Advanced Practice Roles

Original article

The development of advanced practice roles: implications in the international nursing community
S. Ketefian1 EdD, RN, FAAN, R. W. Redman2 PhD, RN, S. Hanucharurnkul3 PhD, RN, A. Masterson4 MN, BSc, PGCEA, RN & E. P. Neves5 DNSc, RN
1 University of Michigan School of Nursing, Ann Arbor, MI, USA 2 Professor and Associate Dean, Academic Affairs, School of Nursing, University of Colorado Health Sciences Center, Colorado, USA 3 Professor of Nursing, Ramathibodi School of Nursing, Mahidol University, Bangkok, Thailand 4 Director, Abi Masterson Consulting Ltd, Southampton, UK 5 Professor of Nursing, Federal University of Santa Catarina, Visiting Professor, State University of Rio de Janeiro, School of Nursing, Rio de Janeiro,
Styles (1996) identified foundational factors that were necessary for the development of defined AP roles. These included health needs in society, support for innovation in health care delivery, governmental health policy and regulation, health workforce supply and demand issues, the nursing profession’s support for new roles, development of advanced education, and the development and dissemination of a significant research base. Bigbee (1996) analysed the development of AP roles as a function of organizational and educational development and inter- and intraprofessional dynamics. Komnenich (1998) conducted interviews with key nurse leaders involved in the development of each type of APN. This analysis focused on factors in the socio-political environment, the leadership within nursing, the influence of private and public agencies, and the contribution of educational institutions. While each of these analyses contributes a unique perspective, there are also commonalties among all of them. Common critical elements we posit here include the influence of: the socio-political environment; health needs in society; health workforce supply and demand; governmental policy and support; intra/interprofessional collaboration; development of nursing education; and documentation of
While nurse anaesthesia and nurse midwifery initially developed educational programmes outside nursing, for the most part they have now become aligned within university-based nursing programmes. CNS and NP programmes began predominantly in colleges of nursing, where they are firmly based today. As the knowledge base in nursing developed from the midcentury to the present, APN preparation became well established in graduate education in nursing. Clearly, education has been a significant force in the development of each APN role, with a gradual movement over time towards postbaccalaureate education (Komnenich 1998). Documentation of effectiveness of the advanced role has been central for all types of AP roles. Early in the 20th century, the pioneering efforts of both nurse anaesthetists and nurse midwives were documented in improving the health and clinical outcomes of patients (Styles 1996; Komnenich 1998). This research and documentation of positive outcomes continues today with an examination of the effectiveness of NP roles (Mundinger et al. 2000). Evidence of the contributions made by nurses in APN roles in terms of quality, cost-effective health care and access has been essential to the ongoing advancement of all nurses. Several factors continue to challenge the APN role (Joel 1998). These include: • reimbursement issues – when available, it is often at levels less than what physicians would receive, • prescriptive authority varies considerably