Chen 2001, Pulcini &
for nursing practice and professional development. It is a way Wagner 2001, White 2001). New APN roles have occurred
of viewing the world that enables questioning of current predominantly in acute care settings. Increasing demand for
practices, creation of new nursing knowledge, and improved APN is expected to continue well into the 21st century,
delivery of nursing and health care services (Patterson & with expansion of such roles in ambulatory and community
Haddad 1992, Davies & Hughes 1995, Elliott 1995, Sutton & settings. Despite the need for this higher level of nursing
Smith 1995). Therefore, continued development of APN is of practice, there are many challenges to the successful
paramount importance for society and the nursing profession. implementation of APN roles (Dunn & Nicklin 1995, Beal
In this paper, six issues influencing APN role develop- et al. 1997, Woods 1998, Irvine et al. 2000, Centre for
ment, implementation and evaluation are described, and Nursing Studies and the Institute for the Advancement of
recommendations for the future introduction of APN roles Public Policy 2001, Guest et al. 2001, Seymour et al.
are proposed. Confusion about the roles is evident in 2002). Preliminary results of an international survey of the
misuse of terms, inconsistent titling and educational roles indicate variability in legislative and regulatory
preparation, and varied interpretations about the purpose mechanisms, titling, role autonomy, prescriptive authority,
of APN roles (Dunn & Nicklin 1995, Woods 1997, Brown role functions, educational preparation, and extent to
1998, Styles & Lewis 2000, Chang & Wong 2001). In which these roles have been evaluated (ICN 2001). Thus,
addressing this issue, the terms ‘advanced nursing practice’ it is unclear which roles truly reflect advanced practice.
and ‘advanced practice nursing’ are distinguished, and this
provides the basis for examining five other issues: lack of
Confusion about terminology
clearly defined APN roles and goal expectations, role
emphasis on physician replacement and support, under- Advanced practice nursing roles can be shaped to address
utilization of the full scope of APN role domains, complex and dynamic health care system needs and demands
environmental factors that undermine APN roles, and the for flexibility in service delivery. While variability among
limited use of research and evidence-based approaches to APN roles is expected and desirable, consistency in core
guide the introduction of new APN roles. characteristics is important for advanced nursing practice to
occur. However, within the nursing profession there is
confusion about the terminology used to describe APN roles.
Global context of APN roles
The terms advanced nursing practice and advanced practice
In the last decade, many countries have witnessed unpre- nursing are often used interchangeably (Brown 1998, CNA
cedented increases in the numbers and types of new APN 2000, Styles & Lewis 2000). Understanding the difference
roles such as acute care nurse practitioners, advanced between these related concepts is necessary for defining and
practice case managers, and clinical nurse specialists/nurse then developing the full potential of the roles (Table 1).

520  2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 519–529
Nursing and health care management and policy Advanced practice nursing roles: part I

Table 1 Definition of terms relevant to advanced practice nursing (APN) roles

Term Definition

Advanced nursing practice or What nurses ‘do’ in the role


advanced practice 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)

Advanced clinical practice Clinical care or direct nurse–client interaction (Brown 1998)

Advancement 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)

Advanced practice nursing The whole field of a specific 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

Advanced practice nursing roles 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 certification

Advanced practice nursing Local conditions: organizational structures and culture of the work environment
environments and environmental Society: values, expectations, demands and needs for health care
factors 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,


Advanced nursing practice
Hamric 2000). Advanced nursing practice includes other role
Advanced nursing practice describes the work, or what nurses domains broadly related to education, research, professional
‘do’ in the role. There is no single definition, but agreement development and organizational leadership (CANO 2001).
that advanced nursing practice extends the traditional scope How role domains are defined varies among advanced nursing
of nursing, involves highly autonomous practice, maximizes practice models. Manley (1997) identified four integrated sub-
the use of nursing knowledge, and contributes to the roles related to direct and indirect expert practice, education,
development of the profession (ANA 1995a, CNA 2000, research, and consultation for the advanced practitioner/
RCNA 2000, Castledine 2002). An inherent function of consultant nurse. Knowledge and skills related to transfor-
advanced nursing practice is that of change agent, involving mational leadership, collaboration, and organizational devel-
collaboration and consultation with health care providers opment were required to operationalize the sub-roles.
and decision-makers. Advanced practice is another term The Synergy Model identifies eight domains of practice for
referring to advanced nursing practice and should not be clinical nurse specialists (Moloney-Harmon 1999). Role
confused with advanced clinical practice, which refers only to domains related to clinical judgement, clinical inquiry,
the clinical care of patients (Brown 1998). teaching/learning, collaboration, systems thinking, advo-
There is consensus in several models that clinical practice is cacy/moral agency, caring practices, and response to diversity
the primary focus of advanced nursing practice (Calkin 1984, impact on three spheres of influence (patient/family, nursing,

 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 519–529 521
D. Bryant-Lukosius et al.

health systems). The Strong Model defines five domains for guided by the knowledge and activities of other role domains
acute care nurse practitioner roles, including direct compre- to improve patient care. Therefore, roles extending beyond
hensive care, support of systems, education, research, publi- traditional boundaries of nursing practice, but designed only
cation, and professional leadership (Ackerman et al. 1996). to provide clinical care, represent expanded but not advanced
Specific aspects of role domains reflect patient, practitioner, nursing practice.
academic, and systems needs unique to practice settings.

Advanced practice nursing


The concept of advancement
Three characteristics distinguish advanced nursing practice Advanced practice nursing refers to the whole field of a
from basic nursing practice: specialization or provision of specific type of nursing practice. Styles and Lewis (2000)
care for a specific population of patients with complex, describe the field of APN as a pyramid. At the base are
unpredictable, and/or intensive health needs; expansion or environmental factors that support the apex or purpose of
acquisition of new knowledge and skills and role autonomy APN roles, which is advanced nursing practice. In this
extending beyond traditional scopes of nursing practice; and context, APN includes but is more than advanced nursing
advancement, which includes specialization and expansion practice. The field of APN encompasses a variety of APN
(ANA 1995b). roles, the environments in which the roles exist and interact,
Advancement is broadly defined as ‘the integration of environmental factors that influence the purpose and nature
theoretical, research-based, and practical knowledge that of APN roles, and the resources and structures that permit
occurs as part of graduate nursing education’ (ANA 1995b, advanced nursing practice to occur (see Table 1).
p. 14). Implicit characteristics include innovation, orientation
to practice, and synthesis of knowledge and skills (Table 1). Advanced practice nursing roles
Innovation involves professional activity that promotes Advanced practice nursing includes a variety of roles in which
development of new nursing knowledge (McGee & Castledine nurses function at an advanced level of practice (ANA 1995a,
2003) or improves nursing care (Davies & Hughes 1995). Brown 1998, RCNA 2000). In countries such as the United
Professional activities include evaluating nursing interven- States, where legislation, regulatory mechanisms and pro-
tions, enhancing the nursing role in new models of care tected titles for clinical nurse specialists, nurse midwives,
delivery, or facilitating change in health care policies and nurse anaesthetists, and nurse practitioners exist, there is less
practices. Innovation or the advancement of nursing practice difficulty distinguishing APN roles. However, most countries
cannot occur without commitment to the fundamental values do not have protected titles and there is no international
of the profession. These values involve a nursing orientation to agreement about the use of titles to distinguish APN roles.
practice that is patient-centred, health-focused and holistic Role confusion arises when the same title, such a nurse spe-
(McMahon 1992, Watson 1995, Chinn & Kramer 1999). cialist is applied to different roles with varied purposes,
Advancement involves purposeful actions to improve educational preparation, and scopes of practice (Alcock
patient health through integration of knowledge and skills 1996, Bamford & Gibson 2000, Whyte 2000). Role compe-
related to clinical practice, education, research, professional tencies involving domains of advanced nursing practice re-
development, and organizational leadership (Calkin 1984, lated to clinical practice, education, research, organizational
Ackerman et al. 1996, Moloney-Harmon 1999). Davies and leadership, and professional development are better in-
Hughes (1995, p. 160) refer to this integration of role dicators of APN roles than role titles alone. There is
domains as the ‘synthesis’ of competencies. The ability to mounting agreement that graduate education combined with
synthesize and apply this depth and breadth of knowledge practice experience is required for APN roles (ANA 1995a,
suggests that advancement involves more than expertise CNA 2000, RCNA 2000, ICN 2003).
developed through experience, and also requires high levels
of critical thinking and analysis (McGee & Castledine 2003). Advanced practice nursing environments and environmental
Advancement also occurs when advanced nursing practice factors
role domains ‘function synergistically to produce a whole Numerous environments influence the development,
that is greater than the sum of its parts’ (Hamric 2000, p. 58). implementation and evaluation of APN roles, including local
As such, advanced clinical practice does not occur in isolation conditions, culture, the health care system, government, the
from other role domains. Acquisition of specialty or expan- nursing profession, and the APN community (Brown 1998;
ded clinical knowledge and skills is not indicative of Read 1999, Hamric 2000, Styles & Lewis 2000). Local
advanced practice unless clinical practice directs and is conditions refer to the work environment, organizational

522  2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 519–529
Nursing and health care management and policy Advanced practice nursing roles: part I

structures, and culture of the employer and local health care tion, licensure and certification for specialty-based practice
system (Brown 1998, Hamric 2000). Organizational struc- (Brown 1998, Hamric 2000, Centre for Nursing Studies and
tures include contracts, policies and procedures that define the Institute for the Advancement of Public Policy 2001) and
and support role autonomy, scope of practice, role respon- is dependent on research to justify the need, document the
sibilities and accountability; outline work schedules and effectiveness, and promote the development of APN roles
workload; provide mechanisms for re-imbursement; (Roy & Martinez 1983, Kleinpell 2001). Defining and
document provision of resources and support; and facilitate clarifying APN roles within and external to the profession
collaboration, referral and consultation with other health is important for role consistency and promoting the effective
care providers (Brown 1998, Read 1999, Hamric 2000, use of APN roles (Dunn & Nicklin 1995, Read 1999). Role
Guest et al. 2001). development also depends on the nursing profession’s
The development, acceptability, and demand for APN roles strength in lobbying for laws and regulations that support
are driven by societal values, expectations, and needs for APN (Roy & Martinez 1983).
nursing and health care services. For example, greater social The APN community includes advanced practice nurses,
acceptance of women in the workforce and heightened educational institutions, specialty organizations and social
demands for care providers during military conflicts enabled networks that influence APN role development (Roy &
expansion of nursing roles and education for nurse midwives, Martinez 1983, Brown 1998). For example, the Nurse Prac-
nurse anaesthetists, and clinical nurse specialists (Komnenich titioner/Advanced Practice Network established by the Inter-
1998). Nurse practitioner roles have also developed in national Council of Nurses (ICN 2001) connects advanced
response to health needs in under-serviced, rural, and remote practice nurses and provides resources and evidence-based
populations (Komnenich 1998, Centre for Nursing Studies data to support the global development of APN roles.
and the Institute for the Advancement of Public Policy 2001,
Duffy 2001).
Failure to define APN roles based on systematic
The health care system influences APN roles through
identification of needs and goals
fluctuations in the supply and demand of care providers, new
practice trends, and economic pressures affecting the delivery Organizations often initiate new APN roles as a solution to a
of health services. For example, the need for cost containment specific health care issue, rather than with well-defined goals
through shorter hospital stays and improved medical treat- resulting from systematic need assessments and clear under-
ment and technology to support outpatient care contributed standing of APN roles (Dunn & Nicklin 1995, Alcock 1996,
to the shift from hospital to community care, and has led to Cameron & Masterson 2000, Centre for Nursing Studies and
the introduction of APN roles in ambulatory and community the Institute for the Advancement of Public Policy 2001).
settings (Read 1999, Whyte 2000, Wilson-Barnet 2001). Evaluations of national initiatives suggest that many organiza-
Competition among health care providers for finite health tions fail to assess local health care needs in order to clearly
care resources also affects the introduction and re-imburse- define new APN roles and how they will achieve government
ment of APN roles (Brown 1998, Mundinger 1999, Cameron priorities for improving health care (Guest et al. 2001, Read
& Masterson 2000, Centre for Nursing Studies and the et al. 2001). In the absence of clearly-defined goals, APN roles
Institute for the Advancement of Public Policy 2001). become shaped by the expectations of stakeholders such as
Government health care priorities influence the develop- managers, health care providers, and nurses in the role,
ment of new APN roles through allocation of funds and resulting in wide variations in how APN roles are interpreted
policies that require changes in health care delivery. For and used. Lack of role clarity and inconsistent expectations
example, government polices in the United Kingdom to contribute to problems such as role conflict, role overload, and
restrict junior doctors’ working hours and improve primary variable stakeholder acceptance of APN roles (Beal et al. 1997,
care and palliative care services necessitated the introduction Knaus et al. 1997, Woods 1998, Kleinpell-Nowell 1999, Irvine
of new APN roles in various settings (Read 1999, Seymour et al. 2000, Sidani et al. 2000, Centre for Nursing Studies and
et al. 2002). the Institute for the Advancement of Public Policy 2001).
The nursing profession is responsible for defining APN Inexperience with APN by those involved in introducing the
roles, establishing standards for practice and education, and roles can lead to misinterpretation, under-use of the role and
regulating and monitoring advanced practice nurses to ensure inconsistency among APN roles related to purpose, titling,
the safety, effectiveness and quality of practice. The legitim- scope of practice, education, funding, and reporting mecha-
acy of APN is determined by the profession’s support of nisms (Dunn & Nicklin 1995, Alcock 1996, Dillon & George
prerequisites for advanced practice, such as graduate educa- 1997, Cameron & Masterson 2000).

 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 519–529 523
D. Bryant-Lukosius et al.

with disability and psychological distress (Corner et al. 1995,


Role emphasis on physician replacement or
1996, Bredin et al. 1999). When compared with patients
support
randomized to traditional supportive care, patients in the
The introduction of APN roles is characterized by an APN group demonstrated fewer problems with depression,
emphasis on physician replacement or support rather than a improved physical symptoms, decreased breathlessness, and
patient-centred, health-focused, holistic nursing orientation enhanced performance status.
to practice that is complementary to existing models of care These studies suggest that the value added component of
delivery (Knaus et al. 1997, Woods 1998, Mundinger 1999, APN roles involves a nursing orientation to practice charac-
Cameron & Masterson 2000, Irvine et al. 2000). A survey of terized by coordinated, integrated, holistic, and patient-
Canadian hospitals found that 46% of new APN roles were centred care designed to maximize health, quality of life
developed to provide physician replacement or support, while and functional capacity. Opportunities for innovation and
fewer than 21% of new APN roles were established in improved patient and health care systems outcomes occur
response to health needs (Dunn & Nicklin 1995). A nursing when the introduction of APN roles represent a complement-
orientation to practice and participation in nursing activities ary addition to the model of care rather than a transfer of role
may decline as APN roles become more medically-driven functions between care providers.
(Beal et al. 1997, Irvine et al. 2000). A nursing orientation to
practice is also important for developing confidence in
Underutilization of the full scope of APN role
nursing practice skills and knowledge (Thibodeau & Haw-
domains
kins 1994). When the primary focus of APN roles is not
defined in relation to health needs, as described in models of A third issue is the underutilization of the full scope of APN role
advanced nursing practice, the nursing components of the domains and extent to which roles are truly advanced.
roles may become less valued and visible. Advanced practice nurses value the non-clinical aspects of
their role, and these activities contribute to role satisfaction
(McMillan et al. 1995, Sanchez et al. 1996, Mick & Ackerman
Research evaluating APN roles
2000, Sidani et al. 2000; Guest et al. 2001). However,
Evaluation studies indicate that the value-added component insufficient administrative support and competing time de-
of APN roles extends beyond the transfer of medical mands associated with clinical practice and medical functions
functions. In primary care, meta-analyses have shown that are frequently-reported barriers to participating in education,
nurse practitioners and physicians provide equivalent care research and leadership activities (McFadden & Miller 1994,
with respect to assessment and diagnostic accuracy, and Sanchez et al. 1996, Beal et al. 1997, Irvine et al. 2000, Sidani
achieve similar health outcomes (Brown & Grimes 1995, et al. 2000). As the Strong Model suggests, time allocated for
Horrocks et al. 2002). However, nurse practitioner care was each role domain varies among APN roles, but a balance
also associated with improved patient satisfaction and quality between clinical and non-clinical activities is required to
of care related to patient education, communication and facilitate innovative nursing practice (Ackerman et al. 1996).
documentation. The APN model of care for breathlessness in lung cancer
In acute care, several studies have evaluated the impact of described previously is an excellent example of advancement
the Transition Model, in which advanced practice nurses and need for nursing roles extending beyond clinical care.
provide continuous care between home and hospital (Brooten Developing and evaluating new nursing interventions and
et al. 2002). High-risk older, neonatal, and obstetric patients models of care require opportunity for professional develop-
randomized to APN care had reduced hospital lengths of ment, reflective and scholarly work, and collaboration with
stay, lower re-admission rates, decreased health care costs, other advanced practice nurses and nurse researchers (Corner
increased health promotion behaviours, and higher satisfac- et al. 1995, Plant et al. 2000). Integrating new practices into
tion with care compared with those receiving standard care. existing models of care requires strategies to effect systems
In oncology, women newly diagnosed with breast cancer change, disseminate research results, and educate nurses and
randomized to APN care had improved quality of life other health care providers to adopt new practices.
compared with those receiving standard care (Ritz et al. The synthesis of role competencies described by Davies and
2000). Patients receiving APN care for the management of Hughes (1995) is a challenge for advanced practice nurses, and
breathlessness in advanced lung cancer received individually some suggest that this is a utopian view of APN (Woods 1997).
tailored, holistic and multi-dimensional strategies to improve Difficulties with time management and role overload are
physical function, tolerate reduced lung capacity, and cope reported, even when clinical practice is <50% of workload

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Nursing and health care management and policy Advanced practice nursing roles: part I

time (Guest et al. 2001). This suggests that the issue is not that The APN roles by their nature represent innovation and
the multi-dimensional nature of APN roles is too broad, but continuously challenge the boundaries of nursing practice
that insufficient attention is paid to defining and communica- and existing modes of health care delivery. Yet, the imple-
ting role priorities and achievable goals for how components of mentation of health care policies to support the introduction
the APN role will meet patient and health care systems needs. of APN roles, such as realignment of health care providers’
Role overload occurs when APNs lack direction to address roles and authority and reallocation of resources, is politic-
competing, excessive and unexpected role demands. Clearly- ally difficult and more likely to occur in incremental stages
defined goals are important for establishing realistic role (Alford 1975, Hutchinson et al. 2001). Thus, it is not
expectations within the health care team and enabling effective surprising that policies and regulations to support role
decision-making to manage workload conflicts. autonomy and legitimize expanded practice related to diag-
Clearly-defined goals are also important for identifying nostic and prescriptive authority, patient referrals, hospital
strategies to support the implementation of role priorities. privileges and re-imbursement often lag behind the introduc-
Research is often the most underutilized aspect of APN roles. tion of new APN roles (Martin & Hutchinson 1999, Sidani
Nurses often lack the knowledge, skills, experience and et al. 2000, Lynch et al. 2001; Marsden et al. 2003). The
resources to participate in research activities and even absence of government policies, regulations, and stable
evaluate the impact of their APN role (Bamford & Gibson funding to support APN has contributed to the ad hoc
2000, Sidani et al. 2000, Guest et al. 2001, Read et al. 2001). introduction of roles, inconsistent role development, inad-
In the absence of administrative and practical supports to equate resources and limited opportunities for planned
develop the research component of APN roles, a critical change and innovation, and has implications for the safety
feature of advancement and opportunities to develop new and quality of patient care (Cameron & Masterson 2000,
nursing knowledge are lost. 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
Failure to address environmental factors that
roles is also evident within local environments. Nurses report
undermine APN roles
feelings of isolation and lack of support in pioneering the
The development of new APN roles requires an assessment introduction of their roles in health care systems not yet
of environmental conditions or local, social, health care designed to accommodate APN (Dillon & George 1997,
system, government, nursing, and APN-related factors that Bamford & Gibson 2000, Guest et al. 2001, Seymour et al.
influence advanced nursing practice. Lack of planning and 2002). Lack of office space, clerical support, communication
inattention to systems’ readiness for the role means that technology, and educational opportunities are common role
barriers and strategies to facilitate role implementation are barriers, and inattention to these basic resources marginalizes
not addressed, and this has major implications for the the purpose and legitimacy of APN roles (McFadden &
legitimacy, effectiveness, utilization, and ultimate impact of Miller 1994, Sanchez et al. 1996, Martin & Hutchinson
APN roles. 1999, Irvine et al. 2000, Guest et al. 2001, Read et al. 2001).
A Canadian study of primary care nurse practitioners Role acceptance and the support of physicians, nurses and
(PCNP) illustrated the importance of environmental assess- other care providers are associated with role satisfaction and
ments that examine government policies and stakeholder extent to which APN roles can be implemented (McFadden
perceptions of APN roles within local environments (Centre & Miller 1994, Beal et al. 1997, Dillon & George 1997,
for Nursing Studies and the Institute for the Advancement of Irvine et al. 2000, Read et al. 2001). These stakeholders are
Public Policy 2001). Inconsistent education policies and often unfamiliar with APN and are not included in planning
access to graduate education resulted in variable role new APN roles. As a result, APNs expend considerable effort
preparation, and led physicians and nurses to question the overcoming role conflicts and resistance by educating stake-
competency of PCNPs. Legislation and physician resistance holders about APN and negotiating implementation of their
limited expanded practice and utilization of PCNP expertise roles (Martin & Hutchinson 1997, Woods 1998, Bamford &
(Centre for Nursing Studies and the Institute for the Gibson 2000, Irvine et al. 2000, Seymour et al. 2002).
Advancement of Public Policy 2001). These barriers result Resistance to change and bureaucratic health systems limit
from failure to develop APN roles that complement rather the extent to which APNs can negotiate organizational
than compete with existing roles, and failure to implement polices to support role autonomy and expanded practice.
policies that address re-imbursement issues and physician The need for strong administrative support to facilitate
concerns about loss of income. organizational change required for the introduction of APN

 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 519–529 525
D. Bryant-Lukosius et al.

roles cannot be understated. Administrative support is


Recommendations for the introduction of future
associated with APN role satisfaction, role autonomy, role
APN roles
clarity, role innovation and fewer problems related to role
conflict and role overload (McFadden & Miller 1994, These six common and inter-related issues suggest that the
Sanchez et al. 1996, Read 1999, Guest et al. 2001). Nurse introduction and evaluation of APN roles warrant greater
administrators are also important for promoting role clarity, attention to the concept of advancement, other attributes of
nurturing a nursing orientation to practice, and addressing advanced nursing practice, and environmental factors that
nursing practice issues (Beal et al. 1997, Cameron & affect APN roles. Lack of clarity about the multi-dimensional
Masterson 2000, Irvine et al. 2000, Marsden et al. 2003). nature and mandate of APN roles to improve patient health
through innovation in nursing and health care delivery is a
central barrier to the optimal utilization of APN roles. The ad
Limited use of research and evidence-based
hoc introduction of APN roles suggests the nursing profession
approaches to guide the systematic development,
and APN community must provide stronger leadership by:
implementation, and evaluation of APN roles
establishing consensus and communicating clearer messages
Similar to new health interventions, the introduction of new about the purpose, scope and education of APN roles;
health care provider roles, including advanced practice providing organizations with guidance about the introduct-
nurses, should be based on evidence documenting the need ion of APN roles; and advocating for health polices that
and effectiveness of the role (Spitzer 1978). Only a few support APN role development.
reports of the wide-scale introduction of primary care and Advanced practice nursing roles interact across various
neonatal nurse practitioners document a systematic process clinical settings and influence change to improve patient
using rigorous research methods to establish the need, define health through clinical, educational, professional develop-
the role, and evaluate and monitor the implementation, ment, organizational, and research activities (Corner et al.
effectiveness and integration of the role (Spitzer 1978, 1995, Davies & Hughes 1995, Plant et al. 2000, Brooten et al.
Mitchell et al. 1995, Mitchell-DiCenso et al. 1996a, Sidani 2002, McGee & Castledine 2003). This broad vision of APN
et al. 2000). suggests the need for a systems approach to role introduction
At organizational levels, evaluating new APN roles is often that recognizes the environments in which the roles operate.
an afterthought. Failure to collect baseline data prior to the Of primary importance is identification of social factors or
introduction of the APN and to define performance indicators patient health needs and stakeholder expectations for how the
has made it difficult to evaluate the impact of new nursing APN role will improve care delivery. Existing models of care
roles (Guest et al. 2001, Read et al. 2001). Evaluations of the delivery are defined by health care provider roles and
roles should also consider the responsibilities of other health relationships, and are influenced by stakeholder values,
care team members and environmental factors that affect role beliefs, and experiences with APN (Dunn & Nicklin 1995,
implementation. Formative evaluations examining the impact Beal et al. 1997, Woods 1998, Cameron & Masterson 2000).
of environmental factors such as educational preparation, Role implementation is affected by the role acceptance and
organizational structures and government policies on APN support of administrators and health care providers. These
roles have been useful for identifying role barriers and needs stakeholders must participate in the introduction of APN roles
for additional support (Woods 1998, Kleinpell-Nowell 1999, in order to promote role clarity, systems entry, and integration
Irvine et al. 2000, Centre for Nursing Studies and the of roles within local environments.
Institute for the Advancement of Public Policy 2001, Guest The value added component of APN roles involves
et al. 2001, Read et al. 2001, Marsden et al. 2003). maximizing health and quality of life through coordinated,
Advanced practice nursing roles may improve patient and holistic, patient-centred care (Watson 1995, Bredin et al.
health care systems outcomes related to health status, 1999, Brooten et al. 2002). The extent to which medically-
functional status, quality of life, satisfaction with care and driven and illness-oriented health systems permit these
cost efficiency (Spitzer 1978, Mitchell-DiCenso et al. 1996a, dimensions of care is a challenge for developing innovative
Brown 1998). Outcome evaluations have mostly compared APN roles. Therefore, the process of role introduction must
APNs with physicians in their ability to improve patient include strategies to promote social change consistent with
outcomes associated with medical care (Spitzer et al. 1974, the fundamental values of APN.
Mitchell-DiCenso et al. 1996b, Mundinger et al. 2000, Many barriers to realizing the full potential of APN roles
Horrocks et al. 2002). As a result, less is known about the could be avoided with better planning and systematic efforts to
impact of nursing care and non-clinical aspects of APN roles. develop and evaluate APN roles. Lack of role clarity and

526  2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 519–529
Nursing and health care management and policy Advanced practice nursing roles: part I

• provide ongoing and rigorous evaluation of APN roles


What is already known about this topic related to predetermined outcome-based goals.
• There is growing international demand for increased A framework for developing, implementing and evaluating
numbers and new types of advanced practice nursing APN roles – the PEPPA framework – is discussed in Bryant-
roles. Lukosius (2004).
• The successful introduction and effective utilization of
such roles is challenged by inconsistent expectations of
Conclusion
the nature, scope, and purpose of advanced nursing
practice and gaps in the resources and structures to Definitions of advanced nursing practice and APN have
support role development. provided the foundation for describing six issues influencing
the introduction APN roles and proposing recommendations
to improve the future introduction of APN roles. The
What this paper adds introduction of these roles is as complex and dynamic as
• The relevance of the roles and clarification of the con- the roles themselves. Their ad hoc introduction is a barrier to
cepts of advanced nursing practice, advanced practice their optimal utilization. Developing and evaluating the
nursing, and related terms relevant to the introduction effectiveness of strategies to overcome systemic barriers to
of new advanced practice nursing roles. the implementation of APN roles will be important for the
• Analysis of six common issues influencing the intro- continued development of APN and efforts to ‘move forward
duction of advanced practice nursing roles. the nursing care provided to society’ (Davies & Hughes 1995,
• Recommendations for a collaborative, systematic and p. 160).
evidence-based process designed to develop and evalu-
ate advanced practice nursing roles.
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