Keywords

The introduction of advanced nursing practice (ANP) entails a process that includes consideration of what models, frameworks, or prototypes are suitable for use in the healthcare environment. Assessment of the rationale for interest in these new nursing roles and/or the need for ANP services is a starting point that guides development. Evaluation of the institutional and healthcare milieu such as conducting an environmental scan will bring attention and focus to the receptivity for integrating this concept. Committed advocates supportive of advanced practice nursing (APN) roles are vital in order to face the challenges that affect not only healthcare systems but also all healthcare professionals employed in provision of services and the populations receiving the services. This chapter offers a framework and ideas to assess the environment in order to progress through developmental stages. Topics relevant to institutional planning, inclusion of APN roles in diverse practice settings, relationships with other healthcare professionals and service users are discussed. Strategies to support the APN and ethics specific to ANP conclude the chapter.

5.1 Introducing the Role and Function

Even though there is extensive literature to support the value of ANP, a distinct implementation process suitable for all countries and various settings within a country is unclear. A review of available publications indicates that most available studies and narratives originate in more developed countries such as Australia, Canada, New Zealand, countries of the UK, the Netherlands, Ireland, Singapore, Switzerland, and the USA [9–11, 23, 24, 27]. It is uncertain what components are universally applicable beyond these country contexts. Chapter Two includes a comprehensive global overview of country experiences, and additional country references can be found throughout this publication. Accounts with personalized details of other country experiences, successes, and challenges can be helpful in deciding how to proceed.

In the process of launching an ANP initiative, multiple stakeholders and decision makers including the public have the capability to facilitate or impede development. Key stakeholders may include ministries of health, additional national health agencies, consumer representatives, hospital administrators, academic institutions, professional associations, medical directors, educators, labor, healthcare workforce planners, and nursing leaders. Crucial decisions may be made by persons in positions of authority that have a limited understanding of the issues that are important to promoting ANP as a professional able to provide healthcare services.

5.1.1 The PEPPA Framework

In order to facilitate favorable development, implementation, and evaluation of APN roles, Canadian researchers [3] developed the PEPPA (participatory, evidence-based, patient-focused process for advanced practice nursing) Framework. Steps of the framework take into consideration the complexity of healthcare systems in implementing a new role into an existing healthcare system. Based on principles of participatory action research, the PEPPA Framework (Fig. 5.1) for planning and implementation is intended to establish an atmosphere supportive of ANP.

Fig. 5.1
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PEPPA framework (Bryant-Lukosius and DiCenso [3], p. 532)

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The PEPPA Framework involves a nine-step process. Steps 1–6 concentrate on setting up role structures. Step 7 looks at role processes and beginning implementation and introduction of the APN roles. Steps 8 and 9 seek to accomplish short and long term evaluations of the APN role and model of care with an aim to assess progress and sustainability of agreed-to target aims and outcomes. The following is an interpretative synopsis of the steps in Fig. 5.1.

5.1.1.1 PEPPA Framework Steps

  • Step 1 – Identify the target patient population and establish limits relative to the current model of care.

  • Step 2 – Key stakeholders and decision makers (including populations and their families) representing the current model of care are invited to contribute input to the discussion of a new model of care that includes the APN role.

  • Step 3 – Determine the strengths and weakness of the current model of care.

  • Step 4 – Identify priorities for unmet healthcare concerns with an aim to improve healthcare outcomes.

  • Step 5 – Define the model of care and healthcare strategies including numbers and mix of healthcare providers. At this time, participants in the process gain an understanding of ANP and various options for APN roles. If the decision is taken to include APNs, a job description and scope of practice is developed that is fit for purpose for the healthcare model.

  • Step 6 – Strategic implementation planning is done during this step to verify the readiness of the healthcare setting for ANP. This step includes identification of obstacles and facilitators that could influence implementation. Establishing timelines and goals are a critical aspect.

  • Step 7 – The plan developed in Step 6 for APN implementation is initiated in this step. Full implementation is a continuous process that includes methods to scrutinize various aspects of changes in the approach to provision of healthcare services along with the status of APN role implementation.

  • Step 8 – Outcomes specific to the identified changes in the model of care are evaluated with a view to identify any needs for APN role development or further role enhancement.

  • Step 9 – Long term, periodic, and continuous monitoring are emphasized in this step to assess if the model of care integrating APN role continues to be relevant and sustainable.

(Bryant-Lukosius and DiCenso [3])

The PEPPA framework not only provides a comprehensive and practical guide to approaching the inclusion of ANP in provision of healthcare services but also demonstrates the complexity and dynamics of considering such an initiative. Although it may seem overwhelming at first glance, the framework can be used as a flexible guide when deciding how to tailor ANP services for a specific healthcare setting and/or targeted population. The framework has been used in 16 countries with detailed documentation of utilization of the framework in Switzerland [4].

5.1.2 Environmental Scanning and SWOT Analysis

In anticipation of introducing APN roles or refining existing roles assessing the context where these changes will take place can contribute to purposeful planning. Environmental scanning and SWOT (strengths, weaknesses, opportunities, threats) analysis are comprehensive and strategic tools that can be used to establish the level of understanding needed for a successful plan. An environmental scan assists in assessing internal needs and the external environment. Inclusion of the SWOT analysis assists in confirming or disproving widespread perceptions [6, 7]. Although each of these tools can be used independently, using these tools together promotes the collection of information to assist in determining the readiness of a country, institution, or agency for the introduction of ANP.

The environmental scan collects information and data to gain an understanding of the situation. The SWOT analysis categorizes the information as to strengths, weaknesses, opportunities, and threats present in the system. Strengths are internal factors helpful to achieving desired goals; weaknesses are internal factors that may block achievement of objectives; opportunities are external factors that could be beneficial in achieving goals; and threats are external factors that may block achievement of objectives. A completed SWOT matrix can be used to identify strategies to maximize strengths, defeat threats, overcome weaknesses, and take advantage of opportunities in order to set priorities for actions (see Appendices 5.1 and 5.2 at the end of this chapter for a SWOT analysis matrix template and a SWOT analysis illustration).

Conducting an environmental scan along with a SWOT analysis identifies gaps that need to be addressed, thus contributing to development of strategies to close these gaps in order to proceed forward [7]. Information and trends discovered during the environmental scan can provide a basis for a SWOT analysis finding. For example, if the environmental scan predicts a shortage of funding for APN, this can be viewed as a threat to an ANP initiative. A prediction of a physician shortage in primary healthcare can be seen as an opportunity to consider the introduction of ANP. For more detailed guidance on doing an environmental scan that focuses on doing a stakeholder analysis access see http://www.who.int/workforcealliance/knowledge/toolkit/33.pdf, for Part 2 of a World Health Organization’s “Policy Toolkit for Strengthening Health Sector Reform.”

5.2 Interconnectedness

The inclusion of ANP and APN roles does not occur in isolation. Numerous questions arise as the roles evolve and APNs are required to relate to other nurses, healthcare professionals, organizations/healthcare systems, regulatory systems, and the public. Strategies to facilitate an effective integration of the APN when connecting with various healthcare entities and healthcare professionals are suggested in Sects. 5.2.1, 5.2.2, and 5.2.3.

5.2.1 Between and Within Institutional Environments

Integrating ANP into the healthcare workforce of established institutions will likely change the dynamic of the delivery of healthcare services. Persons in various positions of authority can facilitate or impede such changes. Administrators and managers need to identify what services the APN is expected to offer and how the delivery of these services connects with the healthcare structure. In the face of healthcare reform and rising healthcare costs, healthcare planners will be called upon to propose the cost-effectiveness and value of an additional healthcare professional. A clear explanation and evidence of the beneficial aspects of ANP will strengthen any proposal that aims to integrate the APN roles. Ideally, APNs should promote the value of their practice and thus collaborate with healthcare administrators who are in a position to orchestrate a welcoming institutional environment.

The following question can provide focus when considering an organizational workforce approach:

If you were in a position with full authority to create a healthcare model for an institution that included APNs what would it look like?

At a medical center in the United States, the director of advanced practice professionals responded to that question, sought the input of others, and organized a subcommittee of APNs (nurse practitioners and clinical nurse specialists) in order to come up with a model that could to be implemented in the organization. Discussions led to the creation of a patient-centered, collaborative-care approach intended to decrease hospital readmissions, costs of care, and improve patient outcomes. Outcomes of the model demonstrated that when healthcare disciplines work collaboratively and APNs are given responsibilities that allow them to use their administrative and clinical expertise, there are benefits for patients, physicians, and the organization. The model, which originally focused on heart failure patients, was implemented in January 2012. Over a 12-month period, 30-day readmission rates dropped from 26 to 8 %. Healthcare costs for the identified group of patients receiving care via the new model decreased significantly during 30 days after discharge.

In this model of care by a multidisciplinary team, the APN identified heart failure patients who qualified to be admitted per program criteria, met the patient and family, introduced the APN role, and provided basic patient education in the hospital. In addition, the APN and family scheduled post-discharge follow up for more intensive education sessions. Any necessary follow up with a physician was scheduled as needed. The APN developed a management plan with the physician, ensured all diagnostic tests and reports were completed, assessed if the patient’s condition was stable before hospital discharge, and implemented the discharge plan. After discharge, the APN contacted the patient by phone within 24–48 h. During the first follow up visit, the APN performed a full physical assessment and a full educational session along with a family member or support person. The education session included review of diet, daily weights, and a medication management tool. Improved outcomes with this model led to APN care being added to more of the medical center’s services including cardiology, chronic care management, oncology, and genetics. In addition, the model’s success influenced initiation of APN healthcare service delivery beyond the hospital to community services [19, 28].

5.2.1.1 Strategies for Integrating APN Roles Within Organizational/Institutional Systems

The following are proposed strategies to consider when preparing to integrate APNs into healthcare systems and institutional settings:

  • Develop a clear role definition, scope of practice, and the position of the APN based on the setting where the APN will practice

  • Include key decision makers and stakeholders in discussions on the value of ANP to institution services

  • Provide outcomes studies and evidence supportive of ANP

  • Develop a plan for healthcare workforce planning and skill mix

  • Discuss standards, education needs, and regulatory issues

  • Consider a framework for strategic planning that includes follow up and evaluation of ANP services

  • Make available choices for funding and resources for creating positions, education, and support for competence maintenance

5.2.2 Among Other Settings

In a survey of 32 countries, Pulcini et al. [20] found that over 70 % of roles identified as ANP were in hospital based or institutional settings. However, there appears to be a growing presence in out-of-hospital environments. These settings include primary care/primary healthcare, community, acute/emergency care, and APN-led clinics. Although the settings are diverse, the key to integration of APNs in these sites, as in hospital/institutional settings, is also familiarity with the role and scope of practice as it relates to the healthcare infrastructure and locale. Systematic patient-focused planning to guide role development along with identification of funding for positions is essential along with support within the organizational structure that allocates a place for new positions. Identifying and integrating the APN in the system is ultimately necessary for effective functioning of the system. The complexities and diversity of various systems of care, even within the same country, can be daunting. Discussions are not always positive and can be argumentative when discussing changes that involve professional boundaries.

De Geest et al. [9] recommend a conceptual framework to analyze the introduction of APN roles through five drivers. The identified drivers are: (1) the healthcare needs of the population, (2) education, (3) workforce, (4) practice patterns, and (5) legal and health policy framework (p. 626). Similarly, Blair and Jansen [29] suggest that an assessment and understanding of the setting and healthcare environment or culture is a necessity when preparing to introduce the APN role. An awareness of these multifaceted dimensions is likely to identify if the setting is able to implement the changes needed for the APN to practice effectively (see also Sect. 5.1.1 on environmental scanning and SWOT analysis).

5.2.3 Between Other Healthcare Professionals

In the process of role acquisition and implementation, boundaries for APN roles based on basic nursing principles are in a state of flux. APNs usually take on some skills and critical thinking associated with care management that has traditionally been associated with medicine. This raises questions about the APNs’ professional scope of practice as nurses. Schober and Affara [25] posed the question “When is a nurse no longer a nurse?” (p. 60). Nurses in advanced roles express uncertainty about their place in the healthcare settings in which they practice and report adverse working relationships with other nurses [12, 24]. In a study conducted in the Netherlands [22], physicians viewed the APN as demonstrating a positive effect on the identity of nurses but the nurses themselves did not share this view reporting that they were conflicted about role expectations. APNs in this study portrayed conflict about expectations for the role. From one perspective the APN is expected to be a nurse while there are also expectations of the role that is more closely aligned with medicine.

5.2.3.1 Relations with Nursing

It can happen that in the process of introducing APN roles to a healthcare setting, other nurses are not necessarily receptive to the idea. In some situations physicians are the advocates for ANP, while nursing colleagues abandon the novice APN, or are reluctant to facilitate advanced practice opportunities for practice. In a study conducted in Singapore [24], the nurses viewed the APNs as not belonging to the nursing culture anymore. In addition, there was a view that APNs no longer practiced nursing but acted like physicians.

Nursing managers, sometimes with limited knowledge of the role, are usually responsible for the implementation of APN services and may be uncertain as to how the role should be implemented [8, 14, 21]. The issue of role ambiguity [12] appears to add to the skepticism exhibited by other nurses expected to work with the APN. Reay et al. [21] address the anticipated facilitative role of nurse managers and recommend that managers: (1) clarify reallocation of tasks, (2) manage altered relations in the healthcare team, and (3) continue to actively manage the healthcare team in evolving circumstances to ease relations between APNs and other nurses. Consistent with the recommendations by Reay et al. [21], the following strategies are proposed to promote more amicable relations between APNs and other nursing staff.

5.2.3.1.1 Strategies for Facilitating Relations with Other Nurses

  • Clearly define and differentiate the APN role from other nurses in the healthcare setting and healthcare workforce.

  • Provide a clear and visible description of the APN and expected scope of practice.

  • Identify any areas of concern by nursing staff related to introducing this new nursing role along with actively taking steps to resolve any concerns.

  • Facilitate communication between all nurses to develop understanding of their respective positions in the healthcare workforce. e.g., conferences, workshops, meetings that require decisions associated with both roles.

5.2.3.2 Relations with Medical Colleagues

Resolving collegial relationships between two autonomous practitioners such as APNs and doctors with substantial overlap in their scope of practice requires the utmost diplomacy at times. Even though APNs and doctors share certain competencies, the focus of their practice is different. However, turf battles can occur when professionals compete to perform the same tasks. Evidence on the issue of physician support is mixed with respondents in two studies citing medical group opposition on the one hand [20] and limited physician opposition on the other [17]. However, medical dominance and control over healthcare services in many countries indicate this group of healthcare professionals has the ability and authority to impede or support optimal utilization of APNs. Baerlocher and Detsky [1] recommend negotiation that focuses on keeping the publics’ rather than the professions’ interests in mind. The following strategies are suggested to enhance a positive environment.

5.2.3.2.1 Strategies for Facilitating Positive Communication with Medical Colleagues

  • Make available a clear role definition and scope of practice for the APN.

  • Involve medical practitioners in collaborative efforts such as developing practice guidelines or standards within a healthcare facility.

  • Clearly position the APN in the nursing professional group.

  • Define the position of the APN within the healthcare workforce including what a person in this position is expected to do.

  • Support attendance at conferences or workshops on topics where all healthcare professionals discuss case management.

  • Emphasize collaborative management of patient populations.

The path to introducing the APN role for the individual APN, especially in the early stages, is not simple. Experiencing conflict and a sense of isolation is a common experience [24]. Section 5.3 emphasizes the importance of developing support strategies for the APN.

5.3 Role Support for the Advanced Practice Nurse

Introducing a new nursing role and being the first to provide ANP services can be a solitary experience. Acceptance from other professionals can be limited and conditional until the APN is able to demonstrate competence and confidence in the role. The public may be interested and curious but confused, especially when used to seeking care with a physician. Managers may be enthusiastic but unable to provide the professional support the APN seeks. Lack of support can be disheartening, particularly when there is doubt as to the legitimacy of a nurse functioning in a manner associated with medical practice rather than nursing.

Role development for APNs is viewed by Brykczynski [5] as a two-phase process of role acquisition in the educational program and role implementation after program completion. New graduates were found by Sullivan-Bentz et al. [26] to move from feeling overwhelmed to confident in their ability to function. Additional research on acquisition of knowledge and skills proposes that a progression through stages of performance from novice to expert takes place over time [2, 13].

In a study conducted in Singapore, APNs reported that the nurses no longer viewed the APNs as part of the nursing staff and medical consultants were confused and initially resistant to the new function of these nurses [24]. Sullivan-Bentz et al. [26] examined role transition and support requirements for nurse practitioner (NP) graduates in their first year of practice in Canada and found that the healthcare environment was ill prepared to receive the NPs. In addition, professional territoriality, regulatory barriers, and policies limiting their ability to practice to the full scope of practice negatively impacted inclusion of the role. Study finding by Sullivan-Bentz et al. [26] also revealed that staff and professionals might not be aware of the anxiety new NPs face. Development of strategies to prepare for the inclusion of APNs into healthcare settings with identification of how the strategies will be implemented by healthcare professionals and administrators is vital.

5.3.1 Strategies to Support Advanced Practice Nurses

Preparing students for the realities of the work place that include anticipatory guidance for role transition is possible in theory; however, multiple strategies deserve consideration to support the actual real life process of integrating the APN role into various practice settings. Recommended strategies include the following:

  • Identify interprofessional mentor/relationships/supervision before the APN begins employment. An identified mentor can function as a role advocate.

  • Clarify reporting mechanisms and expectations of the APN.

    • Who does the APN report to? nursing, medicine, or both

    • Evaluation to be done by: nursing, medicine, or both

  • Physicians, allied health professionals, administrators, receptionists, and other nurses all receive clear descriptions of role and scope of practice.

  • Periodic scheduled meetings.

  • Peer support groups – formal and informal; internal and external to the healthcare organization.

    • Provide opportunities to exchange experiences and develop problem solving techniques

    • Opportunities and strategies to resolve barriers and obstacles arising

  • Professional development/continuing competence maintenance

    • Interprofessional and joint education/learning experiences

  • Designate funding for educational conferences, workshops, meetings

Integration of ANP into the healthcare workforce is a process that takes time. Lack of knowledge of what an APN can contribute to healthcare services in a specific practice setting leads new and inexperienced APNs to develop their role based on an interpretation of theory learned in educationalist preparation [24, 26]. The new APN graduate may define aspects of the role differently from management and other healthcare professionals leading to a sense of disillusionment and disappointment by both the APN and the systems in which they work. Identifying methods of support provides encouragement for the APN in transition to a new role and prepares the healthcare environment and the public for the ANP services that will be provided.

5.4 Situational Ethics

The issue of ethical decision making is fundamental to all nursing practice; however, the APN is in a position as a clinical leader to take on a more vital role in identifying moral and ethical dilemmas, creating ethical environments, and promoting social integrity within healthcare systems [16]. It is not within the scope of this chapter to provide an in-depth discussion of ethics and ethical decision making, but to draw attention to the level of ethical decision making manifest in ANP. (The reader is referred to the ICN Code of Ethics for Nurses [18] and a discussion by Hamric and Delgado [16] specific to ANP on this topic.)

The capacity for APNs to participate in ethical decisions arises from their clinical expertise and collaborative proficiency. As nursing leaders in advanced practice with clinical insight, APNs identify ethical dilemmas. In their advanced capacity, APNs have the capacity to assess and facilitate the decision-making process. The autonomous responsibilities and independent decision making associated with APN roles modifies the interchange between nurses and physicians when approaching an ethical situation. Disagreements based on differing professional views with dual professional accountability usually occur in connection to patient care management [15]. An ethical dilemma occurs when responsibilities require that a person confronts alternative actions but cannot carry out all of them. Conflict occurs when varying demands and choices exist, all of which are unpleasant [16].

For example, in the following scenario an APN determines a woman is a victim of domestic violence based on the APN’s assessment. The patient denies there is any such problem. The APN is faced with reporting the situation to the appropriate existing supportive services and putting at risk the professional-client relationship, or avoiding any interference in the situation and possibly allowing the abuse to continue. In this case, the APN consults with the medical consultant on duty. The consultant advises the APN to ignore the situation in order to complete the workload for the day. Based on a model for ethical analysis and decision making proposed by Fry and Johnstone [15], questions the APN can consider include:

What is the significance of the conflict to the involved parties?

Nurses, including APNs, often find that to disagree with a doctor is unpleasant and try to avoid confrontation. In many clinical settings the authority of the doctor is accepted without question. If the medical consultant views the APN as agreeable and collaborative their professional relationship remains intact. The APN could privately provide the woman advice, but this could undercut her credibility and the woman’s trust in the physician in addition to comprising care for this woman.

What should be done?

By asking this question the APN considers options for resolving the conflict.

It is important to respect collegial relationships; however, the APN has a responsibility to facilitate reasonable and credible care. In this situation the issues and concerns about the case should be discussed openly with the medical consultant and cannot ethically be avoided. There is not always one correct ethical decision but a decision that is based on the values of those involved, known relevant information, and best judgment on what to do.

Hamric and Delgado [16] discuss general themes for APNs to take into account to decrease uncertainty in ethical decision-making. These include clarifying communication problems, resolving interdisciplinary conflict, and balancing multiple commitments. Specific ethical decisions may be unique to the specialty clinical setting in which the APN practices and are heightened with ANP as a consequence of their advanced clinical expertise and presence in interdisciplinary teams. APNs should obtain competence in this area to avoid power struggles, lead effective communication, and facilitate decisions in ethically difficult situations. Acquired competence increases the ability of an APN to resolve ethically demanding situations.

Conclusion

Introducing and promoting ANP within the healthcare workforce is complex involving institutions, diverse healthcare settings, healthcare managers, and other healthcare professionals. The APNs themselves require encouragement as they initiate a new nursing role with advanced capabilities, especially when there are no role models. Key decisions may be made by influential individuals in positions of authority with diverse levels of understanding as to the function and capabilities of APNs in providing healthcare services. Other nurses and medical professionals are likely to approach the integration of ANP with caution. This chapter identifies key topics to clarify when introducing the role and suggests approaches to issues that could arise. Strategies for providing role support for APNs are offered and ethical decision making specific to ANP is discussed.

5.5 Appendix 5.1. SWOT Analysis Matix Template

figure a

5.6 Appendix 5.2. SWOT Analysis Illustration

figure b