Keywords

The field of advanced nursing practice (ANP) and diverse levels of advanced nursing is a growing trend worldwide in the provision of a variety of healthcare services. This chapter introduces the concept of ANP by offering an international definition and key characteristics of an advanced practice nurse (APN). Assumptions that should be found wherever nursing exists are identified as the foundation for progressing to advanced levels of nursing practice. In addition, topics to consider when forging a new nursing role are discussed along with country issues that shape ANP development.

The terms “advanced nursing practice” and “advanced practice nursing” are often used interchangeably in reference to advanced nursing roles or advanced levels of nursing practice. Lacking an international consensus on the use of terminology, the terms “advanced nursing practice” (ANP) for the purpose of this publication will refer comprehensively to the discipline or this entire field of nursing and “advanced practice nursing” (APN) and “advanced practice nurse” (APN) will refer to a specific role, the nurse that practices in that role, specific education, and specific professional regulation relevant to the nurse. These definitions are consistent with language used by the Canadian Nurses Association [1] national framework for ANP and the Scottish ANP Toolkit [11] that has provided guidance [12] to the other countries in the United Kingdom (England, Northern Ireland, and Wales) and in an earlier publication [10] written under the auspices of ICN. The comprehensive use of ANP, as an umbrella term, includes but is not limited in reference to country-specific titles such as nurse practitioner, clinical nurse specialist, and advanced practice nurse practitioner. Chapter 3, Nature of Practice, provides a more in-depth discussion of the use of designated titles for APN roles. The following section offers an international definition and profile for an APN.

1.1 Definition and Profile of an Advanced Practice Nurse

During the 1990s, the International Council of Nurses (ICN) observed the growing presence of ANP as countries reviewed their healthcare systems and looked for new alternatives for the provision of healthcare services. In an effort to keep up with increasing demands and economic limitations, it appeared that there was better acceptance of new nursing roles and practice models [10]. Since the time ICN began noting the presence of APN roles, there has been an increasing consensus that APNs are effective and beneficial when integrated into a variety of healthcare systems [2, 5, 14].

Noting a need to improve visibility and international representation of the emerging ANP discipline, ICN launched the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) in 2000. This event followed collaboration of representatives from the United Kingdom and the United States who had already initiated conferences in 1993 to begin to embody a global identity for ANP. The governing structure of a Core Steering Group and seven subgroups was established for the Network along with a web site (http://www.icn-apnetwork.org). As the Network has evolved, international representation has increased, ANP-focused conferences take place every two years, and ongoing research in the field of ANP is promoted. A more in-depth description of INP/APNN can be found on the Network web site and in Chap. 2.

Simultaneously as the Network was established and in the process of international dialogue, confusion rather than consensus emerged when trying to define and characterize the APN role. In an attempt to explain the nature of this nursing role, ICN took the first step by providing a definition in 2002 [6]. A recommendation for scope of practice and suggestions to guide development of standards for professional regulation, education, and competencies subsequently followed [7]. The ICN publication serves as a benchmark for international discussion on the concept of ANP and APN roles. Significant development has occurred in the field since the launching of INP/APNN and the release of this landmark document. However, literature continues to confirm not only growth in the presence of APNs but also a continued theme of uncertainty in defining ANP [3, 4, 8, 9]. This publication, written under the auspices of ICN, continues to facilitate the discourse on a dynamic and growing nursing discipline.

1.1.1 Definition

Clear definitions are essential to identifying and positioning a profession within a healthcare system [13]. In offering a definition for the APN role, ICN acknowledged that country milieu shapes role development and provided the following definition as a point of reference for discussion:

[The] APN is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level. (ICN [6] and [7] p. 29)

In order to provide a profile of the APN role, ICN offered also a delineation of APN characteristics. These characteristics follow in Sect. 1.1.2.

1.1.2 Characteristics of the Advanced Practice Nurse

In order to support and add to the APN definition, ICN identified characteristics of an APN and provided the following recommendations:

  • Educational preparation

    • Educational preparation beyond generalist nursing education

    • Formal recognition of educational programs preparing for the advanced practice nursing role (accredited or approved)

    • Formal system of licensure, registration, certification, and credentialing

  • Nature of Practice

    • The ability to Integrate research [evidence based practice], education and clinical management

    • High degree of professional autonomy and independent practice

    • Case management/[manage] own caseload at an advanced level

    • Advanced assessment, decision-making skills and diagnostic reasoning skills

    • Recognized advanced clinical competencies

    • The ability to provide consultant services to other healthcare professionals

    • Plans, implements and evaluates programs

    • Recognized first point of contact for clients

  • Regulatory mechanisms – Country specific professional regulation underpins APN practice

    • Right to diagnose

    • Authority to prescribe medications and treatments

    • Authority to refer clients to other professionals

    • Authority to admit patients to hospital

    • Officially recognized titles for nurses working in advanced practice roles

    • Legislation to confer and protect the title (e.g. nurse practitioner, advanced practice nurse, clinical nurse specialist)

    • Legislation, policies or some form of regulatory mechanism specific to advanced practice nurses

(Adapted from ICN [7], p. 29)

The definition and characteristics offered by ICN are necessarily broad given the necessity to take into consideration variations in healthcare systems, regulatory mechanisms, and nursing education in individual countries. Since the release of the ICN publication in 2008, the ANP discipline has matured with the APN increasingly seen as a clinical expert with characteristics of the role crosscutting over numerous themes that include understanding of issues of governance, policy development, and clinical leadership. As a result, promoting leadership as an aspect of the APN role has become increasingly important. Integration of research knowledge and skills has also become more central to role education and development.

In spite of a lack of consensus in attempting to define APN roles, certain conditions supportive of ANP exist wherever nursing is present. These assumptions are identified next in Sect. 1.1.3.

1.1.3 Assumptions: The Foundation for Advanced Nursing Practice

There are key components for ANP that should be found wherever nursing exists and that provide the foundation for the development of advanced levels of nursing practice. The following assumptions provide points for international consideration and dialogue. All APNs:

  • are practitioners of nursing providing safe and competent patient care

  • have their foundation in registered generalist nurse education

  • have roles which require formal education beyond the preparation of the generalist nurse

  • have roles of increased levels of competency that are measurable

  • have competencies which address the ethical, legal, care giving and professional development of the advanced practice role

  • have competencies and standards which are periodically reviewed for maintaining currency in practice

  • are influenced by the global, social, political, economic and technological milieu

(ICN [7] p. 11)

The position of ICN emphasizes that:

The degree of judgment, skill, knowledge and accountability increases between the preparation of nurse generalists and that of the APN. This added breadth and depth of practice is achieved through additional education and experience in clinical practice; however, the core does not change and it remains the context of nursing. (ICN [7] p. 9)

Further in-depth discussion of titles, role characteristics, scope of practice, and competencies can be found in Chap. 3: Nature of Practice. Section 1.2 highlights issues to consider when undertaking the ANP concept.

1.2 Forging a New Nursing Role

Forging a new nursing role when there are no role models in place highlights issues for debate and discussion. The following questions require consideration when exploring and progressing with the ANP concept:

  • What is the nurses’ perspective of advancement and advanced nursing practice?

  • What does advancement or professional progression for nursing mean within the country?

  • Is there a career structure for promotion that could support the integration of advanced practice nurses?

  • Is there an official place for the APN within the healthcare system with well-defined job descriptions and a career pathway commensurate to their qualifications and capabilities?

  • Are the key components of APN practice acknowledged and addressed?

1.2.1 Country Issues that Shape Development

The fundamental level of nursing practice and access to an adequate level of nursing education that exists in a country shapes the potential for introducing and developing the APN role. The professional status of nursing and its ability to introduce a new role will influence the launching of an ANP scheme. The prominence and maturity of nursing can be assessed by the presence of other nursing specialties, levels of nursing education, policies specific to nurses, and the extent of nursing research (F. Affara, 18 February 2016, personal communication).

Conclusion

International enthusiasm for advanced nursing practice has increased. The result is increased visibility of this concept and associated advanced practice nursing roles. However, there is a need to offer clarity, guidelines, and resources for key stakeholders, decision makers, healthcare planners, administrators, and professionals as they proceed to explore advanced practice nursing roles as an option for provision of healthcare services. This chapter offers a definition and role characteristics for the advanced practice nurse as a point of reference to facilitate discussion. Key issues to consider when coordinating, planning, or launching an advanced nursing practice initiative are suggested.