Review Article
Ann Nurs Res Pract. 2023; 8(2): 1057.
A Systematic Review on the Definition Advanced Nursing Practice
Muayyad M Ahmad, PhD, RN¹; Hayat Sulieman Abu-Shaikha²; Feda Al-Shatnawi³
¹Department of Clinical Nursing, School of Nursing, University of Jordan, Jordan
²Faculty of Nursing, Philadelphia University, Jordan
³College of Nursing - Al-Balqa Applied University, Jordan
*Corresponding author: Muayyad M Ahmad Professor, Clinical Nursing Department, School of Nursing, University of Jordan, Amman – Jordan 11942, Jordan. Email: [email protected]; [email protected]
Received: August 12, 2023 Accepted: September 25, 2023 Published: October 02, 2023
Abstract
This study aims to review and critique the definitions of Advanced Practice Nursing (APN) in the literature. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Following the methodology of Arksey and O’mllay, four electronic databases were searched between 1990 and 2022. Articles published in English that discuss the definition of APN were screened for eligibility based on their full texts. Extracted, compiled, and summarized data. After removing duplicates, screening the titles and abstracts of the articles, and eliminating those that did not meet the eligibility requirements, the final number of articles included in this review was 11. Results revealed a variety of APN definitions and referral models, as well as the fact that APN titles, laws, roles, and regulations vary by country. The absence of standardized measures that enable stakeholders and health care providers to distinguish APN from other levels of nursing practice. It is necessary to clearly define APN at international levels in order to advance and improve our nursing disciplines. However, we advise utilizing the robust model of APN “as presented by Glenn and Budd [1]” to distinguish their roles from those of other related practices.
Keywords: Advanced practice nurse; Advance practice nursing; APN; Definition
Introduction
Advanced Practice Nursing (APN) is a relatively new term that has been widely used in recent nursing literature. There are numerous factors that have contributed to the evolution of advanced practice nursing, including changes in the healthcare system, population needs, and clinical standards and training [2]. Advanced nursing practice encompassed four advanced roles of practice: nurse anesthetist, nurse midwife, clinical nurse specialist, and nurse practitioner. In the United States, the first two APN roles to emerge were nurse anesthetist and nurse midwife [3]. During World War I and II, nurse anesthesia was developed to reduce anesthesia-related mortality. While nurse midwifery was introduced as early as 1920 to meet the needs of impoverished women in rural areas, it remains largely unregulated [4]. In 1954, when psychiatric nurses were provided with advanced training, the Clinical Nurse Specialist (CNS) position emerged [5]. The Nurse Practitioner emerged as the fourth advanced role.
It is well documented in the literature that advanced practice nursing holds the promise of delivering quality, cost-effective, and patient-satisfying health care [6]. In addition, the position contributes uniquely to health promotion, disease prevention, and disease treatment [7]. However, no consensus has been reached regarding the definition of APN [8]. Regarding the precise definition of this concept in terms of its roles, responsibilities, and regulations, there is a great deal of ambiguity. Additionally, the definitions vary depending on the context and even the country [9,10]. Literature revealed the international complexity of advanced practice roles and the difficulty of identifying the unique contribution of advanced practitioners in nursing and midwifery to health care [11] (Dowling, Beauchesne, Farrelly, & Murphy, 2013). To advance APN internationally and to have a standardized understanding of their roles, responsibilities, and scope of practice, universal consensus is required. This concept's clarity will be reflected in the provision of clear and precise responsibilities for APNs, other health care professionals, clients and users of services, and academic institutions designing and marketing degrees [10,12]. The purpose of this paper was to review and summarize the available literature regarding the definition of APN.
Methods
Design
This analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [13]. We used the five-stage framework developed by Arksey and O'Malley for this evaluation [14]. Identify the research question, identify the relevant literature, select the literature, chart the data, and compile, summarize, and report results are the stages of the process [15].
Search Methods
The following databases were searched: PubMed, Sage publication, Wiley, and Science Direct. APN, advanced practice nurse, advance practice nursing, and their respective definitions as well as their Boolean search variants were used. This range was chosen in relation to the recent evolution of the APN and encompasses articles published from 1990 to June 2022. In total, 216 articles were retrieved and screened according to the eligibility criteria, resulting in the review of 11 studies.
Search Outcomes
The criteria for inclusion in this review were articles discussing the definition of APN. Included research designs may be qualitative, quantitative, review articles, or grey literature. Two reviewers screened the titles and abstracts of 174 articles after removing duplicates from a total of 216 articles identified by our search strategy. Two investigators independently evaluated the full texts of the remaining 28 articles to determine their eligibility. Eleven articles remained as remaining eligible studies in this review (Figure 1).
Figure 1: Flow chart for studies selection.
Quality Appraisal
Two authors assessed the methodological quality of the reviewed articles using the PRISMA method [13]. The PRISMA checklist is a 27-item evidence-based list for evaluating the title, abstract, methods, results, discussion, and funding. It is utilized for both evaluating randomized trials and reporting systematic reviews of other types of research [13].
Data Abstraction
After the initial screening, two reviewers extracted the definitions of the APN in various countries and contexts, and then disagreements were discussed and resolved by consensus.
Synthesis
For each study, the definition or conclusion of the authors regarding the definition of APNs was reported in a table containing the study's objective, methods, results, authors, and publication year.
Results
Eleven studies were included in this review; two were qualitative descriptive studies; one explored the experience of nurses as APNs, and the other was from the patient's perspective. The remaining studies were concept analyses, mixed methods exploratory studies, cross-sectional surveys, and reviews (reflection paper, column paper, and scholarly dialogue paper). Studies were conducted in Saudi Arabia, Finland, North Carolina, the United States (US), the United Kingdom (UK), New Zealand, Canada, Australia, and Sweden. The definition of APNs was discussed in different contexts and from different perspectives in the studies. The results of these studies were categorized as follows: APN definitions, APN titles, and APN-related terms.
Definitions of the APNs
This review includes studies with varying APN definitions. Comellas-Oliva [16] reported a variety of APN definitions and reference models. According to various associations' definitions (American Nursing Association, Canadian Nursing Association, international council of nursing), the models used to comprehend APN were the Benner model, the Oberle and Allen model, and the Hamric model. The author did not provide a clear conclusion regarding definition and the most applicable model. Similarly, Hibbert, et al. [17] concluded in their paper that the APN in Saudi Arabia is not yet defined, regulated, or subject to legislation.
In a qualitative study, Wisur-Hokkanen, et al. [8] determined that the essence of the APN can be broken down into three themes: a broader and deeper holistic view of the patient's health, an independent and accountable working style, and knowing one's own limits. The participants went through both an inner personal transition and a role transition. Participants' role transition was hindered by vague or nonexistent definitions and concepts, insufficient knowledge, insufficient support, and undefined roles. Ahmad, et al. [18] described the experience of patients who have received nursing care from APNs from the patient's perspective.
The analysis revealed one major theme with three subthemes: The subthemes of the theme "professional approach that enables safe and secure health care with high quality" were: respectful and flexible approach, trust in skills and clinical decision making, and meets the need for adequate accessibility of health care.
Stasa, et al. [10] drew the conclusion that there is a lack of clarity regarding the precise definitions of key terms surrounding advanced practice and that the five selected countries regulate advanced practice nursing and their roles in vastly different ways. In the United States, an individual must complete an approved graduate-level program and pass a qualifying exam in order to use the title of advanced practice nurse, whereas in the United Kingdom, this title is unregulated and can be used to refer to nurses who practice with a high level of autonomy and responsibility. In addition, no master or specific requirements are necessary. In contrast, the APN title in Canada, New Zealand, and Australia refers to level of practice rather than specific scope, and a master's degree is required to be an APN. García Mayor [19], in their concept analysis of advanced practice nursing, revealed different articulations of the advanced practice nursing role in the literature. Additionally, the analysis revealed the complexity of advanced practice roles internationally and the difficulty in identifying the unique contribution of APNs to healthcare. In addition, Mousavi, Pimenidis and Jahankhani [14] identified 23 distinct titles used by APNs in their mixed-method studies.
In contrast, other authors defined APN explicitly or adopted the nursing association's definition. Thoun [20] explicitly defined APN, and Fougère, et al. [21] adopted the definition of ICN. Table 1 summarizes these definitions.
Reference
Aims of the study
Methods
Results (APN Definition )
Conclusion
Comellas- Oliva, 2016
To conceptualize APN and its reference models, as well as to contextualize and reflect on APN in Catalonia in order to assimilate them into advanced practice.
Reflection paper
The author cited the definitions of American Nursing Association (ANA), Canadian Nursing Association (CNA), and International council of nursing (ICN). Different models were also mentioned: Benner model, Oberle and Allen model and Hamric model.
Different models and definitions to conceptualize APN, no consensus reached regarding roles and definitions.
Wisur-Hokkanen, Glasberg, makela & Fagerstr omg, 2015
To explore advanced practice nurses’ experiences of the content of their nursing care and to describe promoting or inhibiting factors for working with a full scope of advanced nursing practice.
Qualitative descriptive (24 nurses were interviewed regarding experiences of being APN) in Finland
The substance (essence) of APN can be described with three main themes: a broader and deeper holistic view of patients’ state of health, an independent and responsible manner of working and knowing own limits.
Vague or nonexistent definitions and concepts, insufficient knowledge, insufficient support and undefined roles hindered participants’ role transition
Hibber, Aboshaiqah, Sienko, Harb, Yousuf, Kelley, Brenan, Serrant, Leary, 2017
to disseminate information from a Saudi APN thought leadership meeting, to chronicle the history of APN within Saudi Arabia, while identifying strategies for moving forward.
Special communication
No definition is provided.
Still not define, not legislate or regulate APN in Saudi Arabia.
Dowling, Beauchesne, Farrelly, Morphy, 2013
To clarify what is meant by advanced practice nursing internationally, what attributes signify advanced practice nursing and what are its antecedents, consequences, references and related terms.
Concept analysis
Different articulations of the advanced practice nursing role outlined in the literature, the results revealed the complexity of advanced practice roles internationally and the difficulties in identifying the unique contribution of advanced practitioners in nursing and midwifery to health care. There are seven competencies of APN: Direct clinical care, Collaboration, Coaching and guidance, Research, Ethical decision-making, and Consultation, Leadership. There are different related terms: Specialist nurse, Lead cancer nurse, Advanced clinical nurse, Modern matron, Macmillan nurse (palliative care), Nursing triage, Clinical nurse leader, Nurse-led, Midwife-led Case manager, Clinical research nurse, Lecturer-practitioner, Clinical nurse resource.
No Consensus on definition and titles.
Fougere et al, 2016
To define precisely what is meant by the term “advanced practice nurse (APN),” describe the state of development of APN roles, and review the main factors motivating the implementation of APN in different countries.
Review article
“A Nurse Practitioner/Advanced Practice Nurse (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.
The author adopted the definition of International Council of Nurses of advanced practice nursing: An international review identified no fewer than 13 different titles that APNs may have in various countries, such as “nurse practitioner, "advanced nurse practitioner,”“nurse consultant,” “clinical nurse specialist,” and others.
Erikson, Linblad, Moller, Gillijo, 2017
To describe patients' experiences of health care provided by an APN in primary health care in Sweden.
Descriptive qualitative (interview with 10 patients) regarding their experience of receiving care from APN
Main theme was: Professional approach that enables safe and secure health care with high quality, Sub themes : Respectful and flexible approach, Trust in skills and clinical decision-making, Satisfies need of accessibility of health care on an appropriate level.
APN definition reflects the APNS characteristics in the clinical practice.
Gardner, Duffield, Doubrovsky, Adama, 2016
To identify and delineate advanced practice from other levels of nursing practice.
Cross-sectional electronic surveys of 5662 nurses using the practice role delineation tool based on the strong model across all states and territories of Australia.
The APN concept can be clearly defined by the advanced practice role delineation tool. The survey tool was able to identify position titles where nurses were practicing at an advanced level. The results showed that nurses who practice at an advanced level are characterized by high mean scores across all domains of strong model of advanced practice.
The advanced role delineation tool has the capacity to delineate and define advanced practice nursing.
Thoun, 2011
explore the inextricable link as well as the differences between the advanced practice nursing and specialty practice
Column paper
Definition: a dynamic process of being with others that is guided by the highly developed and complex terrain of nursing science, its associated ethics, models of practice, research methods, and modes of inquiry, arising from experience in and formal (graduate) study of the art and science in nursing, as well as the essential knowledge bases, skills sets, and competencies germane to and consonant with regulated standards of practice, and manifesting in professional growth, leadership, and contribution to disciplinary expansion.
There is a difference between nursing specialty and advanced practice nursing related to depth, extent, complexity addressed at different level of education.
Fawcett, Newman, McAllister, 2004
To discuss and define advance practice nursing
Scholarly dialogue
"The application of an expanded range of practical, theoretical, and research based therapeutics to phenomena experienced by patients, within a specialized clinical area of the larger disciplines of nursing (p. 205)".
They adopted Hanson and Hamric (2003) definition: the application of an expanded range of practical, theoretical, and research based therapeutics to phenomena experienced by patients, within a specialized clinical area of the larger disciplines of nursing (p. 205).
Newall, Towmey, Lima, 2018
To make transparent advanced practice nurses' scope of practice
Two phase mixed methods exploratory study by validated survey tool in phase1 and workshops conducting to develop a clear understanding of APN`s perspective of role titling, reporting and professional engagement in the second phase
23 different titles were used by APNs in the organization.
The use of an empiric tool enabled a clear description of APNs and therefore clear expectations of nurses practicing at advanced level and how practice can be acknowledged, supported and developed.
To align workforce to organizational strategic goals
There were very few differentiating responses to the 41 activities listed against the five domains of APN. The workshops identified four themes: role clarity, creating links, professional development and reporting.
To standardize APN titles, positions descriptions and classifications.
Stata, Cashin, Buckley, Donoghue, 2014
To highlight the significant variability in how advanced practice nursing and associated terms are defined and regulated across a variety of English speaking countrie, including the US, UK, New Zealand, Canada and Australia.
Discursive paper
Is a registered nurse who possesses the skills and capacities to undertake practice outside the RN scope (extended scope) and has received the appropriate legislative approval to do so.
There is still confusion in defining the APN, to reduce this confusion, the authors recommended the minimizing of using the term "expanded practice" and refer to the type of practice in defined and regulated advanced practice nursing scopes; and defining APN as expert practice within a regulated nursing scope.
US: an individual is required to have completed an approved graduate level course and passed an appropriate qualifying exam
UK: A level of practice along a continuum.
Canada: a level of practice rather than to a particular role and is within RN scope of practice. Master degree is required
New Zealand & Australia: a level of practice within the registered nurse scope of practice or registered nurse and extended scope of practice and master degree is required
Table 1: Summary for the definitions of advanced practice nursing in the literature.
Using the advanced practice role delineation tool, Gardner, et al. [22] were able to identify position titles where nurses were practicing at an advanced level and distinguish their sample from other levels of nursing practice.
Different Titles and Terminology for APNs
The term advanced practice nurse encompasses nurse practitioners, nurse anesthetists, midwives, and clinical nurse specialists. Gardner, et al. [22] reported over 70 position titles held by participants, including clinical nurse consultants, clinical nurse specialists, and nurse educators, among others. Mousavi, Pimenidis and Jahankhani [14] also list 23 titles for APNs, including clinical nurse consultant, nurse coordinator, care manager, clinical coordinator, nurse liaison, nurse practitioner, nurse practitioner candidate, and nurse researcher.
Related Terms with APNs
Many terms were used interchangeably with APNs, including specialist nurse; lead cancer nurse; advanced clinical nurse; and modern motor vehicle technician [19,23]. ANPs and APNs are used interchangeably; an ANP is a set of personal characteristics developed within a regulated Scope of Practice (SOP) and enabling full utilization of the SOP. In contrast, they contend that APN is a regulated SOP, similar to how nurses regulate SOPs [10].
Discussion
Our findings revealed that the definitions and names of APNs vary between countries. Different authors define APNs in accordance with various institutions and models. Fougère, et al. [21] adopted the definition of the International Council of Nursing (ICN), which defines a Nurse Practitioner/Advanced Practice Nurse (APN) as 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 influenced by the context and/or country in which the nurse is credentialed to practice. A master's degree is recommended for entry-level positions) while Rababa, Hayajneh and Ahmad [24] adopted Hanson and Hamric's model to define Advanced Practice Nurses (APNs) (which defines it as the application of an expanded range of practical, theoretical, and research based therapeutics to phenomena within a specialized clinical area). Some authors concluded that the debate and inconsistency in defining APN led to an impasse [8,25]. While there are four APN titles in the United States (CNS, NP, nurse anesthetist, and midwife), more than 70 titles were identified in these studies [5,22].
Different nations define, legislate, and regulate APN differently. In the United States, the APN is regulated and requires specific requirements and qualifications, whereas in the United Kingdom, there is still a lack of clear regulations and no specific qualifications are required to hold this title. A master's degree is required to hold this designation in Canada, New Zealand, and Australia [10]. APNs have contributed uniquely to the quality, cost, and accessibility of the health care system [26]. This review of qualitative studies revealed, from the perspective of Swedish patients, that APN nurses possessed the knowledge and skills to provide safe and secure individual and holistic healthcare with a respectful and adaptable attitude. They conveyed confidence and safety and provided patients with satisfactory care [6,27]. In contrast, APN nurses in Finland encountered ambiguous and inconsistent definitions and concepts, undefined roles, and insufficient knowledge and support regarding their work as APNs.
Despite these inconsistencies, it is evident that APN will soon have a clear definition and roles. Using the strong model of advanced practice, Glenn and Budd [1] were able to identify position titles where nurses were practicing at an advanced level and distinguish the study cohort from other levels. The APNs reported high mean scores in all of the model's domains [28]. It is evident that the advanced practice role delineation tool, which was derived from the robust model, has the capacity to clearly outline and define what constitutes an advanced practice in nursing and what does not. However, these findings should be interpreted with caution due to the limitations of this study; it was conducted in an Australian context, and the nurses were recruited via the web. In addition, data were self-reported, which may have compromised the study's internal validity. Therefore, future studies employing objective metrics are required to validate the robust model for elucidating the function and definition of APNs. The limited search strategy utilizing four databases yielded only eleven papers for review. It is possible that additional relevant studies were not identified.
Conclusion
In the absence of standardized measures that enable stakeholders and nations to distinguish APN from other levels of nursing practices, there is a need to clearly define APN internationally in order to advance and improve our nursing disciplines. The robust model of advanced practice nurses may be well-suited to clearly define APNs, but further testing and validation in various contexts is still required.
Author Statements
Conflict of Interest
The authors declare that they have no competing interests.
References
- Glenn CH, Budd G. Concepts and challenges of the professional nurse practitioner. Role development for the nurse practitioner. Jones and Bartlett Publishers Learning. 2021; 351-366.
- Brooten D, Youngblut JM, Deosires W, Singhala K, Guido-Sanz F. Global considerations in measuring effectiveness of advanced practice nurses. Int J Nurs Stud. 2012; 49: 906-12.
- Dulisse B, Cromwell J. No harm found when nurse anesthetists work without supervision by physicians. Health Aff (Millwood). 2010; 29: 1469-75.
- Bani Hani SB, Ahmad M. Effective prediction of mortality by heart disease among women in Jordan using the chi-squared automatic interaction detection model: retrospective validation study. JMIR Cardio. 2023; 7: e48795.
- Newall F, Twomey B, Lima S. Advanced practice nursing–Promoting organisation clarity and connectedness: a mixed methods approach. Collegian. 2018; 25: 97-103.
- Eriksson I, Lindblad M, Möller U, Gillsjö C. Holistic health care: patients’ experiences of health care provided by an Advanced Practice Nurse. Int J Nurs Pract. 2018; 24: e12603.
- Ahmad M, Hani SHB, Sabra MA, Almahmoud O. Big data can help prepare nurses and improve patient outcomes by improving quality, safety, and outcomes. Front Nurs. 2023; 10: 241-8.
- Wisur-Hokkanen C, Glasberg AL, Mäkelä C, Fagerström L. Experiences of working as an advanced practice nurse in Finland–the substance of advanced nursing practice and promoting and inhibiting factors. Scand J Caring Sci. 2015; 29: 793-802.
- Anshasi H, Ahmad M. Cancer-related fatigue: systematic reviews and meta-analyses of mind–body intervention. Palliat Support Care. 2021; 19: 361-6.
- Stasa H, Cashin A, Buckley T, Donoghue J. Advancing advanced practice—clarifying the conceptual confusion. Nurse Educ Today. 2014; 34: 356-61.
- Alammar K, Ahmad M, Almutairi S, Salem O. Nursing students’ perception of the clinical learning environment. Open Nurs J. 2020; 14: 174-9.
- Albsoul RA, Safadi RR, Alshyyab MA, FitzGerald G, Hughes JA, Ahmad M. Missed nursing care in medical and surgical wards in Jordan: A cross-sectional study. Policy Polit Nurs Pract. 2023; 24: 140-50.
- Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4: 1.
- Mousavi SA, Pimenidis E, Jahankhani H. Five stage development framework for electronic government. In: ECEG2010-Proceedings of the 10th European Conference on E-Government: national Center for Taxation Studies University of Limerick, Ireland 17-18 June 2010. Academic Conferences Limited. 2010; 259.
- Colquhoun HL, Levac D, O’Brien KK, Straus S, Tricco AC, Perrier L, et al. Scoping reviews: time for clarity in definition, methods, and reporting. J Clin Epidemiol. 2014; 67: 1291-4.
- Comellas-Oliva M. Developing the advanced practice nurse in Catalonia. Rev Bras Enferm. 2016; 69: 991-5.
- Hibbert D, Aboshaiqah AE, Sienko KA, Forestell D, Harb AW, Yousuf SA, et al. Advancing nursing practice: the emergence of the role of advanced practice nurse in Saudi Arabia. Ann Saudi Med. 2017; 37: 72-8.
- Ahmad MM, Elayan RM, Bani Hani SB, Qzih ES, Alhalaiqa F. When nurses become ill, are they able to identify the predictors of the quality of care they received?. Electron J Gen Med. 2023; 20.
- García Mayor S. Effectiveness of advanced practice nursing interventions in older people and their description through the nursing interventions classification. A systematic review and qualitative study. 2014.
- Thoun DS. Specialty and advanced practice nursing: discerning the differences. Nurs Sci Q. 2011; 24: 216-22.
- Fougère B, Morley JE, Decavel F, Nourhashémi F, Abele P, Resnick B, et al. RETRACTED: development and implementation of the advanced practice nurse worldwide with an interest in geriatric care. J Am Med Dir Assoc. 2016; 17: 782-8.
- Gardner G, Duffield C, Doubrovsky A, Adams M. Identifying advanced practice: A national survey of a nursing workforce. Int J Nurs Stud. 2016; 55: 60-70.
- Hani HSB, Ahmad MM. Large-scale data in health care: a concept analysis. Georgian Medical News. 2022; 325: 33-6.
- Rababa M, Hayajneh AA, Ahmad M. Measuring knowledge and attitudes of pain in older adults among culturally diverse nursing students. Collegian. 2021; 28: 580-6.
- Al Tamimi D, Ahmad M. Risk of malnutrition and clinical outcomes among mechanically ventilated patients in intensive care units. Dimens Crit Care Nurs. 2022; 41: 18-23.
- Ahmad MM, Al-Daken LI. Clinical trial on mindfulness with family caregivers for patients with cancer. J Cancer Educ. 2022; 37: 304-10.
- Afaneh T, Abu-Moghli F, Ahmad M. Nursing-sensitive indicators: A concept analysis. Nurs Manag (Harrow). 2021; 28: 28-33.
- Saber EAE, Abdalla SM, Ahmad MM, Yousef HR, Ayasrah SM. Motivate nurses and reduce the absenteeism rate in Intensive Care Units. Nurs Care Res/Nosileia kai Ereuna. 2021; 60.
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