Identifying advanced practice: A national survey of a nursing workforce

Abstract

Background

The size and flexibility of the nursing workforce has positioned nursing as central to the goals of health service improvement. Nursing's response to meeting these goals has resulted in proliferation of advanced practice nursing with a confusing array of practice profiles, titles and roles. Whilst numerous models and definitions of advanced practice nursing have been developed there is scant published research of significant scope that supports these models. Consequently there is an ongoing call in the literature for clarity and stability in nomenclature, and confusion in the health industry on how to optimise the utility of advanced practice nursing.

Objectives

To identify and delineate advanced practice from other levels of nursing practice through examination of a national nursing workforce.

Design

A cross-sectional electronic survey of nurses using the validated Advanced Practice Role Delineation tool based on the Strong Model of Advanced Practice.

Participants

Study participants were registered nurses employed in a clinical service environment across all states and territories of Australia.

Methods

A sample of 5662 registered nurses participated in the study. Domain means for each participant were calculated then means for nursing position titles were calculated. Position titles were grouped by delineation and were compared with one-way analysis of variance on domain means. The alpha for all tests was set at 0.05. Significant effects were examined with Scheffe post hoc comparisons to control for Type 1 error.

Results

The survey tool was able to identify position titles where nurses were practicing at an advanced level and to delineate this cohort from other levels of nursing practice, including nurse practitioner. The results show that nurses who practice at an advanced level are characterised by high mean scores across all Domains of the Strong Model of Advanced Practice. The mean scores of advanced practice nurses were significantly different from nurse practitioners in the Direct Care Domain and significantly different from other levels of nurse across all domains.

Conclusions

The study results show that the nurse practitioner, advanced practice nurse and foundation level registered nurse have different patterns of practice and the Advanced Practice Role Delineation tool has the capacity to clearly delineate and define advanced practice nursing. These findings make a significant contribution to the international debate and show that the profession can now identify what is and what is not advanced practice in nursing.

Introduction

Nursing work is conducted in a range of service contexts, on patients of varying levels of complexity and clinical urgency. It is undertaken in a variety of specialty fields, with populations across the lifespan, and with individuals or communities in health and illness. As such, nursing easily traverses what Thoun (2011) described as the vast array of biological, demographic and geographic foci of health care. This range dictates that nursing practice is not a uniform activity; nurses work with variable levels of expertise, depths of knowledge and practice profiles.

Over the past two decades, this flexibility in service delivery and graduated levels of expertise have situated nursing as central to the goals of reducing spiralling health care costs and addressing health inequity on a global level (Commonwealth of Australia, 2009). Meeting these goals is important for health care providers to achieve health service improvement in a landscape that is increasingly complex with high cost drivers for change. Researchers have reported that the creation and growth of nursing roles has been effective in addressing short term problems of service delivery but the consequence has been uncoordinated development of nursing with a confusing array of practice profiles, titles and roles (Duffield et al., 2008). Furthermore, the authors assert this development has occurred in the absence of evidence-informed service planning.

The area of advanced practice nursing is particularly exposed to ad hoc service planning at the local level by service managers and medical specialists and at the macro level by government bodies and health services experts (Health Workforce Australia, 2010). Furthermore, development of these new roles often progresses without formal and broad-based consultation with the profession (Victorian Department of Health, 2010). In part, this is a consequence of the confusion and lack of consensus related to the meaning of advanced practice nursing.

The volume of research papers, scholarly discussion and polemic debate in the peer-reviewed international literature relating to advanced practice nursing is vast, attesting to the quest to progress and refine knowledge about this evolving level of nursing service and its impact on patient outcomes (for example: Currie et al., 2007, Jones, 2005, Lowe et al., 2012, Newhouse et al., 2011, Pulcini et al., 2010, Thoun, 2011). Paradoxically, this international body of literature also contributes to perpetuating the confusion by continuing to assert its nature with scant attention to systematically debating the core issues. The continuous and uncritical use of advanced practice nursing as a label to cover and capture the diversity of nursing practice and nursing roles that are beyond the foundation level of practice is at the core of the confusion.

Much of the extant literature fails to delineate the practice profile of advanced practice nursing titles from other levels of nursing, nor does it provide operational definitions for the level and type of nursing practice that is being discussed, debated and researched. In many reports the advanced nature of the practice beyond that of the title advanced practice nurse is not revealed at all or not until well into the manuscript.

Of more concern is that on an international level a range of influential documents and web sites support the existing confusion. For example, the UK Position Statement (United Kingdom Government Department of Health, 2010) and the Canadian Nurses Association Position Statement (Canadian Nurses Association, 2008) on advanced practice nursing provide generic statements and ‘nationally agreed elements’ or ‘characteristics’ of advanced practice but give no attention to the potential for difference in practice between, for example, the nurse practitioner role and other advanced practice patterns of nursing. Similarly, the much cited International Council of Nurses’ definition of advanced practice nursing (International Council of Nurses, 2005) is multipurpose and applies to any senior clinical nursing role that may fall under the umbrella of advanced practice, without attention to varying legislated frameworks of practice. In an attempt to be universally meaningful and ‘represent current and potential roles worldwide’, the International Council of Nurses’ definition lacks utility (Gardner et al., 2013, Jokiniemi et al., 2012).

The many definitions and descriptions that are offered in these and other publications (International Advanced Practice Nursing Symposium, 2014, Nursing and Midwifery Board of Australia, 2014) reflect what we readily accept would be elements of advanced practice nursing. They speak to the values and practices easily recognised as central to the best of nursing practice. However, these definitions are mostly attribute-focused and not developed from robust research that takes the question of what is advanced to examination of the practice of nursing in the service context.

Some progress has been made to clarify advanced practice nursing across nations. Thoun (2011) published a scholarly discussion paper that critiqued the distinction between advanced practice and specialty practice. She proposed that the difference was ‘one of depth, extent and complexity addressed at different levels of education’ (p. 220). Thoun asserted that specialist education has its foundation in the undergraduate, entry to practice degree where on-going study and practice experiences foster awareness of nursing specialities. Following undergraduate studies, nurses are in a position to then pursue specialty, competency-based education. Conversely, advanced practice education is characterised by in-depth study at the postgraduate master's level; this position is supported by recent research into nurse practitioners (O’Connell et al., 2014). Furthermore, Thoun (2011) argued cogently that the term advanced characterises practice not nursing; the latter she asserted is the academic and practice discipline. This distinction is meaningful and gives semantic support and substance to the term advanced practice nursing in contrast to advanced nursing practice and informs a side-running debate that has lacked this level of argument (Stasa et al., 2014). Whilst Thoun's (2011) paper makes an important contribution to bringing clarity to the discussion on advanced practice nursing her critique does not address the problem of disparate practice profiles that are covered by the term.

The research reported in this paper draws upon prior research in this field. This includes research to identify an advanced practice nursing model of practice (Gardner et al., 2007); testing and validating a survey tool based on the advanced practice nursing model for the Australian context (Chang et al., 2010), establishing construct validity of the tool (Chang et al., 2012) and administering the amended and validated questionnaire to examine a sample of the nursing workforce in one Australian jurisdiction (Gardner et al., 2013).

This research applied this advanced practice nursing framework and the validated tool with permission from the authors to survey a national sample of registered nurses. The study aim was twofold, (i) to map titles of nurses across the eight Australian jurisdictions and describe the patterns of practice according to position title, and (ii) to identify and delineate advanced practice nursing from other levels of practice. The study outcome reported here was to bring an evidence base to definition and description of the activities, level and practice domains of advanced practice nursing.