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 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: bryantl@mcmaster.ca

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.

Confusion about terminology

Advanced practice nursing roles can be shaped to address complex and dynamic health care system needs and demands for exibility in service delivery. While variability among APN roles is expected and desirable, consistency in core 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. The terms advanced nursing practice and advanced practice nursing are often used interchangeably (Brown 1998, CNA 2000, Styles & Lewis 2000). Understanding the difference between these related concepts is necessary for dening and then developing the full potential of the roles (Table 1).

Global context of APN roles

In the last decade, many countries have witnessed unprecedented increases in the numbers and types of new APN roles such as acute care nurse practitioners, advanced practice case managers, and clinical nurse specialists/nurse
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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

Advanced practice nursing roles: part I

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)

Advanced clinical practice Advancement

Advanced practice nursing

Advanced practice nursing roles

Advanced practice nursing environments and environmental factors

Advanced nursing practice

Advanced nursing practice describes the work, or what nurses do in the role. There is no single denition, but agreement that advanced nursing practice extends the traditional scope of nursing, involves highly autonomous practice, maximizes the use of nursing knowledge, and contributes to the development of the profession (ANA 1995a, CNA 2000, RCNA 2000, Castledine 2002). An inherent function of advanced nursing practice is that of change agent, involving collaboration and consultation with health care providers and decision-makers. Advanced practice is another term referring to advanced nursing practice and should not be confused with advanced clinical practice, which refers only to the clinical care of patients (Brown 1998). There is consensus in several models that clinical practice is the primary focus of advanced nursing practice (Calkin 1984,

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.

Advanced practice nursing

Advanced practice nursing refers to the whole eld of a specic type of nursing practice. Styles and Lewis (2000) describe the eld of APN as a pyramid. At the base are environmental factors that support the apex or purpose of APN roles, which is advanced nursing practice. In this context, APN includes but is more than advanced nursing practice. The eld of APN encompasses a variety of APN roles, the environments in which the roles exist and interact, environmental factors that inuence the purpose and nature of APN roles, and the resources and structures that permit advanced nursing practice to occur (see Table 1). Advanced practice nursing roles Advanced practice nursing includes a variety of roles in which nurses function at an advanced level of practice (ANA 1995a, Brown 1998, RCNA 2000). In countries such as the United States, where legislation, regulatory mechanisms and protected titles for clinical nurse specialists, nurse midwives, nurse anaesthetists, and nurse practitioners exist, there is less difculty distinguishing APN roles. However, most countries do not have protected titles and there is no international agreement about the use of titles to distinguish APN roles. Role confusion arises when the same title, such a nurse specialist is applied to different roles with varied purposes, educational preparation, and scopes of practice (Alcock 1996, Bamford & Gibson 2000, Whyte 2000). Role competencies involving domains of advanced nursing practice related to clinical practice, education, research, organizational leadership, and professional development are better indicators of APN roles than role titles alone. There is mounting agreement that graduate education combined with practice experience is required for APN roles (ANA 1995a, CNA 2000, RCNA 2000, ICN 2003). Advanced practice nursing environments and environmental factors Numerous environments inuence the development, implementation and evaluation of APN roles, including local conditions, culture, the health care system, government, the nursing profession, and the APN community (Brown 1998; Read 1999, Hamric 2000, Styles & Lewis 2000). Local conditions refer to the work environment, organizational

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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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Role emphasis on physician replacement or support

The introduction of APN roles is characterized by an emphasis on physician replacement or support rather than a patient-centred, health-focused, holistic nursing orientation to practice that is complementary to existing models of care delivery (Knaus et al. 1997, Woods 1998, Mundinger 1999, Cameron & Masterson 2000, Irvine et al. 2000). A survey of Canadian hospitals found that 46% of new APN roles were developed to provide physician replacement or support, while fewer than 21% of new APN roles were established in response to health needs (Dunn & Nicklin 1995). A nursing orientation to practice and participation in nursing activities may decline as APN roles become more medically-driven (Beal et al. 1997, Irvine et al. 2000). A nursing orientation to practice is also important for developing condence in nursing practice skills and knowledge (Thibodeau & Hawkins 1994). When the primary focus of APN roles is not dened in relation to health needs, as described in models of advanced nursing practice, the nursing components of the roles may become less valued and visible.

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.

Underutilization of the full scope of APN role domains

A third issue is the underutilization of the full scope of APN role domains and extent to which roles are truly advanced. 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 2000, Sidani et al. 2000; Guest et al. 2001). However, insufcient administrative support and competing time demands associated with clinical practice and medical functions are frequently-reported barriers to participating in education, research and leadership activities (McFadden & Miller 1994, Sanchez et al. 1996, Beal et al. 1997, Irvine et al. 2000, Sidani et al. 2000). As the Strong Model suggests, time allocated for each role domain varies among APN roles, but a balance between clinical and non-clinical activities is required to facilitate innovative nursing practice (Ackerman et al. 1996). The APN model of care for breathlessness in lung cancer described previously is an excellent example of advancement and need for nursing roles extending beyond clinical care. Developing and evaluating new nursing interventions and models of care require opportunity for professional development, reective and scholarly work, and collaboration with other advanced practice nurses and nurse researchers (Corner et al. 1995, Plant et al. 2000). Integrating new practices into existing models of care requires strategies to effect systems change, disseminate research results, and educate nurses and other health care providers to adopt new practices. The synthesis of role competencies described by Davies and Hughes (1995) is a challenge for advanced practice nurses, and some suggest that this is a utopian view of APN (Woods 1997). Difculties with time management and role overload are reported, even when clinical practice is <50% of workload

Research evaluating APN roles

Evaluation studies indicate that the value-added component of APN roles extends beyond the transfer of medical functions. In primary care, meta-analyses have shown that nurse practitioners and physicians provide equivalent care with respect to assessment and diagnostic accuracy, and achieve similar health outcomes (Brown & Grimes 1995, Horrocks et al. 2002). However, nurse practitioner care was also associated with improved patient satisfaction and quality of care related to patient education, communication and documentation. In acute care, several studies have evaluated the impact of the Transition Model, in which advanced practice nurses provide continuous care between home and hospital (Brooten et al. 2002). High-risk older, neonatal, and obstetric patients randomized to APN care had reduced hospital lengths of stay, lower re-admission rates, decreased health care costs, increased health promotion behaviours, and higher satisfaction with care compared with those receiving standard care. In oncology, women newly diagnosed with breast cancer randomized to APN care had improved quality of life compared with those receiving standard care (Ritz et al. 2000). Patients receiving APN care for the management of breathlessness in advanced lung cancer received individually tailored, holistic and multi-dimensional strategies to improve physical function, tolerate reduced lung capacity, and cope
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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.

Failure to address environmental factors that undermine APN roles

The development of new APN roles requires an assessment of environmental conditions or local, social, health care system, government, nursing, and APN-related factors that inuence advanced nursing practice. Lack of planning and inattention to systems readiness for the role means that barriers and strategies to facilitate role implementation are not addressed, and this has major implications for the legitimacy, effectiveness, utilization, and ultimate impact of APN roles. A Canadian study of primary care nurse practitioners (PCNP) illustrated the importance of environmental assessments that examine government policies and stakeholder perceptions of APN roles within local environments (Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001). Inconsistent education policies and access to graduate education resulted in variable role preparation, and led physicians and nurses to question the competency of PCNPs. Legislation and physician resistance limited expanded practice and utilization of PCNP expertise (Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001). These barriers result from failure to develop APN roles that complement rather than compete with existing roles, and failure to implement policies that address re-imbursement issues and physician concerns about loss of income.

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).

Recommendations for the introduction of future APN roles

These six common and inter-related issues suggest that the introduction and evaluation of APN roles warrant greater attention to the concept of advancement, other attributes of advanced nursing practice, and environmental factors that affect APN roles. Lack of clarity about the multi-dimensional 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 hoc introduction of APN roles suggests the nursing profession and APN community must provide stronger leadership by: establishing consensus and communicating clearer messages about the purpose, scope and education of APN roles; providing organizations with guidance about the introduction of APN roles; and advocating for health polices that support APN role development. Advanced practice nursing roles interact across various clinical settings and inuence change to improve patient health through clinical, educational, professional development, organizational, and research activities (Corner et al. 1995, Davies & Hughes 1995, Plant et al. 2000, Brooten et al. 2002, McGee & Castledine 2003). This broad vision of APN suggests the need for a systems approach to role introduction that recognizes the environments in which the roles operate. Of primary importance is identication of social factors or patient health needs and stakeholder expectations for how the APN role will improve care delivery. Existing models of care delivery are dened by health care provider roles and relationships, and are inuenced by stakeholder values, beliefs, and experiences with APN (Dunn & Nicklin 1995, Beal et al. 1997, Woods 1998, Cameron & Masterson 2000). Role implementation is affected by the role acceptance and support of administrators and health care providers. These stakeholders must participate in the introduction of APN roles in order to promote role clarity, systems entry, and integration of roles within local environments. The value added component of APN roles involves maximizing health and quality of life through coordinated, holistic, patient-centred care (Watson 1995, Bredin et al. 1999, Brooten et al. 2002). The extent to which medicallydriven and illness-oriented health systems permit these dimensions of care is a challenge for developing innovative APN roles. Therefore, the process of role introduction must include strategies to promote social change consistent with the fundamental values of APN. Many barriers to realizing the full potential of APN roles could be avoided with better planning and systematic efforts to develop and evaluate APN roles. Lack of role clarity and

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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What is already known about this topic

There is growing international demand for increased numbers and new types of advanced practice nursing roles. The successful introduction and effective utilization of such roles is challenged by inconsistent expectations of the nature, scope, and purpose of advanced nursing practice and gaps in the resources and structures to support role development.

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).

What this paper adds

The relevance of the roles and clarication of the concepts of advanced nursing practice, advanced practice nursing, and related terms relevant to the introduction of new advanced practice nursing roles. Analysis of six common issues inuencing the introduction of advanced practice nursing roles. Recommendations for a collaborative, systematic and evidence-based process designed to develop and evaluate advanced practice nursing roles.

References
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