Competency frameworks for advanced practice nursing: a literature review P. Sastre-Fullana1 RN, MSN, J.E. De Pedro-Gómez2 RN, BSc, PhD, M. Bennasar-Veny3 RN, BSc, PhD, P. Serrano-Gallardo4 RN, BSc, PhD & J.M. Morales-Asencio5 RN, BSc, PhD 1 Associate Professor, 3 Director, Department of Nursing, 2 Dean, Faculty of Nursing and Physiotherapy, University of Balearic Islands, Palma de Mallorca, 4 Professor, Department of Nursing, Autonomous University of Madrid, Madrid, 5 Director, Department of Nursing, University of Málaga, Málaga, Spain
SASTRE-FULLANA P., DE PEDRO-GÓMEZ J.E., BENNASAR-VENY M., SERRANO-GALLARDO P., & MORALES-ASENCIO J.M. (2014) Competency frameworks for advanced practice nursing: a literature review. International Nursing Review 61, 534–542 Aim: This paper describes a literature review that identified common traits in advanced practice nursing that are specific to competency development worldwide. Background: There is a lack of international agreement on the definition of advanced practice nursing and its core competencies. Despite the lack of consensus, there is an ongoing process worldwide to establish and outline the standards and competencies for advanced practice nursing roles. Introduction: International agencies, such as the International Council of Nurses, have provided general definitions for advanced practice nursing. Additionally, a set of competency standards for this aim has been developed. Methods: A literature review and a directed search of institutional websites were performed to identify specific developments in advanced practice nursing competencies and standards of practice. To determine a competency map specific to international advanced practice nursing, key documents were analysed using a qualitative approach based on content analysis to identify common traits among documents and countries. Results: The review process identified 119 relevant journal articles related to advanced practice nursing competencies. Additionally, 97 documents from grey literature that were related to advanced practice nursing competency mapping were identified. From the text analysis, 17 worldwide transversal competency domains emerged. Conclusions: Despite the variety of patterns in international advanced practice nursing development, essential competency domains can be found in most national frameworks for the role development of international advanced practice nursing. These 17 core competencies can be used to further develop instruments that assess the perceived competency of advanced practice nurses. Implications for Nursing and Health Policy: The results of this review can help policy developers and researchers develop instruments to compare advanced practice nursing services in various contexts and to examine their association with related outcomes.
Correspondence address: Pedro Sastre-Fullana, C/Glosadors N°5 Bj A, CP 07010, Palma de Mallorca, Spain; Tel: 34605047432; E-mail: [email protected].
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Literature Review
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Keywords: Advanced Practice Nursing, Clinical Competence, Competence, Competency Assessment, Literature Review, Nurse Practitioners, Nursing, Practice Patterns, Professional Role, Scope of Practice
Introduction The progressive spread of advanced practice nursing (APN) worldwide has generated a range of approaches as well as controversy and conceptual ambiguity. The development and establishment of new APN roles is a complex process that has resulted from a wide variety of factors, many of which are related to their context. Delamaire & Lafortune (2010) combined these factors into four groups: a response to a shortage of doctors; a response to changing demand for services; a response to growing healthcare costs; and an element of improvement for the professional development of nurses. The International Council of Nurses (ICN) proposed the following definition for advanced practice nurses: ‘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’ (Schober & Affara 2006, p. 126). The ICN added several characteristics that define the role, such as the level of academic training and the nature of interventions. The British Nursing and Midwifery Council (Hinchliff & Rogers 2008) and the Canadian Nurses Association (CNA 2008) have provided other definitions that include high expert knowledge and advanced clinical skills. Some studies have analysed aspects related to the implementation of new APN roles. These include academic training, economic impact, professional practice, legislative regulations and impact on health care. Two studies reviewed up to 69 APN roles in 35 countries and revealed a global trend in the development of new advanced practice roles (Schober & Affara 2006; Sheer & Wong 2008). Another study investigated the implementation processes and future pathways for APN in 12 countries of the Organisation for Economic Co-operation and Development (OECD), identifying up to 41 advanced practice roles (Delamaire & Lafortune 2010). Most studies have concluded that the definition of competencies plays a key role in the conceptualization and development of these advanced roles, characterized by maximizing the use of specialist competencies and nursing knowledge. However, it is worth noting that the concept of competency offers wide heterogeneity, with numerous definitions and conceptual developments (Alles 2007; Canós et al. 2003).
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The progressive implementation of APN roles worldwide has led to a growing development of standards of practice and competency maps (Duffield et al. 2009). Currently, however, models have not been compared at an international level.
Study aim The aim of this research was to review APN models and competency assessment tools with a special focus on competency maps and practice standards. This review can enable the identification of common competencies and their comparative analysis. This initial step will cluster related competencies into domains that can serve as a framework for the development of future APN competency assessment tools.
Methods A review of the literature was conducted to search for specific competency maps for recognized advanced practice nursing roles. If there was any doubt as to whether the role described was part of APN, the case was compared by two reviewers to the APN defining characteristics described by the ICN (Schober & Affara 2006). Advanced practice nursing-specific development of standards of practice and competency maps, competency-based conceptual models and competency assessment tools were selected. Competency maps for midwifery roles were excluded when their academic training involved a completely separate curricular pathway from nursing, as were competency maps for nonuniversity trained advanced nursing roles. The defining characteristics expounded in the ICN document on competencies for nurse specialists (Affara 2009) and a framework that distinguishes between levels of nursing practice (Daly & Carnwell 2003) facilitated the identification and exclusion of specialist nursing roles. The sources that were consulted included databases (PubMed, CINAHL, Elsevier Institutions, Cuiden Plus, Web of Knowledge and ScienceDirect), specific search engines (advanced practice nursing Literature Database, Scirus, OAIster, Health Sciences Online) and metasearch engines (NHS Evidence and Google Scholar). The search period was limited to 2002–2014 because most competency systems and the context in which they were developed are periodically updated, although prior documents were considered depending on their relevance. Most of the search aimed to identify corporate
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documents on the websites of institutional agencies that were related to standards of practice and professional competency maps specific to the field of APN. Search systematization was limited using different combinations of the following descriptors: a primary: competency, competencies, standards, advanced, practice; nurse; b secondary: practitioner, anaesthetist, clinical specialist, midwife, consultant, case manager, role, higher level, extended; expanded. The main search was performed in English and Spanish. An accessory search using additional languages was conditioned using website translation tools (Google translator; Babylon 9). Articles were separated according to whether they were published or were grey literature, followed by a critical review of each paper to identify the following: • explicit advanced practice roles; • aspects related to standards of practice or professional competencies. The relevant articles were classified into three groups: a conceptual models; b competency assessment tools; c standards of practice and competency maps. All of the articles were then ordered by chronological order of publication, author or responsible agency/institution, publisher/ journal and country of publication. The studies were assessed for inclusion by two reviewers. In case of doubt, a third external reviewer was consulted. Document analysis method
A pure content analysis process was used to infer word elements common to all documents, according to the methods described by Berelson (1952; Krippendorff 1980; Polit & Hungler 1999). MAXQDA® data analysis software (VERBI GmbH, Berlin, Germany) was used for this purpose. The analysis first determined the frequencies of words in the selected documents, and then the words were classified according to frequency and document of origin. Using this method, the most frequent words related to possible transversal domains were selected using the APN conceptual models and competency scales as a framework for the coding process. Subsequently, an extended analysis of previously identified terms related by Booleans was conducted to identify common competency elements across all of the analysed documents. Each document was coded according to the country to which it belonged, which enabled a final analysis that revealed new results. This process yielded a set of categories or domains that enabled us to compare concepts between sources and between different settings. A manual review was conducted to
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analyse all documents that did not allow a software analysis approach because of their language or format.
Results For the review, 119 scientific literature documents and 97 grey literature and corporate documents (all of them available from the author) were selected. Advanced practice nursing competency models and assessment tools
Five APN models based on professional competencies and four specific APN competency assessment instruments emerged in the review. These items served as a reference framework because this review focused on APN competency maps and standards of practice. A summary of models and scales (and related competency domains) can be found in Table 1. Advanced practice nursing roles
Six main APN roles were identified through further analysis: nurse practitioner, clinical nurse specialist, nurse midwife, nurse anaesthetist, consultant nurse and nurse case manager. For each role, the systems of professional regulation vary depending on the country of reference. In most cases, formal recognition is the responsibility of professional organizations or government or health agencies. In some cases, professional recognition is granted by nursing councils. A summary of the roles is given in Table 2. Across 26 countries, the results show a clear predominance of the APN role (27.08%), followed by nurse practitioners (18.75%). Most were in Anglo-Saxon countries. Despite this finding, a worldwide APN role implementation process is evident, with several official documents outlining competencies and regulatory standards at national levels. These standards are especially complex at the European level. International competency dimensions
A content analysis of the documents enabled the selection of 17 descriptive competency-related APN domains (listed in Table 3) in addition to the international presence of each domain identified across 29 countries. Identifying cross elements common to most of the countries allowed us to isolate a set of competency domains related to APN independent of the setting of professional practice. Dimensions such as ‘research’, ‘clinical and professional leadership’, ‘mentoring and coaching’ and ‘expert clinical judgement’ were present in 16 or more countries and constituted 44.29% of the competency dimensions found in all countries.
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Table 1 Competency-based APN framework models and assessment instruments
Model Fenton & Brykczynski (Fenton & Brykczynski 1993) Strong (Ackerman et al. 1996) Synergy model (Edwards 1999) University Health Network (UHN) framework for APN (Micevski et al. 2004) Hamric (Hamric 2005) Instrument Conceptual framework for advanced practice (Manley 1997) Substantive areas of clinical nurse specialist practice (Lewandowski & Adamle 2009) Criterion-based performance assessment for advanced practice nurses (Scarpa 2011) APN clinical competencies (Nieminen et al. 2011)
Origin/field of application
Competency domains
Clinical nurse specialist and nurse practitioner roles Acute care nurse practitioner roles Critical care nursing roles Canadian advanced practice roles
Col; Ldr; Men; Con; Eth; Col; Ldr; Men Col; Ldr; Men; Adv Col; Ldr; Cha
Clinical nurse specialist role
Col; Ldr; Res; Men; Con; Eth
Advanced practitioner and consultant nurse roles Clinical nurse specialist role
Edu; Exp; Res; Ldr; Con; Col; Car Car; Col; Edu; Con; Cha
APN roles
Ldr; Col; Con; Edu; Res
Scandinavian APN roles
Exp; Aut; Con; Coa; Col; Evi
Competency domains: Adv, advocacy; Aut, professional autonomy; Car, care management; Cha, change agent; Col, collaboration; Com, communication; Con, consulting; Evi, evidence-based practice; Edu, education; Eth, ethical and legal practice; Exp, expert clinical judgement; Ldr, clinical and professional leadership; Men, mentoring and coaching; Res, research; Tea, teaching.
Discussion The aim of this study was to conduct a review of the competency definition and assessment models developed in various countries, especially those found in grey literature documents and documents published in media outside of peer-reviewed journals. Based on the six different APN roles identified worldwide (Delamaire & Lafortune 2010; Hamric 2005; Schober & Affara 2006) and considering models of professional regulation and accreditation in nursing (Pulcini et al. 2010), the research focused on searching for APN competency mapping developments within regulatory agencies to provide a more accurate description of their competencies and practice standards. This search enabled us to establish international comparisons. The documents compiled from 29 countries cover a wide range of heterogeneous APN roles, confirming the extensive dissemination of this role worldwide and the establishment of standards of practice and competency maps as standard procedure in most of the countries where APN roles exist. The implementation of APN roles is not exempted from controversy, which mainly arises from the formal transfer of responsibilities and duties from medical to nursing professionals and the analysis of their impact on health quality and the efficiency of healthcare services. Nevertheless, many countries are turning to this approach to address various healthcare needs (Ter Maten-Speksnijder et al. 2014). Autonomy, recognition and alliance by the rest of the team (Burgess et al. 2011) as well as safety concerns (Villegas & Allen 2012) are important
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priorities and may have more significant implications for the diversity of APN development than the definition of competency frameworks. Currently, the relationship between APN and the specific professional competencies of these roles has not been considered in the leading studies in this area (Delamaire & Lafortune 2010; Schober & Affara 2006). This gap may contribute to the variability and ambiguity in the definitions of roles and responsibilities (Gardner et al. 2013). Other APN competency developments exist, but they are either very generic (Nieminen et al. 2011) or are confined to specific roles or contexts (Lewandowski & Adamle 2009; Sue et al. 2010). Additionally, there is no nursing competency review specifically devoted to the role of advanced practice, as is the case in general nursing (Putra & Petpichetchian 2011; Traynor et al. 2011). Nevertheless, it is worth noting the methodological difficulties in terms of designing competency assessment methods in nursing. These difficulties are derived from the conceptual frailty of many instruments and difficulties in defining competency attributes (Axley 2008; Scott 2008). Moreover, many competencies in health professions are subject to contextual and local determinants that make it difficult to extend them to other contexts of care (Epstein & Hundert 2002). Nonetheless, the existence of common competencies across various countries can help to identify key features that shape the role of advanced practice nurses. Research, leadership or expert clinical judgement seems to be a regular pattern in
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Table 2 APN roles by country Country
America USA
No. of documents reviewed
No. of APN roles described
Roles APN
NP
CNS
NM
NA
x
x
25
6
x
x
x
Canada
16
5
x
x
x
Oceania Australia
5
5
x
x
Papua New Guinea
2
1
x
New Zealand
1
1
x
Europe Austria
1
1
Cyprus
1
1
Denmark
2
2
x
Finland
1
1
x
France
1
1
x
Germany
1
1
x
Ireland
1
2
x
Italy
1
1
x
Netherlands
2
2
Norway
2
2
x
10
3
x
Sweden
5
2
Switzerland
2
2
x
UK
2
4
x
Asia Hong Kong
1
1
Indonesia
1
1
Japan
6
1
Singapore
1
1
South Korea
1
1
x
Thailand
1
1
x
Africa South Africa
1
1
Spain
NC
CMN
Other
x x
x xxx
x x x
x
x
x x x
x
x x x
x
x
x
x x x x
x
APN, advanced practice nursing generic/non-specific role; CMN, case manager nurse; CNS, clinical nurse specialist; NA, nurse anaesthetist; NC, nurse consultant; NM, nurse midwife; NP, nurse practitoner; Other, country-specific and/or highly specialized role.
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•
•
•
•
Research
Clinical and professional
Mentoring and coaching
Collaboration and
•
•
•
•
•
•
•
•
•
•
•
•
Ethical and legal practice
Education and teaching
Quality management and safety
Consulting
Care management
Evidence-based practice
Professional autonomy
Health promotion
Communication
Cultural competencies
Advocacy
Change management
*Pacific Islands.
•
Expert clinical judgement
interprofessional relationships
leadership
USA
Competency dimensions
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
GBR
•
•
•
•
•
•
•
•
•
•
•
•
•
CAN
•
•
•
•
•
•
•
•
•
•
•
•
AUS
•
•
•
•
•
•
•
•
•
NZL
•
•
•
•
•
•
•
•
ESP
•
•
•
•
•
•
•
•
•
INA
•
•
•
•
•
•
•
•
SWE
•
•
•
•
•
•
•
•
SIN
•
•
•
•
•
•
•
•
THA
•
•
•
•
•
•
•
•
RSA
•
•
•
•
•
•
•
NED
•
•
•
•
•
•
•
AUT
•
•
•
•
•
•
•
KOR
•
•
•
•
•
•
•
CHI
Table 3 Common competency domains on an international scale, according to country (IOC codification)
•
•
•
•
•
•
•
FRA
•
•
•
•
•
•
SUI
•
•
•
•
•
•
GER
•
•
•
•
•
•
HKG
•
•
•
•
•
•
CYP
•
•
•
•
•
•
JPN
•
•
•
•
•
IRL
•
•
•
•
•
DEN
•
•
•
•
•
PNG
•
•
•
•
•
FIN
•
•
•
•
•
PAC*
•
•
•
•
TRI
•
•
•
•
ITA
•
•
•
•
NOR
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APNs’ competencies. This fact is consistent with a substantial part of the ICN’s conceptualization of an advanced practice nurse as a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice (International Council of Nurses 2002). Research and knowledge brokering have been reported to be important roles in APN, with marked leadership in promoting evidence-based practice among clinical nurses (Gerrish et al. 2011). International comparisons among the various roles and competencies of APN could be performed by considering these common dimensions. This aim should be pursued by using validated instruments, similar to attempts at a European level with the development of self-assessment instruments for competencies among general nurses (Cowan et al. 2008). Regarding Spain, there is controversy (De Pedro 2006; Hernández 2011) regarding whether the recently developed specialist nurse roles correspond to APN. We identified other advanced practice roles, such as in Andalusia and Catalonia, where development focuses on the fields of home care, hospital care and emergency care. There is also the role of the nurse case manager, which is recognized as APN and has been assessed in some cases (Morales Asencio et al. 2008; Ridao et al. 2011). In the Basque Country, Navarra, Madrid and Galicia, case management roles have also been introduced in various chronic disease management strategies. This development reveals the growth of new advanced practice roles.
Implications for nursing and health policy There is a growing development of APN standards of practice worldwide. Competency mapping is a common practice in the development and implementation of new advanced practice roles. However, there is a lack of consensus with respect to specific competencies. This review identifies the underlying international dimensions of competency and considers competencybased frameworks of APN roles and competency assessment tools that have already been developed. These results can be used by policy developers and researchers to compare APN services in various contexts on a national or international scale and to analyse their association with the outcomes of the services provided.
Study limitations This study has some limitations derived from the difficulty in ensuring maximum thoroughness in the search for grey literature, mainly because of language barriers and the heterogeneity of the regulation frameworks of each country. This issue made it especially difficult to precisely identify APN roles as opposed to other levels of nursing practice.
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Another limiting factor was the difficulty in accessing institutional documents in countries where the literature pointed towards developments in APN but there was a lack of institutional accessibility or reference contacts. Additionally, emerging legislative or training developments for APN roles that had not previously been described were found, but it was not possible to determine the existence of specific documents regarding competency maps or standards of practice. Finally, there are certain inconsistencies regarding the level of specificity of the documents. They vary from general proposals of new APN roles to specific, comprehensive regulatory documents.
Conclusion A main objective of this review was to search for common international trends in APN competency mapping. After considering all the advanced practice competency-related elements (competency models/frameworks, competency maps and competency assessment scales/instruments) that emerged through the review process, it was clear that our attention needed to focus on competency map documents. Based on this approach, frameworks and scales were used as background references to identify common elements. This approach guided us towards the identification of competency clusters (domains). We encountered these clusters as competency organizations in various competency map developments, which were found through the review process of grey literature documents. This review identifies a minimum set of competency domains that can be attributed to APN roles and can act as a benchmark in the implementation process of new APN roles. Additionally, the nursing role can be assessed to compare the level of competency performance to APN standards in non-regulated settings. This review is a key initial step towards the development of an instrument to assess the level of competence of advanced practice nurses independent of the legislative, regulatory and professional context of each country.
Authors contributions Study conception and main design: PS-F, JD-G and JMM-A. Data collection and document analysis: PS-F. Drafting of manuscript: PS-F and JMM-A. Critical revisions for important intellectual content: JMM-A and JD-G. Supervision: JD-G and JMM-A. Statistical expertise: MB-V and PS-G. Technical and material support: MB-V and PS-G.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
APN competency frameworks review
Conflicts of interest No conflict of interest has been declared by the author(s).
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Traynor, V., Inoue, K. & Crookes, P. (2011) Literature review: understanding nursing competence in dementia care. Journal of Clinical Nursing, 20 (13–14), 1948–1960. Villegas, W.J. & Allen, P.E. (2012) Barriers to advanced practice registered nurse scope of practice: issue analysis. Journal of Continuing Education in Nursing, 43 (9), 403–409.
SASTRE-FULLANA P., DE PEDRO-GÓMEZ J.E., BENNASAR-VENY M., SERRANO-GALLARDO P., & MORALES-ASENCIO J.M. (2014) Competency frameworks for advanced practice nursing: a literature review. International Nursing Review 61, 534–542 Aim: This paper describes a literature review that identified common traits in advanced practice nursing that are specific to competency development worldwide. Background: There is a lack of international agreement on the definition of advanced practice nursing and its core competencies. Despite the lack of consensus, there is an ongoing process worldwide to establish and outline the standards and competencies for advanced practice nursing roles. Introduction: International agencies, such as the International Council of Nurses, have provided general definitions for advanced practice nursing. Additionally, a set of competency standards for this aim has been developed. Methods: A literature review and a directed search of institutional websites were performed to identify specific developments in advanced practice nursing competencies and standards of practice. To determine a competency map specific to international advanced practice nursing, key documents were analysed using a qualitative approach based on content analysis to identify common traits among documents and countries. Results: The review process identified 119 relevant journal articles related to advanced practice nursing competencies. Additionally, 97 documents from grey literature that were related to advanced practice nursing competency mapping were identified. From the text analysis, 17 worldwide transversal competency domains emerged. Conclusions: Despite the variety of patterns in international advanced practice nursing development, essential competency domains can be found in most national frameworks for the role development of international advanced practice nursing. These 17 core competencies can be used to further develop instruments that assess the perceived competency of advanced practice nurses. Implications for Nursing and Health Policy: The results of this review can help policy developers and researchers develop instruments to compare advanced practice nursing services in various contexts and to examine their association with related outcomes.
Correspondence address: Pedro Sastre-Fullana, C/Glosadors N°5 Bj A, CP 07010, Palma de Mallorca, Spain; Tel: 34605047432; E-mail: [email protected].
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Literature Review
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Keywords: Advanced Practice Nursing, Clinical Competence, Competence, Competency Assessment, Literature Review, Nurse Practitioners, Nursing, Practice Patterns, Professional Role, Scope of Practice
Introduction The progressive spread of advanced practice nursing (APN) worldwide has generated a range of approaches as well as controversy and conceptual ambiguity. The development and establishment of new APN roles is a complex process that has resulted from a wide variety of factors, many of which are related to their context. Delamaire & Lafortune (2010) combined these factors into four groups: a response to a shortage of doctors; a response to changing demand for services; a response to growing healthcare costs; and an element of improvement for the professional development of nurses. The International Council of Nurses (ICN) proposed the following definition for advanced practice nurses: ‘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’ (Schober & Affara 2006, p. 126). The ICN added several characteristics that define the role, such as the level of academic training and the nature of interventions. The British Nursing and Midwifery Council (Hinchliff & Rogers 2008) and the Canadian Nurses Association (CNA 2008) have provided other definitions that include high expert knowledge and advanced clinical skills. Some studies have analysed aspects related to the implementation of new APN roles. These include academic training, economic impact, professional practice, legislative regulations and impact on health care. Two studies reviewed up to 69 APN roles in 35 countries and revealed a global trend in the development of new advanced practice roles (Schober & Affara 2006; Sheer & Wong 2008). Another study investigated the implementation processes and future pathways for APN in 12 countries of the Organisation for Economic Co-operation and Development (OECD), identifying up to 41 advanced practice roles (Delamaire & Lafortune 2010). Most studies have concluded that the definition of competencies plays a key role in the conceptualization and development of these advanced roles, characterized by maximizing the use of specialist competencies and nursing knowledge. However, it is worth noting that the concept of competency offers wide heterogeneity, with numerous definitions and conceptual developments (Alles 2007; Canós et al. 2003).
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The progressive implementation of APN roles worldwide has led to a growing development of standards of practice and competency maps (Duffield et al. 2009). Currently, however, models have not been compared at an international level.
Study aim The aim of this research was to review APN models and competency assessment tools with a special focus on competency maps and practice standards. This review can enable the identification of common competencies and their comparative analysis. This initial step will cluster related competencies into domains that can serve as a framework for the development of future APN competency assessment tools.
Methods A review of the literature was conducted to search for specific competency maps for recognized advanced practice nursing roles. If there was any doubt as to whether the role described was part of APN, the case was compared by two reviewers to the APN defining characteristics described by the ICN (Schober & Affara 2006). Advanced practice nursing-specific development of standards of practice and competency maps, competency-based conceptual models and competency assessment tools were selected. Competency maps for midwifery roles were excluded when their academic training involved a completely separate curricular pathway from nursing, as were competency maps for nonuniversity trained advanced nursing roles. The defining characteristics expounded in the ICN document on competencies for nurse specialists (Affara 2009) and a framework that distinguishes between levels of nursing practice (Daly & Carnwell 2003) facilitated the identification and exclusion of specialist nursing roles. The sources that were consulted included databases (PubMed, CINAHL, Elsevier Institutions, Cuiden Plus, Web of Knowledge and ScienceDirect), specific search engines (advanced practice nursing Literature Database, Scirus, OAIster, Health Sciences Online) and metasearch engines (NHS Evidence and Google Scholar). The search period was limited to 2002–2014 because most competency systems and the context in which they were developed are periodically updated, although prior documents were considered depending on their relevance. Most of the search aimed to identify corporate
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documents on the websites of institutional agencies that were related to standards of practice and professional competency maps specific to the field of APN. Search systematization was limited using different combinations of the following descriptors: a primary: competency, competencies, standards, advanced, practice; nurse; b secondary: practitioner, anaesthetist, clinical specialist, midwife, consultant, case manager, role, higher level, extended; expanded. The main search was performed in English and Spanish. An accessory search using additional languages was conditioned using website translation tools (Google translator; Babylon 9). Articles were separated according to whether they were published or were grey literature, followed by a critical review of each paper to identify the following: • explicit advanced practice roles; • aspects related to standards of practice or professional competencies. The relevant articles were classified into three groups: a conceptual models; b competency assessment tools; c standards of practice and competency maps. All of the articles were then ordered by chronological order of publication, author or responsible agency/institution, publisher/ journal and country of publication. The studies were assessed for inclusion by two reviewers. In case of doubt, a third external reviewer was consulted. Document analysis method
A pure content analysis process was used to infer word elements common to all documents, according to the methods described by Berelson (1952; Krippendorff 1980; Polit & Hungler 1999). MAXQDA® data analysis software (VERBI GmbH, Berlin, Germany) was used for this purpose. The analysis first determined the frequencies of words in the selected documents, and then the words were classified according to frequency and document of origin. Using this method, the most frequent words related to possible transversal domains were selected using the APN conceptual models and competency scales as a framework for the coding process. Subsequently, an extended analysis of previously identified terms related by Booleans was conducted to identify common competency elements across all of the analysed documents. Each document was coded according to the country to which it belonged, which enabled a final analysis that revealed new results. This process yielded a set of categories or domains that enabled us to compare concepts between sources and between different settings. A manual review was conducted to
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analyse all documents that did not allow a software analysis approach because of their language or format.
Results For the review, 119 scientific literature documents and 97 grey literature and corporate documents (all of them available from the author) were selected. Advanced practice nursing competency models and assessment tools
Five APN models based on professional competencies and four specific APN competency assessment instruments emerged in the review. These items served as a reference framework because this review focused on APN competency maps and standards of practice. A summary of models and scales (and related competency domains) can be found in Table 1. Advanced practice nursing roles
Six main APN roles were identified through further analysis: nurse practitioner, clinical nurse specialist, nurse midwife, nurse anaesthetist, consultant nurse and nurse case manager. For each role, the systems of professional regulation vary depending on the country of reference. In most cases, formal recognition is the responsibility of professional organizations or government or health agencies. In some cases, professional recognition is granted by nursing councils. A summary of the roles is given in Table 2. Across 26 countries, the results show a clear predominance of the APN role (27.08%), followed by nurse practitioners (18.75%). Most were in Anglo-Saxon countries. Despite this finding, a worldwide APN role implementation process is evident, with several official documents outlining competencies and regulatory standards at national levels. These standards are especially complex at the European level. International competency dimensions
A content analysis of the documents enabled the selection of 17 descriptive competency-related APN domains (listed in Table 3) in addition to the international presence of each domain identified across 29 countries. Identifying cross elements common to most of the countries allowed us to isolate a set of competency domains related to APN independent of the setting of professional practice. Dimensions such as ‘research’, ‘clinical and professional leadership’, ‘mentoring and coaching’ and ‘expert clinical judgement’ were present in 16 or more countries and constituted 44.29% of the competency dimensions found in all countries.
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Table 1 Competency-based APN framework models and assessment instruments
Model Fenton & Brykczynski (Fenton & Brykczynski 1993) Strong (Ackerman et al. 1996) Synergy model (Edwards 1999) University Health Network (UHN) framework for APN (Micevski et al. 2004) Hamric (Hamric 2005) Instrument Conceptual framework for advanced practice (Manley 1997) Substantive areas of clinical nurse specialist practice (Lewandowski & Adamle 2009) Criterion-based performance assessment for advanced practice nurses (Scarpa 2011) APN clinical competencies (Nieminen et al. 2011)
Origin/field of application
Competency domains
Clinical nurse specialist and nurse practitioner roles Acute care nurse practitioner roles Critical care nursing roles Canadian advanced practice roles
Col; Ldr; Men; Con; Eth; Col; Ldr; Men Col; Ldr; Men; Adv Col; Ldr; Cha
Clinical nurse specialist role
Col; Ldr; Res; Men; Con; Eth
Advanced practitioner and consultant nurse roles Clinical nurse specialist role
Edu; Exp; Res; Ldr; Con; Col; Car Car; Col; Edu; Con; Cha
APN roles
Ldr; Col; Con; Edu; Res
Scandinavian APN roles
Exp; Aut; Con; Coa; Col; Evi
Competency domains: Adv, advocacy; Aut, professional autonomy; Car, care management; Cha, change agent; Col, collaboration; Com, communication; Con, consulting; Evi, evidence-based practice; Edu, education; Eth, ethical and legal practice; Exp, expert clinical judgement; Ldr, clinical and professional leadership; Men, mentoring and coaching; Res, research; Tea, teaching.
Discussion The aim of this study was to conduct a review of the competency definition and assessment models developed in various countries, especially those found in grey literature documents and documents published in media outside of peer-reviewed journals. Based on the six different APN roles identified worldwide (Delamaire & Lafortune 2010; Hamric 2005; Schober & Affara 2006) and considering models of professional regulation and accreditation in nursing (Pulcini et al. 2010), the research focused on searching for APN competency mapping developments within regulatory agencies to provide a more accurate description of their competencies and practice standards. This search enabled us to establish international comparisons. The documents compiled from 29 countries cover a wide range of heterogeneous APN roles, confirming the extensive dissemination of this role worldwide and the establishment of standards of practice and competency maps as standard procedure in most of the countries where APN roles exist. The implementation of APN roles is not exempted from controversy, which mainly arises from the formal transfer of responsibilities and duties from medical to nursing professionals and the analysis of their impact on health quality and the efficiency of healthcare services. Nevertheless, many countries are turning to this approach to address various healthcare needs (Ter Maten-Speksnijder et al. 2014). Autonomy, recognition and alliance by the rest of the team (Burgess et al. 2011) as well as safety concerns (Villegas & Allen 2012) are important
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priorities and may have more significant implications for the diversity of APN development than the definition of competency frameworks. Currently, the relationship between APN and the specific professional competencies of these roles has not been considered in the leading studies in this area (Delamaire & Lafortune 2010; Schober & Affara 2006). This gap may contribute to the variability and ambiguity in the definitions of roles and responsibilities (Gardner et al. 2013). Other APN competency developments exist, but they are either very generic (Nieminen et al. 2011) or are confined to specific roles or contexts (Lewandowski & Adamle 2009; Sue et al. 2010). Additionally, there is no nursing competency review specifically devoted to the role of advanced practice, as is the case in general nursing (Putra & Petpichetchian 2011; Traynor et al. 2011). Nevertheless, it is worth noting the methodological difficulties in terms of designing competency assessment methods in nursing. These difficulties are derived from the conceptual frailty of many instruments and difficulties in defining competency attributes (Axley 2008; Scott 2008). Moreover, many competencies in health professions are subject to contextual and local determinants that make it difficult to extend them to other contexts of care (Epstein & Hundert 2002). Nonetheless, the existence of common competencies across various countries can help to identify key features that shape the role of advanced practice nurses. Research, leadership or expert clinical judgement seems to be a regular pattern in
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Table 2 APN roles by country Country
America USA
No. of documents reviewed
No. of APN roles described
Roles APN
NP
CNS
NM
NA
x
x
25
6
x
x
x
Canada
16
5
x
x
x
Oceania Australia
5
5
x
x
Papua New Guinea
2
1
x
New Zealand
1
1
x
Europe Austria
1
1
Cyprus
1
1
Denmark
2
2
x
Finland
1
1
x
France
1
1
x
Germany
1
1
x
Ireland
1
2
x
Italy
1
1
x
Netherlands
2
2
Norway
2
2
x
10
3
x
Sweden
5
2
Switzerland
2
2
x
UK
2
4
x
Asia Hong Kong
1
1
Indonesia
1
1
Japan
6
1
Singapore
1
1
South Korea
1
1
x
Thailand
1
1
x
Africa South Africa
1
1
Spain
NC
CMN
Other
x x
x xxx
x x x
x
x
x x x
x
x x x
x
x
x
x x x x
x
APN, advanced practice nursing generic/non-specific role; CMN, case manager nurse; CNS, clinical nurse specialist; NA, nurse anaesthetist; NC, nurse consultant; NM, nurse midwife; NP, nurse practitoner; Other, country-specific and/or highly specialized role.
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•
•
•
•
Research
Clinical and professional
Mentoring and coaching
Collaboration and
•
•
•
•
•
•
•
•
•
•
•
•
Ethical and legal practice
Education and teaching
Quality management and safety
Consulting
Care management
Evidence-based practice
Professional autonomy
Health promotion
Communication
Cultural competencies
Advocacy
Change management
*Pacific Islands.
•
Expert clinical judgement
interprofessional relationships
leadership
USA
Competency dimensions
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
GBR
•
•
•
•
•
•
•
•
•
•
•
•
•
CAN
•
•
•
•
•
•
•
•
•
•
•
•
AUS
•
•
•
•
•
•
•
•
•
NZL
•
•
•
•
•
•
•
•
ESP
•
•
•
•
•
•
•
•
•
INA
•
•
•
•
•
•
•
•
SWE
•
•
•
•
•
•
•
•
SIN
•
•
•
•
•
•
•
•
THA
•
•
•
•
•
•
•
•
RSA
•
•
•
•
•
•
•
NED
•
•
•
•
•
•
•
AUT
•
•
•
•
•
•
•
KOR
•
•
•
•
•
•
•
CHI
Table 3 Common competency domains on an international scale, according to country (IOC codification)
•
•
•
•
•
•
•
FRA
•
•
•
•
•
•
SUI
•
•
•
•
•
•
GER
•
•
•
•
•
•
HKG
•
•
•
•
•
•
CYP
•
•
•
•
•
•
JPN
•
•
•
•
•
IRL
•
•
•
•
•
DEN
•
•
•
•
•
PNG
•
•
•
•
•
FIN
•
•
•
•
•
PAC*
•
•
•
•
TRI
•
•
•
•
ITA
•
•
•
•
NOR
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APNs’ competencies. This fact is consistent with a substantial part of the ICN’s conceptualization of an advanced practice nurse as a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice (International Council of Nurses 2002). Research and knowledge brokering have been reported to be important roles in APN, with marked leadership in promoting evidence-based practice among clinical nurses (Gerrish et al. 2011). International comparisons among the various roles and competencies of APN could be performed by considering these common dimensions. This aim should be pursued by using validated instruments, similar to attempts at a European level with the development of self-assessment instruments for competencies among general nurses (Cowan et al. 2008). Regarding Spain, there is controversy (De Pedro 2006; Hernández 2011) regarding whether the recently developed specialist nurse roles correspond to APN. We identified other advanced practice roles, such as in Andalusia and Catalonia, where development focuses on the fields of home care, hospital care and emergency care. There is also the role of the nurse case manager, which is recognized as APN and has been assessed in some cases (Morales Asencio et al. 2008; Ridao et al. 2011). In the Basque Country, Navarra, Madrid and Galicia, case management roles have also been introduced in various chronic disease management strategies. This development reveals the growth of new advanced practice roles.
Implications for nursing and health policy There is a growing development of APN standards of practice worldwide. Competency mapping is a common practice in the development and implementation of new advanced practice roles. However, there is a lack of consensus with respect to specific competencies. This review identifies the underlying international dimensions of competency and considers competencybased frameworks of APN roles and competency assessment tools that have already been developed. These results can be used by policy developers and researchers to compare APN services in various contexts on a national or international scale and to analyse their association with the outcomes of the services provided.
Study limitations This study has some limitations derived from the difficulty in ensuring maximum thoroughness in the search for grey literature, mainly because of language barriers and the heterogeneity of the regulation frameworks of each country. This issue made it especially difficult to precisely identify APN roles as opposed to other levels of nursing practice.
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Another limiting factor was the difficulty in accessing institutional documents in countries where the literature pointed towards developments in APN but there was a lack of institutional accessibility or reference contacts. Additionally, emerging legislative or training developments for APN roles that had not previously been described were found, but it was not possible to determine the existence of specific documents regarding competency maps or standards of practice. Finally, there are certain inconsistencies regarding the level of specificity of the documents. They vary from general proposals of new APN roles to specific, comprehensive regulatory documents.
Conclusion A main objective of this review was to search for common international trends in APN competency mapping. After considering all the advanced practice competency-related elements (competency models/frameworks, competency maps and competency assessment scales/instruments) that emerged through the review process, it was clear that our attention needed to focus on competency map documents. Based on this approach, frameworks and scales were used as background references to identify common elements. This approach guided us towards the identification of competency clusters (domains). We encountered these clusters as competency organizations in various competency map developments, which were found through the review process of grey literature documents. This review identifies a minimum set of competency domains that can be attributed to APN roles and can act as a benchmark in the implementation process of new APN roles. Additionally, the nursing role can be assessed to compare the level of competency performance to APN standards in non-regulated settings. This review is a key initial step towards the development of an instrument to assess the level of competence of advanced practice nurses independent of the legislative, regulatory and professional context of each country.
Authors contributions Study conception and main design: PS-F, JD-G and JMM-A. Data collection and document analysis: PS-F. Drafting of manuscript: PS-F and JMM-A. Critical revisions for important intellectual content: JMM-A and JD-G. Supervision: JD-G and JMM-A. Statistical expertise: MB-V and PS-G. Technical and material support: MB-V and PS-G.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
APN competency frameworks review
Conflicts of interest No conflict of interest has been declared by the author(s).
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Traynor, V., Inoue, K. & Crookes, P. (2011) Literature review: understanding nursing competence in dementia care. Journal of Clinical Nursing, 20 (13–14), 1948–1960. Villegas, W.J. & Allen, P.E. (2012) Barriers to advanced practice registered nurse scope of practice: issue analysis. Journal of Continuing Education in Nursing, 43 (9), 403–409.
