How do role acquisition and role implementation experiences of APN graduates of DNP programs compare with those reported here for master’s-prepared APNs?.
How do role acquisition and role implementation experiences of APN graduates of DNP programs compare with those reported here for master’s-prepared APNs?
Chapter 3 A Definition of Advanced Practice Nursing Ann B. Hamric This chapter considers two central questions that provide the foundation for this text: ?Why is it important to define carefully and clearly what is meant by the term advanced practice nursing? ?What distinguishes the practices of advanced practice nurses (APNs) from those of other nurses and other health care providers? Advanced practice nursing is considered here as a concept, not a role, a set of skills, or a substitution for physicians. Rather, it is a powerful idea, the origins of which date back more than a century. Such a conceptual definition provides a stable core understanding for all APN roles (see Chapter 2), it promotes consistency in practice that can aid others in understanding what this level of nursing entails, and it promotes the achievement of value-added patient outcomes and improvement in health care delivery processes. Advanced practice nursing is a relatively new concept in nursing’s evolution (see Chapter 1). Although debates and dissention are necessary and even healthy in forging consensus, ultimately the profession must agree on the key issues of definition, education, credentialing, and practice. This agreement is critically important to the survival, much less the growth, of advanced practice nursing. In this chapter, advanced practice nursing is defined and the scope of practice of APNs is discussed. Various APN roles are differentiated and key factors influencing advanced practice in health care environments are identified. The importance of a common and unified understanding of the distinguishing characteristics of advanced practice nursing is emphasized. The advanced practice of nursing builds on the foundation and core values of the nursing discipline. APN roles do not stand apart from nursing; they do not represent a separate profession, although references to ?the nurse practitioner (NP) profession,? for example, are seen in the literature. It is the nursing core that contributes to the distinctiveness seen in APN practices. According to the American Nurses Association (ANA, 2010), contemporary nursing practice has seven essential features: ? provision of a caring relationship that facilitates health and healing; attention to the range of human experiences and responses to health and illness within the physical and social environments; integration of assessment data with knowledge gained from an appreciation of the patient or the group; application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking; advancement of professional nursing knowledge through scholarly inquiry; influence on social and public policy to promote social justice; and, assurance of safe, quality, and evidence-based practice (p. 9). These characteristics are equally essential for advanced practice nursing. Core values that guide nurses in practice include advocating for patients, respecting patient and family values and informed choices, viewing individuals holistically within their environments, communities, and cultural traditions, and maintaining a focus on disease prevention, health restoration, and health promotion (ANA, 2001; Creasia & Friberg, 2011; Hood, 2010). These core professional values also inform the central perspective of advanced practice nursing. Efforts to standardize the definition of advanced practice nursing have been ongoing since the 1990s (American Association of Colleges of Nursing [AACN], 1995, 2006; ANA, 1995, 2003, 2010; Hamric, 1996, 2000, 2005, 2009; National Council of State Boards of Nursing [NCSBN], 1993, 2002, 2008). However, full clarity regarding advanced practice nursing has not yet been achieved, even as this level of nursing practice spreads around the globe. The growing international use of APNs with differing understandings in various countries has only complicated the picture (see Chapter 6). Different interpretations of advanced practice (AACN, 2006; ANA, 2005), debates about who is and is not an APN, and discrepancies in educational preparation for APNs remain issues for the international community, even as they are being standardized within countries. In spite of this lack of clarity (Ruel and Motyka, 2009; Pearson, 2011), emerging consensus on key features of the concept is increasingly evident. The definition that I have developed has been relatively stable throughout the five editions of this book. The primary criteria used in this definition are now standard elements used in the United States and, increasingly, elsewhere to regulate APNs. Similarly, consensus is growing in understanding advanced practice nursing in terms of core competencies. Even authors who deny a clear understanding of the concept propose competencies?variously called attributes, components, or domains?that are generally consistent with, although not always as complete as, the competencies proposed here. It is important to distinguish the conceptual definition of advanced practice nursing from regulatory requirements for any APN role (in the regulatory arena, the alternative term advanced practice registered nurse [APRN] is most commonly used; NCSBN, 2008). Of necessity, regulatory understandings focus on the more basic and measurable primary criteria of graduate educational preparation, advanced certification in a particular population focus, and practice in one of the four common APN roles: nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), and certified nurse-midwife (CNM). This approach is clearly seen in the APRN definition outlined in the Consensus Model (NCSBN, 2008) and has been very helpful and influential in standardizing state requirements for APRN licensure across the United States. Although necessary for regulation, however, this approach does not constitute an adequate understanding of advanced practice nursing. Limiting the profession’s understanding of advanced practice nursing to regulatory definitions can lead to a reductionist approach that results in a focus on a set of concrete skills and activities, such as diagnostic acumen or prescriptive authority. Understanding the advanced practice of the nursing discipline requires a definition that encompasses broad areas of skilled performance (the competency approach). As Chapter 2 notes, conceptual models and definitions are also useful for providing a robust framework for graduate APN curricula and for building an APN professional role identity. Distinguishing Between Specialization and Advanced Practice Nursing Before the definition of advanced practice nursing can be explored, it is important to distinguish between specialization in nursing and advanced practice nursing. Specialization involves the development of expanded knowledge and skills in a selected area within the discipline of nursing. All nurses with extensive experience in a particular area of practice (e.g., pediatric nursing, trauma nursing) are specialized in this sense. As the profession has advanced and responded to changes in health care, specialization and the need for specialty knowledge have increased. Thus, few nurses are generalists in the true sense of the word (Kitzman, 1989). Although family NPs traditionally represented themselves as generalists, they are specialists in the sense discussed here because they have specialized in one of the many facets of health care?namely, primary care. As Cockerham and Keeling note in Chapter 1, early specialization involved primarily on-the-job training or hospital-based training courses, and many nurses continue to develop specialty skills through practice experience and continuing education. Examples of currently evolving specialties include genetics nursing, forensic nursing, and clinical research nurse coordination. As specialties mature, they may develop graduate-level clinical preparation and incorporate the competencies of advanced practice nursing for their most advanced practitioners (Hanson & Hamric, 2003; also see Chapter 5); examples include critical care, oncology nursing, and palliative care nursing. The nursing profession has responded in various ways to the increasing need for specialization in nursing practice. The creation of specialty organizations, such as the American Association of Critical-Care Nurses and the Oncology Nursing Society, has been one response. The creation of APN roles?the CRNA and CNM roles early in nursing’s evolution and the CNS and NP roles more recently?has been another response. A third response has been the development of specialized faculty, nursing researchers, and nursing administrators. Nurses in all these roles can be considered specialists in an area of nursing (e.g., education, research, administration); some of these roles may involve advanced education in a clinical specialty as well. However, they are not necessarily advanced practice nursing roles. Advanced practice nursing includes specialization but also involves expansion and educational advancement (ANA, 1995, 2003; Cronenwett, 1995). As compared with basic nursing practice, APN practice is further characterized by the following: (1) acquisition of new practice knowledge and skills, particularly theoretical and evidence-based knowledge, some of which overlap the traditional boundaries of medicine; (2) significant role autonomy; (3) responsibility for health promotion in addition to the diagnosis and management of patient problems, including prescribing pharmacologic and nonpharmacologic interventions; (4) the greater complexity of clinical decision making and leadership in organizations and environments; and (5) specialization at the level of a particular APN role and population focus (ANA, 1996; 2003; NCSBN, 2008). It is necessary to distinguish between specialization as understood in this chapter and the term population focus. The framers of the Consensus Model for APRN regulation were interested in licensing and regulating advanced practice nursing in two broad categories. The first was regulation at the level of role?CNS, NP, CRNA, or CNM. The second category was termed population focus and, although not explicitly defined, six population foci were identified: family and individual across the life span, adult-gerontology, pediatrics, neonatal, women’s health and gender-related, and psychological and mental health. These foci are at different levels of specialization; for example, family and individual across the life span is broad, while neonatal is a subspecialty designation under the specialty of pediatrics. Therefore, this term is not synonymous with specialization and should not be understood in the same light. As the Consensus Model states (NCSBN, 2008): Education, certification, and licensure of an individual must be congruent in terms of role and population foci. APRNs may specialize but they cannot be licensed solely within a specialty area. In addition, specialties can provide depth in one’s practice within the established population foci. Education and assessment strategies for specialty areas will be developed by the nursing profession, i.e., nursing organizations and special interest groups. Education for a specialty can occur concurrently with APRN education required for licensure or through post-graduate education. Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations. Distinguishing Between Advanced Nursing Practice and Advanced Practice Nursing The terms advanced practice nursing and advanced nursing practice have distinct definitions and cannot be seen as interchangeable. In particular, recent definitions of advanced nursing practice do not clarify the clinically focused nature of advanced practice nursing. For example, ANA’s 2010 edition of Nursing’s Social Policy Statement defines the term advanced nursing practice as ?characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education.? This broad definition has evolved from the American Association of Colleges of Nursing’s ?Position Statement on the Practice Doctorate in Nursing? (AACN, 2004), which recommended doctoral-level educational preparation for individuals at the most advanced level of nursing practice. The Doctor of Nursing Practice (DNP) position statement (AACN, 2004) advanced a broad definition of advanced nursing practice as the following: ? any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. A definition this broad goes beyond advanced practice nursing to include other advanced specialties not involved in providing direct clinical care to patients, such as administration, policy, informatics, and public health. One reason for such a broad definition was the desire to have the DNP degree be available to nurses practicing at the highest level in many varied specialties, not only those in APN roles. A decision was reached by the original Task Force (AACN, 2004) that the DNP degree was not to be a clinical doctorate, as was advocated in early discussions (Mundinger, Cook, Lenz, et al., 2000) but, rather, a practice doctorate in an expansive understanding of the term practice. The AACN’s The Essentials of Doctoral Education for Advanced Nursing Practice (2006) distinguishes between roles with an aggregate, systems, and organizational focus (advanced specialties) and roles with a direct clinical practice focus (APN roles of CNS, NP, CRNA, and CNM), while recognizing that these two groups share some essential competencies. It is important to understand that the DNP is a degree, much as is the Master’s of Science in Nursing (MSN), and not a role; DNP graduates can assume varied roles, depending on the specialty focus of their program. Some of these roles are not APN roles as advanced practice nursing is defined here. The end result of this work requires a distinction to be made between the terms advanced nursing practice and advanced practice nursing. Advanced practice nursing is a concept that applies to nurses who provide direct patient care to individual patients and families. As a consequence, APN roles involve expanded clinical skills and abilities and require a different level of regulation than non-APN roles. This text focuses on advanced practice nursing and the varied roles of APNs. Graduate programs that prepare students for APN roles will have different curricula from those preparing students for administration, informatics, or other specialties that do not have a direct practice component (AACN, 2006). Defining Advanced Practice Nursing As noted, the concept of advanced practice nursing continues to be defined in various ways in the nursing literature. The Cumulative Index to Nursing and Allied Health Literature defines advanced practice broadly as anything beyond the staff nurse role: ?The performance of additional acts by registered nurses who have gained added knowledge and skills through post-basic education and clinical experience?? (Advanced Nursing Practice, 2012). As noted with the DNP definition, a definition this broad incorporates many specialized nursing roles, not all of which should be considered as advanced practice nursing. Advanced practice nursing is often defined as a constellation of four roles: the NP, CNS, CNM, and CRNA (NCSBN, 2002, 2008; Stanley, 2011). For example, the ANA’s Scope and Standards of Practice, Third Edition (2010) does not provide a definition of advanced practice nursing but uses a regulatory definition of APRNs: A nurse who has completed an accredited graduate-level education program preparing her or him for the role of certified nurse practitioner, certified registered nurse anesthetist, certified nurse-midwife, or clinical nurse specialist; has passed a national certification examination that measures the APRN role and population-focused competencies; maintains continued competence as evidenced by recertification; and is licensed to practice as an APRN. In the past, some authors discussed advanced practice nursing only in terms of selected roles such as NP and CNS (Lindeke, Canedy, & Kay, 1997; Rasch & Frauman, 1996) or the NP role exclusively (Hickey, Ouimette, & Venegoni, 2000; Mundinger, 1994). Defining advanced practice nursing in terms of particular roles limits the concept and denies the reality that some nurses in these four APN roles are not using the core competencies of advanced practice nursing in their practice. These definitions are also limiting because they do not incorporate evolving APN roles. Thus, although such role-based definitions are useful for regulatory purposes, it is preferable to define and clarify advanced practice nursing as a concept without reference to particular roles. Core Definition of Advanced Practice Nursing The definition proposed in this chapter builds on and extends the understanding of advanced practice nursing proposed in the first four editions of this text. Important assertions of this discussion are as follows: ?Advanced practice nursing is a function of educational and practice preparation and a constellation of primary criteria and core competencies. ?Direct clinical practice is the central competency of any APN role and informs all the other competencies. ?All APNs share the same core criteria and competencies, although the actual clinical skill set varies, depending on the needs of the APN’s specialty patient population. A definition should also clarify the critical point that advanced practice nursing involves advanced nursing knowledge and skills; it is not a medical practice, although APNs perform expanded medical therapeutics in many roles. Throughout nursing’s history, nurses have assumed medical roles. For example, common nursing tasks such as blood pressure measurement and administration of chemotherapeutic agents were once performed exclusively by physicians. When APNs begin to transfer new skills or interventions into their repertoire, they become nursing skills, informed by the clinical practice values of the profession. Actual practices differ significantly based on the particular role adopted, specialty practiced, and organizational framework within which the role is performed. In spite of the need to keep job descriptions and job titles distinct in practice settings, it is critical that the public’s acceptance of advanced practice nursing be enhanced and confusion decreased. As Safriet (1993, 1998) noted, nursing’s future depends on reaching consensus on titles and consistent preparation for title holders. The nursing profession must be clear, concrete, and consistent about APN titles and their functions in discussions with nursing’s larger constituencies: consumers, other health care professionals, health care administrators, and health care policymakers. Conceptual Definition Advanced practice nursing is the patient-focused application of an expanded range of competencies to improve health outcomes for patients and populations in a specialized clinical area of the larger discipline of nursing. 1 The term competencies refers to a broad area of skillful performance; seven core competencies combine to distinguish nursing practice at this level. Competencies include activities undertaken as part of delivering advanced nursing care directly to patients. Some competencies are processes that APNs use in all dimensions of their practice, such as collaboration and leadership. At this stage of the development of the nursing discipline, competencies may be based in theory, practice, or research. Although the discipline is expanding its research-based evidence to guide practice, an expanded ability to use theory also is a key distinguishing feature of advanced practice nursing. In addition, a strong experiential component is necessary to develop the competencies and clinical practice expertise that characterize APN practice. Graduate education and in-depth clinical practice experience work together to develop the APN. The definition also emphasizes the patient-focused and specialized nature of advanced practice nursing. APNs expand their capability to provide and direct care, with the ultimate goal of improving patient and specialty population outcomes; this focus on outcome attainment is a central feature of advanced practice nursing and the main justification for differentiating this level of practice. Finally, the critical importance of ensuring that any type of advanced practice is grounded within the larger discipline of nursing is made explicit. Certain activities of APN practice overlap with those performed by physicians and other health care professionals. However, the experiential, theoretical, and philosophical perspectives of nursing make these activities advanced nursing practice when they are carried out by an APN. Advanced practice nursing further involves highly developed nursing skill in areas such as guidance and coaching, as well as the performance of select medical therapies. Particularly with regard to physician practice, the nursing profession needs to be clear that advanced practice nursing is embedded in the nursing discipline?the advanced practice of nursing is not the junior practice of medicine. Advanced practice nursing is further defined by a conceptual model integrating three primary criteria and seven core competencies, one of them central to the others. This discussion and the chapters in Part II isolate each of these core competencies to clarify them. The reader should recognize that this is only a heuristic device for clarifying the conceptualization of advanced practice nursing used in this text. In reality, these elements are integrated into an APN’s practice; they are not separate and distinct features. The concentric circles in Figures 3-1 through 3-3 represent the seamless nature of this interweaving of elements. In addition, an APN’s skills function synergistically to produce a whole that is greater than the sum of its parts. The essence of advanced practice nursing is found not only in the primary criteria and competencies demonstrated, but also in the synthesis of these elements into a unified composite practice that conforms to the conceptual definition just presented. 1 The term patient is intended to be used interchangeably with individual and client. Primary Criteria Certain criteria (or qualifications) must be met before a nurse can be considered an APN. Although these baseline criteria are not sufficient in and of themselves, they are necessary core elements of advanced practice nursing. The three primary criteria for advanced practice nursing are shown in Figure 3-1 and include an earned graduate degree with a concentration in an advanced practice nursing role and population focus, national certification at an advanced level, and a practice focused on patients and their families. As noted, these criteria are most often the ones used by states to regulate APN practice because they are objective and easily measured (see Chapter 21). FIG 3-1 Primary criteria of advanced practice nursing. Graduate Education First, the APN must possess an earned graduate degree with a concentration in an APN role. This graduate degree may be a master’s or a DNP. Advanced practice students acquire specialized knowledge and skills through study and supervised practice at the graduate level. Curricular content includes theories and research findings relevant to the core of a particular advanced nursing role, population focus, and relevant specialty. For example, a CNS interested in palliative care will need coursework in CNS role competencies, the adult population focus, and the palliative care specialty. Because APNs assess, manage, and evaluate patients at the most independent level of clinical nursing practice, all APN curricula contain specific courses in advanced health and physical assessment, advanced pathophysiology, and advanced pharmacology (the so-called three Ps; AACN, 1995, 2006, 2011). Expansion of practice skills is acquired through faculty-supervised clinical experience, with master’s programs requiring a minimum of 500 clinical hours and DNP programs requiring 1000 hours. As noted earlier in the ANA definition, there is consensus that a master’s education in nursing is a baseline requirement for advanced practice nursing (nurse-midwifery was the latest APN specialty to agree to this requirement; see ACNM, 2009). Why is graduate educational preparation necessary for advanced practice nursing? Graduate education is a more efficient and standardized way to inculcate the complex competencies of APN-level practice than nursing’s traditional on the job or apprentice training programs (see Chapter 5). As the knowledge base within specialties has grown, so too has the need for formal education at the graduate level. In particular, the skills necessary for evidence-based practice (EBP) and the theory base required for advanced practice nursing mandate education at the graduate level. Some of the differences between basic and advanced practice in nursing are apparent in the following: the range and depth of APNs’ clinical knowledge; APNs’ ability to anticipate patient responses to health, illness, and nursing interventions; their ability to analyze clinical situations and explain why a phenomenon has occurred or why a particular intervention has been chosen; the reflective nature of their practice; their skill in assessing and addressing nonclinical variables that influence patient care; and their attention to the consequences of care and improving patient outcomes. Because of the interaction and integration of graduate education in nursing and extensive clinical experience, APNs are able to exercise a level of discrimination in clinical judgment that is unavailable to other experienced nurses (Spross & Baggerly, 1989). Professionally, requiring at least master’s-level preparation is important to create parity among APN roles so that all can move forward together in addressing policymaking and regulatory issues. This parity advances the profession’s standards and ensures more uniform credentialing mechanisms. Moving toward a doctoral-level educational expectation may also enhance nursing’s image and credibility with other disciplines. Decisions by other health care providers, such as pharmacists, physical therapists, and occupational therapists, to require doctoral preparation for entry into their professions have provided compelling support for nursing to establish the practice doctorate for APNs to achieve parity with these disciplines (AACN, 2006). Nursing has a particular need to achieve greater credibility with medicine. Organized medicine has historically been eager to point to nursing’s internal differences in APN education as evidence that APNs are inferior providers. The new clinical nurse leader (CNL) role represents a new and different understanding of the master’s credential. Historically, master’s education in nursing was, by definition, specialized education (see Chapter 1). However, the master’s-prepared CNL is described as a generalist, a staff nurse with expanded leadership skills at the point of care (AACN, 2003). AACN’s recent revision of The Essentials of Master’s Education in Nursing (2011) was developed for this generalist practice, whereas the DNP Essentials (2008) are aligned more with the understanding of advanced practice nursing described here. Even though CNLs have expanded leadership skills and graduate-level education, they are clearly not APNs. APN graduate education is highly specialized and involves preparation for an expanded scope of practice, neither of which characterizes CNL education. The existence of generalist and APN specialty master’s programs has the potential to confuse consumers, institutions, and nurses alike; it is incumbent on educational programs to differentiate clearly the curricula for generalist CNL versus specialist APN roles to avoid role confusion for these graduates. AACN’s proposed 2015 deadline for APNs to be prepared at the DNP level continues to be debated (Cronenwett, Dracup, Grey, et al., 2011) and undoubtedly will not be realized, even though DNP programs are increasing dramatically in number (from 20 programs in 2006 to 182 by 2011 [http://www.aacn.nche.edu/membership/members-only/presentations/2012/12doctoral/Potempa-Doc-Programs.pdf). As a result, master’s-level programs that prepare APNs are continuing. Certification The second primary criterion is professional certification for practice at an advanced level within a clinical population focus. The continuing growth of specialization has dramatically increased the amount of knowledge and experience required to practice safely in modern health care settings. National certification examinations have been developed by specialty organizations at two levels. The first level that was developed tested the specialty knowledge of experienced nurses and not knowledge at the advanced level of practice. More recently, organizations have developed APN-specific certification examinations in a specialty. CNM and CRNA organizations were farsighted in developing certifying examinations for these roles early in their history (see Chapter 1). As regulatory groups, particularly state boards of nursing, increasingly use the certification credential as a component of APRN licensure, the certification landscape continues to change. As noted, the Consensus Model has mandated regulation of APRNs at a role and population focus level (NCSBN, 2008), accelerating the development of more broad-based APN certification examinations. National certification at an advanced practice level is an important primary criterion for advanced practice nursing. Continuing variability in graduate curricula make sole reliance on the criterion of graduate education insufficient to protect the public. Although standardization in educational requirements for each APN role has improved over the last decade, it is difficult to argue that graduate education alone can provide sufficient evidence of competence for regulatory purposes. National certification examinations provide a consistent standard that must be met by each APN to demonstrate beginning competency for an advanced level of practice in his or her role. Finally, certification enhances title recognition in the regulatory arena, which promotes the visibility of advanced practice nursing and enhances the public’s access to APN services. Table 3-1 lists the numbers of APNs and numbers certified in the United States from 2000 through 2008. Certification percentages have increased for all APN groups except CNSs, with CRNAs and CNMs having the consistently highest percentage of certified practitioners. It is critically important that certifying organizations work to clarify the certification credential as appropriate only for currently practicing APNs. Given the centrality of the direct clinical practice component to the definition of advanced practice nursing, certification examinations must establish a significant number of hours of clinical practice as a requirement for maintaining APN certification. Some faculty and nursing leaders who do not maintain a direct clinical practice component in their positions have been allowed to sit for certification examinations and represent themselves as APNs. Statements such as ?Once a CNS, always a CNS,? which are heard with NPs and CNMs as well, perpetuate the mistaken notion that an APN title is a professional attribute rather than a practice role. Such a misunderstanding is confusing inside and outside of nursing; by definition, these individuals are no longer APNs. As noted, the Consensus Model focuses regulatory efforts on these broad role and population foci rather than on particular specialties, although some specialties are represented (e.g., neonatal NPs). This decision not to recognize established APN certification examinations in specialties such as oncology or critical care for state licensure purposes has challenged the CNS role more than other APN specialties. The American Nurses’ Credentialing Center (ANCC) has become the dominant certifying organization for State Board of Nursing?supported CNS examinations; the number of examination options for CNSs is decreasing as the Consensus Model is being implemented (see the ANCC website for a listing of currently available CNS examinations?www.nursecredentialing.org). Even though APRN regulation is becoming more standardized, a need exists for the continued development of specialty examinations at the advanced practice nursing level, particularly for CNS specialties; as it stands now, many CNSs have to take the broad-based certification examination recognized by their state in addition to an APN-level specialty certification examination necessary for their practice. Another unintended consequence of the limitations set by recognizing only six population foci is that educational programs have closed CNS concentrations given the lack of a sanctioned certification examination in the specialty. Although other factors also influenced these decisions, not recognizing specialty examinations for regulatory purposes is a key factor in these closures. The limited population foci sanctioned at present can be seen as a first step in standardizing regulation; the Consensus Model report notes the expectation that additional population foci will evolve. Even with these transitional issues, the Consensus Model represents an important standardization of APRN regulation and has helped cement the primary criterion of certification as a core regulatory requirement for APRN licensure. Practice Focused on Patient and Family The third primary criterion is a practice focused on patients and their families. As noted in describing DNP graduates, the AACN DNP Essentials Task Force differentiated APNs from other roles using this primary criterion. They noted two general role categories (AACN, 2006): ?roles which specialize as an advanced practice nurse (APN) with a focus on care of individuals; and roles that specialize in practice at an aggregate, systems, or organizational level. This distinction is important as APNs face different licensure, regulatory, credentialing, liability, and reimbursement issues than those who practice at an aggregate, systems, or organizational level.? This criterion does not imply that direct practice is the only activity that APNs undertake, however. APNs also educate others, participate in leadership activities, and serve as consultants (Brown, 1998); they understand and are involved in practice contexts to identify and effect needed system changes; and, they work to improve the health of their specialty populations (AACN, 2006). But to be considered an APN role, the patient/family direct practice focus must be primary. TABLE 3-1 Number of Advanced Practice Nurses in the United States 2000* 2004? 2008? APN Category Total No. Currently in Nursing (%) Nationally Certified (%) Total No. Currently in Nursing (%) Nationally Certified (%) Total No. Currently in Nursing (%) Nationally Certified (%) CRNA 29,844 85.7 84.4 32,523 89.6 95.3 34,821 91.5 90.9 CNM 9,232 85.7 88.4 13,684 89.3 93.7 15,328 84.3 89.7 CNS 54,374 87 36.5 57,832 85.1 44.7 42,400 84 39.7 NP 88,186 89 74 126,520 87.7 77.6 141,978 89.2 83.8 Blended CNS-NP preparation (not included in CNS or NP numbers) 14,654 95.7 73.4 14,689 93.4 Not reported 16,370 88.1 Not reported * From U.S. Department of Health and Human Services (HHS), Division of Nursing. (2002). The registered nurse population March 2000: Findings from the national sample survey of registered nurses. Washington, DC: Author. ? From HHS, Division of Nursing. (2006). The registered nurse population March 2004: Findings from the seventh national sample survey of registered nurses. Washington, DC: Author. ? From HHS, Division of Nursing. (2010). The registered nurse population: Findings from the March 2008 national sample survey of registered nurses. Washington, DC: Author. Historically, APN roles have been associated with direct clinical care. Recent work is solidifying this understanding. The Consensus Model (NCSBN, 2008) has made clear that the provision of direct care to individuals as a significant component of their practice is the defining factor for all APRNs. The centrality of direct clinical practice is further reflected in the core competencies presented in the next section. This requirement for a patient-focused practice puts some community health nurses in a gray area between advanced practice nursing and specialized practices of program development or consultation. Some APNs in community-based practices take a community view of their practice and consider the community to be their patient or client. Certainly, the broad perspective of the APN encompasses the community and society in which care is provided (AACN, 2006; Davies & Hughes, 1995); effecting positive outcomes for populations of patients is an important expectation for APNs in general. The National Organization of Nurse Practitioner Faculties (NONPF) has integrated community health concepts into NP education and considers them to be a core competency of NP practice (NONPF, 2000). However, advanced practice nursing is focused on and realized at the level of clinical practice with patients and families. As long as APNs in community health practices maintain a direct clinical practice focused on patients and their families, in addition to program or consulting responsibilities, they are APNs by this definition. Community and public health specialists who do not have a patient-focused practice but focus on community assessment, monitoring community health status, and developing policies and program plans are more appropriately considered advanced specialty nurses rather than APNs (AACN, 2006; Hanson & Hamric, 2003). Community and public health nursing leaders have differentiated their specialty from this understanding of advanced practice nursing in two reports (ANA, 2005; Association of Community Health Nursing Educators Task Force on Community and Public Health Master’s Level Preparation, 2000). The competencies listed for the community and public health specialty differ from the core APN competencies outlined here, particularly with regard to direct clinical practice. This specialty’s movement away from the direct clinical practice requirement of advanced practice nursing is similarly reflected in the ANCC’s change of the certification credential from community health CNS to advanced public health nurse (http://www.nursecredentialing.org/Certification/NurseSpecialties/AdvPublicHealth.html). Why limit the definition of advanced practice nursing to roles that focus on clinical practice to patients and families? There are many reasons. Nursing is a practice profession. The nurse-patient interface is at the core of nursing practice; in the final analysis, the reason that the profession exists is to render nursing services to individuals in need of them. Clinical practice expertise in a given specialty develops from these nurse-patient encounters and lies at the heart of advanced practice nursing. In addition, ongoing direct clinical practice is necessary to maintain and develop an APN’s expertise. Without regular immersion in practice, the cutting edge clinical acumen and expertise found in APN practices cannot be sustained. In addition, the knowledge base needed for APN roles differs from that for non-APN roles. If every specialized role in nursing were considered advanced practice nursing, the term would become so broad as to lack meaning and explanatory value. Distinguishing between APN roles and other specialized roles in nursing can help clarify the concept of advanced practice nursing to consumers, other health care providers, and even other nurses. In addition, the monitoring and regulation of advanced practice nursing are increasingly important issues as APNs work toward more authority for their practices (see Chapter 21). If the definition of advanced practice nursing included nonclinical roles, development of sound regulatory mechanisms would be impossible. It is critical to understand that this definition of advanced practice nursing is not a value statement but, rather, a differentiation of one group of nurses from other groups for the sake of clarity within and outside the profession. Some nurses with specialized skills in administration, research, and community health have viewed the direct practice requirement as a devaluing of their contributions. Some faculty who teach clinical nursing but do not themselves maintain an advanced clinical practice have also thought themselves to be disenfranchised because they are not considered APNs by virtue of this primary criterion. Perhaps this problem has been exacerbated with use of the term advanced, because this term can inadvertently imply that nurses who do not fit into the APN definition are not advanced (i.e., are not as well prepared or highly skilled as APNs). The contention advanced in this text is that no value difference exists between nurses in non-APN specialties and APNs; both groups are equally important to the overall growth and strengthening of the profession. The profession must be able to differentiate its various roles without such differentiation being viewed as a disparagement of any one group. Thus, it is critical to understand that this definition of advanced practice nursing is not a value statement but a differentiation of one group of nurses from other groups for the sake of clarity within and outside the profession. We must be able to say what advanced practice nursing is not, as well as what it is, if we are to clarify the concept. As the ANA (1995) has noted, all nurses?whether their focus is clinical practice, educating students, conducting research, planning community programs, or leading nursing service organizations?are valuable and necessary to the integrity and growth of the larger profession. However, all nurses, particularly those with advanced degrees, are not the same, nor are they necessarily APNs. Historically, the profession has had difficulty differentiating itself and has struggled with the prevailing lay notion that ?a nurse is a nurse is a nurse.? This antiquated view does not match the reality of the health care arena, nor does it celebrate the diverse contributions of all the various nursing roles and specialties. Seven Core Competencies of Advanced Practice Nursing Direct Clinical Practice: The Central Competency As noted earlier, the primary criteria are necessary but insufficient elements of the definition of advanced practice nursing. Advanced practice nursing is further defined by a set of seven core competencies that are enacted in each APN role. The first core competency of direct clinical practice is central to and informs all of the others (Fig. 3-2). In one sense, it is ?first among equals? of the seven core competencies that define advanced practice FIG 3-2 Central competency of advanced practice nursing. nursing. Although APNs do many things, excellence in direct clinical practice provides the foundation necessary for APNs to execute the other competencies, such as consultation, guidance and coaching, and leadership within organizations. However, clinical expertise alone should not be equated with advanced practice nursing. The work of Patricia Benner and colleagues (Benner, 1984; Benner, Hooper-Kyriakidis, & Stannard, 1999; Benner, Tanner, & Chesla, 1996) is a major contribution to an understanding of clinically expert nursing practice. These researchers extensively studied expert nurses in acute care clinical settings and described the engaged clinical reasoning and domains of practice seen in clinically expert nurses. Although some of the participants in this research were APNs (in the most recent report [Benner et al., 1999], 16% of the nurse participants were APNs), most were nurses with extensive clinical experience who did not have APN preparation. Calkin (1984) has characterized these latter nurses as ?experts by experience.? (See Chapter 2 for a discussion of Calkin’s conceptual differentiation between levels of nursing practice.) Benner and colleagues did not discuss differences in the practices of APNs as compared with other nurses that they have studied. They stated that ??Expert? is not used to refer to a specific role such as an advanced practice nurse. Expertise is found in the practice of experienced clinicians and advanced practice nurses? (Benner et al., 1999). Although clinical expertise is a central ingredient of an APN’s practice, the direct care practice of APNs is distinguished by six characteristics: (1) use of a holistic perspective; (2) formation of therapeutic partnerships with patients; (3) expert clinical performance; (4) use of reflective practice; (5) use of evidence as a guide to practice; and (6) use of diverse approaches to health and illness management (see Chapter 7). These characteristics help distinguish the practice of the expert by experience from that of the APN. APN clinical practice is also informed by a population focus (AACN, 2006) because APNs work to improve the care for their specialty patient population, even as they care for individuals within the population. As noted, experiential knowledge and graduate education combine to develop these characteristics in an APN’s clinical practice. It is important to note that the three Ps that form core courses in all APN programs (pathophysiology, pharmacology, and physical assessment) are not separate competencies in this understanding, but provide baseline knowledge and skills to support the direct clinical practice competency. The specific content of the direct practice competency differs significantly by specialty. For example, the clinical practice of a CNS dealing with critically ill children differs from the expertise of an NP managing the health maintenance needs of older adults or a CRNA administering anesthesia in an outpatient surgical clinic. In addition, the amount of time spent in direct practice differs by APN specialty. CNSs in particular may spend most of their time in activities other than direct clinical practice (see Chapter 14). Thus, it is important to understand this competency as a central defining characteristic of advanced practice nursing rather than as a particular skill set or expectation that APNs only engage in direct clinical practice. Additional Advanced Practice Nurse Core Competencies In addition to the central competency of direct clinical practice, six additional competencies further define advanced practice nursing regardless of role function or setting. As shown in Figure 3-3, these additional core competencies are as follows: ?Guidance and coaching ?Consultation ?Evidence-based practice ?Leadership ?Collaboration ?Ethical decision making These competencies have repeatedly been identified as essential features of advanced practice nursing. In addition, each role is differentiated by some unique competencies (see the specific role chapters in Part III). The nature of the patient population receiving APN care, organizational expectations, emphasis given to specific competencies, and practice characteristics unique to each role distinguish the practice of one APN group from others. Each APN role organization publishes role-specific competencies on their websites (CNS?www.nacns.org; NP?www.nonpf.com; CNM?www.acnm.org; CRNA?www.aana.com). There is a dynamic interplay between the core APN competencies and each role; role-specific expectations grow out of the core competencies and similarly serve to inform them as APNs practice in a changing health care system. In addition, competencies promoted by other professional groups become important to the understanding of advanced practice nursing; for example, the Interprofessional Education Collaborative (IPEC) competencies on interprofessional practice are helping shape the understanding of collaboration (IPEC Expert Panel, 2011; see Chapter 12). It is also important to understand that each of the competencies described in Part II of this text have specific definitions in the context of advanced practice nursing. For example, leadership has clinical, professional, and systems expectations for the APN that differ from those for a nurse executive or staff nurse. These unique definitions of each competency help distinguish practice at the advanced level. Similarly, certain competencies are important components of other specialized nursing roles. For example, collaboration and consultation are important competencies for nursing administrators. The uniqueness of advanced practice nursing is seen in the synergistic interaction between direct clinical practice and this constellation of competencies. In Figure 3-3, the openings between the central practice competency and these additional competencies represent the fact that the APN’s direct practice skill interacts with and informs all the other competencies. For example, APNs consult with other providers who seek their practice expertise to plan care for specialty patients. They are able to provide expert guidance and coaching for patients going through health and illness transitions because of their direct practice experience and insight. The core competencies are not unique to APN practices. Physicians and other health care providers may have developed some of them. Experienced staff nurses may master several of these competencies with years of practice experience. These nurses are seen as exemplary performers and are often encouraged to enter graduate school to become APNs. What distinguishes APN practice is the expectation that every APN’s practice encompasses all these competencies and seamlessly blends them into daily practice encounters. This expectation makes APN practice unique among that of other providers. FIG 3-3 Core competencies of advanced practice nursing. These complex competencies develop over time. No APN emerges from a graduate program fully prepared to enact all of them. However, it is critical that graduate programs provide exposure to each competency in the form of didactic content and practical experience so that new graduates can be tested for initial credentialing and be given a base on which to build their practices. These key competencies are described in detail in subsequent chapters and are not further elaborated here. Scope of Practice The term scope of practice refers to the legal authority granted to a professional to provide and be reimbursed for health care services. The ANA (2010) defined the scope of nursing practice as ?The description of the who, what, where, when, why, and how of nursing practice.? This authority for practice emanates from many sources, such as state and federal laws and regulations, the profession’s code of ethics, and professional practice standards. For all health care professionals, scope of practice is most closely tied to state statutes; for nursing in the United States, these statutes are the nurse practice acts of the various states. As previously discussed, APN scope of practice is characterized by specialization, expansion of services provided, including diagnosing and prescribing, and autonomy to practice (NCSBN, 2008). The scopes of practice also differ among the various APN roles; various APN organizations have provided detailed and specific descriptions for their particular role. Carving out an adequate scope of APN practice authority has been an historic struggle for most of the advanced practice groups (see Chapter 1) and this continues to be a hotly debated issue among and within the health professions. Significant variability in state practice acts continues, such that APNs can perform certain activities in some states, notably prescribing certain medications and practicing without physician supervision, but may be constrained from performing these same activities in another state (Lugo, O’Grady, Hodnicki, & Hanson, 2007). The Consensus Model’s proposed regulatory language can be used by states to achieve consistent scope of practice language and standardized APRN regulation (NCSBN, 2008). The Pew Commission’s Taskforce on Health Care Workforce Regulation (Finocchio, Dower, Blick, et al., 1998) noted that the tension and turf battles between professions and the increased legislative activities in this area ?clog legislative agendas across the country.? These battles are costly and time-consuming and lawmakers’ decisions related to scope of practice are frequently distorted by campaign contributions, lobbying efforts, and political power struggles rather than being based on empirical evidence. More recently, the Institute of Medicine report, The Future of Nursing (2011), made a number of recommendations to expand the scope of APN practice in the primary care arena, including one entire recommendation devoted to supporting the Consensus Model and efforts to remove scope of practice barriers across the various states (see Chapter 21 for further discussion). Encouraging progress is being made on these issues, particularly in regard to interdisciplinary scopes of practice (NCSBN, Association of Social Work Boards, Federation of State Boards of Physical Therapy, Federation of State Medical Boards, National Association of Boards of Pharmacy, & National Board for Certification in Occupational Therapy, 2006), although much remains to be done. Differentiating Advanced Practice Roles: Operational Definitions of Advanced Practice Nursing As noted earlier, it is critical to the public’s understanding of advanced practice nursing that APN roles and resulting job titles reflect actual practices. Because actual practices differ, job titles should differ. The following corollary is also true?if the actual practices do not differ, the job titles should not differ. For example, some institutions have retitled their CNSs as clinical coordinators or clinical educators, even though these APNs are practicing consistent with that of a CNS. This change in job title renders the CNS practice less clearly visible in the clinical setting and thereby obscures CNS role clarity. As noted, differences among roles must be clarified in ways that promote understanding of advanced practice nursing, and the Consensus Model (NCSBN, 2008) clarifies appropriate titling for APNs. Workforce Data Table 3-1 provides U.S. sample survey data on RNs prepared to practice as APNs from 2000 to 2008. As of 2008, an estimated 250,527 RNs, or 8.2% of the RN population, were prepared in at least one APN role (U.S. Department of Health & Human Services [HHS], 2010). Almost 17% of these individuals were from racial or ethnic minority backgrounds, a percentage comparable to that of the overall RN population (16.8%). This represents a substantial increase compared with 2004, when only 8% of APNs were from minority backgrounds. However, the diversity of the RN population remains lower than the U.S. population, of whom 34.4% are from racial or ethnic minority backgrounds. The overall number of RNs prepared as APNs represents a 4.2% increase as compared with 2004 data. When changes in APN group numbers are compared over time, different patterns are evident. CRNA numbers show a 7% increase from 2004 to 2008. CNMs experienced 12% growth, although this is based on a small sample, and only 55.5% of CNMs reported graduate preparation. CNSs were the only APN role to experience a decrease, declining 18.3% between 2004 and 2008. However, there was an increase of 11.4% in the number of RNs prepared as both NPs and CNSs. Even so, this represents a net 7% decrease in the total number of RNs educated as CNSs. The APN role that continues to show the most significant growth is the NP. Although the rate of growth slowed between 2004 and 2008, the number of RNs educated as NPs increased by 12.3% (excluding dual-prepared CNS and NP) and more than doubled from 1996 to 2008. The number of RNs with dual preparation as a CNS and NP showed an 11.4% increase, as noted earlier; most of these nurses reported working as NPs. The 2008 National Sample Survey noted that there are APNs with additional role preparation, notably combining NP and CNM credentials; these APNs represent 17% of nurse-midwives. The breakdown of various APN roles is shown in Figure 3-4. Four Established Advanced Practice Nurse Roles Advanced practice nursing is applied in the four established roles and in emerging roles. These APN roles can FIG 3-4 Registered nurses prepared for advanced practice, March 2008. (From U.S. Department of Health and Human Services [HHS], Division of Nursing. . The registered nurse population March 2008: Findings from the national sample survey of registered nurses. Washington, DC: Author.) be considered to be the operational definitions of the concept of advanced practice nursing. Although each APN role has the common definition, primary criteria, and competencies of advanced practice nursing at its center, it has its own distinct form. Some of these distinctive features of the various roles are listed here. Differences and similarities among roles are further explored in Part III. The National Association of Clinical Nurse Specialists (NACNS, 2004) has distinguished CNS practice by characterizing ?spheres of influence? in which the CNS operates. These include the patient-client sphere, the nursing personnel sphere, and the organization-network sphere (see Chapter 14). A CNS is first and foremost a clinical expert who provides direct care to patients with complex health problems and not only learns consultation processes, as do other APNs, but also functions as a formal consultant to nursing staff and other care providers within his or her organization. Developing, supporting, and educating nursing staff and other interprofessional staff to improve the quality of patient care is a core part of the nursing personnel sphere. Managing system change in complex organizations to build teams and improve nursing practices, and effecting system change to enable better advocacy for patients, are additional role expectations of the CNS. Expectations regarding sophisticated evidence-based practice activities have been central to this role since its inception. NPs, whether in primary care or acute care, possess advanced health assessment, diagnostic, and clinical management skills that include pharmacology management (see Chapters 15 and 16). Their focus is expert direct care, managing the health needs of individuals and their families. Incumbents in the classic NP role provide primary health care focused on wellness and prevention; NP practice also includes caring for patients with minor, common acute conditions and stable chronic conditions. The acute care NP (ACNP) brings practitioner skills to a specialized patient population within the acute care setting. The ACNP’s focus is the diagnosis and clinical management of acutely or critically ill patient populations in a particular specialized setting. Acquisition of additional medical diagnostic and management skills, such as interpreting computed tomography (CT) and magnetic resonance imaging (MRI) scans, inserting chest tubes, and performing lumbar punctures, also characterize this role. The CNM (see Chapter 17) has advanced health assessment and intervention skills focused on women’s health and childbearing. CNM practice involves independent management of women’s health care. CNMs focus particularly on pregnancy, childbirth, the postpartum period, and neonatal care, but their practices also include family planning, gynecologic care, primary health care for women through menopause, and treatment of male partners for sexually transmitted infections (ACNM, 2012). The CNM’s focus is on providing direct care to a select patient population. CRNA practice (see Chapter 18) is distinguished by advanced procedural and pharmacologic management of patients undergoing anesthesia. CRNAs practice independently, in collaboration with physicians, or as employees of a health care institution. Like CNMs, their primary focus is providing direct care to a select patient population. Both CNM and CRNA practices are also distinguished by well-established national standards and certification examinations in their specialties. These differing roles and their similarities and distinctions are explored in detail in subsequent chapters. It is expected that other roles may emerge as health care continues to change and new opportunities become apparent. This brief discussion underscores the rich and varied nature of advanced practice nursing and the necessity for retaining and supporting different APN roles and titles in the health care marketplace. At the same time, the consistent definition of advanced practice nursing described here undergirds each of these roles, as will be seen in Part III of this text. Critical Elements in Managing Advanced Practice Nursing Environments The health care arena is increasingly fluid and changeable; some would even say it is chaotic. Advanced practice nursing does not exist in a vacuum or a singular environment. Rather, this level of practice occurs in an increasing variety of health care delivery environments. These diverse environments are complex admixtures of interdependent elements. The term environment refers to any milieu in which an APN practices, ranging from a community-based rural health care practice for a primary care NP to a complex tertiary health care organization for an ACNP. Certain core features of these environments dramatically shape advanced practice and must be FIG 3-5 Critical elements in advanced nursing practice environments. managed by APNs in order for their practices to survive and thrive (Fig. 3-5). Although not technically part of the core definition of advanced practice nursing, these environmental features are included here to frame the understanding that APNs must be aware of these key elements in any practice setting. Furthermore, APNs must be prepared to contend with and shape these aspects of their practice environment to be able to enact advanced practice nursing fully. The environmental elements that affect APN practice include the following: ?Managing payment mechanisms and business aspects of the practice ?Dealing with marketing and contracting considerations ?Understanding legal, regulatory, and credentialing requirements ?Understanding and shaping health policy considerations ?Strengthening organizational structures and cultures to support advanced practice nursing ?Enabling outcome evaluation and performance improvement With the exception of organizational structures and cultures, Part IV of this text explores these elements in depth. Discussion of organizational considerations are presented in Chapter 4 and woven throughout the chapters in Part III. Common to all these environmental elements is the increasing use of technology and the need for APNs to master various new technologies to improve patient care and health care systems. The ability to use information systems and technology and patient care technology is an essential element of master’s and DNP curricula (AACN, 2006, 2011). Electronic technology is changing health care practice in documentation formats, coding schemas, communications, Internet use, and provision of care across state lines through telehealth practices. These changes, in turn, are reshaping all seven APN core competencies. Proficiency in the use of new technologies is increasingly necessary to support clinical practice, implement quality improvement initiatives, and provide leadership to evaluate outcomes of care and care systems (see Chapter 24). Managing the business and legal aspects of practice is increasingly critical to APN survival in the competitive health care marketplace. All APNs must understand current reimbursement issues, even as changes related to the Patient Protection and Affordable Care Act (2010) are being instituted. Payment mechanisms and legal constraints must be managed, regardless of setting. Given the increasing competition among physicians, APNs, and nonphysician providers, APNs must be prepared to market their services assertively and knowledgeably. Marketing oneself as a new NP in a small community may look different from marketing oneself as a CNS in a large health system, but the principles are the same. Marketing considerations often include the need to advocate for and actively create positions that do not currently exist. Contract considerations are much more complex at the APN level and all APNs, whether newly graduated or experienced, must be prepared to enter into contract negotiations. Health policy at the state and federal levels is an increasingly potent force shaping advanced practice nursing; regulations and policies that flow from legislative actions can enable or constrain APN practices. Variations in the strength and number of APNs in various states attest to the power of this environmental factor. Organizational structures and cultures, whether those of a community-based practice or a hospital unit, are also important facilitators of or barriers to advanced practice nursing; APN students must learn to assess and intervene to build organizations and cultures that strengthen APN practice. Finally, APNs are accountable for the use of evidence-based practice to ensure positive patient and system outcomes. Measuring the favorable impact of advanced practice nursing on these outcomes and effecting performance improvements are essential activities that all APNs must be prepared to undertake, because continuing to demonstrate the value of APN practice is a necessity in chaotic practice environments. Special mention must be made of health care quality. As quality concerns have escalated, more attention is being paid to quality metrics for all settings (see Chapter 24). APNs are an important part of the solution to ensuring quality outcomes for their specialty populations. Quality is not itself a competency or an environmental element, but is an important feature that should be evident in the processes that APNs use and the outcomes that they achieve. For example, coaching for wellness should demonstrate the quality processes of a therapeutic nurse-patient relationship and the patient being a partner with the APN in achieving wellness outcomes. The importance of APN involvement in quality initiatives can be seen in the work of the Nursing Alliance for Quality Care, a national partnership of organizations, consumers, and other stakeholders in the safety and quality arena (http://www.gwumc.edu/healthsci/departments/nursing/naqc/). Implications of the Definition of Advanced Practice Nursing A number of implications for education, regulation and credentialing, practice, and research flow from this understanding of advanced practice nursing. The Consensus Model (NCSBN, 2008) makes the important point that effective communication between legal and regulatory groups, accreditors, certifying organizations, and educators (LACE) is necessary to advance the goals of advanced practice nursing. Decisions made by each of these groups affect and are affected by all the others. Historically, advanced practice nursing has been hampered by the lack of consensus in APN definition, terminology, educational and certification requirements, and regulatory approaches. The Consensus Model process, by combining stakeholders from each of the LACE areas, has taken a giant step forward toward the profession’s achieving needed consensus on APN practice, education, certification, and regulation. Implications for Advanced Practice Nursing Education Graduate programs should provide anticipatory socialization experiences to prepare students for their chosen APN role. Graduate experiences should include practice in all the competencies of advanced practice nursing, not just direct clinical practice. For example, students who have no theoretical base or guided practice experiences in consultative skills or clinical, professional, and systems leadership will be ill-equipped to demonstrate these competencies on assuming a new APN role. In addition, APN students need to understand the critical elements in health care environments, such as the business aspects of practice and health care policy that must be managed if their practices are to survive and grow. All APN roles require at least a specialty master’s education; master’s programs are continuing even as the DNP degree is being developed in many institutions. The profession has embraced a wide variety of graduate educational models for preparing APNs, including direct-entry programs for non-nurse college graduates and RN to MSN programs. It is highly unlikely that doctoral preparation for advanced practice nursing will supplant these various master’s programs by 2015, as originally proposed by the AACN. Debate on the issue of the DNP continues (Marion et al., 2003; Dracup, Cronenwett, Meleis, & Benner, 2005; Fulton & Lyon, 2005; Cronenwett, Dracup, Grey, et al., 2011; see also Part III for views of leaders in each APN role). Ensuring quality and standardization of APN education in the various specialties is imperative if the profession is to guarantee a highly skilled, uniformly educated APN to the public. The definition of advanced practice nursing used here can serve as a guide for developing quality courses and clinical practice experiences that prepare APN students to practice at an advanced level. Implications for Regulation and Credentialing Clarifying the definition of advanced practice nursing helps explain the concept to nursing’s external stakeholders, such as legislators, insurers, and those in other disciplines. Significant progress has been made toward an integrative view of APRN regulation over the past decade, culminating in the LACE regulatory framework detailed in the Consensus Model. In particular, the primary criteria of graduate education, advanced certification, and focus on direct clinical practice for all APN roles proposed in this definition have been affirmed as the key elements in regulating and credentialing APRNs (NCSBN, 2008). Such internal cohesion can go a long way toward removing barriers to the public’s access to APN care. The Consensus Model has been an important unifying force within the APN community. The regulatory clarity in this document has increasingly been seen in other national statements and the work was highlighted in the IOM Report on the Future of Nursing (IOM, 2011). The NCSBN has embarked on the ?Campaign for APRN Consensus? (https://www.ncsbn.org/aprn.htm), a nationwide effort to have this model enacted in all the states. In addition, the IOM Report has given rise to action coalitions, funded by the Robert Wood Johnson Foundation, in numerous states (http://www.thefutureofnursing.org). The Campaign for Action has a dual focus, implementing solutions to the challenges facing the nursing profession and strengthening nurse-based approaches to transform how Americans receive quality health care. Although the Campaign for Action is broader in scope than just advanced practice nursing, many of the solutions for transforming health care involve APNs being able to practice to the full extent of their education. It is critically important for all APNs to be aware of and involved in these efforts. One implication for credentialing flows from the diverse specialty and role base of advanced practice nursing. Just as no APN can be characterized as a generalist, no one APN program can prepare students for the full depth and breadth of advanced practice nursing. As a consequence, APNs must practice and be certified in the specific population focus and role for which they have been educated. APNs who wish to change their specialty, population focus, or APN role need to return to school for education targeted to that area. The days are past when a primary care NP could take a job in a specialized acute care practice without further education to prepare for that specialty. This issue of aligning APN job expectations with education and certification is not always well understood by practice environments, educators, or even APNs themselves. However, the need to ensure congruence among particular APN specialties and roles and education, certification, and subsequent practice has been identified by regulators, and more stringent regulations regarding this issue are being promulgated (NCSBN, 2008). Implications for Research As noted in Chapter 10, one of the core competencies of advanced practice nursing is the use of evidence-based practice in an APN’s practice and in changing the practice environment to incorporate the use of evidence. The practice doctorate initiative identified the increased need for leadership in evidence-based practice and application of knowledge to solve practice problems and improve health outcomes as reasons for moving to the DNP degree for APN practice (AACN, 2006). If research is to be relevant to health care delivery and to nursing practice at all levels, APNs must be involved. APNs need to recognize the importance of advancing the profession’s and health care system’s knowledge about effective patient care practices and to realize that they are a vital link in building and translating this knowledge in clinical practice. Related to this research involvement is the necessity for more research differentiating basic and advanced practice nursing and identifying the patient populations that benefit most from APN intervention. For example, there is compelling empirical evidence that APNs can effectively manage chronic disease?preventing or mitigating complications, reducing rehospitalizations, and increasing patients’ quality of life. This evidence is presented in the chapters in Part III and in Chapter 23. Linking advanced practice nursing to specific patient outcomes remains a major research imperative for this century. It is interesting to note the increasing research being conducted in international settings as more countries implement advanced practice nursing and study the effectiveness of these new practitioners; discussions of this research are woven throughout the chapters of this book. Similarly, research is needed on the outcomes of the different APN educational pathways in terms of APN graduate experiences and patient outcomes. Such data would be invaluable in continuing to refine advanced practice education. Outcomes achieved by graduates from DNP programs need similar study in comparison to master’s-level APN graduates; in critiquing the need for the DNP degree, Fulton and Lyon (2005) noted the absence of research data on whether there are weaknesses in current master’s-level graduates. Implications for Practice Environments Because of the centrality of direct clinical practice, APNs must hold onto and make explicit their direct patient care activities. They must also articulate the importance of this level of care for patients. In addition, it is important to identify those patients who most need APN services and ensure that they receive this care. APN roles require considerable autonomy and authority to be fully enacted. Practice settings have not always structured APN roles to allow sufficient autonomy or accountability for achievement of the patient and system outcomes that are expected of advanced practitioners. It is equally important to emphasize that APNs have expanded responsibilities?expanded authority for practice requires expanded responsibility for practice. APNs must demonstrate a higher level of responsibility and accountability if they are to be seen as legitimate providers of care and full partners on provider teams responsible for patient populations. This willingness to be accountable for practice will also promote consumers’ and policymakers’ perceptions of APNs as credible providers in line with physicians. The APN leadership competency mandates that APNs serve as visible role models and mentors for other nurses (see Chapter 11). Leadership is not optional in APN practice; it is a requirement. APNs must be a visible part of the solution to the health care system’s problems. For this goal to be realized, each APN must practice leadership in his or her daily activities. In practice environments, APNs need structured time and opportunities for this leadership, including mentoring activities with new nurses. New APNs require a considerable period of role development before they can master all the components and competencies of their chosen role, which has important implications for employers of new APNs. Employers should provide experienced preceptors, some structure for the new APN, and ongoing support for role development (see Chapter 4 for further recommendations). Finally, APN roles must be structured in practice environments to allow APNs to enact advanced nursing skills rather than simply substitute for physicians. It is certainly necessary for APNs to gain additional skills in medical diagnosis and therapeutic interventions, including the knowledge needed for prescriptive authority. However, advanced practice nursing is a value-added complement to medical practice, not a substitute for it. This is particularly an imperative in the primary care arena; it may well be that substituting APNs for physicians in classic, medically driven primary care configurations is not the best use of APN skills. Because APN competencies include those of partnering with patients, use of evidence, and coaching skills, APNs may be more effectively used in wellness programs, working with chronically ill patients to strengthen their self-management and adherence and designing and implementing educational programs for patients with complex management needs. New models are needed that are more collaborative and configure teams in innovative ways to minimize fragmentation of care and make the best use of the APN as a value-added complement to the traditional medical team. As physician shortages increase, particularly the number of physicians prepared in family practice and the new hospitalist practices, this distinction between advanced practice nursing and medical practice must be clear in the minds of employers, insurers, and APNs themselves. As advanced practice nursing evolves, it is becoming clear that APNs represent a choice and an alternative for patients seeking care. Consequently, understanding what APNs bring to health care must be articulated to multiple stakeholders to enable informed patient choice. A competency-based definition of advanced practice nursing aids in this articulation, so that APNs are not just seen as physician substitutes. Conclusion Since the first edition of this text in 1996, substantial progress has been made toward clarifying the definition of advanced practice nursing. This progress is enabling APNs, educators, administrators, and other nursing leaders to be clear and consistent about the definition of advanced practice nursing so that the profession speaks with one voice. This is a critical juncture in the evolution of advanced practice nursing as national attention on nursing and recommendations for nursing’s central role in redesigning the health care system are increasing. APNs must continue to clarify that the advanced practice of nursing is not the junior practice of medicine but represents an important alternative practice that complements rather than competes with medical practice. In some cases, patients need advanced nursing and not medicine; identifying these situations and matching APN resources to patients’ needs are important priorities for transforming the current health care system. APNs must be able to articulate their defining characteristics clearly and forcefully so that their practices will survive and thrive amidst continued cost cutting in the health care sector. For a profession to succeed, it must have internal cohesion and external legitimacy, and have them at the same time (Safriet, 1993). Clarity about the core definition of advanced practice nursing and recognition of the primary criteria and competencies necessary for all APNs enhance nursing’s internal cohesion. At the same time, clarifying the differences among APNs and showcasing their important roles in the health care system enhance nursing’s external legitimacy. References Advanced Nursing Practice. (2012). Cumulative index to nursing and allied health literature. 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Chapter 4 Role Development of the Advanced Practice Nurse
Karen A. Brykczynski
What is it like to become an advanced practice nurse (APN)? Role development in advanced practice nursing is described here as a process that evolves over time. The process is more than socializing and taking on a new role. It involves transforming one’s professional identity and the progressive development of the seven core advanced practice competencies (see Chapter 3). The scope of nursing practice has expanded and contracted in response to societal needs, political forces, and economic realities (Levy, 1968; Safriet, 1992; see Chapter 1). Historical evidence suggests that the expanded role of the 1970s was common nursing practice during the early 1900s (DeMaio, 1979). However, the core of nursing is not defined by the tasks nurses perform. This task-oriented perspective is inadequate and disregards the complex nature of nursing.
In the current cost-constrained environment, the pressure to be cost-effective and to make an impact on outcomes is greater than ever, but studies have shown that the initial year of practice is one of transition (Brown & Olshansky, 1998; Brykczynski, 2009; Kelly & Mathews, 2001) and an APN’s maximum potential may not be realized until after approximately 5 or more years in practice (Cooper & Sparacino, 1990). This chapter explores the complex processes of APN role development, with the objectives of providing the following: (1) an understanding of related concepts and research; (2) anticipatory guidance for APN students; (3) role facilitation strategies for new APNs, APN preceptors, faculty, administrators, and interested colleagues; and (4) guidelines for continued role evolution. This chapter consolidates literature from all the APN specialties?including clinical nurse specialists (CNSs), nurse practitioners (NPs), certified nurse-midwives (CNMs), and certified registered nurse anesthetists (CRNAs)?to present a generic process relevant to all APN roles. Some of this literature is foundational to understanding issues of role development for all APN roles and, although dated, remains relevant. This chapter has been expanded to include international APN role development experiences.
The discussion is separated into (1) the educational component of APN role acquisition and (2) the occupational or work component of role implementation. This division in the process of role development is intended to clarify and distinguish the changes occurring during role transitions experienced during the educational period (role acquisition) and the changes occurring during the actual performance of the role after program completion (role implementation). Strategies for enhancing APN role development are described. The chapter concludes with summary comments and suggestions to facilitate future APN role development and evolution.
Perspectives on Advanced Practice Nurse Role Development
Professional role development is a dynamic ongoing process that, once begun, spans a lifetime. The concept of graduation as commencement, whereby one’s career begins on completion of a degree, is central to understanding the evolving nature of professional roles in response to personal, professional, and societal demands (Gunn, 1998). Professional role development literature in nursing is abundant and complex, involving multiple component processes, including the following: (1) aspects of adult development; (2) development of clinical expertise; (3) modification of self-identity through initial socialization in school; (4) embodiment of ethical comportment (Benner, Sutphen, Leonard, & Day, 2010); (5) development and integration of professional role components; and (6) subsequent resocialization in the work setting. Similar to socialization for other professional roles, such as those of attorney, physician, teacher, and social worker, the process of becoming an APN involves aspects of adult development and professional socialization. The professional socialization process in advanced practice nursing involves identification with and acquisition of the behaviors and attitudes of the advanced practice group to which one aspires (Waugaman & Lu, 1999, p. 239). This includes learning the specialized language, skills, and knowledge of the particular APN group, internalizing its values and norms, and incorporating these into one’s professional nursing identity and other life roles (Cohen, 1981).
Novice to Expert Skill Acquisition Model
Acquisition of knowledge and skill occurs in a progressive movement through the stages of performance from novice to expert, as described by Dreyfus and Dreyfus (1986, 2009), who studied diverse groups, including pilots, chess players, and adult learners of second languages. The skill acquisition model has broad applicability and can be used to understand many different skills better, ranging from playing a musical instrument to writing a research grant. The most widely known application of this model is Benner’s (1984) observational and interview study of clinical nursing practice situations from the perspective of new nurses and their preceptors in hospital nursing services. Although this study included several APNs, it did not specify a particular education level as a criterion for expertise. As noted in Chapter 3, there has been some confusion about this criterion. The skill acquisition model is a situation-based model, not a trait model. Therefore, the level of expertise is not an individual characteristic of a particular nurse but is a function of the nurse’s familiarity with a particular situation in combination with his or her educational background. This model could be used to study the level of expertise required for other aspects of advanced practice, including guidance and coaching, consultation, collaboration, evidence-based practice ethical decision making, and leadership (see Brykczynski  for a detailed discussion of the Dreyfus model).
Figure 4-1 shows a typical APN role development pattern in terms of this skill acquisition model. A major implication of the novice to expert model for advanced practice nursing is the claim that even experts can be expected to perform at lower skill levels when they enter new situations or positions. Hamric and Taylor’s report (1989) that an experienced CNS starting a new position experiences the same role development phases as a new graduate, only over a shorter period, supports this claim.
The overall trajectory expected during APN role development is shown in Figure 4-1; however, each APN experiences a unique pattern of role transitions and life transitions concurrently. For example, a professional nurse who functions as a mentor for new graduates may decide to pursue an advanced degree as an APN. As an APN graduate student, she or he will experience the challenges of acquiring a new role, the anxiety associated with learning new skills and practices, and the dependency of being a novice. At the same time, if this nurse continues to work as a registered nurse, his or her functioning in this work role will be at the competent, proficient, or expert level, depending on experience and the situation. On graduation, the new APN may experience a limbo period, during which the nurse is no longer a student and not yet an APN, while searching for a position and meeting certification requirements (see later). Once in a new APN position, this nurse may experience a return to the advanced beginner stage as he or she proceeds through the phases of role implementation. Even after making the transition to an APN role, progression in role implementation is not a linear process. As Figure 4-1 indicates, there are discontinuities, with movement back and forth as the trajectory begins again. Years later, the APN may decide to pursue yet another APN role. The processes of role acquisition, role implementation, and novice to expert skill development will again be experienced?although altered and informed by previous experiences?as the postgraduate student acquires additional skills and knowledge. Role development involves multiple, dynamic, and situational processes, with each new undertaking being characterized by passage through earlier transitional phases and with some movement back and forth, horizontally or vertically, as different career options are pursued.
Direct-entry students who are non-nurse college graduates (NNCGs) and APN students with little or no experience as nurses before entry into an APN graduate program would be expected to begin their APN role development at the novice level (see Fig. 4-1). Some evidence indicates that although these inexperienced nurse students may lack the intuitive sense that comes with clinical experience, they avoid the role confusion associated with letting go of the traditional RN role commonly reported with experienced nurse students (Heitz, Steiner, & Burman, 2004). This finding has implications for APN education as the profession moves toward the Doctor of Nursing Practice (DNP) as the preferred educational pathway for APN preparation (American Association of Colleges of Nursing [AACN], 2006).
Another significant implication of the Dreyfus model (Dreyfus & Dreyfus, 1986, 2009) for APNs is the observation that the quality of performance may deteriorate when performers are subjected to intense scrutiny, whether their own or that of someone else (Roberts, Tabloski, & Bova, 1997). The increased anxiety experienced by APN students during faculty on-site clinical evaluation visits or during videotaped testing of clinical performance in
Typical APN role development pattern. 1a, APN students may begin graduate school as proficient or expert nurses. 1b, Some enter as competent RNs, with limited practice experience. Depending on previous background, the new APN student will revert to novice level or advanced beginner level on assuming the student role. 2, A direct-entry APN student or NNCG student with no experience would begin the role transition process at the novice level. 3, The graduate from an APN program is competent as an APN student but has no experience as a practicing APN. 4, A limbo period is experienced while the APN graduate searches for a position and becomes certified. 5, The newly employed APN reverts to the advanced beginner level in the new APN position as the role trajectory begins again. The imposter phenomenon may be experienced here (Arena & Page, 1992; Brown & Olshansky, 1998). 6, Some individuals remain at the competent level. There is a discontinuous leap from the competent to the proficient level. 7, Proficiency develops only if there is sufficient commitment and involvement in practice along with embodiment of skills and knowledge. 8, Expertise is intuitive and situation-specific, meaning that not all situations will be managed expertly. See text for details.
NOTE: Refer to the Dreyfus skill acquisition model for further details (Benner, 1984;Benner, Tanner, & Chesla, 2009; Dreyfus & Dreyfus, 1986; 2009). For the purpose of illustration, this figure is more linear than the individualized role development trajectories that actually occur.
simulated situations is an example of responding to such intense scrutiny. A third implication of this skill acquisition model for APNs is the need to accrue experience in actual situations over time, so that practical and theoretical knowledge are refined, clarified, personalized, and embodied, forming an individualized repertoire of experience that guides advanced practice performance. As the profession encourages new nurses to move more rapidly into APN education, students, faculty, and educational programs must search for creative ways to incorporate the practical and theoretical knowledge necessary for advanced practice nursing. Discussing unfolding cases is a useful approach for teaching the clinical reasoning in transition so essential for clinical practice (Benner, Sutphen, Leonard, & Day, 2010; Day, Cooper, & Scott, 2012).
TABLE 4-1 Selected Role Concepts
Concept Definition Examples
Role stress A situation of increased role performance demand Returning to school while maintaining work and family responsibilities
Role strain Subjective feeling of frustration, tension, or anxiety in response to role stress Feeling of decreased self-esteem when performance is below expectations of self or significant others
Role stressors Factors that produce role stress Financial, personal, or academic demands and role expectations that are ambiguous, conflicting, excessive, or unpredictable
Role ambiguity Unclear expectations, diffuse responsibilities, uncertainty about subroles Some degree of ambiguity in all professional positions because of the evolving nature of roles and expansion of skills and knowledge
Role incongruity A role with incompatibility between skills and abilities and role obligations or between personal values, self-concept, and role obligations An adult NP in a role requiring pediatric skills and knowledge
Role conflict Occurs when role expectations are perceived to be mutually exclusive or contradictory Role conflict between APNs and other nurses and between APNs and physicians
Role transition A dynamic process of change over time as new roles are acquired Changing from a staff nurse role to an APN role
Role insufficiency Feeling inadequate to meet role demands New APN graduate experiencing the imposter phenomenon (Arena & Page, 1992; Brown & Olshansky, 1998)Role supplementation Anticipatory socialization Role-specific educational components in a graduate program
Adapted from Hardy, M.E., & Hardy, W.L. (1988). Role stress and role strain. In M.E. Hardy & M.E. Conway (Eds.), Role theory: Perspectives for health professionals (pp. 159?239, 2nd ed.). Norwalk, CT: Appleton & Lange; and Schumacher, K.L., & Meleis, A.I. (1994). Transitions: A central concept in nursing. Image: The Journal of Nursing Scholarship, 26, 119?127.
Role Concepts and Role Development Issues
This discussion of professional role issues incorporates role concepts described by Hardy and Hardy (1988) along with the concept that different APN roles represent different subcultural groups within the broader nursing culture (Leininger, 1994). Building on Johnson’s (1993) conclusion that NPs have three voices, Brykczynski (1999a) described APNs as tricultural and trilingual. They share background knowledge, practices, and skills of three cultures?biomedicine, mainstream nursing, and everyday life. They are fluent in the languages of biomedical science, nursing knowledge and skill, and everyday parlance. Some APNs (e.g., CNMs) are socialized into a fourth culture as well, that of midwifery. Others are also fluent in more than one everyday language.
The concepts of role stress and strain discussed by Hardy and Hardy (1988) are useful for understanding the dynamics of role transitions (Table 4-1). Hardy and Hardy described role stressas a social structural condition in which role obligations are ambiguous, conflicting, incongruous, excessive, or unpredictable. Role strain is defined as the subjective feeling of frustration, tension, or anxiety experienced in response to role stress. The highly stressful nature of the nursing profession needs to be recognized as the background within which individuals seek advanced education to become APNs (Aiken, Clarke, Sloan, et al., 2002; Dionne-Proulz & Pepin, 1993). Role strain can be minimized by the identification of potential role stressors, development of coping strategies, and rehearsal of situations designed for application of those strategies. However, the difficulties experienced by neophytes in new positions cannot be eliminated. As noted, expertise is holistic, involving embodied perceptual skills (e.g., detecting qualitative distinctions in pulses or types of anxiety), shared background knowledge, and cognitive ability. A school-work, theory- practice, ideal-real gap will remain because of the nature of human skill acquisition.
Bandura’s (1977) social cognitive theory of self-efficacy may be of interest to APNs in terms of understanding what motivates individuals to acquire skills and what builds confidence as skills are developed. Self-efficacy theory, a person’s belief in their ability to succeed, has been used widely to further understanding of skill acquisition with patients (Burglehaus, 1997; Clark & Dodge, 1999;Dalton & Blau, 1996). Self-efficacy theory has also been applied to mentoring APN students (Hayes, 2001) and training health care professionals in skill acquisition (Parle, Maguire, & Heaven, 1997).
Role ambiguity (see Table 4-1) develops when there is a lack of clarity about expectations, a blurring of responsibilities, uncertainty regarding role implementation, and the inherent uncertainty of existent knowledge. According to Hardy and Hardy (1988), role ambiguity characterizes all professional positions. They have noted that role ambiguity might be positive in that it offers opportunities for creative possibilities. It can be expected to be more prominent in professions undergoing change, such as those in the health care field. Role ambiguity has been widely discussed in relation to the CNS role (Bryant-Lukosius, Carter, Kilpatrick, et al, 2010; Hamric, 2003; see also Chapter 14), but is also a relevant issue for other APN roles (Kelly & Mathews, 2001), particularly as APN roles evolve (Stahl & Myers, 2002).
Role incongruity is intrarole conflict, which Hardy and Hardy (1988) described as developing from two sources. Incompatibility between skills and abilities and role obligations is one source of role incongruity. An example of this is an adult APN hired to work in an emergency department with a large percentage of pediatric patients. Such an APN will find it necessary to enroll in a family NP or pediatric NP program to gain the knowledge necessary to eliminate this role incongruity. This is a growing issue as NP roles become more specialized. Another source of role incongruity is incompatibility among personal values, self-concept, and expected role behaviors. An APN interested primarily in clinical practice may experience this incongruity if the position that she or he obtains requires performing administrative functions. An example comes from Banda’s (1985)study of psychiatric liaison CNSs in acute care hospitals and community health agencies. She reported that they viewed consultation and teaching as their major functions, whereas research and administrative activities produced role incongruity.
Role conflict develops when role expectations are perceived to be contradictory or mutually exclusive. APNs may experience conflict with varying demands of their role, as well as intraprofessional and interprofessional role conflict.
Intraprofessional Role Conflict
APNs experience intraprofessional role conflict for a variety of reasons. The historical development of APN roles has been fraught with conflict and controversy in nursing education and nursing organizations, particularly for CNMs (Varney, 1987), NPs (Ford, 1982), and CRNAs (Gunn, 1991; see also Chapter 1). Relationships among these APN groups and nursing as a discipline have improved markedly in recent years, but difficulties remain (Fawcett, Newman, & McAllister, 2004). The degree to which APN roles demonstrate a holistic nursing orientation as opposed to a more disease-specific medical orientation remains problematic (see value-added discussion under collaboration, later).
Communication difficulties that underlie intraprofessional role conflict occur in four major areas: (1) at an organizational level; (2) in educational programs; (3) in the literature; and (4) in direct clinical practice. Kimbro (1978) initially described these communication difficulties in reference to CNMs, but they are relevant for all APN roles. The fact that CNSs, NPs, CNMs, and CRNAs each have specific organizations with different certification requirements, competencies, and curricula creates boundaries and sets up the need for formal lines of communication. Communication gaps occur in education when courses and textbooks are not shared among APN programs, even when more than one specialty is offered in the same school. Specialty-specific journals are another formal communication barrier because APNs may read primarily within their own specialty and not keep abreast of larger APN issues. In clinical settings, some APNs may be more concerned with providing direct clinical care to individual patients, whereas staff nurses and other APNs may be more concerned with 24-hour coverage and smooth functioning of the unit or institution. These differences may set the stage for intraprofessional role conflict.
During the 1980s and 1990s, when there was more confusion about the delineation of roles and responsibilities between RNs and NPs, RNs would sometimes demonstrate resistance to NPs by refusing to take vital signs, obtain blood samples, or perform other support functions for patients of NPs (Brykczynski, 1985; Hupcey, 1993; Lurie, 1981), and they were not admonished by their supervisors for these negative behaviors. These behaviors are suggestive of horizontal violence (a form of hostility), which may be more common during nursing shortages (Thomas, 2003). Roberts (1983) first described horizontal violence among nurses as oppressed group behavior wherein nurses who were doubly oppressed as women and as nurses demonstrated hostility toward their own less powerful group, instead of toward the more powerful oppressors. Recognizing that intraprofessional conflict among nurses is similar to oppressed group behavior can be useful in the development of strategies to overcome these difficulties (Bartholomew, 2006; Brykczynski, 1997;Farrell, 2001; Freshwater, 2000; Roberts, 1996; Rounds, 1997; see Chapter 11). According to Rounds (1997), horizontal violence is less common among NPs as a group than among RNs generally. Over the years, as the NP role has become more accepted by nurses, there appear to be fewer cases of these hostile passive-aggressive behaviors, often currently referred to as bullying, toward NPs. However, they are still reported in APN transition literature (Heitz et al., 2004; Kelly & Mathews, 2001).
One way to address these issues would be to include APN position descriptions in staff nurse orientation programs. Curry’s claim (1994) that thorough orientation of staff nurses to the APN role, including clear guidelines and policies regarding responsibility issues, is an important component of successful integration of NP practice in an emergency department setting is also applicable to other roles and settings. Another significant strategy for minimizing intraprofessional role conflict is for the new APN, and APN students, to spend time getting to know the nursing staff to establish rapport and learn as much as possible about the new setting from those who really know what is going on?the nurses. This action affirms the value and significance of nurses and nursing and sets up a positive atmosphere for collegiality and intraprofessional role cooperation and collaboration. In Kelly and Mathews’ study (2001) of new NP graduates, such a strategy was exactly what new NPs regretted not having incorporated into their first positions.
Interprofessional Role Conflict
Conflicts between physicians and APNs constitute the most common situations of interprofessional conflict. Major sources of conflict for physicians and APNs are the perceived economic threat of competition, limited resources in clinical training sites, lack of experience working together, and the historical hierarchy. The relationship between anesthesiologists and CRNAs is an ongoing exemplar for examination of the issues of interprofessional role conflict between physicians and APNs.
Exemplar 4-1 Interprofessional Role Conflict: The Case of Certified Registered Nurse Anesthetists and Anesthesiologists
For many years, nurse anesthetists have provided high-quality anesthesia care in a variety of settings. They are the primary anesthesia providers in rural U.S. hospitals (www.aana.com). According to the American Association of Nurse Anesthetists (AANA, 2012), more than 42,000 certified registered nurse anesthetists provide quality anesthesia care to more than 65% of all patients undergoing surgical or other medical interventions that necessitate the services of an anesthetist (see Chapter 18). The fact that nurse anesthetists predated the first physician anesthesiologists by many years (see Chapter 1) may partly explain why the relationship between anesthesiologists and CRNAs has historically been interpreted by anesthesiologists as one of direct competition, thus creating an adversarial stance. Over the years, this relationship might be characterized as a cold war with overt offensives mounted periodically by anesthesiologists.
In 1970, CRNAs outnumbered anesthesiologists by a ratio of 1.5:1. By 2000, anesthesiologists outnumbered CRNAs (Blumenreich, 2000). This is one of the factors underlying conflicts over CRNA autonomy (see the AANA website, www.aana.com, for updates on this issue). Another factor is the decision made by the Centers for Medicare and Medicaid Services, after study of the available evidence in 1997, to reimburse nurse anesthetists directly under Medicare (Kleinpell, 2001). In response, anesthesiologists and the American Medical Association (AMA) launched a major campaign against CRNA autonomy in the operating room, claiming that supervision of CRNAs by physicians is essential for public safety (Federwisch, 1999; Kleinpell, 2001; Stein, 2000; see alsoChapter 18). This struggle with physicians over limiting the scope of practice of CRNAs is ongoing and reflects the experiences of other advanced practice nurse (APN) groups as well. An example of this continuing struggle is the Scope of Practice Partnership (SOPP), a coalition recently formed by the AMA with other physician organizations, to mount initiatives to limit the scope of practice of nonphysician clinicians (Waters, 2007).
One way to promote positive interprofessional relationships is to provide education and practice experiences that include APN students, medical students, and both physician and APN faculty to enhance mutual understanding of both professional roles (Kelly & Mathews, 2001). Developing such interprofessional education (IPE) experiences is difficult because of different academic calendars and clinical schedules. However, these obstacles can be overcome if these interdisciplinary activities are considered essential for improved health care delivery and if they have sufficient administrative support. Some programs attempt to overcome these scheduling issues by mandating IPE for APNs while it remains an elective experience for medical students, thereby reinforcing an optional and not important perspective among medical students.
The issues of professional territoriality and physician concern about being replaced by APNs were reported by Lindblad and colleagues (2010) from an ethnographic study of the first four APNs to graduate in 2005 from the first CNS program in Sweden. The APNs and general practitioners (GPs) agreed that the usefulness of the APNs would have been greater if the APNs had been able to prescribe medications and order treatments. After working with the APNs, the GPs saw them more as an additional resource and complement rather than a threat. By 2009, there were 16 APNs working in the new role in primary health care. Further clarification and definition of APN role responsibilities and collaboration will be forthcoming from Sweden.
The complementary nature of advanced practice nursing to medical care is a foreign concept for some physicians, who view all health care as an extension of medical care and see APNs simply as physician extenders. This misunderstanding of advanced practice nursing underlies physicians’ opposition to independent roles for nurses because they believe that APNs want to practice medicine without a license (see Chapters 1 and 3). In fact, numerous earlier studies of APN practice have demonstrated that advanced practice roles incorporate a holistic approach that blends elements of nursing and medicine (Brown, 1992; Brykczynski, 1999a, b; Fiandt, 2002; Grando, 1998;Johnson, 1993). However, when APNs are viewed by physicians as direct competitors, it is understandable that some physicians would be reluctant to be involved in assisting with APN education (National Commission on Nurse Anesthesia Education, 1990). In addition, some nurse educators have believed that physicians should not be involved in teaching or acting as preceptors for APNs. Improved relationships between APNs and physicians will require redefinition of the situation by both groups. The Interprofessional Education Collaborative’s (IPEC, 2011) advocacy for an interprofessional vision for all health professionals and the Institute of Medicine’s (IOM, 2003) recommendation that the health professional workforce be prepared to work in interdisciplinary teams underscore the imperative of interprofessional collaboration (see Chapter 12). Competency in interprofessional collaboration is critical for APNs because it is central to APN practice. This content is incorporated into the leadership and interprofessional partnership components of The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006).
Some interesting research has recently emerged on this issue in Canada and Europe. A participatory action research study conducted in British Columbia, Canada (Burgess & Purkis, 2010) indicated that NPs viewed collaboration as both a philosophy and a practice. ?They cultivated collaborative relations with clients, colleagues, and health care leaders to address concerns of role autonomy and role clarity, extend holistic client-centered care and team capacity, and create strategic alliances to promote innovation and system change? (p. 300). Of particular importance is the fact that the NP participants described themselves as being nurses first and practitioners second. This is significant because when role emphasis is on physician replacement and support rather than on the patient-centered, health-focused, holistic nursing orientation to practice, the nursing components of the role become less valued and invisible (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004). Medically driven and illness-oriented health systems tend to devalue these value-added components of APN roles and reimbursement mechanisms for including these aspects of care are lacking. Fleming and Carberry (2011) reported on a grounded theory study of expert critical care nurses transitioning to the role of APN in an intensive care unit (ICU) setting in Scotland. Initial perceptions were that the APN role was closely aligned with medical practice, but later perceptions supported earlier studies that the APN role was characterized by an integrated, holistic, patient-centered approach to care, which was close to the medical model, but different because it was carried out within an expert nursing knowledge base. They identified that further research is needed to explore the outcomes of this integrated practice. This is the research imperative for APNs?to demonstrate the impact of the holistic nursing approach to care on patient outcomes.
Nurse-midwives have been in the forefront of developing collaborative relationships with physicians for many years. All APN groups would benefit from attention to the progress that CNMs have made in collaboration with physicians. The joint practice statement of the American College of Nurse Midwives (ACNM) and the American College of Obstetricians and Gynecologists (ACOG) can be used as a model for other APN groups (ACOG/ACNM, 2011). It highlights key principles for improving communication, working relationships, and seamlessness in the provision of women’s health services (see also the ACNM’s website, www.acnm.org). Problems with previous joint practice statements were that they included varying interpretations of physician supervision. According to the most recent statement, ?OB-GYNs and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed, independent providers who may collaborate with each other based on the needs of their patients. Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and accountability? (ACOG/ACNM, 2011).
Role transitions are defined here as dynamic processes of change that occur over time as new roles are acquired (see Table 4-1). Five essential factors influence role transitions (Schumacher & Meleis, 1994): (1) personal meaning of the transition, which relates to the degree of identity crisis experienced; (2) degree of planning, which involves the time and energy devoted to anticipating the change; (3) environmental barriers and supports, which refer to family, peer, school, and other components; (4) level of knowledge and skill, which relates to prior experience and school experiences; and (5) expectations, which are related to such factors as role models, literature, and media. The role strain experienced by individuals in response to role insufficiency (see Table 4-1for definitions) that accompanies the transition to APN roles can be minimized, although certainly not completely prevented, by individualized assessment of these five essential factors, development of strategies to cope with them, and rehearsal of situations designed for application of these strategies. Entering graduate school may be associated with a ripple effect of concurrent role transitions in family, work, and other social arenas (Klaich, 1990).
Advanced Practice Nurse Role Acquisition in Graduate School
The personal meaning of role transitions was a major focus of literature in nursing role development in the United States from the 1970s through 2005. This topic is currently more prevalent in the international APN literature as APN roles are being established in different countries. In a review of APN role development literature from certificate and graduate NP programs, alterations in self-identity and self-concept emerged as a consistent theme, with role acquisition experiences commonly described as identity crises (see Brykczynski  for a detailed discussion of this earlier work).
In their study of NP students, Roberts and colleagues (1997) reported findings similar to those observed decades earlier by Anderson, Leonard, and Yates (1974). Anderson and colleagues described the process of role development observed in three NP programs (a graduate program, post-baccalaureate certificate program, and continuing education program), whereas Roberts and associates described a current graduate NP program. Anderson and colleagues’ (1974) description of NP students’ progression from dependence to interdependence being accompanied by regression, anxiety, and conflict was found to be similar to observations made by Roberts and coworkers (1997) in graduate NP students over a period of 6 years (Table 4-2). For many years, my NP faculty colleagues and I have observed similar role transition processes in teaching role and clinical courses for graduate NP students. In a discussion of role transition experiences for neonatal NPs, Cusson and Viggiano (2002) made the important point that even positive transitions are stressful.
Roberts and colleagues (1997) observed 100 NP graduate students and reviewed their student clinical journals. They identified three major areas of transition as students progressed from dependence to interdependence: (1) development of professional competence; (2) change in role identity; and (3) evolving relationships with preceptors and faculty. The lowest level of competence coincided with the highest level of role confusion. This occurred at the end of the first semester and the beginning of the second semester in the three-semester program examined (Roberts et al., 1997). The most intense transition period seemed to come at the end of the students’ first clinical immersion experience.
Roberts and colleagues (1997) described the first transition as involving an initial feeling of loss of confidence and competence accompanied by anxiety (see Table 4-2, stage I). Initial clinical experiences were associated with the desire to observe, rather than provide care, the inability to recall simple facts, the omission of essential data from history taking, feelings of awkwardness with patients, and difficulty prioritizing data. The students’ focus at this time was almost exclusively on acquiring and refining assessment skills and continued development of physical examination techniques. By the end of the first semester, students reported returning feelings of confidence and the regaining of their former competence in interpersonal skills. Although they were still tentative about diagnostic and treatment decisions, students reported feeling more comfortable with patients as some of their basic nursing abilities began to return (see Table 4-2, stage II).
Transitions in nursing role identity occurring during the first two stages were associated with feelings of role confusion. Students were dismayed at how slowly and inefficiently they were performing in clinical situations and reported feelings of self-doubt and lack of confidence in their abilities to function in the real world of health care. They sought shortcuts in attempts to increase their efficiency. They reported profound feelings of responsibility regarding diagnostic and treatment decisions and, at the same time, increasingly realized the limitations of clinical practice when they were confronted with the real-life situations of their patients. They recalled finding it easy to second-guess physicians’ decisions in their previous nursing roles, but now they found those decisions more problematic when they were responsible for making them. They joked about feeling like adolescents. This is the point that Cusson and Viggiano (2002) were making when they commented, in reference to neonatal NPs, that the infant really does look different when viewed from the head of the bed rather than the side of the bed. They explained that ?rather than taking orders, as they did as staff nurses, neonatal NPs must synthesize incredibly complex information and decide on a plan of action. Experienced neonatal nurses often guide house staff regarding care decisions and writing orders to match the care that is being given. However, the shift in responsibility to actually writing the orders can be very intimidating? (p. 24).
TABLE 4-2 Role Acquisition Process in School
Stage Definition Descriptive Features
I Complete dependence Immersion in learning medical components of care; role transition associated with role confusion and anxiety; decreased appreciation for psychosocial components of health and illness concerns; loss of confidence in clinical skills; feelings of incompetence
II Developing competence Ongoing clinical preceptorship experiences; didactic classes that incorporate medical diagnostic and nursing and medical therapeutic components, along with personal experience of illness components; renewed sense of appreciation for the value of nursing knowledge and skills; more realistic self-expectations of clinical performance, although still uncomfortable about accountability; increased confidence in ability to succeed in learning and making a valid contribution to care; initial formation of own philosophy and standards of practice
III Independence Comfortable with ability to conduct holistic assessments (physical and psychosocial); concentration on intervention and management options; conflicts with preceptors as student and preceptor challenge one another; conflicts with faculty relate to management options, clinical evaluations, examination questions, concern over not being taught all there is to know
IV Interdependence Renewed appreciation for interdependence of nursing and medicine; development of individualized version of advanced practice role
Adapted from Anderson, E.M., Leonard, B.J., & Yates, J.A. (1974). Epigenesis of the nurse practitioner role. American Journal of Nursing, 10, 12?16; and Roberts, S.J., Tabloski, P., & Bova, C. (1997). Epigenesis of the nurse practitioner role revisited. Journal of Nursing Education, 36, 67?73.
Roberts and colleagues (1997) observed that a blending of the APN student and the former nurse developed during stage II as students renewed their appreciation for their previous interpersonal skills as teachers, supporters, and collaborators and again perceived their patients as unique individuals in the context of their life situations. Students developed increased awareness of the uncertainty involved in the process of making definitive diagnostic and treatment decisions. In spite of current attempts to reduce diagnostic and treatment uncertainty through evidence-based practice, a basic degree of uncertainty is still inherent in clinical practice. Although these insights served to demystify the clinical diagnostic process, the students’ anxiety about providing care increased. Learning about strategies to cope with clinical decision making in situations of uncertainty, such as ruling out the worst case scenario, seeking consultation, and monitoring patients closely with phone calls and follow-up visits, can decrease anxiety and promote increased confidence (Brykczynski, 1991).
The transition in the relationships between students and preceptors and students and faculty in the study by Roberts and colleagues (1997) involved students feeling anxious that they were not learning enough and would never know enough to practice competently. Students felt frustrated and perceived that faculty and preceptors were not providing them with all the information they needed. During the third stage (see Table 4-2), as they felt more confident and competent, students began to question the clinical judgments of their preceptors and faculty. This process is thought to help students advance from independence to interdependence?the last stage of the transition process. Much of the conflict at this juncture appeared to derive from students’ feelings of ?ambivalence about giving up dependence on external authorities? (Roberts et al., 1997, p. 71) such as preceptors and faculty and assuming responsibility for making independent judgments based on their own assessments from their clinical and educational experiences and the literature. The relevance of these role acquisition processes for other APN roles has not been reported. This is another area in which research would be helpful.
Until recently, the literature on APN role acquisition in school has focused exclusively on individuals who were already nurses. A commonly held assumption among nurses is ?the more clinical experience, the better? for acquiring the necessary knowledge and skill to take on complex APN roles. At least 1 year of nursing practice is typically preferred for admission to APN programs. The process of role acquisition for students in direct-entry APN master’s programs that admit NNCGs may differ because these individuals were not functioning as nurses before they entered the program. For additional information regarding this topic, see the qualitative study reported by Rich and Rodriguez (2002). In their qualitative study of family nurse practitioner (FNP) role transition,Heitz and colleagues (2004) found differences in role acquisition experiences between FNP students who were inexperienced nurses and FNP students who were experienced nurses. Feelings of insecurity, inadequacy, vulnerability, and being overwhelmed were typical, but role confusion was reported primarily by the more experienced RN students as they went through the letting go process of the RN role and taking on the FNP role. It will be interesting to observe whether this finding holds true for BSN to DNP students.
Strategies to Facilitate Role Acquisition
The anticipatory socialization to APN roles that occurs in graduate education is analogous to a process that Kramer (1974) described for undergraduate RNs called ?immunization.? The overall objective is to expose role incumbents to as many real-life experiences as possible during the educational program to minimize reality shock and role insufficiency on graduation and initial role implementation. Role content can be incorporated into APN curricula in a variety of ways, including the following: (1) in the overall framework for designing an APN curriculum; (2) in a specific role course; (3) as part of specific assignments; and (4) in role seminars that span an entire curriculum. Hamric and Hanson (2003) asserted that it is an ethical mandate for all APN educators, regardless of specialty, to provide graduates with up to date knowledge of professional role and regulatory issues in addition to concentration on clinical competence. The importance of explicit role preparation for the complex and challenging roles of graduates of DNP programs is recognized in the curriculum proposed by the American Association of Colleges of Nursing (AACN, 2006). If there is not a separate role course, careful attention must be paid to this curriculum component so that it does not become integrated out of existence.
Specific strategies for facilitating role acquisition can be categorized according to three major purposes: (1) role rehearsal; (2) development of clinical knowledge and skills, including strategies for dealing with uncertainty; and (3) creation of a supportive network. For adequate role rehearsal, APN students should experience all aspects of the core competencies (see Chapter 3) directly while faculty and fellow students are available to help them process or debrief these experiences. Faculty can help students by identifying role acquisition periods of high stress in their particular program so that support can be built in during those periods. APN students should be cautioned that other nurses, physicians, other providers, and administrators in the work setting may value only clinical expertise and not the other core competencies. Strategies for enhancing understanding of how the core competencies are embedded in each APN role include preparation of short-term and long-term goals to use as guides in the development of professional portfolios, analysis of existing position descriptions, and development of the ideal position description. These are also helpful for guiding students in their search for an initial APN position.
The development of clinical knowledge and skills for APN role acquisition can be promoted by planning for realistic clinical experiences with the support of faculty and preceptors nearby. Emphasis on realism and a holistic situational perspective are important in clinical experiences for helping students understand that the complex clinical judgments involved in APN assessment and management of patient situations over time are not simply technical medical knowledge, but a hybrid of nursing and medical knowledge and experience. Teaching and learning experiences for all the APN role components should integrate elements of research and theory and be incorporated into specialty APN courses to build on the knowledge gained in the traditional graduate core and clinical support courses in the curriculum. New APN graduates can benefit from familiarity with role transition processes by not expecting to be able to demonstrate all APN role components fully and expertly immediately on graduation.
Clinical mentoring by preceptors is an important component of ensuring realistic clinical learning experiences (Hayes, 2001; Heitz, et al., 2004; Kelly & Mathews, 2001; Kleinpell-Nowell, 2001). A survey of 258 graduating NP students at 10 institutions indicated that students who selected their own preceptor scored higher on mentoring and self-efficacy than those whose preceptors were assigned by faculty (Hayes, 1998). In addition, students with non-nurse preceptors scored lower than those with nurse preceptors. These findings need to be considered in planning preceptor arrangements. A mix of APN and non-nurse preceptors during the program can be valuable. Hayes (2001) observed that requiring students to locate their own preceptors can be problematic for some students who may not have the necessary professional connections to identify a qualified preceptor.
Anticipatory planning for the first APN position after program completion is important. Reports of the transition experiences of new NP graduates during their first year after graduation suggested that the first position can be critical in terms of solidifying the NP’s career (Brown & Olshansky, 1997; Heitz et al., 2004; Kelly & Mathews, 2001). Preparation of students for assuming APN roles on graduation should be a collaborative effort of students, faculty, and preceptors. The need for position descriptions that clearly outline roles and responsibilities has been emphasized as essential for smooth role transition (Cooper & Sparacino, 1990; Hamric & Taylor, 1989; McMyler & Miller, 1997). The transition to the first position is a process, not an event, that may take 6 months to 2 years (Steiner et. al., 2004). It needs to be a focus of role content in APN programs (Hamric & Hanson, 2003; Hunter, Bormann, & Lops, 1996). Some APN faculty share the belief that frequent position changes or staying in the same registered nurse job after graduation from an APN program reflects role disillusionment. Substantive role courses are critical to smooth the path to full APN role implementation (Hamric & Hanson, 2003; Hunter et al., 1996).
Finally, and perhaps most importantly, an overall strategy for enhancing APN clinical knowledge and skill is for faculty to maintain competency in clinical practice. Clinical competency enhances the faculty’s ability to evaluate students clinically, discuss clinically relevant examples in classes, serve as preceptors for students, and evaluate the care provided in clinical preceptorship sites. The clinical competence of faculty is important to prevent a wide gap between education and practice, enhance faculty credibility, and foster realistic expectations for new APN graduates.
Establishing a peer support system, planning social functions with faculty and preceptors, and creating a virtual community can facilitate the development of a support network. Computer literacy is critical for networking and access to the high-quality materials available on websites (Table 4-3), in literature searches, and on smartphones. The importance of forming a support network was emphasized by study findings (Kelly & Mathews, 2001; Kleinpell-Nowell, 2001). The establishment of a system for self-directed learning activities during the first few years after program completion forms the basis for maintaining competence throughout one’s career (Gunn, 1998). The establishment of a process for lifelong learning should be initiated during the APN educational program as students create a computer-based, self-monitoring system that includes clinical and role transition experiences over time to serve as a reality check or timetable. On graduation, continuing education program attendance could be incorporated into this monitoring system to facilitate compilation of necessary documentation for certification, along with ongoing self-evaluation and role development.
TABLE 4-3 Useful Internet Sites for Creating a Support Network
Website Organization Highlights
Association of Academic Health Centers Interdisciplinary education and practice in prevention; resources for building a practice
National Organization of Nurse Practitioner Faculties NP competencies, publications, resource centers
American Association of Nurse Practitioners*
Certification, legislative news, research, continuing education
National Association of Clinical Nurse Specialists Position statement on CNS practice and education
American Nurses Association Credentialing center; patient safety, advocacy
National Association of Pediatric Nurse Practitioners Scope of practice for PNPs, healthy eating initiative, immunization education
American Association of Nurse Anesthetists Click on ?Resources? for professional practice documents
American College of Nurse- Midwives Click on ?About Midwives? for Scope of practice
National Council of State Boards of Nursing Click on ?Nursing Policy? for APRN consensus model
The American Academy of Nurse Practitioners and the American College of Nurse Practitioners merged to form the American Association or Nurse Practitioners in 2013.
Advanced Practice Nursing Role Implementation at Work
After successfully emerging from the APN educational process, new APN graduates face yet another transition, from the student role to the professional APN role (see Fig. 4-1). APN graduates can be expected to experience attitudinal, behavioral, and value conflicts as they move from the academic world, in which holistic care is highly valued, to the work world, in which organizational efficiency is paramount. Anticipatory guidance is needed for role transition yet again. The process of APN role implementation is an example of a situational transition (Schumacher & Meleis, 1994), which has been described as a progressive movement through phases. There is general agreement that significant overlap and fluidity exist among the phases. However, for purposes of discussion, the phases will be considered sequentially.
Hamric and Taylor’s (1989) study of CNS role development and Brown and Olshansky’s (1997) study of NP role transition are two major U.S. investigations of APN role implementation processes. Additional U.S. studies that have contributed to an understanding of the transitional processes as APNs implement their roles include the following: the longitudinal survey of acute care NP practice (Kleinpell-Nowell, 1999, 2001; Kleinpell, 2005), in which the first six cohorts to take the adult acute care national certification examination were followed annually for 5 years; Kelly and Mathews’ (2001) qualitative focus group study of 21 recent NP graduates; Heitz and colleagues’ (2004)qualitative study of nine FNPs’ role transition experiences; and Steiner and colleagues’ (2008)follow-up of the study by Heitz and associates. Reports of role implementation studies from other countries will also be integrated into the discussion.
Hamric and Taylor (1989) described seven phases of CNS role development, along with associated characteristics and developmental tasks derived from the analysis of questionnaires returned by 100 CNSs (Table 4-4). Of 42 CNSs in their first positions for 3 years or less, 40 experienced progression through the first three phases (identical to those phases identified by Baker ). Most of the CNS respondents went through these three phases within 2 years. Phase 1, the orientation phase, is characterized by enthusiasm, optimism, and attention to mastery of clinical skills. The second phase, the frustration phase, is associated with feelings of conflict, inadequacy, frustration, and anxiety. Arena and Page (1992) identified the imposter phenomenon as a feature of CNS practice that could interfere with effective role implementation. In retrospect, it appears that the imposter phenomenon is one of the distressing features of the frustration phase. The next phase, the implementation phase, is described as one of role modification in response to interactions with others. This phase is associated with a renewed or returning perspective.
CNSs with more than 3 years of experience described their role development experiences in terms very different from Baker’s (1979) phases. Content analysis of these data led to a description of four additional phases (see Table 4-4). Experienced CNSs identified the integration phase, which was characterized by ?self-confidence and assurance in the role, high job satisfaction, an advanced level of practice, and signs of recognition and respect for expertise within and outside the work setting? (Hamric & Taylor, 1989, p. 56). Only 10% of the CNSs with less than 5 years of experience in the role met the criteria for this phase, whereas 50% of those with more than 6 years of experience could be categorized as being in this phase. The integration phase was typically reached after 3 to 5 years in the CNS role. This fourth phase, of integration?thought to be reached only after successful transition through the earlier phases?is characterized by refinement of clinical expertise and integration of role components appropriate for the particular situation.
Llahana and Hamric (2011) reported on a nationwide study of the role development experiences of diabetes specialist nurses (DSNs) conducted in 2001 in the United Kingdom, which was based onHamric and Taylor’s (1989) work. Although the 334 DSNs were not all master’s prepared, most held postgraduate qualification in diabetes care. The findings indicated that role development phases were similar to those in the earlier study, with the addition of a transition phase associated with the orientation phase when a competent DSN moved to a different practice site. The anxiety experienced during the transition phase was related to orienting to a new work setting rather than to knowledge or competence in the role.
Hamric and Taylor (1989) also described three negative phases not evident in previous literature. The frozen phase is described as being associated with frustration, anger, and lack of career satisfaction. Restructuring of role responsibilities and changing organizational expectations characterize the reorganization phase. The complacent phase is characterized by comfort, stability, and maintenance of the status quo. Unlike the integration phase, these additional phases share a negative nonproductive character. It is of interest that there was a higher proportion of nurses in negative phases (58%) in the UK study (Llahana & Hamric, 2011) than reported in the originalHamric and Taylor study (1989) (27%). One might speculate that APNs experiencing these negative phases would be more vulnerable to position changes in today’s cost-constrained health care system.
TABLE 4-4 Phases of Advanced Practice Nurse Role Development
The complexity of APN role development processes is further demonstrated by findings fromBrown and Olshansky’s (1997) longitudinal grounded theory study of the role transition experiences of 35 novice NPs conducted at 1, 6, and 12 months for two different cohorts of graduates during their first year of practice. They described a four-stage process of moving from ?limbo to legitimacy? during the first year of practice, outlined in Table 4-5. Related developmental tasks and strategies included in this table were specifically developed for this chapter. The first stage, laying the foundation, was not described in previous literature. During this stage, new graduates take certification examinations, obtain necessary recognition or licensure from state boards of nursing, and look for positions. This stage has been shortened because of the availability of certification examinations by computer.
The second stage, the launching stage, was defined as beginning with the first NP position and lasting at least 3 months. During this stage, the new graduate NP experiences the anxiety associated with the crisis of confidence and competence that accompanies taking on a new position and the return to the advanced beginner skill level (Benner et al., 2009; Dreyfus & Dreyfus, 1986, 2009). As the advanced beginner becomes increasingly aware of the number of elements relevant to actual performance in the role, he or she may become overwhelmed with the complexity of the skills required for the role and exhausted by the effort required for mastery. New NPs in Kelly and Mathews’ (2001) study described similar experiences of exhaustion and frustration with lack of control over time. This is the at-work version of the crisis of confidence and competence experienced during stage I of the in-school role acquisition process (see Table 4-2).
The feeling of being ?an imposter? or ?a fake,? described by Brown and Olshansky (1997), Arena and Page (1992), and Huffstutler and Varnell (2006), was first reported in the psychological literature in reference to high-achieving women (Clance & Imes, 1978). Clinical symptoms associated with this phenomenon?generalized anxiety, lack of self confidence, depression, frustration?are commonly reported by APNs experiencing the frustration or launching phase. It is related to feeling unable to meet one’s own expectations and those of others (Clance & Imes, 1978)and feelings of inadequacy and constantly being tested (Arena & Page, 1992). This phenomenon is typically a temporary experience associated with taking on a new role or beginning a new job.Heitz and colleagues’ (2004) study related similar role transition experiences of self-doubt, disillusionment, and turbulence and also reported that engaging in positive self-talk was helpful. They suggested that issues of gender and age may underlie differing perceptions of personal commitments and sacrifices as obstacles to surmount in role transition.
TABLE 4-5 Transition Stages in First Year of Primary Care Practice
Stage Features Developmental Tasks Facilitation Strategies
Laying the foundation Period of role identity confusion immediately after graduation; not yet an NP, but no longer a student; feelings of worry, confusion, and insecurity about ability to practice successfully as an NP Recuperate from school.
Initiate a job search and secure a position.
Obtain certification. Take time out to recuperate from the pressures of school.
Plan rewards for self.
Maintain peer support network.
Refine professional portfolio and use it to analyze available positions in terms of future goals.
Launching Discomfort of advanced beginner level of knowledge and skills; feelings of unreality, insecurity?the imposter phenomenon; pervasive performance anxiety; daily stress; time pressure Develop realistic expectations.
Incorporate feeling of legitimacy into NP role identity.
Cope with anxiety.
Mobilize problem-solving skills.
Work on time management and setting priorities.
Develop support system. Plan for longer appointments initially.
Anticipate need for time to feel comfortable in new role.
Realize that the transition process is time-limited.
Schedule debriefing sessions with experienced MD or APN.
Seek peer and mentor support regularly.
Learn time-saving tips.
Clarify appropriate patient problems to work with initially.
Monitor internal self-talk; be positive.
Meeting the challenge Decreased anxiety; increased feeling of legitimacy; increased confidence develops, along with increased competence; increased acceptance and comfort with the uncertainty inherent in primary care Expand recognition of practice concerns to include the work environment.
Gain situational knowledge and skill in managing clinical problems.
Identify tangible accomplishments.
Develop individualized style of approaching patients and organizing care. Schedule a 6-mo evaluation.
Maintain communication with peers, administrators, and others.
Modify expectations to be more realistic.
Learn from repetitive practice.
Structure work situation so that resources are readily available.
Practice strategies to manage uncertainty.
Gain ability to handle uncertainty.
Broadening the perspective Feeling of enhanced self-esteem; solid feeling of legitimacy and competence; realistic and positive feelings about future practice Acknowledge strengths and identify ways to incorporate additional challenges.
Identify larger system problems and seek solutions.*
Schedule a 12-mo evaluation to reflect on progress and accomplishments.
Continue to seek verification and feedback from colleagues.
Make changes in work situation to increase support and effectiveness.
Inform staff and colleagues about NP role.
Affirm self-worth.?Adapted from Hamric, A.B., & Taylor, J.W. (1989). Role development of the CNS. In A.B. Hamric & J.A. Spross (Eds.), The clinical nurse specialist in theory and practice (2nd ed., p. 48). Philadelphia: WB Saunders.
Data from Brown, M.A., & Olshansky, E. (1997). From limbo to legitimacy: A theoretical model of the transition to the primary care nurse practitioner role. Nursing Research, 46, 46?51; and Brown, M.A., & Olshansky, E. (1998). Becoming a primary nurse practitioner: Challenges of the initial year of practice. Nurse Practitioner, 23, 46, 52?56.
All the developmental tasks from the integration phase in Table 4-4 would be appropriate here also.
Facilitation strategies from the Integration phase of Table 4-4 would be useful here also)
Although Brown and Olshansky (1997, 1998) did not relate their findings about NP role transition toHamric and Taylor’s (1989) findings about CNS role development, there appear to be many similarities in the results of the two studies. The characteristics of the launching stage are similar to those described by Hamric and Taylor (1989) for the frustration phase. Brown and Olshansky’s (1997, 1998) third stage, meeting the challenge, is associated with feelings of regaining confidence and increasing competence. This stage has much in common with Hamric and Taylor’s (1989)implementation phase, which is noted for returning optimism and enthusiasm as expectations are realigned. The last stage, broadening the perspective, is characterized by feelings of legitimacy and competency as NPs. This last stage is similar to Hamric and Taylor’s (1989) fourth stage of integration, during which the role is expanded and refined.
Fleming and Carberry (2011) studied expert critical care nurses transitioning to APN roles in an ICU setting in Scotland. The core category of steering the course to advanced practice and the phases of finding a niche, coping with the pressures, feeling competent to do, and internalizing the role share many similarities with the findings from the studies of Hamric and Taylor (1989) and Brown and Olshansky’s (1997). Fleming and Carberry observed that the extreme anxiety provoked by moving from expert to novice and back to expert again was similar to findings reported in previous studies of this process in critical care settings (Ball & Cox, 2004; Cussons & Strange, 2008).
Rich (2005) investigated the relationship between duration of experience as an RN and NP clinical skills in practice among NPs who graduated within 4 years from three universities in the Northeast. These graduates, 150 NPs, completed the self-report instrument assessments of their clinical skills (a response rate of 21%), and 60% of the collaborating physicians completed assessments of their NP clinical skills. Findings from the NP self-report data indicated that duration of practice experience as an RN was not correlated with level of competency in NP practice skills. ?An unexpected finding was that there was a significant negative correlation between years of experience as an RN and NP clinical practice skills as assessed by the collaborating physicians? (Rich, 2005, p. 55). Data describing which role development phase the NP participants were experiencing would have been helpful for enhancing understanding of the findings. The finding that collaborating physicians rated the NPs as more clinically competent than the NPs rated themselves (Rich, 2005) would be expected for NPs in the frustration or launching phase (see Tables 4-4 and 4-5). Inclusion of assessments of role development and clinical competency in APN follow-up studies would be helpful for building on the existing knowledge base.
Strategies to Facilitate Role Implementation
The seven major developmental phases identified by Hamric and Taylor (1989) to describe CNS role development are combined with strategies for facilitating APN role implementation (see Table 4-4).Table 4-5 lists the four stages of NP role implementation and their characteristics, as identified byBrown and Olshansky (1997), and includes developmental tasks and strategies for facilitating NP role development in an attempt to link this study with those findings from the Hamric and Taylor (1989) study. The reader is encouraged to compare and contrast Tables 4-4 and 4-5 to glean relevant content for their particular APN role.
The phases described by Hamric and Taylor (1989) are used here to structure discussion of strategies to facilitate role implementation. The importance of being patient and recognizing that it takes time to develop fully in a new APN role was stressed by NPs in Kleinpell-Nowell’s surveys (1999, 2001). A strategy to facilitate role implementation for all APNs during the orientation phase is development of a structured orientation plan. Brown and Olshansky (1997, 1998) noted the importance of clarification of values, needs, and expectations and of recognition that transitional experiences are time-limited. They also noted the importance of anticipatory guidance and realizing that these transition experiences follow a common pattern in new graduates. An APN in a new position, whether experienced in the role or not, needs to be aware of the importance of being informed about the organizational structure, philosophy, goals, policies, and procedures of the agency.
Networking was emphasized by NPs in Kleinpell-Nowell’s surveys (1999, 2001). Peer support within and outside of the work setting is important, as noted by Hamric and Taylor (1989). New NPs stressed the importance of getting to know other nurses in the work setting, gaining their respect, and forming key alliances with them to enhance optimal functioning in their new position (Kelly & Mathews, 2001). Designating a more experienced APN in the work setting as a mentor would be helpful and would provide support for all APNs new to a position. APNs who serve as preceptors for students might be particularly effective mentors for new graduates (Hayes, 2005). The importance of careful selection of a mentor was reported by NPs in the study by Kelly and Mathews (2001). Additional strategies suggested for networking within the system include developing peer support groups, being accessible to colleagues by phone or email, and getting involved in interdisciplinary committees (Page & Arena, 1991). APNs should be encouraged to join local APN groups for peer support, legislative and political updates, and networking opportunities. Numerous Internet sites are also available for networking, as noted earlier.
Page and Arena (1991) recommended that CNSs schedule and devote the major portion of their time during the orientation phase to direct patient care to substantiate the clinical expert role. They also suggested making appointments with nursing leaders, physicians, and other health care professionals during this phase to garner administrative support. They recommended distributing business cards and making the job description available for discussion. They also counseled new CNSs to withhold suggestions for change until they have had the opportunity to assess the system more fully. When a new APN joins the staff of an organization, the administrator should send a letter describing the APN’s background experiences and new position to key people in the organization.
Hamric and Taylor (1989) observed that the frustration phase might come and go and may overlap other phases. They noted that painful affective responses are typical of this difficult phase. They suggested that monthly sessions for sharing concerns with a group of peers and an administrator might facilitate movement through this phase. Strategies identified as helpful for energizing movement from the frustration phase to the implementation phase include the following: obtaining assistance with time management (Allen, 2001); participating in support groups to ameliorate feelings of inadequacy; engaging in discussions for conflict resolution and role clarification; reassessing priorities and setting realistic expectations; and focusing on short-term, visible goals.
Page and Arena (1991) suggested keeping a work portfolio to document activities so that APN progress is more readily visible and accessible. This can be an expansion of the portfolio and self-monitoring system initiated during the APN program. Brown and Olshansky (1997) noted that organized sources of support such as phone calls, seminars, planned meetings with mentors, and scheduled time for consultation can significantly decrease feelings of anxiety. They noted that recognition of the discomfort arising from moving from expert back to novice and the realization that previous expertise can be valuable in the new role may help reduce feelings of inadequacy. They suggested that new APNs request reasonable time frames for initial patient visits because novices take longer than experienced practitioners, and this may be key to successful adjustment to a new position.
During the implementation phase, it is important for the APN to reassess demands to prevent feeling overwhelmed. Priorities may need to be readjusted and short-term goals may need to be reformulated. Brown and Olshansky (1997, 1998) observed that competence and confidence are fostered through repetition. They also recommend scheduling a formal evaluation after approximately 6 months in which feedback about areas of strength and those needing improvement can be ascertained. Strategies mentioned as important during this time include seeking administrative support through involvement in meetings, maintaining visibility in clinical areas, and developing in-service programs with input from staff (Page & Arena, 1991). After some time in the implementation phase, APNs may plan and execute small-scale projects to demonstrate their effectiveness in their new role.
Hamric and Taylor’s (1989) survey data indicated that CNSs maximize their role potential during the integration phase. Satisfactory completion of the earlier phases appears to be essential for passage into this phase. One strategy for enhancing and maintaining optimal role implementation during this phase is having a trusted colleague who can act as a safe sounding board for ?feedback, constructive criticism, and advice? (Hamric & Taylor, 1989, p. 79). During this phase, it is important to have a plan to guide continued role expansion and refinement, such as the portfolio mentioned earlier. Seeking appointment to key committees is important to increase recognition of APNs in the organization. Administrative support and constructive feedback from a trusted mentor continue to be important. Development of a promotional system that offers professional advancement in the APN practice role remains a challenge for practitioners and administrators. Page and Arena (1991)observed that less time is required for establishing relationships and assessing the system during this phase; therefore, more time can be devoted to areas of scholarly interest. Brown and Olshansky (1997, 1998) noted the importance of formulating short-term goals to further development.
Whether the frozen, reorganization, and complacent phases are distinct developmental phases or variations of the implementation and integration phases, they are clearly negative resolutions for APNs and their organizations. Table 4-4 includes strategies described by Hamric and Taylor (1989)for enhancing role development in these phases (see the earlier editions of this text for further discussion of these phases). APNs should engage in periodic self-assessment so that they recognize beginning signs associated with these phases, such as feelings of anger or dissatisfaction, conflict between self-goals and those of the organization or supervisor, feeling pressure to change one’s APN role in ways that are incongruent with one’s concept of the role, and feelings of complacency. Early recognition of problems and taking proactive steps to deal with organizational changes can help prevent or ameliorate the negative feelings associated with these phases.
Further analysis of the relationships between the stages described by Brown and Olshansky (1997,1998) for NPs and the phases described by Hamric and Taylor (1989) for CNSs is needed. The relevance of these frameworks for transition processes experienced by other APNs also needs study. Further refinement of these findings could promote their incorporation into APN teaching, research, and practice. The following are questions of interest:
? 1.Is the laying the foundation stage common to other APN groups?
? 2.Do the negative phases?frozen, reorganization, and complacent?appear after 3 years of practice in APN groups other than CNSs?
? 3.How do role acquisition and role implementation experiences of APN graduates of DNP programs compare with those reported here for master’s-prepared APNs?
International Experiences with Advanced Practice Nurse Role Development and Implementation: Lessons Learned and A Proposed Model for Success
Over the last decade, as APN roles have been introduced in other countries, there has been increasing interest in APN role development and implementation internationally. The most recent research on APN roles has been conducted in countries outside the United States. The Canadian experience provides significant lessons learned and suggestions for successful APN role implementation worldwide. CNS and NP roles have existed in Canada for 40 years, but their implementation has been sporadic because of numerous system-level factors (DiCenso, Martin-Misnener, Bryant-Lukosius, et al., 2010; Sangster-Gormley, Martin-Misener, Downe-Wamboldt, & DiCenso, 2011). A decreased demand for APN roles in Canada resulted from many factors, including lack of legislative and regulatory authority of APN roles, multiple titles and conflicting definitions, absence of reimbursement mechanisms, opposition from the medical profession, and inconsistent curriculum requirements, which subsequently led to the gradual closure of most NP and CNS programs by the late 1980s (Sangster-Gormley, et al, 2011). Recently, there has been renewed interest in APN roles as a way to promote changes in the Canadian health care system (DiCenso et al., 2010.)
Although external factors such as supports and barriers were addressed, the major focus of APN role development and implementation research has been on the micro level, with a focus on personal experiences of the individual clinician taking on a new role. A new framework for role implementation developed in Canada is noteworthy in that it takes a macro perspective and involves stakeholders (e.g., administrators, patients, advocacy groups, support staff, professional organizations) in the APN role implementation process. It specifically addresses barriers to role implementation at the system, organizational, and practice setting levels (Bryant-Lukosius & DiCenso, 2004). The participatory, evidence-based, patient-focused process for advanced practice nursing role development, implementation and evaluation (PEPPA) framework (Bryant-Lukosius & DiCenso, 2004) recognizes the complexity of the system factors involved in implementing a new role into an existing system. The PEPPA framework (Fig. 4-2) incorporates the principles of participatory action research (PAR) ?to promote more equitable distribution of power and enhance the contributions of nurses, patients, and other stakeholders in APN role development? (Bryant-Lukosius & DiCenso, 2004, p. 531). It was developed to guide APN role implementation and has been used effectively in a variety of practice settings in Canada (McNamara 2009; McAiney, 2008; &Martin-Misener, 2010).
Facilitators and Barriers in the Work Setting
Aspects of the work setting exert a major influence on APN role definitions and expectations, thereby affecting role ambiguity, role incongruity, and role conflict. Findings from a survey byMcFadden and Miller (1994) of CNSs identify access to support services, such as computers, statistical consultation, and secretarial and library services, as facilitators of role development. Factors found to promote NP role development include the following: being recognized as a primary care provider; having one’s own examination room; and being supported by coworkers, administrators, and patients (Andrews, Hanson, Maule, & Snelling, 1999; Hupcey, 1993; Kelly & Mathews, 2001). This need for ongoing peer and administrative support is a theme throughout the literature on role development, beginning with the student experience and extending into practice.
Practical strategies identified by Bonnel and associates (2000) for initiating NP practice in nursing facilities included proactive communication, developing a consistent system for visits, setting up the physical environment, and building a team approach to care. Factors found to impede NP role development include pressure to manage care for large numbers of patients, resistance from staff nurses, and lack of understanding of the NP role (Andrews et al., 1999; Hupcey, 1993; Kelly & Mathews, 2001). More recent constraints operating in today’s health care settings that affect not only APNs but also other providers and office staff include new billing and coding guidelines,Health Insurance Portability and Accountability Act (HIPAA) regulations, monitoring for fraud and abuse, sexual harassment, and demands to integrate technology into practice.
Keating, Thompson, and Lee (2010) reported on a study of perceived barriers to progression and sustainability of NP roles in emergency departments 10 years after they were introduced in Victoria, Australia. The main barriers identified were lack of organizational support, legislative constraints, and lack of ongoing funding for APN education. They noted that some organizations successfully increased their numbers of NPs by using measures such as reallocation of resources and creating a common nursing and medical budget. They encouraged
FIG 4-2 PEPPA framework.
(From Bryant-Lukosius, D., & DiCenso, A. (2004). A framework for the introduction and evaluation of advanced practice nursing roles. Journal of Advanced Nursing, 48, 532.)
continued exploration of role implementation issues and development of methods to address them to realize the potential benefits of NP practice to the health care delivery system.
The ability to incorporate teaching and counseling into the patient encounter may be a function of skill development gained with experience in the APN role. This observation may be used as a rationale for structuring more time for visits and fewer total patients for new APNs, with gradual increases in caseloads as experience is accrued. Older research has indicated that NPs incorporate counseling and teaching into the flow of patient visits?capturing the teachable moment (Brykczynski, 1985; Johnson, 1993; Lurie, 1981). Future plans to redesign primary care payment systems to blend monthly patient panel fees with fee for service charges and include incentives for patient-centered care performance are promising for APNs because these payment systems highlight and support the additional dimensions of care that APNs can provide (Davis, Schoenbaun, & Audet, 2005).
Administrative factors that should be considered include whether APNs are placed in line or staff positions, whether they are unit-based, population-based, or in some other arrangement, who evaluates them, and whether they report to administrative or clinical supervisors. Baird and Prouty (1989) maintained that the organizational design should have enough flexibility to change as the situation changes. The placements of various APN positions may differ, even within one setting, depending on size, complexity, and distribution of the patient population (Andrews et al., 1999;Baird & Prouty, 1989; Nevidjon & Simonson, 2009). Issues of professional versus administrative authority underlie the importance of the structural placement of the APN within the organization. Effectiveness of the APN role is enhanced when there is a mutual fit between the goals and expectations of the individual and the organization (Nevidjon & Simonson, 2009). Clarification of goals and expectations before employment and periodic reassessments can minimize conflict and enhance role development and effectiveness.
Continued Advanced Practice Nurse Role Evolution
CNMs, CRNAs, NPs, and CNSs have attained positive recognition and support in clinical positions in many settings in the United States. However, in spite of the increasing familiarity and popularity of these APN roles, some health care settings have used few, if any, APNs and some staff members have had minimal experience working with APNs. In some areas of the United States, physicians or physician assistants are preferred over APNs. Even experienced APNs can expect to encounter resistance to full implementation of their roles if they seek positions in institutions with no history of employing APNs. Andrews and colleagues (1999) described their experiences introducing the NP role into a large academic teaching hospital. They delineated helpful strategies for marketing a new NP role to staff, patients, and the surrounding community, as well as ways to set up the necessary infrastructure to support the new role in the institution. They referred to this process as evolutionary.
The meaning of the evolution of established APN roles varies according to the type of APN role. For example, for CNMs, role evolution refers to broadening the scope of practice to include primary health care (Kinsley, 2005). For over a decade, midwifery has encompassed primary care management of women in their core competencies for basic midwifery practice (ACNM, 2012; see also the ACNM’s website, www.acnm.org). The emphasis on cost containment in the health care delivery system has led to the trend of having acute care NPs staff intensive care units to compensate for the shortage of house staff physicians (Rosenfeld, 2001; Sechrist & Berlin, 1998; see also Chapter 16). Evolution of APN roles is also reflected in the expansion of practice to multiple areas or sites. Although responsibility for multiple areas in the same facility has been typical of many CNS roles for years, it is an evolutionary process for most other APN roles. Multisite roles might signify practice responsibilities at different sites or multiple areas of responsibility in the same site, and they may combine inpatient and outpatient responsibilities (Stahl & Myers, 2002). Stahl and Myers’ clinical practices (see Exemplar 4-2) are models for APN practice evolving to multiple sites, which constitute a strategy for extending APN resources and trying to use them more efficiently.
Exemplar 4-2 Evolving APN Roles in Multisite Practices
Stahl is a CNS whose practice has evolved from the full range of CNS practice for four medical cardiac units at a tertiary care center to also include support primarily in education, consultation, and program development at two additional hospitals. Myers is an adult NP who directs a hepatitis C program for a specialty physician group with 11 physicians at nine practice locations, and she also provides direct care for patients at four of the sites.
The complexity of multisite roles can be overwhelming if the APN does not develop a certain degree of comfort with ambiguity. Stahl and Myers relied on Quinn’s (1996) wisdom for developing the leader within by expecting to ?build the bridge as you walk on it? (p. 83) and learning ?how to get lost with confidence? (p. 86). Their commitment to being continuous learners is a useful model for APNs to follow as they experience the situational transitions that are inevitable as clinical practices evolve. Stahl and Myers used the National Association of Clinical Nurse Specialists’ (NACNS, 1998) position statement (an updated version is now available on the NACNS website; seeTable 4-3) describing three spheres of CNS influence to stimulate creativity and guide their APN practices as they evolve into new and multiple practice settings.
As individual APNs mature into their respective roles and become comfortable and confident in all role components, greater concentration on the unique nature of APN practice can be expected. In their study of CNSs, Hamric and Taylor (1989) found that freedom to develop their unique APN role, availability of feedback from a mentor, support to broaden their influence and take on new projects, and recognition of their contributions enabled experienced CNSs to stay energized in their clinical practice roles. As Peplau (1997) advocated, nurse leaders must emphasize what nurses do for patients. The claim that APN practice incorporates patient education, family assessment, involvement, and support, and community awareness and connections (Neale, 1999) needs to be documented. For example, Kelly and Mathews (2001) found that graduates with 1 to 7 years of experience as NPs found it difficult to adhere to ideals of holistic care and health promotion, given the pressures of the clinical situation. Continued research that demonstrates positive outcomes of APN care is essential for APN practice to make an impact on health care policy (Brooten et al., 2002;Murphy-Ende, 2002; Russell, VorderBruegge, & Burns, 2002; Ryden et al., 2000; see also Chapter 23).Rashotte (2005) advocated for dialogical forms of research to evoke the more holistic and humanistic aspects of what it means to be an APN to complement the predominant instrumental and economic perspectives underlying most APN research. Brykczynski’s (2012) interpretive phenomenologic study of how NP faculty incorporate holistic aspects of care into teaching NP students is an example of such dialogical research. More research activity and increasing involvement in the larger arena of health policy may also represent continuing role evolution for APNs.
Evaluation of Role Development
Evaluation is fundamental to enhancing role implementation (see Chapter 24). Development of a professional portfolio to document APN accomplishments can be useful for performance and impact (process and outcome) evaluation. Performance evaluation for APNs should include self-evaluation, peer review, and administrative evaluation (Cooper & Sparacino, 1990; Hamric & Taylor, 1989). Use of a competency profile can be helpful for organizing evaluation in a dynamic way that allows for changes in role implementation over time as expertise, situations, and priorities change (Callahan & Bruton-Maree, 1994). The competency profile can be used to assess performance in each of the core APN competencies. APN programs need to include content and skill development regarding self-evaluation and peer evaluation of role implementation so that individuals can learn to monitor their practice and identify difficulties early to avoid moving into negative developmental phases (Hamric & Hanson, 2003).
Outcome evaluation is important to demonstrate the effectiveness of each APN role. Ongoing development of appropriate outcome evaluation measures, particularly for patient outcomes, is important (Ingersoll, McIntosh, & Williams, 2000; see Chapter 23). The existence of a reward system to provide for career advancement through a clinical ladder program and accrual of additional benefits is particularly important for retaining APNs in clinical roles. In less structured situations, APNs can negotiate for periodic reassessments and salary increases through options such as profit sharing.
The evaluation process broadens to incorporate interdisciplinary review when APN practice includes hospital privileges, prescriptive privileges, and third-party reimbursement. This expansion of the evaluation process has positive and negative aspects. Advantages to the review process associated with securing and maintaining hospital privileges include the many factors considered in the evaluation, variety of perspectives, and visibility afforded APNs. APNs should seek key positions on hospital review committees to promote APN roles within the organization. A major difficulty in implementing interdisciplinary peer review is lack of interaction between and among the incumbents of the various health professional groups during their formative educational programs. The resurgence of interest in developing and implementing IPE experiences between nursing students and medical students is encouraging (AACN, 2006; Hamric & Hanson, 2003; Institute of Medicine [IOM], 2003; Interprofessional Education Collaborative Expert Panel [IPEC], 2011; also see websites listed in Table 4-3).
Role development experiences for APNs are described as a two-phase process that consists of role acquisition in school and role implementation after graduation. The limits of the educational process in preparing graduates for the realities of the work world are acknowledged. Students, faculty, preceptors, and administrators need to be informed about the human skill acquisition process and its stages, processes of adult and professional socialization, identity transformation, role acquisition, role implementation, and overall career development. Knowing (theoretical knowledge) and actually experiencing (practical knowledge) are different phenomena, but at least students and new graduates can be forewarned about the transition experiences in school and the turbulence that can be expected during the first year of practice. Anticipatory guidance can be provided through role rehearsal experiences, such as clinical preceptorships and role seminars. Students need to be encouraged to begin networking with practicing APNs through local, state, and national APN groups. This networking is especially important for APNs who will not be practicing in proximity to other APNs. Experienced APNs and new APN graduates can form mutually beneficial relationships.
Although anticipatory socialization experiences in school can facilitate role acquisition, they cannot prevent the transition that occurs with movement into a new position and actual role implementation. APN programs should have a firm foundation in the real world. However, a certain degree of incongruence or conflict between academic ideals and work world reality will continue to exist (Ormond & Kish, 2001). APNs must take a leadership role in guiding and directing planned change and guard against the mere maintenance of the status quo. Establishing mentor programs for new APNs in the work setting is one way to develop and maintain support for the positive developmental phases of role implementation described in this chapter.
APN role development has been described as dynamic, complex, and situational. It is influenced by many factors, such as experience, level of expertise, personal and professional values, setting, specialty, relationships with coworkers, aspects of role transition, life transitions, and organizational, system, and political realities. Frameworks for understanding APN role development processes have been discussed, along with strategies for facilitating role acquisition and role implementation. Ongoing evolution of APN roles in response to organizational and health care system changes and demands will continue. Future research studies to assess the applicability of this information to all APN specialty groups and for APN graduates of DNP programs are needed to further the understanding of APN role development and the impact of APN practice on health care outcomes.
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