A Definition of Advanced Practice Nursing

Conceptual Definition

Advanced practice nursing is the patient-focused application of an expanded range of competencies to improve health outcomes for patients and populations in a specialized clinical area of the larger discipline of nursing.^a

In this definition, the term competencies refers to a broad area of skillful performance; six core competencies combine to distinguish nursing practice at this level. Competencies include activities undertaken as part of delivering advanced nursing care directly to patients. Some competencies are processes that APRNs use in all dimensions of their practice, such as collaboration and leadership. At this stage of the development of the nursing discipline, competencies may be based in theory, practice, or research. Although the discipline is expanding its research-based evidence to guide practice, an expanded ability to use theory also is a key distinguishing feature of advanced practice nursing. In addition, a strong experiential component is necessary to develop the competencies and clinical practice expertise that characterize APRN practice. Graduate education and in-depth clinical practice experiences work together to develop the APRN.

The definition also emphasizes the patient-focused and specialized nature of advanced practice nursing. APRNs expand their capability to provide and direct care, with the ultimate goal of improving patient and specialty population outcomes; this focus on outcome attainment is a central feature of advanced practice nursing and the main justification for differentiating this level of practice. Finally, the critical importance of ensuring that any type of advanced practice is grounded within the larger discipline of nursing is made explicit.

Certain activities of APRN practice overlap with those performed by physicians and other healthcare professionals. However, the experiential, theoretical, and philosophic perspectives of nursing make these activities advanced nursing when they are carried out by an APRN. Advanced practice nursing further involves highly developed nursing skill in areas such as guidance and coaching, as well as the performance of select medical interventions. Particularly with regard to physician practice, the nursing profession needs to be clear that advanced practice nursing is embedded in the nursing discipline—the advanced practice of nursing is not the junior practice of medicine.

Advanced practice nursing is further defined by a conceptual model integrating three primary criteria and six core competencies, one of them central to the others. This discussion and the chapters in Part II of this text isolate each of these core competencies to clarify them. The reader should recognize that this is only a heuristic device for clarifying this conceptualization of advanced practice nursing. In reality, these elements are integrated into an APRN’s practice; they are not separate and distinct features. The concentric circles in Figs. 3.1 through 3.3 represent the seamless nature of this interweaving of elements. In addition, an APRN’s skills function synergistically to produce a whole that is greater than the sum of its parts. The essence of advanced practice nursing is found not only in the primary criteria and competencies demonstrated but also in the synthesis of these elements into a unified composite practice that conforms to the conceptual definition just presented.

Primary Criteria

Certain criteria (or qualifications) must be met before a nurse can be considered an APRN. Although these baseline criteria are not sufficient in and of themselves, they are necessary core elements of advanced practice nursing. The three primary criteria for advanced practice nursing are shown in Fig. 3.1 and include an earned graduate degree with a concentration in an advanced practice nursing role and population focus, national certification at an advanced level, and a practice focused on patients and their families. As noted, these criteria are most often the ones used by states to regulate APRN practice because they are objective and easily measured (see Chapter 20).

Direct Clinical Practice: The Central Competency

As noted earlier, the primary criteria are necessary but insufficient elements of the definition of advanced practice nursing. Advanced practice nursing is further defined by a set of six core competencies that are enacted in each APRN role. The first core competency of direct clinical practice is central to and informs all of the others (see Fig. 3.2). In one sense, it is “first among equals” of the six core competencies that define advanced practice nursing. Although APRNs do many things, excellence in direct clinical practice provides the foundation necessary for APRNs to execute the other competencies, such as collaboration, guidance and coaching, and leadership within organizations.

However, clinical expertise alone should not be equated with advanced practice nursing. The work of Patricia Benner and colleagues (Benner, 1984; Benner et al., 1996, 1999, 2008) is a major contribution to an understanding of clinically expert nursing practice. These researchers extensively studied expert nurses in acute care clinical settings and described the engaged clinical reasoning and domains of practice seen in clinically expert nurses. Although some of the participants in this research were APRNs (in the most recent report [Benner et al., 1999], 16% of the nurse participants were APRNs), most were nurses with extensive clinical experience who did not have APRN preparation. Calkin (1984) has characterized these latter nurses as “experts by experience.” (See Chapter 2 for a discussion of Calkin’s conceptual differentiation between levels of nursing practice.) Benner and colleagues did not discuss differences in the practices of APRNs as compared with other nurses that they have studied. They stated that “‘Expert’ is not used to refer to a specific role such as an advanced practice nurse. Expertise is found in the practice of experienced clinicians and advanced practice nurses” (Benner et al., 1999, p. 9).

Although clinical expertise is a central ingredient of an APRN’s practice, the direct care practice of APRNs is distinguished by six characteristics: (1) use of a holistic perspective, (2) formation of therapeutic partnerships with patients, (3) expert clinical performance, (4) use of reflective practice, (5) use of evidence as a guide to practice, and (6) use of diverse approaches to health and illness management (see Chapter 6). These characteristics help distinguish the practice of the expert by experience from that of the APRN. APRN clinical practice is also informed by a population focus (AACN, 2021), because APRNs work to improve the care for their specialty patient population, even as they care for individuals within the population. As noted, experiential knowledge and graduate education combine to develop these characteristics in an APRN’s clinical practice. It is important to note that the “three Ps” that form core courses in all APRN programs (pathophysiology, pharmacology, and physical assessment) are not separate competencies in this understanding but provide baseline knowledge and skills to support the direct clinical practice competency.

The specific content of the direct practice competency differs significantly by specialty. For example, the clinical practice of a CNS dealing with critically ill children differs from the expertise of an NP managing the health maintenance needs of older adults or a CRNA administering anesthesia in an outpatient surgical clinic. In addition, the amount of time spent in direct practice differs by APRN specialty. CNSs in particular may spend most of their time in activities other than direct clinical practice (see Chapter 12). Thus it is important to understand this competency as a central defining characteristic of advanced practice nursing rather than as a particular skill set or expectation that APRNs only engage in direct clinical practice.

Additional Advanced Practice Nurse Core Competencies

In addition to the central competency of direct clinical practice, five other competencies further define advanced practice nursing regardless of role function or setting. As shown in Fig. 3.3, these additional core competencies are as follows:

• ■ Guidance and coaching
• ■ Evidence-based practice
• ■ Leadership
• ■ Collaboration
• ■ Ethical practice

These competencies have repeatedly been identified as essential features of advanced practice nursing. In addition, each role is differentiated by some unique competencies (see the specific role chapters in Part III of this text). The nature of the patient population receiving APRN care, organizational expectations, emphasis given to specific competencies, and practice characteristics unique to each role distinguish the practice of one APRN group from others. Each APRN role organization publishes role-specific competencies on their websites: the National Association of Clinical Nurse Specialists (NACNS) for CNSs (www.nacns.org), the National Organization of Nurse Practitioner Faculties for NPs (www.nonpf.org), the ACNM for CNMs (www.acnm.org), and the American Association of Nurse Anesthesiology for CRNAs (www.aana.com). There is a dynamic interplay between the core APRN competencies and each role; role-specific expectations grow out of the core competencies and similarly serve to inform them as APRNs practice in a changing healthcare system. In addition, competencies promoted by other professional groups become important to the understanding of advanced practice nursing; for example, the Interprofessional Education Collaborative competencies on interprofessional practice are helping to shape the understanding of collaboration (Interprofessional Education Collaborative Expert Panel, 2016; see Chapter 10).

It is also important to understand that each of the competencies described in Part II of this text have specific definitions in the context of advanced practice nursing. For example, leadership has clinical, professional, and systems expectations for the APRN that differ from those for a nurse executive or staff nurse. These unique definitions of each competency help distinguish practice at the advanced level. Similarly, certain competencies are important components of other specialized nursing roles. For example, collaboration is an important competency for nursing administrators. The uniqueness of advanced practice nursing is seen in the synergistic interaction between direct clinical practice and this constellation of competencies. In Fig. 3.3, the openings between the central practice competency and these additional competencies represent the fact that the APRN’s direct practice skill interacts with and informs all the other competencies. For example, APRNs collaborate with other providers who seek their practice expertise to plan care for specialty patients. They are able to provide expert guidance and coaching for patients going through health and illness transitions because of their direct practice experience and insight.

The core competencies are not unique to APRN practices. Physicians and other healthcare providers may have developed competency in some of them. Experienced staff nurses may master several of these competencies with years of practice experience. These nurses are seen as exemplary performers and are often encouraged to enter graduate school to become APRNs. What distinguishes APRN practice is the expectation that every APRN’s practice encompasses all of these competencies and seamlessly blends them into daily practice encounters. This expectation makes APRN practice unique among that of other providers.

These complex competencies develop over time. No APRN emerges from a graduate program fully prepared to enact all of them. However, it is critical that graduate programs provide exposure to each competency in the form of didactic content and practical experience so that new graduates can be prepared to utilize them at the basic core level, be given a base on which to build their practices, and be tested for initial credentialing. These key competencies are described in detail in subsequent chapters and are not further elaborated here.

Scope of Practice

The term scope of practice refers to the legal authority granted to a professional to provide and be reimbursed for healthcare services. It is intended to protect the public from unsafe, unqualified healthcare providers. The ANA (2021) defined the scope of nursing practice as “… the description of the who, what, where, when, why, and how associated with nursing practice and roles” (p. 113). This authority for practice emanates from many sources, such as state and federal laws and regulations, the profession’s code of ethics, and professional practice standards. For all healthcare professionals, scope of practice is most closely tied to state statutes; for nursing in the United States, these statutes are the nurse practice acts of the various states. As previously discussed, APRN scope of practice is characterized by specialization; expansion of services provided, including diagnosing and prescribing; and autonomy to practice (APRN Joint Dialogue Group, 2008). The scopes of practice also differ among the various APRN roles; various APRN organizations have provided detailed and specific descriptions for their particular role. Carving out an adequate scope of APRN practice authority has been a historic struggle for most of the advanced practice groups (see Chapter 1), and this continues to be a hotly debated issue among and within the health professions. Significant variability in state practice acts continues, such that APRNs can perform certain activities in some states, notably prescribing certain medications and practicing without physician supervision, but may be constrained from performing these same activities in other states (NCSBN, 2021a). The Consensus Model’s proposed regulatory language can be used by states to achieve consistent scope of practice language and standardized APRN regulation (APRN Joint Dialogue Group, 2008).

Although more than 2 decades old, a report by the Pew Health Professions Commission (Finocchio et al. & Taskforce on Health Care Workforce Regulation, 1998) remains relevant today. The Taskforce noted that the tension and turf battles between professions and the increased legislative activities in this area “clog legislative agendas across the country (p. ii).” These battles are costly and time-consuming, and lawmakers’ decisions related to scope of practice are frequently distorted by campaign contributions, lobbying efforts, and political power struggles rather than being based on empirical evidence. More recently, while the National Academy of Medicine reported that progress continues on a state-by-state basis in achieving full practice authority for APRNs, there are still many states where APRNs have reduced or restricted practice authority (National Academies of Sciences, Engineering, & Medicine [NASEM], 2016; Phillips, 2021; see Chapter 20 for further discussion). In addition, the National Academy of Medicine highlighted the fact that medical staff member and hospital privileging criteria are inconsistent due to state laws as well as business preferences. Opposition by some physician associations and physicians is ongoing and has been a significant barrier. Much work remains to be done. The National Academy of Medicine recommended that the coalition of stakeholders to remove these barriers needs to be expanded and diversified to increase collaboration in improving health care for patients (NASEM, 2021).

Workforce Data

It is difficult to obtain accurate numbers for APRNs by role, particularly for those prepared as CNSs. The US Bureau of Labor Statistics has separate classifications for NPs, CRNAs, and CNMs in their Standard Occupational Classification listing, so some data are collected when the Bureau does routine surveys. However, CNSs are not listed as a separate role in the classification system; rather the role is subsumed under the general registered nurse (RN) classification (US Bureau of Labor Statistics, 2021a, 2021b). The Bureau of Labor Statistics has refused to add a CNS classification despite repeated attempts to convince them otherwise. Therefore the latest APRN role numbers are based on the respective organizational data for consistency (Table 3.1).

It is essential to have accurate tracking of APRN numbers by distinct role as well as by geographic distribution and basic demographic statistics. Gathering data only on select APRN roles or as subcategories of the RN role diminishes the profession’s ability to actively and appropriately advocate for patients on a national level for needed care that can best be provided by APRNs.

Four Established Advanced Practice Nurse Roles

Advanced practice nursing is applied in the four established roles and in emerging roles. These APRN roles can be considered to be the operational definitions of the concept of advanced practice nursing. Although each APRN role has the common definition, primary criteria, and competencies of advanced practice nursing at its center, each has its own distinct form. Some of the distinctive features of the various roles are listed here. Differences and similarities among roles are further explored in Part III of this text.

The NACNS (2019) has distinguished CNS practice by characterizing three “spheres of impact” in which the CNS operates. These include the patient direct care sphere, the nurses and nursing practice sphere, and the organizations and systems sphere (see Chapter 12). A CNS is first and foremost a clinical expert who provides direct care to patients with complex health problems. CNSs not only learn collaboration processes, as do other APRNs, but also function as formal consultants to nursing staff and other care providers within their organizations. Developing, supporting, and educating nursing staff and other interprofessional staff to improve the quality of patient care comprise a core part of the nurses and nursing practice sphere. Managing system change in complex organizations to build teams and improve nursing practices and effecting system change to enable better advocacy for patients are additional role expectations of the CNS. Expectations regarding sophisticated evidence-based practice activities have been central to this role since its inception.

NPs, whether in primary care or acute care, possess advanced health assessment, diagnostic, and clinical management skills that include pharmacology management. Their focus is expert direct care, managing the health needs of individuals and their families. Incumbents in the classic NP role provide primary health care focused on wellness and prevention; NP practice also includes caring for patients with minor, common acute conditions and stable chronic conditions (see Chapter 13). The acute care NP (ACNP) brings practitioner skills to a specialized patient population within the acute care setting. The ACNP’s focus is the diagnosis and clinical management of acutely or critically ill patient populations in a particular specialized setting. Acquisition of additional medical diagnostic and management skills, such as interpreting computed tomography and magnetic resonance imaging scans, inserting chest tubes, and performing lumbar punctures, also characterizes this role (see Chapter 14).

The CNM (see Chapter 15) has advanced health assessment and intervention skills focused on women’s health and childbearing. CNM practice involves independent management of women’s health care. CNMs focus particularly on pregnancy, childbirth, the postpartum period, and neonatal care, but their practices also include family planning, gynecologic care, primary health care for women through menopause, and treatment of male partners for sexually transmitted infections (ACNM, 2020). The CNM’s focus is on providing direct care to a select patient population.

CRNA practice (see Chapter 16) is distinguished by advanced procedural and pharmacologic management of patients undergoing anesthesia. CRNAs practice independently, in collaboration with physicians, or as employees of a healthcare institution. Like CNMs, their primary focus is providing direct care to a select patient population. Both CNM and CRNA practices are also distinguished by well-established national standards and certification examinations in their specialties.

These differing roles and their similarities and distinctions are explored in detail in subsequent chapters. It is expected that other roles may emerge as health care continues to change and new opportunities become apparent. This brief discussion underscores the rich and varied nature of advanced practice nursing and the necessity for retaining and supporting different APRN roles and titles in the healthcare marketplace. At the same time, the consistent definition of advanced practice nursing described here undergirds each of these roles, as will be seen in Part III of this text.

Implications for Advanced Practice Nursing Education

Graduate programs should provide anticipatory socialization experiences to prepare students for their chosen APRN role. Graduate experiences should include practice in all of the competencies of advanced practice nursing, not just direct clinical practice. For example, students who have no theoretical base or guided practice experiences in collaboration skills or clinical, professional, and systems leadership will be ill-equipped to demonstrate these competencies on assuming a new APRN role. In addition, APRN students need to understand the critical elements in healthcare environments, such as the business aspects of practice and healthcare policy that must be managed if their practices are to survive and grow.

All APRN roles require at least a specialty master’s education; master’s programs are continuing for the foreseeable future even as the DNP degree is being developed in many institutions. The profession has embraced a wide variety of graduate educational models for preparing APRNs, including direct-entry programs for non-nurse college graduates and RN-to-master’s of science in nursing programs. However, three of the four APRN professional organizations have endorsed doctoral preparation as entry into APRN practice (the AANA by the year 2025 [AANA, 2007], the NACNS by the year 2030 [NACNS, 2015], and the National Organization of Nurse Practitioner Faculties by 2025 [2018]). Ensuring quality and standardization of APRN education in the various specialties is imperative if the profession is to guarantee a highly skilled, uniformly educated APRN workforce to the public. The definition of advanced practice nursing used here can serve as a guide for developing quality courses and clinical practice experiences that prepare APRN students to practice at an advanced level.

It is imperative that nursing leaders and DNP faculty continue to provide increased clarity for the terms advanced nursing practice and advanced practice nursing. The differences between the two, despite being significant in the practice setting, are easily lost on the majority of RNs and even DNP graduates not prepared in an APRN role. Lack of clarity about this distinction has created ongoing problems as DNP graduates prepared in areas other than as an APRN confuse their combined graduate preparation and their RN clinical experience with being an APRN. This type of confusion about roles within nursing only perpetuates the ongoing lack of clarity when communicating with physicians and policymakers (Carter et al., 2013, 2014) and compromises the progress that APRNs have made in the practice arena.

Implications for Regulation and Credentialing

Significant progress has been made toward an integrative view of APRN regulation over the past decade, culminating in the LACE regulatory framework detailed in the Consensus Model. In particular, the primary criteria of graduate education, advanced certification, and focus on direct clinical practice for all APRN roles proposed in Hamric’s definition have been affirmed as the key elements in regulating and credentialing APRNs (APRN Joint Dialogue Group, 2008). Such internal cohesion can go a long way toward removing barriers to the public’s access to APRN care.

The Consensus Model has been an important unifying force within the APRN community. The regulatory clarity in this document has increasingly been seen in other national statements, and the work was highlighted in the Institute of Medicine’s (IOM) report, The Future of Nursing (IOM, 2011). The NCSBN has embarked on the “APRN Campaign for Consensus,” a nationwide effort to have this model enacted in all states. However, as of August 2021, only 16 states and two territories have fully implemented the Consensus Model into legislation (NCSBN, 2021b).

The IOM report also has given rise to action coalitions, funded by the AARP Foundation and the Robert Wood Johnson Foundation, in numerous states (Campaign for Action, n.d.). The Campaign for Action has a dual focus, implementing solutions to the challenges facing the nursing profession and strengthening nurse-based approaches to transform how Americans receive quality health care. Although the Campaign for Action is broader in scope than just advanced practice nursing, many of the solutions for transforming health care involve APRNs being able to practice to the full extent of their education. It is critically important for all APRNs to be aware of and involved in these efforts.

One implication for credentialing flows from the diverse specialty and role base of advanced practice nursing. APRNs must practice and be certified in the specific population focus and role for which they have been educated. APRNs who wish to change their specialty, population focus, or APRN role need to return to school for education targeted to that area. The days are past when a primary care NP could take a job in a specialized acute care practice without further education to prepare for that specialty. This issue of aligning APRN job expectations with education and certification is not always well understood by practice environments, educators, or even APRNs themselves. However, the need to ensure congruence between an APRN’s specialty, education, certification, role, and subsequent practice has been identified by regulators; more stringent regulations regarding this issue have been promulgated (NCSBN, 2021a).

Implications for Research

As noted in Chapter 8, one of the core competencies of advanced practice nursing is the use of an evidence base in an APRN’s practice and in changing the practice environment to incorporate the use of evidence. The practice doctorate initiative identified the increased need for leadership in evidence-based practice and for application of knowledge to solve practice problems and improve health outcomes as reasons for moving to the DNP degree for APRN practice (AACN, 2006); the emphasis has continued in the revised Essentials document (AACN, 2021). If research is to be relevant to healthcare delivery and to nursing practice at all levels, APRNs must be involved. APRNs need to recognize the importance of advancing the profession’s and healthcare system’s knowledge about effective patient care practices and to realize that they are a vital link in building and translating this knowledge into clinical practice.

Related to this research involvement is the necessity for more research differentiating basic and advanced practice nursing and identifying the patient populations that benefit most from APRN intervention. For example, there is compelling empirical evidence that APRNs can effectively manage chronic disease—preventing or mitigating complications, reducing rehospitalizations, and increasing patients’ quality of life. This evidence is presented in the chapters in Part III of this text and in Chapter 21. Linking advanced practice nursing to specific patient outcomes remains a major research imperative for this century. It is interesting to note the increasing research being conducted in international settings as more countries implement advanced practice nursing and study the effectiveness of these new practitioners.

Similarly, research is needed on the outcomes of the different APRN educational pathways in terms of APRN graduate experiences and patient outcomes. Such data would be invaluable in continuing to refine advanced practice education. Outcomes achieved by graduates from DNP programs need similar study in comparison to master’s-level APRN graduates; in critiquing the need for the DNP degree, Fulton and Lyon (2005) noted the absence of research data on whether there are weaknesses in current master’s-level graduates.

Finally, it is incumbent upon DNP faculty to ensure that APRNs understand their role in evidence-based practice vis-à-vis research. In fact, faculty themselves continue to struggle with knowledge and understanding of evidence-based practice and its use in the completion of the scholarly DNP project (AACN, 2015; Dols et al., 2017). Translational, evidence-based practice change, and quality improvement projects are the proper foci for DNP projects; such projects require a complex skill set that is the focus of DNP evidence-based practice courses. DNP students are not sufficiently educated in the particulars of the formal research process to be prepared to conduct independent research successfully, and faculty have an important responsibility to assist the student to identify an appropriate topic. Unfortunately, it is not uncommon to encounter APRN DNP projects that are not an implementation of evidence-based practice or a clinical change project to bring research evidence to influence practice, but rather involve the conduct of a research study. The DNP-prepared APRN is an evidence-based practice expert who evaluates and generates internal evidence, translates research into sustainable practice changes, and uses research to make practice decisions that improve the quality of patient care (AACN, 2021; Melnyk, 2016). Without this important understanding, nursing runs the risk of implying that advancing the science of nursing through research no longer requires PhD preparation. Such a misunderstanding could lead practice institutions to hire DNP graduates with the intention that they conduct rigorous independent research. It could also substantially delay the translation of research findings into clinical practice.

Implications for Practice Environments

Because of the centrality of direct clinical practice, APRNs must hold on to and make explicit their direct patient care activities. They must also articulate the importance of this level of care for patients. In addition, it is important to identify those patients who most need APRN services and ensure that they receive this care.

APRN roles require considerable autonomy and authority to be fully enacted. Practice settings have not always structured APRN roles to allow sufficient autonomy or accountability for achievement of the patient and system outcomes that are expected of advanced practitioners. It is equally important to emphasize that APRNs have expanded responsibilities—expanded authority for practice requires expanded responsibility for practice. APRNs must demonstrate a higher level of responsibility and accountability if they are to be seen as legitimate providers of care and full partners on provider teams responsible for patient populations. This willingness to be accountable for practice will also promote consumers’ and policymakers’ perceptions of APRNs as credible providers in line with physicians.

The APRN leadership competency mandates that APRNs serve as visible role models and mentors for other nurses (see Chapter 9). Leadership is not optional in APRN practice; it is a requirement. APRNs must be a visible part of the solution to the healthcare system’s problems. For this goal to be realized, each APRN must practice leadership in their daily activities. In practice environments, APRNs need structured time and opportunities for this leadership, including mentoring activities with new nurses.

New APRNs require a considerable period of role development before they can master all of the components and competencies of their chosen role, which has important implications for employers of new APRNs. Employers should provide experienced preceptors, some structure for the new APRN, and ongoing support for role development (see Chapter 4 for further recommendations).

As a result of government titling, it is becoming common in the practice setting to label APRNs (as well as physician assistants) as “mid-level providers.” The very use of this term for an APRN implies a hierarchical (and therefore a “less than”) structure for all of nursing. If the APRN is “mid-level,” then the implication is that the physician is at the top and the RN is thus positioned at the bottom of the care provider structure (Boyle, 2011). This is contrary to the reality that all healthcare providers bring unique and valued expertise to the care of patients; the professional leading the care at any given point in a patient’s health encounter is dependent on the needs of the patient and the provider with the corresponding expertise. This concern extends to the use of the term Advanced Practice Provider, which also combines APRNs with roles such as physician assistants. It is important that APRNs distinguish their roles when they are lumped into categories with other providers.

Finally, APRN roles must be structured in practice environments to allow APRNs to enact advanced nursing skills rather than simply substitute for physicians. It is certainly necessary for APRNs to gain additional skills in medical diagnosis and therapeutic interventions, including the knowledge needed for prescriptive authority. However, advanced practice nursing is a value-added complement to medical practice, not a substitute for it. This is true in both the primary care and acute care arenas; it may well be that substituting APRNs for physicians in classic, medically driven care configurations is not the best use of APRN skills. Because APRN competencies include those of partnering with patients, use of evidence, and coaching skills, APRNs may be more effectively used in wellness programs, working with chronically ill patients to strengthen their self-management and adherence, designing and implementing educational programs for patients with complex needs and facilitators of a coordinated approach in patients with complex acute care needs. New sustainable business models are needed that are more collaborative and configure teams in innovative ways to minimize fragmentation of care and make the best use of the APRN as a value-added complement to the traditional medical team.

As physician shortages increase, particularly the number of physicians prepared in family practice and hospitalist practices, this distinction between advanced practice nursing and medical practice must be clear in the minds of employers, insurers, and APRNs themselves. As advanced practice nursing evolves, it is becoming clear that APRNs represent an evident choice for patients seeking care. Consequently, understanding what APRNs bring to health care must be articulated to multiple stakeholders to enable informed patient choice. A competency-based definition of advanced practice nursing aids in this articulation, so that APRNs are not just seen as physician substitutes.