A Systematic Review on the Definition Advanced Nursing Practice

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: mma4jo@yahoo.com; mma4@ju.edu.jo

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.


    


    

    


    


    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.

Table 1: Summary for the definitions of advanced practice nursing in the literature.










  


    
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.

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Citation: Ahmad MM, Abu-Shaikha HS, Al-Shatnawi F. A Systematic Review on the Definition Advanced Nursing Practice. Ann Nurs Res Pract. 2023; 8(2): 1057.