Deriving consensus on the characteristics of advanced practice nursing: meta-summary of more than 2 decades of research.

Deriving Consensus on the Characteristics of Advanced Practice Nursing Meta-summary of More Than 2 Decades of Research Marie Hutchinson ▼ Leah East ▼ Helen Stasa ▼ Debra Jackson

Background: Over recent decades, there has been considerable research and debate about essential features of advanced nursing practice and differences among various categories of advanced practice nurses. Objectives: This study aimed to derive an integrative description of the defining characteristics of advanced practice nursing through a meta-summary of the existing literature. Methods: A three-phase approach involved (a) systematic review of the literature to identify the specific activities characterized as advanced practice nursing, (b) qualitative meta-summary of practice characteristics extracted from manuscripts meeting inclusion criteria; and (c) statistical analysis of domains across advanced practice categories and country in which the study was completed. A descriptive framework was distilled using qualitative and quantitative results. Results: Fifty manuscripts met inclusion criteria and were retained for analysis. Seven domains of advanced nursing practice were identified: (a) autonomous or nurse-led extended clinical practice; (b) improving systems of care; (c) developing the practice of others; (d) developing/delivering educational programs/activities; (e) nursing research/scholarship; (f) leadership external to the organization; and (g) administering programs, budgets, and personnel. Domains were similar across categories of advanced nursing practice; the domain of developing/delivering educational programs/activities was more common in Australia than in the United States or United Kingdom. Discussion: Similarity at the domain level was sufficient to suggest that advanced practice role categories are less distinct than often argued. There is merit in adopting a more integrated and consistent interpretation of advanced practice nursing. Key Words: advanced practice nursing & clinical nurse specialist & meta-summary & nurse consultant

I

nternationally, a large number of studies have sought to examine the characteristics of advanced practice nursing, which, at the broadest level, refers to nursing practice characterized by use of a population- or setting-specific expert knowledge base, complex decision-making skills, and clinical competencies for expanded practice (Currey, Considine, & Khaw, 2011; Fairley & Closs, 2006; Horrocks, Anderson, & Salisbury, 2002; Humphreys, Johnson, Richardson, Stenhouse, & Watkins, 2007; International Council of Nurses, 2012; Jokiniemi, Pietilä, Kylmä, & Haatainen, 2012; Mantzoukas & Watkinson, 2007; Mullen, Gavin-Daley, Kilgannon, & Swift, 2011). The most

Marie Hutchinson, RN, RM, PhD, is Senior Lecturer, School of Health and Human Science, Southern Cross University, Australia.

Leah East, BN (Hons), PhD, is Senior Lecturer, School of Nursing and Midwifery, Deakin University, Australia. Helen Stasa, BA (Hons), BA (Hons), PhD, is Postdoctoral Research Fellow, Sydney Nursing School, The University of Sydney, Australia. Debra Jackson, PhD, RN, is Professor, Faculty of Nursing, Midwifery and Health, University of Technology Sydney, Australia. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nursingresearchonline.com). DOI: 10.1097/NNR.0000000000000021

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common research method has been workforce surveys employing behavior and task description questionnaires, and in recent decades, many such surveys have been undertaken in various settings (Jokiniemi et al., 2012). However, there are a number of weaknesses associated with this research. Specifically, the studies have tended to be self-report of small samples, focused on role perceptions, and examined advanced practice from the perspective of time spent on tasks (Chiarella, Harford, & Lau, 2008; Peplau, 1991). Although other methods, such as qualitative interviews, self-reflective inquiry, focus groups studies, observations of practice, and case review have also been used, these approaches are much less common (Ball & Cox, 2004; Bousfield, 1997; Bryant-Lukosius et al., 2010; Fenton & Brykczynski, 1993; Kilpatrick et al., 2012). A small body of work examines nurse practitoner roles and activities using validated instrumentation (e.g., Gardner et al., 2010). A major limitation in this body of work has been the lack of agreement about what practice domains and practice activities provide an accurate and meaningful description of advanced practice nursing. In part, this has stemmed from extensive and ongoing international debate that has sought to differentiate the various classifications of advanced practice (Ball & Cox, 2003; Chang et al., 2012). Across this body of work, terms describing advanced practice nursing have March/April 2014 • Volume 62 • No. 3

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been used inconsistently. More precisely, in some instances, different terms are used to refer to the same or similar types of activity. Furthermore, what is taken as a key feature of advanced practice in one study is absent from others (Spross & Hason, 2009). This lack of agreement is problematic and has contributed to a surfeit of measurement instruments designed to investigate advanced practice nursing. It has also created difficulties in measuring the impact and efficacy of advanced practice roles. Despite widespread advocacy of a variety of advanced practice nursing roles, research about impact and utility has been limited by continued debate on definition and differentiation across role types. Variability in how the nature of advanced practice has been defined and measured adds further to this complexity. The considerable variability in measurement means that it is difficult to compare or meaningfully synthesize findings from the large body of studies undertaken, and the proliferation of instruments developed has contributed to a fragmented body of research that potentially serves to hamper the capacity to understand this important aspect of the nursing workforce (Lowe, Plummer, O’Brien, & Boyd, 2012). Moreover, the lack of definitional clarity has meant that attempts at systematic analysis have excluded various advanced practice roles from the analysis and thus provided only a partial account for the nature of advanced practice (Chang et al., 2012; Jokiniemi et al., 2012). Although research findings provide some evidence into the positive impact of these advanced roles on patient and service outcomes, such studies have often failed to give attention to the broader remit of advanced practice nursing roles. Within the context of these limitations, it is difficult to empirically ascertain the contribution of the various advanced practice roles to patient and health system outcomes (Drennan & Goodman, 2011).

Conceptualization of Advanced Nursing Practice The evolution of advanced practice nursing roles has been widespread and occurred for various reasons. These include the desire to create clinical career pathway opportunities; to retain experienced nurses in direct care giving roles, rather than in administration; improve patient outcomes; improve access to care; and modernize heath systems (Drennan & Goodman, 2011; Horrocks et al., 2002; O’Baugh, Wilkes, Varughan, & O’Donohue, 2007). However, the introduction of advanced practice roles and titles has frequently occurred in the absence of consensus and agreement. This has resulted in a bewildering proliferation of titles used to designate advanced practice roles. Across international jurisdictions, nurses practicing at an advanced level are variously titled as advanced practice nurse (APN), advanced nurse practitioner (NP), nurse consultant (NC), consultant nurse (CN), clinical NC (CNC), consultant in nursing, higher level practitioner, NP, clinical nurse specialist (CNS), clinical nurse leader (CNL), certified registered nurse (RN) Nursing Research

anesthetist, nurse therapist, and advanced practitioner. It is not simply the variety of terms used to connote advanced practice that is problematic; the interpretation of function and scope of such roles is also inconsistent. A number of authors have attempted to conceptualize the key differences between the activities of the RN and APN (Gardner, Chang, & Duffield, 2007; Mantzoukas & Watkinson, 2007; Royal College of Nursing Australia, 2006). One way in which advanced practice nursing has been described is as involving an “extended” or “expanded” scope of practice (Gardner et al., 2010). Nonetheless, clearly articulating the nature of “extended” or “expanded” practice remains problematic. For example, the Model Nursing Practice Act describes RN practice as encompassing “the full scope of nursing practice” but asserts that advanced practice RN practice constitutes an “expanded scope” (National Council of State Boards of Nursing, 2010). These two statements are somewhat conflicting, as it is not clear how an advanced role may expand on an already “full” scope. The problem in differentiating between the full scope of RN practice and the expanded scope of the APN is further evident in instruments designed to investigate advanced practice, with many containing a range of activities, which do not specifically measure advanced practice activities (e.g., completes mandatory education, exhibits ongoing professional development, completes documentation, maintains ethical practice, takes a patient history, assesses psychosocial factors, patient and family education, collaborate with others; Ball & Cox, 2004; Chang et al., 2012; Mick & Ackerman, 2000). Furthermore, regulation of advanced practice roles, which also governs the specific standards and code of conduct that holders of such posts are required to comply with, also varies across jurisdictions. For example, in the United States, the National Council of State Boards of Nursing (2010) Model Nursing Practice Act stipulates the regulations governing advanced practice roles. Yet, in Australia and the United Kingdom, where many advanced practice roles are not specifically regulated (with the exception of the role of the NP in Australia), such nonregulated roles remain poorly defined and potentially underutilized or inappropriately deployed (Chang et al., 2012). Much research on advanced practice nursing has focused on four or five general, broadly defined practice categories. These “core pillars” or metacategories of practice are conceptualized as specialist; expert or advanced practice; education, research; leadership and clinical services planning; and support or management (Ackerman, Norsen, Martin, Wiedrich, & Kitzman, 1996; Hunter New England Local Health Network, 2011). The “pillars” were initially informed by the work of Hamric and Spross (1989) and have become commonly used in the literature, workforce planning reports, position statements, competency frameworks, and research examining advanced practice (e.g., Baldwin, Clark, Fulton, & Mayo, 2009; Jokiniemi et al., 2012). However, although much has been www.nursingresearchonline.com


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written as to why these pillars are considered to be characteristics of advanced nursing practice, there has been little validation of the proposed pillars of practice (Kim, Kang, & Kim, 2011). Furthermore, given the time lapse since the inception of these categories, it is feasible that they may no longer reflect contemporary advanced practice (Ball & Cox, 2004). Given the potential for APNs to be utilized more effectively, attention has increasingly turned toward establishing tools to assist with workforce planning and evaluation of the role (Chang et al., 2012; Gardner et al., 2010; Kim et al., 2011). A framework that clearly defines the characteristics of advanced practice nursing is a vital requirement for the full development and effective utilization of the role and for articulating the skills, attributes, and knowledge required to undertake the role competently. In this article, a systematic review of advanced practice activities is reported, and a descriptive framework was derived from a meta-summary of studies. The aim in undertaking this analysis was to capture the breadth of constructs relevant to describing advanced practice nursing and usefully synthesize from the large body of work already undertaken an empirical descriptive framework. In so doing, there was concern to more clearly conceptualize an integrated understanding on this important aspect of nursing practice. The method employed in this analysis extends beyond earlier systematic reviews on this topic and provides a taxonomic understanding of advanced practice domains and role activities (Jokiniemi et al., 2012). In addition, the aim was to compare and contrast the ways in which the practice domains and role activities differ across distinct advanced practice roles, such as those of the CNC, NP, and CNS. The design and conduct of this study builds on the recent work of Jokiniemi et al. (2012), who synthesized and evaluated the literature on one specific advanced practice role (i.e., NC, CNC, and nurse specialist) across three countries, namely the United States, United Kingdom, and Australia. Although there is some overlap in the studies included in Jokiniemi et al. and the current research, this study extends the earlier research by taking a global perspective and focusing on advanced practice roles more generally rather than on only one particular role.

METHODS The study involved three stages. First, the literature was systematically searched, and studies meeting inclusion criteria were assessed for quality. Second, qualitative meta-summary was carried out. Third, statistical analysis comparing domains identified in the meta-summary across advanced practice roles and countries in which studies were carried out was completed.

Stage One: Literature Search and Quality Review Literature Search The first stage consisted of a systematic literature search to identify manuscripts that contained detail on specific characteristics and activities of advanced practice 118


nursing. Given the ambiguity and overlap among nursing roles (NCs, nurse specialists, nurse educators and NPs), the definition of advanced practice nursing adopted in this study was purposefully inclusive. The inclusion criteria for the systematic search of the literature consisted of the following: qualitative studies that reported specific activities and

practice characteristics of advanced practice nursing; quantitative and mixed methods studies reporting suffi-

cient detail to discern activities and characteristics of advanced practice investigated; manuscripts reporting instruments designed to measure activities and practice characteristics of advanced practice nursing; and articles written in English. The following databases were searched for the period July 1986– August 2012: Scopus, CINAHL, Medline, Academic Search, Health Source Nursing/Academic Edition, PsychINFO, PsycARTICLES, and ERIC electronic databases. Abstract and keyword searches were performed using the terms nurs*, consultant, practitioner, specialist, clinical nurse, advanced and measure*, instrument, tool, practice, activity, and role. Figure 1 presents detail on the number of manuscripts identified and screened, the number excluded after review of abstract, the number retained for detailed examination, and the final number of manuscripts included in the review. Manuscripts screened but excluded from the final analysis included those that were opinion pieces, those related to nurse prescribing authorization or workforce characteristics or role implementation without presenting detail on specific activities, or those which detailed patient or health professional satisfaction with advanced practice nursing roles. References for the articles used in the analysis are available (see Supplemental Digital Content 1, http://links.lww.com/NRES/A111). Details about designs and findings for the studies meeting inclusion criteria for use in the review are available (see Table, Supplemental Digital Content 2, http://links.lww.com/NRES/A112).

Quality Review Quality assessment, data extraction, and analysis were undertaken on eligible studies. The following tools were used to guide the quality review process: the JBIMAStari (descriptive studies), the JBI-QARI (qualitative studies), and the MMAT tool (mixed methods studies; Pace et al., 2012; The Joanna Briggs Institute, 2011). On the basis of assessed points, each study reviewed fell into one of three quality categories: low (score < – 5), moderate (score = 6-7), or high (score > – 8). Members of the review team undertook the quality reviews independently, and results were then cross-checked. Member cross-checking of review results was undertaken with a randomly selected sample of 20% of the studies reviewed to verify and ensure consistency of the assessment process. The findings of the quality review (low = 60%, medium = 30%, high = 10%) are available (see Table, Supplemental Digital Content 3, http://links.lww.com/NRES/A113). March/April 2014 • Volume 62 • No. 3


FIGURE 1 Summary of the search process.

Stage 2: Qualitative Meta-summary In the second stage, qualitative meta-summary of the specific practice characteristics of the APN was employed. For this analysis, descriptors of advanced practice measured through survey studies (e.g., items on scales) and narrative descriptions reported in qualitative and mixed methods studies were extracted. A method originally intended to synthesize findings from qualitative studies was applied because all of the extracted data were composed of textual descriptors. The textual descriptors of advanced practice were coded, categorized, and further refined through qualitative meta-summary processes (Sandelowski & Barroso, 2003). This method provided a consolidated interpretation of practice charactericstics and activities of the APN role that created a consensus interpretation from the diverse body of qualitative, quantitative, and mixed methods studies. Heterogeneity of samples, settings, and measures precluded statistical meta-analysis of the consolidated findings.

Data Extraction Initially, descriptive textual data extracted from the retained manuscripts were uploaded as Microsoft Word documents into the qualitative analysis software program NVivo 10 (Brennan, Bosch, Buchan, & Green, 2012; Ream et al., 2009). During the extraction process, each document Nursing Research

was reviewed, and data were extracted by one author (MH) and cross-checked by two other authors (LE or HS) working independently. Inductive content analysis was adopted as the method for data analysis of the textual description of advanced practice. Following Carley (1993), three steps were involved in the data analysis: (a) implementing the coding process, (b) defining categories, and (c) reducing categories through specifying relationships.

Framework Development Methods for developing the descriptive framework were based on standard qualitative data techniques and meta-summary processes. During the coding process, text was organized under inductive codes derived from the text (Krippendorff, 2004; Sandelwoski, 2000). Codes were defined to be mutually exclusive sets of categories from which estimates of the proportion of activities and characteristics in each category could subsequently be identified (Sandelowski & Barroso, 2003). Initially, coding was undertaken by one author (MH), and then, to ensure intercoder agreement on the analysis (Taylor & Trujillo, 2001), the coding was independently reviewed and any interpretive differences reconciled between the coauthors (MH, LE, HS). The process of analyzing patterns and relationships between the coded www.nursingresearchonline.com


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Subcategory

Work tasks

• Designs/leads nursing research

• Engages in research

and multidisciplinary team

• Delivers education to the nursing

postgraduate education

Delivers undergraduate and

• Provides in-service/continuing education

develops programs/resources

• Identifies learning needs and

• Develops policies/guidelines • Audits clinical practice/service standards

• Establishes practice standards/ monitors clinician performance

• Develops new services/programs

• Engages in strategic planning

• Challenges current practice

• Works to improve systems of care

• Conducts clinical audits/evaluates clinical services

minimize risk

events- and substandard care • Provides directive advice to avert error or

• Identifies other clinician errors, untoward

optimize care pathways and delivery of care

• Liaises between medical and nursing staff to

pathways and delivery of care

• Links across services to integrate care

• Delivers nurse-led clinics

• Admits and discharges patients

• Undertakes case management and care coordination

practice/systems • Leads change/practice improvement

• Audit/evaluation to improve

promote patient safety

• Identifies risk and intervenes to

service and discipline boundaries

• Optimizes care by working across

• Develops and evaluates plans of care

• Makes and receives referrals

• Undertakes comprehensive patient assessment

• Performs advanced care interventions

• Makes differential diagnosis

• Advanced direct care interventions • Provides complex or advanced thera- • Requests diagnostic procedures • Oversights care plans and optimizes • Prescribes and manages medication and iv therapy peutic interventions care • Undertakes nurse-led case management • Informs, educates, and supports families

Category

Improving systems of care • Leads quality assurance programs

Nursing research/scholarship

and activities

educational programs

Develop and deliver

extended clinical practice

Autonomous or nurse-led

Domain

TABLE 1. Coding Tree Depicting Domains of Practice, Categories and Subcategories, and Related Work Tasks

support

• Works alongside others to role model/provide

• Expert consultancy, ward rounds, and outreach

• Preceptors/mentors nursing/medical staff

• Expert guidance and advice

• Implements evidence/disseminates knowledge • Provides expert guidance/advice for

• Advises on evidence-based practice and equipment

• Supports generalist nurses with specialist knowledge • Engages in active knowledge translation

Work tasks

Stage 3: Statistical Analysis

Nursing Research

• Administers budgets/program staff

activities

The third stage of the analysis involved statistical analysis. To further explore domains across categories of advanced nursing practice, the coded data set was exported to Statistical Package for the Social Sciences (SPSS V20). For each case (study retained from the review), the presence or absence of the practice domains, categories, and tasks was coded on the datasheet, along with details on the country of origin, year, and category of APN examined. The category of APN utilized was the role title employed by the primary authors. To facilitate analysis, studies examining various similarly titled roles were condensed into the categories: consultant, specialist, and practitioner. For example, the categories of CNC, CN, NC, and CN midwife were collapsed into the category “consultant.” Frequency effect sizes (Onwuegbuzie, 2003; Sandelowski, Barroso, & Voils, 2007) were calculated to provide information about the relative occurrence of each domain. Frequency effect size for each domain was calculated by dividing the number of studies coded to a domain by the total number of studies. Kruskal–Wallis one-way analysis of variance was performed to compare domains across advanced nursing practice categories and countries in which studies were carried out. This test was suited to the data, as examination of plots for the outcome variables indicated that the majority had nonnormal distribution.

RESULTS Domains personnel

• Engages in recruitment/retention Administers programs, budgets,

• Engages in external leadership

other clinicians

• Develops high-level partnerships Leadership external to the organization

of others

Developing the practice

Subcategory Category Domain

TABLE 1. Coding Tree Depicting Domains of Practice, Categories and Subcategories, and Related Work Tasks, Continued

data involved an ongoing cycle of refining the analysis by identifying sets of codes that were related to each other or by reviewing coding in light of new insights emerging (Denzin & Lincoln, 2003). At each step of the emerging coding process, the coauthors commented on and challenged the emerging analysis. To ensure dependability and confirmability in the coding process, an auditable decision trail was maintained (Koch, 1996). Through this iterative process of cycles of coding and review, the codes were eventually collapsed as construct definitions became more refined allowing for the identification of practice domains and their constituent major categories, subcategories, and tasks. Table 1 summarizes the final coding scheme.

The analysis revealed seven distinct domains of advanced practice and one domain that related to “standard” RN practice. The standard RN practice domain contained activities such as documents in a reportable manner, participates in professional development, attends meetings, provides reports to managers, works as a member of a team, and provides physical comfort measures. As this domain was not specific to advanced practice, it was deemed redundant and excluded from the final analysis. The seven domains of advanced practice are composed of 19 categories of practice activity, their www.nursingresearchonline.com


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constituent subcategories, and related tasks. Frequency of effect size calculations (see Table 2) showed that each of the practice domains had a size above the minimum .15 cutoff suggested by Sandelowski and Barosso (2003). In the framework, first-order constructs were taken as practice domains represented across more than 50% of the studies. These were (a) autonomous or nurse-led extended clinical practice, (b) developing the practice of others, (c) improving systems of care, (d) developing and delivering educational programs and activities, and (e) nursing research and scholarship.

TABLE 2. Final Practice Domains, Frequency Effect Size, and Major Categories of Activity Domain and related categories of activity Autonomous or nurse-led extended clinical practice

Frequency effect size .82

Advanced direct care interventions Oversighting care plans and optimizing care Developing the practice of others

.62

Expert guidance and advice for other clinicians Engaging in active knowledge translation Improving systems of care

.62

Leading quality assurance projects

Framework Summative detail on the domains and major categories of practice activity in the final framework is presented in Table 3. Information about the characteristics of each domain of practice identified in the framework is summarized below.

Autonomous or Nurse-led Extended Clinical Practice This domain of practice was constituted by two major categories: provides advanced direct care interventions and oversights care plans and optimizing care. The category “advanced direct care interventions” incorporated a range of practice activities. These were titled as follows: undertakes comprehensive patient assessment, makes a differential diagnosis, undertakes nurse-led case management, and provides complex or advanced therapeutic interventions. The category “oversights care plans and optimizing care” was constituted by two subcategories of activity. The first was labeled “optimizes care by working across service and discipline boundaries” and was characterized by linking, liaison, and communication across disciplines, services, and organizational boundaries to optimize care delivery. Complementing this subcategory was another entitled “identify risk and intervene to promote safety.” This subcategory was characterized by APNs’ identifying errors and untoward events; intervening in the event of problems; and providing directive advice to avert error, substandard care, or mitigate risk.

Leading change and practice development

Developing the Practice of Others This domain was con-

Establishing practice standards, monitoring clinician performance Engaging in strategic planning Audit and evaluation to improve practice and systems Developing and delivering educational programs and activities

.60

Deliver undergraduate and postgraduate education Deliver in-service and continuing education Identify learning needs and develop programs & resources Deliver education to the multidisciplinary team Nursing research and scholarship

.54

Design and lead nursing research Engages in research Leadership external to the organization

Improving Systems of Care This domain of practice was .24

Develops high-level partnerships Engages in external leadership Administering programs, budgets, and personnel Administer budgets Engage in recruitment, retention, and staff satisfaction activities

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stituted by two categories of practice activity: provides expert guidance and advice for other clinicians and engages in active knowledge translation. “Expert guidance and advice” incorporated four forms of work task, which involved working alongside other clinicians to role model practice and provide support, consultancy ward rounds and outreach, preceptoring and mentoring nursing and medical students, and providing expert advice to nurses and the multidisciplinary team. “Active knowledge translation” involved tasks that facilitated implementation of evidence-based practice, dissemination of knowledge, developing and disseminating resources, and providing expert opinion and strategies that supported generalist nurses with specialist knowledge.

.18

constituted by five categories of practice activity: leads quality assurance programs; leads change and practice improvement; establishes practice standards and monitors clinician performance, audit, and evaluation to improve systems and standards; and engages in strategic planning. “Leading change and practice improvement” incorporated three forms of work task, which involved working to improve systems of care, developing new services or programs, and challenging current practice. “Establishing standards and monitoring outcomes” incorporated two March/April 2014 • Volume 62 • No. 3


forms of activity characterized by developing policies and guidelines and undertaking applied audit and service evaluation.

Developing and Delivering Educational Programs This domain of practice was constituted by four subcategories: delivers undergraduate and postgraduate education, identifies learning and development needs, provides in service and continuing education, and provides education to the multidisciplinary team. Nursing Research and Scholarship This domain of practice was constituted by two subcategories: design and lead research and engages in research. Domains not Included Two practice domains did not meet the threshold for inclusion as first-order constructs, these were “leadership external to the organization” (represented in 26% of studies) and “administering programs budgets and personnel” (represented in 19% of studies). “Leadership external to the organization” was composed of two subcategories: develops high level partnerships and engages in leadership external to the organization; “administering programs budgets and personnel” had one category: recruitment, retention, and satisfaction activities. APN Categories and Domain Frequencies Examining the frequency of the advanced practice domains according to the category of APNs in the primary studies revealed considerable consistency across the studies. As noted in Table 3, autonomous or nurse-led extended clinical practice resonated similarly across consultant, specialist, and practitioner advanced practice roles. On the other hand, specialist nursing practice was more frequently reported to include activities associated with improving systems of care,

developing others, and developing and delivering education. In contrast, studies examining practitioners were less likely to report a focus on improving systems of care and developing others. Furthermore, 64% of studies identified that nursing research was a characteristic of consultant practice compared with 50% that identified this activity as a feature of practitioner practice. Similarly, administering programs, budgets, and personnel and leadership external to the organization were less commonly reported characteristics of practitioner practice. Kruskal–Wallis one-way analysis of variance was performed to further examine differences in practice characteristics across APN categories. Analysis at the level of domains of practice indicated that there was no statistically significant variance between consultant, specialist, and practitioner role categories and the various domains of APN practice (Table 4). Analysis according to country of study showed that most domains were similar (Table 5); the domain developing and delivering educational programs and activities was statistically different with higher frequency in Australia than in the United States or United Kingdom.

DISCUSSION By systematically distilling the framework presented in this study, this analysis has confirmed that the differences between the various APN roles are less distinct than often postulated. In distilling the framework, attention is also focused on features of advanced practice nursing that are not well articulated in models and descriptions of practice. At a broad level, there are clearly commonalities underlying the various advanced practice roles. However, it was found that working to improve systems of care and developing others in their practice tend to characterize the practice of specialists. Of note, at the broad level, improving systems of care was notably less commonly reported as a characteristic of practitioner

TABLE 3. Practice Domains Frequencies (as Per Cents) by Advanced Practice Nurse Categories APN category Consultant (n = 14)

Specialist (n = 10)

Practitioner (n = 12)

Mixed (n = 14)

Autonomous/nurse-led extended clinical practice

93

90

83

50

Improving systems of care

76

80

33

36

Developing the practice of others

76

80

42

36

Developing/delivering educational

57

80

58

50

Nursing research and scholarship

64

70

50

21

Administering programs, budgets,

26

20

8

14

0

0

0

7

Domain

programs/activities

and personnel Leadership external to the organization

Nursing Research



123

practice. Conversely, specialist and consultant practice tends to be distinguished by autonomous or nurse-led practice and leading and engaging in nursing research. These findings resonate with previous descriptions of these advance practice roles (Dowling, Beauchesne, Farrelly, & Murphy, 2013; Kilpatrick et al., 2012; Lowe et al., 2012). At a broad level, it is possible that these differences may reflect concern with professional boundaries and jurisdictions. For instance, practitioners setting out and defining a practice territory that was differentiated from other forms of advanced

practice and from that of physicians may have led to less of a focus on developing systems of care and supporting others in their practice. On the other hand, differences in the focus of consultant and specialist role enactment may reflect health services concern for the more system-focused characteristics of efficiency and accountability. Of note, there was no statistically significant difference between consultant, specialist, and practitioner practice characteristics across the domains of advanced practice. These findings add more weight to previous studies that have reported

TABLE 4. Kruskal–Wallis One-way Analysis of Variance: Domains of Practice by Advanced Practice Nurse Categories Domain Autonomous or nurse-led extended clinical practice



Developing/delivering educational programs/activities

Nursing research/scholarship

Leadership external to the organization

Administering programs, budgets, and personnel

APN category

n

Mean rank

w2

p

Consultant

14

25.88

1.4

.71

Specialist

10

24.55

Practitioner

12

25.77

Mixed APN

14

25.56

Consultant

14

22.14

4.2

.24

Specialist

10

25.00

Practitioner

12

31.67

Mixed APN

14

29.93

Consultant

14

23.93

1.0

.80

Specialist

10

27.50

Practitioner

12

27.50

Mixed APN

14

23.93

Consultant

14

28.00

2.2

.53

Specialist

10

28.00

Practitioner

12

21.75

Mixed APN

14

24.43

Consultant

14

23.71

.56

.91

Specialist

10

25.50

Practitioner

12

25.50

Mixed APN

14

27.29

Consultant

14

21.50

3.8

.28

Specialist

10

29.55

Practitioner

12

27.92

Mixed APN

14

24.54

Consultant

14

26.43

1.2

.75

Specialist

10

22.50

Practitioner

12

25.83

Mixed APN

14

26.43

Note. N = 50. The df for all tests is 3. APN = advanced practice nurse.

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TABLE 5. Kruskal Wallis One-way Analysis of Variance: Advanced Practice Nurse Domains by Country Domain

Country

n

Mean rank

w2

p

Autonomous/nurse-led extended clinical practice

Australia

15

22.13

3.13

.21

United States

13

28.04

United Kingdom

19

22.71

Australia

15

25.47

1.01

.60

United States

13

25.35

United Kingdom

19

21.92

Australia

15

28.60

3.89

.14

United States

13

23.54

United Kingdom

19

20.68

Australia

15

28.43

6.29

.04

United States

13

27.19

United Kingdom

19

18.32

Australia

15

23.70

3.57

.17

United States

13

28.85

United Kingdom

19

20.92

Australia

15

22.83

.97

.62

United States

13

26.46

United Kingdom

19

23.24

Australia

15

25.37

1.55

.46

United States

13

21.27

United Kingdom

19

24.79



Developing/delivering educational programs/activities

Nursing research and scholarship

Leadership external to the organization

Administering programs, budgets, and personnel

Note. N = 47. The df for each test is 2. APN = advanced practice nurse.

similarities in role function across the various advanced practice nursing roles (Wiilams & Valdivieso, 1994) and resonate with calls for a consolidation of advanced practice roles, rather than continued distinction and differentiation (Lowe et al., 2012). The practice characteristic of developing and delivering educational programs and activities was the only feature of APN practice that varied by country in which the study was conducted. Given that little statistical difference was identified in the various categories of practice when employing a systematically distilled description of practice, it is feasible that differences in role characteristics commonly reported are a feature of measurement and definition rather than substantive difference. Clearly, additional research is needed to establish whether this absence of difference is born out in comparative studies of practice patterns across the major categories of APN. The findings of this review resonate with those of the earlier review published by Jokiniemi et al. (2012), which examined the APN role by reviewing literature on the nature Nursing Research

of the NC in the United Kingdom, the CNS in the United States, and the CNC in Australia. Noteable design differences between the Jokiniemi et al. study and the current review include the inclusion of NPs in the current study, no country limitations in the search criteria, and the extension of the search period by 5 years. Although there are differences in the method and literature reviewed between this earlier study and the current review, both studies confirmed that the domains of extended clinical practice, developing the practice of others, and practice or systems improvement are leading characteristics of the APN role. The finer grained coding performed in the current review resulted in a more detailed interpretation of the adminstrative function of the APN and also brought to light different aspects of the extended practice and consultant functions of the APN role. An additional difference between the studies was that the focus of Jokinieni et al. went beyond the domains of practice to include issues such as prerequisites for the advanced www.nursingresearchonline.com


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roles and challenges affecting the role and role outcomes— these articles were excluded from the current review. By assessing all categories of APNs over a span of 26 years and using intentionally broad inclusion criteria in a larger set of databases, the current study utilized a largely distinct pool of literature, with only a 20% overlap in manuscripts retained between the current and earlier study by Jokiniemi et al. Of note, differences in the pool of literature identified between the two studies appear to have been influenced by search criteria and the databases serarched. Future research on this topic warrants careful consideration of variation in APN nomenclature and scoping of reviews, as the inclusion of “advanced practice” in the search terms of the current study appears to have identified additional studies compared with those identified by Jokiniemi et al. Through distilling the various domains and characteristics of advanced practice, the framework developed draws attention to an important aspect of advanced practice that has received little substantive empirical attention—the “boundary spanning” and risk mitigation functions of APNs. This characteristic of advanced practice functions optimize care delivery and promote safety through directive intervention in plans of care or remedying missed, inappropriate, or substandard care. The various activities specified in the framework for this characteristic of practice focus on activities that involve working across teams, disciplines, services, and organizations to optimize care and avert risk. Although functions such as consultancy, linking, and liaison have been recognized as advanced practice functions (Chang et al., 2012), the meta-summary undertaken in this study has refined a richer understanding. Furthermore, the capacity of APNs to build knowledge capital within clinical teams through role modeling (to both nurses and other members of the healthcare team), joint case management, facilitating knowledge uptake through working collaboratively with clinicians to identify and address shortfalls in care, and facilitating change to reduce or prevent clinical problems are aspects of the advanced practice role that require further detailed investigation. The framework presented here extends the conceptualization of advanced practice to more clearly identify the risk mitigation and directive interventions undertaken by APNs. In the wake of concerns in the British National Health Service about standards of care (Francis, 2010) and similar inquiries in other countries (Davies, 2005; Dawkins, 2011; Garling, 2008), consideration must be given to the important contributions of APNs in mitigating risk and promoting care quality. Identification of mitigating risk and promoting care quality as a characteristic of advanced practice nursing warrants further consideration from health administrators and nurse managers to ensure maximum utility is derived from this important domain. Of note, it is suggested that consideration should be given to establish the benefits derived from embedding APNs within nursing and healthcare teams in addition to outpatient, 126


nurse-led clinics and physician substitution models of advanced practice nursing. This feature of advanced practice nursing extends beyond physician comparability and is an important distinction that warrants further examination. Cost and workforce pressures may drive future utilization of APN roles toward physician substitution (Newhouse et al., 2012), and this may be at the loss of these other functions identified in our framework if this feature of advanced practice is not clearly articulated and the benefits assessed. One of the implications of this study is that the question must be raised as to whether the current four or five “pillars” of advanced practice reflect the contemporary enactment of the role. As shown, the synthesized research evidence suggests that the “domains” of advanced practice nursing do not neatly correspond to this “traditional” taxonomy and that adopting a pillars approach as a means of characterizing advanced practice nursing roles may mean that important aspects of advanced practice are missed (such as the role of APNs as “boundary spanners” with the capacity to oversight care). According to this study, it is believed that these understudied aspects of advanced practice represent great opportunities for future research.

Limitations One limitation of this analysis is that many of the studies reviewed used small sample and cross-sectional self-report or self-reflection methodologies. A number of the studies were of low quality and employed instruments that did not have established validity and reliability. A number of the qualitative studies reported particular aspects of practice with only a small amount of relevant data reported, rather than descriptions of the broader remit or scope of practice. Furthermore, the comparative analysis of the various advanced practice roles may be potentially confounded by the variation in definition of APN roles across jurisdictions and the number of mixed role studies included in the analysis.

CONCLUSIONS There has been extensive and continued debate on the nature of advanced practice nursing, with repeated attempts to differentiate the unique nature of the various roles. The meta-summary presented here has distilled from the international literature a consensus interpretation on the characteristics of advanced clinical practice. The findings suggest that there may be more similarity than difference in the way the various roles have been described. In the future, greater utility may be derived from focusing on the outcomes of advanced practice nursing roles rather than a continued debate on distinction, definition, and differentiation between the various categories. Moreover, discussion might usefully move toward a more unified articulation and greater utility of advanced practice nursing. The detailed coding and analysis March/April 2014 • Volume 62 • No. 3


undertaken in this study provides a framework from which a more comprehensive tool can be developed to further investigate these features of advanced practice.

Accepted for publication November 11, 2013. The authors have no conflicts of interest to report.

Tizard Learning Disability Review, 16, 26-28. doi:10.1108/ 13595471111185738 Denzin, N. K., & Lincoln, Y. S. (2003). Collecting and interpreting qualitative materials. Thousand Oaks, CA: Sage. Dowling, M., Beauchesne, M., Farrelly, F., & Murphy, K. (2013). Advanced practice nursing: A concept analysis. International Journal of Nursing Practice, 19, 131-140. doi:10.1111/ijn.12050

Corresponding author: Marie Hutchinson, RN, RM, PhD, School of Health and Human Science, Southern Cross University, P.O. Box 157, Lismore, NSW, Australia (e-mail: [email protected]).

Drennan, V. M., & Goodman, C. (2011). Sustaining innovation in the health care workforce: A case study of community nurse consultant posts in England. BMC Health Service Research, 11, 200. doi:10.1186/1472-6963-11-200

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REGISTER YOUR SYSTEMATIC REVIEW OR META-ANALYSIS Prospective registration of systematic reviews and meta-analysis reports is recommended. The recommendation does not apply to integrative Biology Reviews. Registration sites for systematic review and meta-analysis are: PROSPERO www.crd.york.ac.uk/prospero Cochrane Collaboration http://www.cochrane.org/cochrane-reviews/registering-titles Include the registry and trial number in the letter to the editor uploaded with your original submission. For questions, please contact Susan J. Henly, Editor, [email protected]

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Coffee Adulteration: More than Two Decades of Research.

Advanced practice nursing in child maltreatment: practice characteristics.

Advanced nursing practice and research contributions to precision medicine.

Characteristics of nursing practice models.

Advanced practice in nursing.

The influence of culture on nursing practice and research.

Research in nursing practice.

Overview of nursing research and relevance to school nursing practice.

Action research: changing nursing practice.

Embracing research in nursing practice.

The application of qualitative research findings to oncology nursing practice.

Advanced practice nursing: shaping health through policy.

Reprint of: From the 90׳s to now: A brief historical perspective on more than two decades of estrogen neuroprotection.

Predictors and Characteristics of Multiple (More Than 2) Catheter Ablation Procedures for Atrial Fibrillation.

Epididymal research: more warp than weft?

The advance practice exam: understanding the 7 domains of advanced practice nursing.

Using advanced mobile devices in nursing practice--the views of nurses and nursing students.

From the 90's to now: A brief historical perspective on more than two decades of estrogen neuroprotection.

Narrative in nursing practice, education and research.

Clinical research: translation into nursing practice.

Translating research findings to clinical nursing practice.

More than genes: the advanced fetal programming hypothesis.

Adult neuroplasticity: more than 40 years of research.

Adult cardiothoracic transplant nursing: an ISHLT consensus document on the current adult nursing practice in heart and lung transplantation.