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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.
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
Term Definition
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)
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.
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.
524 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
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.
526 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 519–529
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