Conceptualizations of Advanced Practice Nursing

In 2004, an APRN Consensus Conference was convened to achieve consensus regarding the credentialing of APRNs (APRN Joint Dialogue Group, 2008; Stanley et al., 2009) and the development of a regulatory model for advanced practice nursing. Independently, the APRN Advisory Committee for the National Council of State Boards of Nursing (NCSBN) was charged by the NCSBN Board of Directors with a similar task of creating a future model for APRN regulation and, in 2006, disseminated a draft of the APRN Vision Paper (NCSBN, 2006), a document that generated debate and controversy. Within a year, these groups came together to form the APRN Joint Dialogue Group, with representation from numerous stakeholder groups, and the outcome was the APRN Consensus Model (APRN Joint Dialogue Group, 2008).

The APRN Consensus Model includes important definitions of roles, titles, and population foci. Furthermore, it defines specialties and describes how to make room for the emergence of new APRN roles and population foci within the regulatory framework. A timeline for adoption and strategies for implementation were put forth, and progress has been made in these areas (see Chapter 20 for further information; only the model is discussed here). Fig. 2.1 depicts the components of the APRN Consensus Model, the four recognized APRN roles and six population foci. The term advanced practice registered nurse refers to all four APRN roles. An APRN is defined as a nurse who meets the following criteria (APRN Joint Dialogue Group, 2008):

• ■ Completes an accredited graduate-level education program preparing them for one of the four recognized APRN roles and a population focus (see discussion in Chapter 3)
• ■ Passes a national certification examination that measures APRN role and population-focused competencies and maintains continued competence by national recertification in the role and population focus
• ■ Possesses advanced clinical knowledge and skills preparing them to provide direct care to patients; the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals
• ■ Builds on the competencies of RNs by demonstrating greater depth and breadth of knowledge and greater synthesis of data by performing more complex skills and interventions and by possessing greater role autonomy
• ■ Is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance, as well as the assessment, diagnosis, and management of patient problems, including the use and prescription of pharmacologic and nonpharmacologic interventions
• ■ Has sufficient depth and breadth of clinical experience to reflect the intended license
• ■ Obtains a license to practice as an APRN in one of the four APRN roles

Graduate education for the four APRN roles is described in the Consensus Model document (APRN Joint Dialogue Group, 2008). It must include completion of at least three separate, comprehensive graduate courses in advanced physiology and pathophysiology, physical health assessment, and advanced pharmacology (the “three Ps”), consistent with requirements for the accreditation of APRN education programs. In addition, curricula must address three other areas—the principles of decision making for the particular APRN role, preparation in the core competencies identified for the role, and role preparation in one of the six population foci.

The Consensus Model asserts that licensure must be based on educational preparation for one of the four existing APRN roles and a population focus, that certification must be within the same area of study, and that the four separate processes of LACE are necessary for the adequate regulation of APRNs (APRN Joint Dialogue Group, 2008; see Chapter 20). The six population foci displayed in Fig. 2.1 include the individual and family across the life span as well as adult/gerontologic, neonatal, pediatric, women’s health/gender-specific, and psychiatric/mental health populations. Preparation in a specialty, such as oncology or critical care, cannot be the basis for licensure. Specialization

indicates that an APRN has additional knowledge and expertise in a more discrete area of specialty practice. Competency in the specialty area could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (e.g., portfolios, examinations).

(APRN Joint Dialogue Group, 2008, p. 12)

This was a critical decision for the group to reach, given the numbers of specialties and APRN specialty examinations in place when the document was prepared.

Even with this brief overview of the APRN Consensus Model, one sees how this model advanced the conceptualization of advanced practice nursing. It is helpful for many reasons. First, for the United States, it affirms that there are four APRN roles. Second, it is advancing a uniform approach to LACE and advanced practice nursing that has practical and policymaking effects, including better alignment between and among APRN curricula and certification examinations. Furthermore, it addresses the issue of differentiating between RNs and APRNs and has been foundational to differentiate among nursing roles. By addressing the issue of specialization, the model offers a reasoned approach for the following: (1) avoiding confusion from a proliferation of specialty certification examinations; (2) ensuring that, because of a limited and parsimonious focus (four roles and six populations), there will be sufficient numbers of APRNs for the relevant examinations to ensure psychometrically valid data on test results; and (3) allowing for the development of new APRN roles or foci to meet society’s needs.

Although there are a number of noted strengths of the Consensus Model, there are also limitations. First, competencies that are common across APRN roles are not addressed beyond defining an APRN and indicating that students must be prepared “with the core competencies for one of the four APRN roles across at least one of the six population foci” (APRN Joint Dialogue Group, 2008, p. 10). The model leaves it to the different APRN roles to develop their own core competencies.

In addressing specialization, the model also leaves open the issue of the importance of educational preparation, in addition to experience, for advanced practice in a specialty, which is of particular importance to the CNS role. Additionally, Martsolf and colleagues (2020) recently raised concerns regarding the misalignment between specialty NP education, certification, and practice location and called for an evaluation of the policy and practice implications of the Consensus Model, along with an examination of the scope and scale of NP misalignment within healthcare systems.

Two years after the 2004 APRN consensus conference, the American Association of Colleges of Nursing (AACN, 2006) put forth “The Essentials of Doctoral Education for Advanced Nursing Practice.” The Essentials established the DNP, the highest practice degree and the preferred preparation for specialty nursing practice. The AACN called for doctorate-level preparation of APRNs by the year 2015. DNP preparation for entry to practice has been endorsed by the Council on Accreditation of Nurse Anesthesia Educational Programs (2019), the National Association of Clinical Nurse Specialists (NACNS, 2015), and the National Organization of Nurse Practitioner Faculties (NONPF, 2015). However, the American College of Nurse-Midwives (ACNM, 2019) has not endorsed the DNP as a requirement for entry into practice for CNMs, instead supporting the completion of a graduate degree program requirement for certification and entry into clinical practice.

Although experience in an area is certainly a factor that leads to the emergence of new specialties, experience alone may be insufficient for the APRN who specializes in oncology or critical care (or another specialty) to achieve desired outcomes in timely and cost-effective ways. These are specialties in which the population’s needs are many and complex and the scope of research knowledge is similarly broad and deep. These are important areas of conceptualization that need to be addressed by the American Nurses Association (ANA) and specialty professional nursing organizations, rather than by a group with a regulatory focus.

Numerous efforts are under way to implement this model in the United States. The NCSBN has an extensive toolkit to help educators, APRNs, and policymakers implement the APRN regulatory model (NCSBN, 2015). The work undertaken to produce the APRN Consensus Model (APRN Joint Dialogue Group, 2008) illustrates the power of interorganizational collaboration and is a promising example of how a model can, as Fawcett and Desanto-Madeya (2013) have suggested, reduce conflict and facilitate communication within the profession, across professions, and with the public.

American Nurses Association

As the only full-service professional organization representing the interests of the 4 million RNs in the United States through its constituent and state nurses associations and its organizational affiliates, the ANA and its constituent organizations have also been active in developing documents that address advanced practice nursing. Two of these are particularly important for the contemporary conceptualizations of advanced practice nursing. Since 1980, the ANA has periodically updated its Social Policy Statement (ANA, 2010). Specialization has consistently been identified as a concept that differentiates advanced practice nursing from basic nursing practice. The most recent edition of the policy notes that specialization (“focusing on nursing practice in a specific area, identified from within the whole field of professional nursing”; ANA, 2010, p. 17) can occur at basic or advanced levels and that APRNs use additional specialized knowledge and skills obtained through graduate education in their practices. According to this statement, advanced nursing practice “builds on the competencies of the registered nurse and is characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education” (ANA, 2010, p. 18). In this document, APRNs are defined as RNs who hold master’s or doctoral degrees and are licensed, certified, and/or approved to practice in their roles by state boards of nursing or regulatory oversight bodies. APRNs are prepared through graduate education in nursing for one of four APRN roles (NPs, CRNAs, NMs, CNSs) and at least one of six population foci (family/individual across the life span, adult/gerontology, neonatal, pediatrics, women’s health/gender-related health, psychiatric/mental health; ANA, 2010). These definitions of specialization and advanced practice are consistent with the APRN Consensus Model.

The ANA also establishes and promulgates standards of practice and competencies for RNs and APRNs. Six standards of practice and 12 standards of professional performance are described in the fourth edition of Nursing: Scope and Standards of Practice (ANA, 2021). Each standard is associated with competencies. Of the 18 total standards, all outline additional competencies for APRNs compared with RNs. For example, Standard 5, “Implementation,” addresses the consultation and prescribing responsibilities of APRNs and Standard 12, “Leadership,” addresses the competency that APRNs will model expert nursing practice to members of interprofessional teams and to consumers of health care. It is in the description of the competencies that APRN practice and the practice of nurses prepared in a specialty at the graduate level are differentiated from RN practice.

In addition to these documents, the ANA, together with the American Board of Nursing Specialties (ABNS), convened a task force on clinical nurse specialist competencies. For many reasons, including the recognition that developing psychometrically sound certifications for numerous specialties, especially for CNSs, would be difficult as the profession moved toward implementing the APRN Consensus Model, the ANA and ABNS convened a group of stakeholders in 2006 to develop and validate a set of core competencies that would be expected of CNSs entering practice, regardless of specialty (NACNS/National CNS Core Competency Task Force, 2010). This work and recent updates are discussed later in this chapter in the section on the NACNS.

American Association of Colleges of Nursing

Over the last 2 decades, the AACN has undertaken two nursing education initiatives aimed at transforming nursing education. In 2006 the AACN called for APRN preparation to be at the doctoral level in practice-based programs (DNP), with master’s-level education being refocused on generalist preparation (e.g., clinical nurse leaders, staff, and clinical educators). Clinical nurse leaders are not APRNs (AACN, 2021a) and therefore are not included in this discussion of conceptualizations. Through these initiatives, and to the extent that the AACN and Commission on Collegiate Nursing Education influence accreditation, the DNP is becoming the preferred degree for most APRNs. The growth of DNP education has advanced considerably. In 2006 there were 20 DNP programs; most recently in 2019 there were 348 DNP programs (AACN, 2019). Enrollments in and graduation from DNP programs have also risen substantially (AACN, 2019).

The DNP Essentials (AACN, 2006) were composed of eight competencies for DNP graduates. For APRNs, “Essential VIII specified the foundational practice competencies that cut across specialties and are seen as requisite for DNP practice” (AACN, 2006, p. 16). Recognizing that DNP programs also prepare nurses for non-APRN roles, the AACN acknowledged that organizations representing APRNs were expected to develop Essential VIII as it related to specific advanced practice roles and to “develop competency expectations that build upon and complement DNP Essentials 1 through 8” (AACN, 2006, p. 17). These Essentials affirmed that the advanced practice nursing core includes the “three Ps” (three separate courses)—advanced health/physical assessment, advanced physiology/pathophysiology, and advanced pharmacology—and is specific to APRNs. The specialty core must include content and clinical practice experiences that help students acquire the knowledge and skills essential to a specific advanced practice role. These requirements were reconfirmed in the Consensus Model (APRN Joint Dialogue Group, 2008).

The DNP has been described as both a “disruptive innovation” (Hathaway et al., 2006) and a natural evolution for NP practice. The DNP has been endorsed as entry for APRN practice by three of the four professional association/organizations representing APRNs, with the exception of the ACNM (2019). As a result of national DNP discussions, APRN organizations have promulgated practice competencies that address doctorally prepared APRNs (e.g., ACNM, 2011b; NACNS, 2019). The NONPF (2012) now has one set of core competencies for NPs and developed population-based competencies for nurse practitioners (NONPF, 2013). Organizational positions on doctoral education are briefly explored in the discussion of APRN organizations later in this chapter.

Although not a conceptual model per se, the AACN’s publication The Essentials: Core Competencies for Professional Nursing Education (2021b) represents a new approach to nursing education designed to provide consistency in graduate outcome. This framework conceptualizes the discipline of nursing via five key concepts: human wholeness, health, healing and well-being, environment–health relationship, and caring. It includes level 2 advanced-level nursing education subcompetencies designed to prepare nurses for advanced nursing practice specialty or advanced nursing practice roles, with specialty competencies designed to complement and build on level 2 competencies. These advanced-level nursing competencies are conceptualized to affirm a set of common competencies across APRN roles and are an important contribution to conceptual clarity about APRN practice in the United States. The Essentials provide guidance that DNP graduates attain and integrate level 2 competencies and subcompetencies for at least one APRN specialty or advanced nursing practice role and complete a scholarly project/project that the faculty will evaluate (AACN, 2021b). A discussion of APRN organizations’ conceptualization of APRN practice follows, along with a discussion of the extent to which their responses to the DNP influence conceptual clarity on advanced practice nursing.

National Organization of Nurse Practitioner Faculties

The mission of the NONPF is to provide leadership in promoting quality NP education. Since 1990 the NONPF has fulfilled this mission in many ways, including the development, validation, and promulgation of NP competencies. As of 2012, there is only one set of NP core competencies (NONPF, 2012), along with recently added population-focused NP competencies (NONPF, 2013). A brief history of the development of competencies for NPs is presented here, in part because their development has influenced other APRN models.

In 1990 the NONPF published a set of domains and core competencies for primary care NPs based on Benner’s (1984) domains of expert nursing practice and the results of Brykczynski’s (1989) study of the use of these domains by primary care NPs (Price et al., 1992; Zimmer et al., 1990). Within each domain were a number of specific competencies that served as a framework for primary care NP education and practice.

After endorsing the DNP as entry-level preparation for the NP role, and consistent with the recommendations in the APRN Consensus Model (APRN Joint Dialogue Group, 2008), new NP core competencies were developed in 2011 and amended in 2012, with core competency content developed in 2014 (NONPF, 2011 [amended 2012], 2014) and population-focused NP competencies added in 2013. Each of the nine core competencies is accompanied by specific behaviors that all graduates of NP programs, whether master’s or DNP prepared, are expected to demonstrate. Population-specific competencies for specific NP roles, together with the nine core competencies, are intended to inform curricula and ensure that graduates will meet certification and regulatory requirements.

From a conceptual perspective, these NP core and population-specific competency documents are notable for several reasons: (1) the competencies for NPs were developed collaboratively by stakeholder organizations; (2) empirical validation is used to affirm the competencies; (3) overall, the competencies are conceptually consistent with statements in the APRN Consensus Model, the DNP Essentials (AACN, 2006), and the ANA’s Nursing: Scope and Standards of Practice 4th edition (ANA, 2021); and (4) the revised competencies are responsive to society’s needs for advanced nursing care and the contextual factors that will shape NP practice for at least the next decade. In the amended 2011 NONPF competencies (NONPF, 2011, 2012), there is an emphasis on practice that is not in the APRN Consensus Model (APRN Joint Dialogue Group, 2008); patient-centered care, interprofessional care, and independent or autonomous NP practice, clearly responsive to healthcare reform initiatives, are addressed.

National Association of Clinical Nurse Specialists

The NACNS originally published the Statement on Clinical Nurse Specialist Practice and Education in 1998, revised it in 2004, and updated it in 2019. While acknowledging the early conceptualization of CNS practice as subroles proposed by Hamric and Spross (1983, 1989), the 2019 version differentiated CNS practice from that of other APRNs, refined the competencies of the three spheres, and renamed the spheres of influence to the spheres of impact. These include patient direct care, nurses and nursing practice, and organizations and systems, each of which requires a unique set of competencies (NACNS, 2019; see Fig. 2.2). The statement also outlines expected outcomes (patient, nurse, and organization) of CNS practice within each sphere of impact and competencies.

As work on the APRN Consensus Model neared completion, the NACNS and the APRN Consensus Work Group asked the ANA and the ABNS to “convene and facilitate the work of a National CNS Competency Task Force,” using a standard process to develop nationally recognized education standards and competencies (NACNS/National CNS Competency Task Force, 2010, p. 3). The process of developing and validating the competencies is described in the document. Fig. 2.3 illustrates the model of CNS competencies that emerged from this work, a synthesis of the NACNS’s spheres of influence (NACNS, 2004), Hamric’s seven advanced practice nursing competencies (Hamric, 2009), and the Synergy Model (Curley, 1998). Subsequently, new criteria for evaluating CNS education programs were developed, based on the competencies (Validation Panel of the NACNS, 2011). The APRN Consensus Model has affected certification for CNS roles more than any other APRN role.

Several key updates were included in the most recent statement (NACNS, 2019). It combined into a single document all competencies from the original statement on CNS practice and education and updated important aspects of the 2004 Statement. Additionally, the most recent statement updated the CNS model, changed the language to spheres of impact (replacing spheres of influence), enhanced the focus on the social mandate of the CNS, enhanced the integration with and of the APRN consensus model, and expanded references.

Initially the NACNS published a white paper describing a position of neutrality regarding the DNP as an option for CNS education (NACNS, 2005). However, in 2009, the NACNS did develop core competencies for doctoral-level practice, recognizing that some CNSs would pursue advanced clinical doctorates (NACNS, 2009). Three years later, the NACNS (2012) published a Statement on the APRN Consensus Model Implementation, outlining the importance of grandfathering currently practicing CNSs and monitoring the implementation of the Consensus Model to ensure that its adoption would not negatively affect the ability of CNSs to practice. To this end, the competencies outlined in the NACNS 2019 Statement on Clinical Nurse Specialist Practice and Education apply to CNSs with graduate preparation (master’s or doctorate) in nursing.

In June 2015, the NACNS issued a position statement endorsing the DNP as entry into practice for CNSs by 2030. Within this position statement, the NACNS stated support for “CNSs who pursued other graduate education to retain their ability to practice within the CNS role without having to obtain the DNP for future practice as an APRN after 2030” (NACNS, 2015, p. 2). For further information, see the NACNS website and Chapter 12.

American Association of Nurse Anesthesiology

CRNAs are recognized as APRNs within the APRN Consensus Model. Advanced practice competencies, as described in the DNP Essentials (AACN, 2006), the ANA Scope and Standards (ANA, 2021), and the APRN competencies identified in this text, are evident in the official statements of the AANA (2019, 2020). These statements include scopes of practice, standards for practice, and ethics. Chapter 16 provides a thorough discussion of CRNA practice.

The CRNA’s scope and standards of practice are defined in two separate documents from the AANA: Scope of Nurse Anesthesia Practice (2020) and Standards for Nurse Anesthesia Practice (2019). The Scope of Nurse Anesthesia Practice addresses the responsibilities of CRNAs, and the Standards for Nurse Anesthesia Practice describe standards of professional CRNA practice. The Scope document addresses the professional role; education, licensure, certification and accountability; clinical anesthesia practice; leadership, advocacy, and policymaking; and the future of nurse anesthesia practice. The purposes of the 14 Standards are to support the delivery of patient-centered, consistent, high-quality, and safe anesthesia care and assist the public in understanding the CRNA’s role in anesthesia care (AANA, 2019). The Scope of Nurse Anesthesia Practice and Standards for Nurse Anesthesia Practice provide descriptions of clinical competencies and responsibilities of CRNAs.

Initially, the AANA did not support the DNP for entry into CRNA practice and established a task force to evaluate doctoral preparation further. In 2019 the Council on Accreditation of Nurse Anesthesia Educational Programs revised its 2015 accreditation standards for nurse anesthesia education stating that students accepted into accredited entry-level programs on or after January 1, 2022, must graduate with doctoral degrees as of January 1, 2025. Further, Standard E.1 states, ”The curriculum is designed to award a DNP or Doctor of Nurse Anesthesia Practice to graduate students who successfully complete graduation requirements unless a waiver for this requirement has been approved by the Council” (Council on Accreditation of Nurse Anesthesia Educational Programs, 2019). The Council on Accreditation of Nurse Anesthesia Educational Programs (2019) also includes a requirement for the “three P” courses, consistent with requirements specified in the APRN Consensus document.

American College of Nurse-Midwives

Certified nurse-midwives (CNMs) are APRNs who are recognized in the APRN Consensus Model. Advanced practice competencies, described in the DNP Essentials (AACN, 2006), the ANA Scope and Standards (ANA, 2021), and the APRN competencies are apparent in the official statements of the ACNM (2011a, 2011c). These statements include scopes of practice, standards for practice, and ethics. Chapter 15 presents a thorough discussion of CNM practice.

The scope of practice for CNMs (and certified midwives who are not nurses) has been defined in four ACNM documents: Definition of Midwifery and Scope of Practice of Certified Nurse-Midwives and Certified Midwives (ACNM, 2011a), the Core Competencies for Basic Midwifery Practice (ACNM, 2012a), Standards for the Practice of Midwifery (ACNM, 2011c), and the Code of Ethics with Explanatory Statements (ACNM, 2015a). The core competencies are organized into 16 hallmarks describing the art and science of midwifery and the components of midwifery care. The components of midwifery care include professional responsibilities, midwifery management processes, fundamentals, and care of women and of the newborn, within which are prescribed competencies. According to the definition, “CNMs are educated in two disciplines: nursing and midwifery” (ACNM, 2011a, p. 1). Competencies “describe the fundamental knowledge, skills and behaviors of a new practitioner” (ACNM, 2012a, p. 1). The hallmarks, components, and associated core competencies are the foundation on which midwifery curricula and practice guidelines are based.

In addition to the competencies, there are eight ACNM standards that midwives are expected to meet (ACNM, 2011c) and a code of ethics (ACNM, 2015a). The standards address issues such as qualifications, safety, patient rights, culturally competent care, assessment, documentation, and expansion of midwifery practice. Three ethical mandates related to the ACNM mission of midwifery to promote the health and wellbeing of women and newborns within their families and communities are identified in the ethics code.

As of 2010, CNMs entering practice must earn a graduate degree, complete an accredited midwifery program, and pass a national certification examination (see Chapter 15 for detailed requirements; ACNM, 2011a); the type of graduate degree is not specified. The ACNM does recognize the value of doctoral education as a valid and valuable path for CNMs, as evidenced by a statement on the practice doctorate in midwifery, including competencies (ACNM, 2011b). Although not cited, these competencies align with those in the DNP Essentials (AACN, 2006); the ACNM recognizes that there are other paths for a practice doctorate in midwifery. At the present time, the ACNM (2019) does not support the DNP as a requirement for entry into nurse-midwifery practice. Reasons cited are (1) midwifery practice is safe, based on the rigor of their curriculum standards and outcome data; (2) there is inadequate evidence to justify the DNP as a mandatory educational requirement for CNMs; and (3) the costs of attaining such a degree could limit the applicant pool and access to midwifery care (ACNM, 2012b, 2015b). Midwifery organizations have recently addressed the aspects of the 2008 Consensus Model that they support and identified those aspects that are of concern (ACNM et al., 2011).

International Organizations and Conceptualizations of Advanced Practice Nursing

In this section, issues of a common language and conceptual framework for advanced practice nursing are addressed. International perspectives on advanced practice nursing are covered more extensively in Chapter 5.

The ICN Nurse Practitioner/Advanced Practice Nursing Network (2020) defines a nurse practitioner/advanced practice nurse as “a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice.” A master’s degree is recommended for entry level (ICN Nurse Practitioner/Advanced Practice Nursing Network, 2020). Key concepts include educational preparation, the nature of practice, and regulatory mechanisms. The statement is necessarily broad, given the variations in health systems, regulatory mechanisms, and nursing education programs in individual countries.

In 2008 the CNA published Advanced Nursing Practice: A National Framework, which defined advanced nursing practice, described educational preparation and regulation, identified the two APRN roles (CNS and NP), and specified competencies in clinical practice, research, and leadership. In addition, they have issued position statements on advanced nursing practice (CNA, 2007) that affirm the key points in the national framework document and define and describe the roles and contributions to health care of NPs (CNA, 2009b) and CNSs (CNA, 2009a). In 2010 the CNA published a Core Competency Framework for NPs, which included the incorporation of theories of advanced practice nursing. The CNA (2019) published the Pan-Canadian framework for advanced practice nursing, which not only distinguishes the role of the CNS from that of the NP but also strengthens it and aligns it with ICN competencies.

Furthermore, leaders have undertaken an evidence-based, patient-centered, coordinated effort (called a decision support synthesis) to develop, implement, and evaluate the advanced practice nursing roles of the CNS and NP in Canada (DiCenso et al., 2010), a process different from the one used to advance these roles in the United States. This process included a review of 468 published and unpublished articles and interviews conducted with 62 key informants and four focus groups that included a variety of stakeholders. The purpose of this work was to “describe the distinguishing characteristics of CNSs and NPs relevant to Canadian contexts”; identify barriers and facilitators to effective development and use of advanced practice nursing roles; and inform the development of evidence-based recommendations that individuals, organizations, and systems can use to improve the integration of advanced practice nurses into Canadian health care (DiCenso et al., 2010, p. 21). The European Specialist Nurses Organisations (2015) defined 10 core (generic) competencies of CNS practice in Europe. The competencies address clinical role, patient relationship, patient teaching/coaching, mentoring, research, organization and management, communication and teamwork, ethics and decision making, leadership/policymaking, and public health. The competencies were developed to clarify the role of the CNS and include advanced knowledge in anatomy, physiology, pathophysiology, and pharmacology, similar to the APRN Consensus Model. It is expected that CNSs will collaborate with other health professionals to deliver high-quality patient care to ensure safety, quality of care, and equity of access to promote health and prevent disease.

Section Summary: Implications for Advanced Practice Nursing Conceptualizations

From this overview of organizational statements that clarify and advance APRN practice, it is clear that, nationally and internationally, stakeholders are actively defining advanced practice nursing. Progress in this area includes global agreement that this level of clinical nursing practice is advanced and builds on basic nursing education. As such, it requires additional education and is characterized by additional competencies and responsibilities. In the United States the consensus on an approach to APRN regulation was critical for the following reasons: (1) clarifying what an APRN is and the role of graduate education and certification in licensing APRNs, (2) ensuring that APRNs are fully recognized and integrated in the delivery of health care, (3) reducing barriers to mobility of APRNs across state lines, (4) fostering and facilitating ongoing dialogue among APRN stakeholders, and (5) offering common language regarding regulation.

Although there may not be unanimous agreement on the DNP as the requirement for entry into advanced practice nursing, the promulgation of the document fostered dialogue nationally and within APRN organizations on the clinical doctorate (whether or not it is the DNP) as a valid and likely path for APRNs to pursue. As a result, each APRN organization has taken a stand on the role of the clinical doctorate for those in the role and has developed or is developing doctoral-level clinical competencies. In doing so, it appears that the needs of their patients, members, other constituencies, and contexts have been considered. Until the time when a clinical doctorate becomes a requirement for entry into practice for all APRN roles, the development of doctoral-level competencies for APRN roles will help stakeholders distinguish between master’s- and clinical doctorate–prepared APRNs with regard to competencies.

Although important differences exist between roles and across countries, a common identity for APRNs resulting from policy and regulatory initiatives would facilitate communication within and outside the profession, consistent with assertions by Styles (1998) and Fawcett and Desanto-Madeya (2013) on the purposes of models. There are important differences among APRN organizations regarding such issues as doctoral preparation, which is also consistent with Fawcett and Desanto-Madeya’s assertion that there is not one best model.

The level of consensus regarding regulation in the United States reflects considerable and laudable progress, paving the way for policies and healthcare system transformations that will enable APRNs to be able to more fully ensure access to health care and improve its quality. The processes that have led to this juncture in the United States have required openness, civility, a willingness to disagree, and wisdom. Finally, there are at least two different approaches (collaborative policymaking in the United States and an evidence-based approach in Canada) to determine how best to assess contributions of APRNs and develop ways to integrate APRNs more fully into healthcare infrastructures in order to maximize their benefits to patients and populations. The global APRN community can examine these processes for insights on how to adapt them to suit their particular context.

The organizational models described address professional roles, licensing, accreditation, certification, education, competencies, and clinical practice. The descriptive statements about APRN roles and competencies demonstrate the common elements that exist across all APRN roles. These include a central focus on and accountability for patient care, knowledge and skills specific to each APRN role, and a concern for patient rights. The published definitions, standards, and competencies offer models against which similarities and differences among APRN roles and practices can be distinguished, educational programs can be developed and evaluated, and knowledge and behaviors can be measured for certification purposes. These will also assist practitioners to understand, examine, and improve their own practice and develop job descriptions. As advanced practice nursing moves forward in the United States and globally, the profession will continue to define situations in which a conceptual consensus, as well as alternative conceptualizations, will serve the public and the nursing profession.

Advanced Practice Nursing Transitional Care Models

There are several models of transitional care in which care is provided by APRNs. Early work by Brooten et al. (1988) continues to inform these models of APRN care (e.g., Partiprajak et al., 2011) and illustrates how a theory of clinical care can be studied to obtain a better understanding of the work of APRNs. It is a model that has evolved but has resulted in steady contributions to understanding and improving APRN practice. This theoretical and empirical steadfastness has had a significant influence on the new policies evolving as the United States undergoes healthcare reform.

Using a conceptual model proposed by Doessel and Marshall (1985), Brooten et al. integrated this framework into their evaluation of outcomes of APRN transitional care with different clinical populations. APRN transitional care was defined as “comprehensive discharge planning designed for each patient group plus APN home follow-up through a period of normally expected recovery or stabilization” (Brooten et al., 2002, p. 370). Brooten’s model was intended to address outlier patient populations (e.g., those whose care, for clinical reasons, was likely to cost more). Across all studies, care was provided by NPs and/or CNSs whose clinical expertise was matched to the needs of the patient population. In these studies, APRN care was associated with improved patient outcomes and reduced costs.

Research by Brooten, Naylor, and others (Bradway et al., 2012) who have studied transitional care by APRNs has provided empirical support for several elements important to a conceptualization of advanced practice nursing. In a summary of the studies conducted, the investigators identified several factors that contribute to the effectiveness of APRNs: content expertise, interpersonal skills, knowledge of systems, ability to implement change, and ability to access resources (Brooten et al., 2003). This finding provides empirical support for the importance of the APRN competencies of direct care, collaboration, coaching, and systems leadership.

Two other important findings were the existence of patterns of morbidity within patient populations and an apparent dose effect (i.e., outcomes seemed to be related to how much time was spent with patients, number of APRN interactions with patients, and numbers and types of APRN interventions; Brooten et al., 2003). Subsequently, based on this finding of a dose effect, Brooten and Youngblut (2006) proposed a conceptual explanation of “nurse dose.” Their explanation suggests that nurse dose depends on patient and nurse characteristics. For the nurse, differences in education and experience can influence the dose of nursing needed.

The concept of nurse dose, which has empirical support, may enable the profession to differentiate more clearly among novice, expert, and advanced levels of nursing practice. Taken together, findings from this program of research suggest that characteristics of patients and characteristics and dose of APRN interventions are important to the conceptualization of advanced practice nursing. Finally, the fact that this program of research has used NPs and CNSs to intervene with patients provides support for a broad conceptual model of APRN practice that encompasses APRN characteristics, competencies, patient factors, environment, and other concepts that can inform role-specific models.

Although there have been other studies of APRNs providing transitional care, Brooten’s work is highlighted because of the additional analyses that were done and the ultimate influence on health policy of this program of research (e.g., Naylor, 2012). The findings help understand the APRN characteristics and interventions that contributed to the success of the interventions and a model of care that evolved from the skilled care provided by APRNs.

The effect of the research conducted by Naylor et al. (2013) using the translational care model, in which APRNs are the primary coordinators of care, provide home visits, and collaborate with the patient, family caregivers, and healthcare colleagues (physicians, nurses, social workers, and other health team members), is evident in many of the provisions of the ACA and its implementation (Naylor et al., 2011). The Community-Based Care Transitions Program was created by Section 3026 of the ACA and is being implemented by the Centers for Medicare & Medicaid Services Partnership for Patients (2017).

Dunphy and Winland-Brown’s Circle of Caring: A Transformative, Collaborative Model

A central premise of Dunphy and Winland-Brown’s model (1998) is that the healthcare needs of individuals, families, and communities are not being met in a healthcare system dominated by medicine in which medical language (i.e., the International Classification of Diseases, 10th Revision, Clinical Modification codes) is the basis for reimbursement. They proposed the circle of caring to foster a more active and visible nursing presence in the healthcare system and to explain and promote medical-nursing collaboration. Dunphy and Winland-Brown’s transformative model (Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011; Fig. 2.12) is a synthesized problem-solving approach to advanced practice nursing that builds on nursing and medical models (Dunphy & Winland-Brown, 1998).

The authors argued that a model such as theirs is needed because nursing and medicine have two different traditions, with the medical model being viewed as reductionistic and the nursing model being regarded as humanistic. Neither model, by itself, provided a structure that allowed APRNs to be recognized for their daily practice and the positive patient health outcomes that can be attributed to APRN care. The model’s authors viewed the development of nursing diagnoses as an attempt to differentiate nursing care from medical care, but because few nursing diagnoses are recognized by current reimbursement systems, the nursing in APRN care was rendered invisible.

The circle of caring model was proposed to incorporate the strengths of medicine and nursing in a transforming way. The conceptual elements are the processes of assessment, planning, intervention, and evaluation, with a feedback loop. Integrating a nursing model with a traditional medical model permits the following to occur:

• ■ The assessment and evaluation are contextualized, incorporating subjective and environmental elements into traditional history taking and physical examination.
• ■ The approach to therapeutics is broadened to include holistic approaches to healing and makes nursing care more visible.
• ■ Measured outcomes include patients’ perceptions of health and care, not just physiologic outcomes and resource use.

The assessment–planning–intervention–evaluation processes in linear configuration are encircled by caring. Caring is actualized through interpersonal interactions with patients and caregivers to which NPs bring patience, courage, advocacy, authentic presence, commitment, and knowing (Dunphy & Winland-Brown, 1998; Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011). Conceptual definitions of these terms would add to the understanding of how these processes interact with and affect the care provided by APRNs. The authors suggested that the model promotes the incorporation of the lived experience of the patient into the provider–patient interaction and that the process of caring is a prerequisite to APRNs providing effective and meaningful care to patients.

The circle of caring is an integrated model of caregiving that incorporates the discrete strengths of nursing and medicine. This is an important concern for many graduate students because some may struggle with integrating their nursing expertise and philosophy with new knowledge and skills that were traditionally viewed as medicine. Although the authors regard the concept of caring as a way to bridge the gap between advanced practice nursing and medicine and raise awareness, the model provides no clear guidance on how faculty can help students to use the model to bridge this gap.

Several issues remain to be considered. For example, if one goal of proposing the model is to resolve differences about the diagnostic language used by medicine and nursing to obtain reimbursement, no specific mechanism is offered for APRNs to resolve this issue using the model. The model does not seem to be described in enough detail to guide policymaking. The conceptual significance of encircling the four practice processes with the six caring processes is unclear, although the primary care textbook by Dunphy, Winland-Brown, Porter, and Thomas (2011) devotes a chapter to caring in the NP role (Boykin & Schoenhofer, 2011). Given today’s health policy context, the value of this model, with its emphasis on the APRN–patient relationship and caring processes, could inform practice evaluation and research on APRN practices. For example, the circle of caring model has been used for the development of an online risk assessment of mental health (McKnight, 2011), evaluation of medication adherence (Palardy & March, 2011), and neonatal transport (J. Thomas, 2011). In addition, the primary care textbook (Dunphy et al., 2011) is informed by their circle of caring model.

Given the emphasis on interprofessional education and efforts to distinguish advanced practice nursing from medical practice, empirical testing of this model is warranted. This testing would help determine whether the model has the following features: (1) is applicable to all APRN roles, (2) has the potential to be used to distinguish expert by experience practice from advanced practice, (3) is viewed by other disciplines as having an interprofessional focus that would promote collaboration, and (4) will result in more visibility for NPs and other APRNs in the healthcare system.

Donabedian Structure/Process/Outcome Model

Donabedian’s structure/process/outcome model (2005) has been used as the conceptual model by several recent studies to evaluate the quality of APRN care (e.g., Bryant-Lukosius et al., 2016; Kilpatrick et al., 2013, 2016). Originally designed to evaluate the quality of medical care, this model encompasses three quality-of-care dimensions: structure, process, and outcomes. Structure is the care delivery context (e.g., hospitals, healthcare staff, cost, equipment) and the factors that dictate how healthcare providers and patients behave and are system measures of quality of care (Donabedian, 1980, 1986, 1988). Process involves the actions taken in the delivery of health care (e.g., diagnosis, treatment, education), whereas outcome is the effect of the health care on patients and populations. Outcome is often viewed as the key quality indicator of care delivery.

Kilpatrick et al. used this model to describe the relationship between CNS role implementation, satisfaction, and intent to stay in the role (Kilpatrick et al., 2016) and to evaluate team effectiveness when an ACNP is added to the healthcare team (Kilpatrick et al., 2013). The model provided the framework to examine outcomes and barriers to CNS practice in Canada and the frequency with which components of the CNS role (clinical, education, research, leadership, scholarly and professional development, and consultation) were enacted. Findings indicated that CNS role components of clinical and research, along with balanced scholarly and professional development and consultation activities, were associated with role satisfaction. Additional research is needed to determine whether implementation of the CNS role influences intention to remain in or actual departure from the role.

Guided by the Donabedian model, Bryant-Lukosius et al. (2016) developed an evaluation framework to inform decisions about the effective utilization of APRNs in Switzerland (Fig. 2.13). An international group of stakeholders (e.g., APRNs, APRN educators, administrators, researchers) from Canada, Germany, Switzerland, and the United States convened to develop and refine the framework. The developed framework is deliberately broad and flexible to respond to the evolving APRN roles in Switzerland. Key concepts of the model are introduction stage, implementation, and long-term sustainability. The introduction stage includes the type of APRN and corresponding competencies. The implementation stage focuses on the resources (e.g., policies, education, funding) to support the different APRN roles and promote the optimal utilization and implementation of the role. Long-term sustainability focuses on long-term benefits and impact of APRN roles (e.g., consumers, system, providers) in Switzerland. Because the role of the APRN is in its early stage, the authors have indicated their plan to engage in concerted efforts with policymakers and other stakeholders to actively involve them in its use and application. Several resources have been developed to actualize this (e.g., toolkit, evaluation plan template).

Conceptualizations of Advanced Practice Nursing

This overview of extant models of advanced practice nursing is necessarily cursory, primarily focused on Western literature (Canada, Europe, United States). Although there is some agreement on selected elements of advanced practice, differences remain regarding the conceptualization of the ARPN. To promote a unified conceptualization of advanced practice nursing, the following recommendations are put forth:

1. 1. Conduct a rigorous content analysis of the statements published by national and international professional organizations that describe the advanced practice nursing of recognized APRNs (CNMs, CNSs, CRNAs, NPs). This would be a natural evolution of the work done by the APRN Consensus Work Group, the NCSBN APRN Advisory Committee, the CNA, and others to inform future work. As part of this analysis, an assessment of the extent to which nursing’s metaparadigmatic concepts are integrated into statements about the nature of advanced practice nursing should be undertaken.
2. 2. Conduct a content analysis of statements that address advanced practice nursing promulgated by specialty organizations.
3. 3. Review recent role delineation studies of the four APRN roles.
4. 4. Conduct a comprehensive integrative review of the advanced practice literature, building on the work of Mantzoukas and Watkinson (2007) and Lewandowski and Adamle (2009). This could be modeled on the work of Reeves et al. (2011) and their conceptualization of interprofessional education, identifying concepts and relationships that need further development.
5. 5. Synthesize results to collaboratively propose a definition of advanced practice nursing to be used nationally and globally.
6. 6. Create a common structure for organizational statements about APRNs that ensures nursing concepts are included:
   1. a. Definition of nursing and advanced practice nursing
   2. b. Specification of assumptions
   3. c. Incorporation of the metaparadigmatic elements (persons, health and illness, nursing, environment) into scopes and introductions to key documents
   4. d. Referencing documents such as the ANA’s social policy statement and the ICN’s statements on nursing
7. 7. Implement a structure for organizations and associations developing statements regarding advanced practice nursing to explicate the foundational and philosophic underpinnings of each statement. Use the results from recommendations 1 through 5 above to inform revisions to standards and other documents that address APRN LACE issues for APRN roles. Future revision of documents regarding APRNs should be informed by a clear conceptualization of advanced practice nursing and empirical evidence.
8. 8. The evolution of conceptual models of APRN practice needs to be contemporized to include concepts of diversity and social determinants of health. As these models are being adapted and modified, evaluation should consider how they impact care for all as well as for all diverse APRNs.
9. 9. Because the terms advanced practice nursing and advanced nursing practice are being used to refer to APRN work in different ways in the United States versus internationally, revisit the work on definitions of these terms done by Styles (1998) and Styles and Lewis (2000) and clarify these definitions as they relate to APRNs.

Consensus Building Around Advanced Practice Nursing

A priority for the profession is a collaboratively developed conceptualization of advanced practice nursing and what is common across the various APRN roles. Achieving this is a prerequisite for building consensus among APRNs, stakeholder organizations, and policymakers and ensuring that all patients will benefit from advanced practice nursing. The APRN Consensus Model, at the time it was released, represented substantial progress in this area with regard to regulation. However, it is now dated and in need of revision. Studies are under way worldwide (see Chapter 5) that could inform efforts to refine conceptualizations of advanced nursing practice. Ongoing development of consensus on advanced practice nursing should involve:

• ■ Periodic updates on the progress of nationwide implementation of the regulatory model—successes and challenges (note that the NCSBN periodically updates state-by-state maps on its website [https://www.ncsbn.org/5397.htm]).
• ■ Communication between national and global APRN accrediting and certification bodies. Because US nurse anesthetists and nurse-midwives operate under different accrediting and certification bodies and mechanisms than CNSs and NPs, their experience may be helpful in countries in which nurses and midwives are regulated separately or where nurse anesthesia is not a practice role.
• ■ Consensus of common terms used in documents describing APRN practice.

• ■ Addressing the legitimate concerns of these organizations (e.g., impact on access to care, concerns about certification or grandfathering existing APRNs)
• ■ Establishing priorities for negotiation and resolution by stakeholder groups and initiating a process to find common ground and address disagreements
• ■ In the face of disagreements, working toward agreement on a common identity to facilitate public understanding of APRN roles

The recently released Essentials (AACN, 2021b) addresses previous concerns regarding variability in DNP curricula content (Ketefian & Redman, 2015) and a reduced emphasis of DNP programs on theory (Whall, 2005) by providing consensus regarding the standard competencies for professional practice at the doctorate of practice level. Included in these competencies is expectation DNP graduates will be prepared to think theoretically, ethically, and conceptually as socially responsible and competent clinicians. Although the ACNM does not currently support the practice doctorate for entry into practice and the AANA has delayed endorsing doctoral preparation for entry into practice until 2025 and the NACNS until 2030, APRN organizations have prepared doctoral-level competencies that are consistent with those proposed in the DNP.

Research on Advanced Practice Nurses and Their Contribution to Patients, Teams, and System Outcomes

Theory-based research on APRNs’ contributions to improved patient outcomes and cost-effectiveness is needed to inform and validate the conceptualizations of advanced practice nursing. Increased knowledge about advanced practice nursing is critical (see Chapter 21). The worth of any service depends on the extent to which practice meets the needs and priorities of healthcare systems, the public policy arena, and society in general. In addition to research that links advanced practice nursing with outcomes, the following recommendations are put forth:

1. 1. Promising conceptual models of advanced practice nursing should be refined based on research that validates key concepts and tests theoretical propositions associated with these models.
2. 2. Studies are needed to examine advanced practice nursing across APRN roles and between physician and APRN practices and APRN and PA practices with regard to processes and outcomes. Studies conducted across APRN roles can determine whether the assumption that a core set of competencies is used by all APRNs is valid and that the activities of APRNs can differentiate one APRN role from another. The studies of APRN and physician practice can identify the factors that distinguish APRN practice from physician practice as a basis for understanding differences in outcomes and developing proposals to optimally use each provider to achieve high-quality, patient-centered, cost-effective care.
3. 3. As conceptualizations of interprofessional teams evolve, the roles and contributions of APRNs and their interdisciplinary colleagues to outcomes need examination.