Advanced practice nurse education in its infancy: an exploratory study of Norwegian higher education institutions’ program descriptions

ABSTRACT There is a growing worldwide interest in educating nurses at an advanced level. Advanced practice nursing (APN) refers to an umbrella term for master-educated nurses working within expanded nursing practice. Previous APN research has primarily addressed comparative characteristics of education globally and several aspects related to practice after graduation. This study aimed to explore how higher education institutions position and legitimize APN as an education requisite for nurses, the health care system, and society. Program descriptions of relevant educational programs in the Norwegian context were analyzed using documentary reality construction. The findings point to how APNs are positioned to have a prominent contextual perspective, which are given precedence over direct patient care, legitimized through descriptions of societal problems and demands. This paper argues that APNs are positioned to hold individual responsibility to solve unmet societal demands.


Introduction
There is a growing worldwide interest in educating nurses at an advanced level.The International Council of Nurses (2020) defines advanced practice nursing (APN) as an umbrella term for mastereducated nurses working within the expanded nursing practice.Since there is a wide variety of educational requirements, regulations, and scopes of practice around the globe (Heale & Rieck Buckley, 2015;Pulcini, Jelic, Gul, & Loke, 2010), the term maintains that context shapes the characteristics of APN practice in each setting.
Compared to other World Health Organization regions, regulatory mechanisms and processes in nursing education are generally high in Europe (World Health Organization, 2020); however, European countries still report less frequently on the existence of advanced nursing roles (World Health Organization, 2020).To unify higher education systems in European countries, including nursing education, the Bologna Declaration was adopted.German-Millberg et al. (2011) argue that the Bologna Process was a driver in shifting the view on knowledge obtained from master's degrees from one that is elitist to one that is more accepting of the possibility that every nurse can advance their education.The declaration aimed to ensure comparability, compatibility, and coherence across higher education systems and facilitate the free movement of EU citizens (Lahtinen et al., 2014).This process led to a shift from vocational training in nursing to nursing degrees through the higher education system and is grounded on the European Credit Transfer and Accumulation System (ECTS), which allows credits to be transferred across countries and institutions.However, despite the Bologna Process, APN education and practice is still characterized by a lack of standardization across Europe (Collins & Hewer, 2014).Throughout the Scandinavian countries alone, considerable differences occur within nursing education from the bachelor's degree to the PhD level (Råholm et al., 2010).
An extended discussion of the consensus on APN education focuses on the concepts of knowledge, skills, and competence within APN education.Many have approached this subject (Bridges, 2015), where Fagerström has been a central figure in the Nordic countries.Fagerström (2021) presents the philosophy of knowledge in advanced nursing through Aristotle's concepts of knowledge.She argues that advanced clinical skills consist of a synthesis of theoretical-scientific knowledge (episteme), practical skills (technê), and practical wisdom (phronesis), brought to light through the nurse's approach to and care for the patient.Independent clinical competence is developed through different parts of knowledge being "combined into a meaningful and fruitful whole" (p.237).In Swedish higher education institutions (hereinafter HEIs; singular: HEI), German-Millberg et al. (2011) identified this amalgamation incorporating professional and academic objectives within specialized nursing education to raise tension among employees with regards to their views on learning.
In Norway, APN education is in the infancy of regulation and implementation.In 2011, the first HEI offered a designated APN education for nurses in Norway, focusing on geriatric nursing (Fagerström, 2021;Henni et al., 2018).The Ministry of Health and Care Services (2015) welcomed the initiative, encouraging other HEIs to progress the initiative, envisioning APN as a changing division of labor in primary care services.Before this initiative, nurses in Norway with at least two years of clinical experience could pursue further education opportunities within anesthesiology, childcare, intensive care, cancer care, scrub nursing, public health, and midwifery.These education pathways are statutory and the content is regulated by law and consists of 60 or 90 ECTS, allowing nurses to graduate as specialist nurses within their respective field.Students can integrate an additional 60 or 30 ECTS to achieve a master's degree of 120 ECTS, which allows them to earn both a master's degree and a specialist nurse certification.Even though some of these roles are often included under the APN umbrella internationally, their establishment in the clinical and legislative fields separates them from the generalist APN recently established.Thus, our study focuses on master's education programs for nurses without a regulated and targeted scope of practice, as described by The Ministry of Health and Care Service (2015).
Despite a lack of conformity of education regulation, APN education has been compared in international research.Jeffery et al. (2020) compare admission criteria, curricular content, clinical requirements, teaching methods, and program delivery and assignment, and evaluative methods across six countries.Pulcini et al. (2010) mapped APN education, titles, roles, and support through an international survey with respondents from 32 countries.Through their scoping review of publications on education content, Ljungbeck et al. (2021) concluded that the focus of education should be on nursing rather than medicine.
Education and health care systems are in dynamic development, dependently and independently of each other, where research in one field can introduce broader policy change in the other (e.g., task shifting) (Maier & Aiken, 2016).The broad body of APN research has addressed aspects after graduation, including patient outcomes and practitioner roles.Reviews show that the implementation of APN roles in a critical setting improves outcomes, yet the evidence is inconsistent due to low-quality studies (Audet et al., 2021;Woo et al., 2017).Systematic reviews describing the role and impact of APN on psychiatric and mental health patients, as well as on those with hip fractures, revealed that the characteristics of the role are evident (i.e., positive impact on patient outcomes) despite its unclear definition (Allsop et al., 2021;Scheydt & Hegedüs, 2021).Nursing research in Norway has primarily been concerned with solving patients' health care needs and addressing the health care systems' problems, but it has neglected education issues, particularly higher levels of education (Bjørk, 2019).
Despite the existing body of research, Jakimowicz et al. (2017) highlighted that APN has no sustainable legitimacy in general practice and that much work remains to establish and maintain this legitimacy.We have not been able to identify any studies that explore how HEIs position and legitimize APN through education programs.Using Norway as a case, we aimed to obtain knowledge on APN in a context where the education reform was initiated before broader legislative regulation is established and implemented.This study aimed to explore how APN is constructed through HEIs' program descriptions with the following research questions: 1. How is APN legitimized?2. How is APN positioned in health care services?

Materials and methods
Guided by the aim and research questions as stated above, an explorative approach of program descriptions was utilized to inform this study.We regard documents in line with Prior (2003) as social products through their production in a social setting.Every document contains several assumptions, concepts, and ideas that reflect the agents who produced it.When understanding documents within this scope, HEIs produce documents, and transform circumstances and people into documentary forms; more precisely, they create documentary realities (Atkinson & Coffey, 2004).Program descriptions are documents that become a product of "bureaucratic rules, ideologies, knowledge, practices, subjectivities, objects, outcomes, and even the organizations themselves" (Hull, 2012).

Data selection
We collected program descriptions from HEIs to inform the aim of the present study.In the Norwegian education system, the Norwegian Agency for Quality Assurance in Education, a public regulatory body, accredits education institutions and educational programs based on program descriptions.As regulated by law, the program description contains "the academic content of the study programs, including provisions concerning required courses, practice and the like and concerning forms of assessment" ( §3-3; University and University Colleges Act, 2005).Moreover, it serves as a tool for students and teachers in planning and management of expectations of educational programs.The program descriptions were collected in the fall of 2020.We used Database for Statistics on Higher Education to identify relevant program descriptions for inclusion.The data warehouse, organized under the Ministry of Education and Research, contains data on educational institutions and programs for steering and decision purposes (Directorate for Higher Education and Competence, 2021).We used the database by searching for master programs offered in 2019 and 2020 within health.In instances where the same program was offered in both years, we included the program description from 2020.We included programs, where bachelor's in nursing or equivalent, was the admission criteria and that the program offered any form of supervised practice studies during the program.As outlined in the introduction, we excluded programs of statutory further education programs within nursing modified or offered as master's degrees.
The search provided 169 educational programs across 17 institutions.We consulted the respective website of each HEI to obtain more information about the programs.Master degrees with nursing as the only eligible inclusion criteria constituted 55 educational programs, of which 34 were identified as statutory further education programs offered as master's degrees and thus excluded.Of the remaining 21, we identified six educational programs without supervised clinical training, focusing on the academic and theoretical aspects of nursing.In total, 15 educational programs were included (Table 1), and we downloaded the associated program descriptions from HEI websites (for details, please see Appendix).Eight websites contained PDFs of program descriptions, and for the remaining seven, we downloaded HTML versions of information connected to the aspects presented in PDFs.Thus, the material included differed in presentation and flow, and the written word was the focus of the analysis.We were able to identify all aspects of the program descriptions in the HTML format from HEI websites.The PDF and HTML documents were processed using NVivo 12, where the text was extracted and used for analysis.

Analytical approach
We developed an analytical approach for this study through an iterative and flexible process.This allowed us to develop a thorough understanding of the material through analysis (Hammersley & Atkinson, 2019).The final analysis presented in this article consists of three continuous and overlapping phrases: familiarization with the material, analyzing learning outcomes, and analyzing legitimization discourse.
When first approaching the documents, we utilized Atkinson and Coffey's (2004) exploration of documentary reality construction.By reading and re-reading the included program description, we acquired a basic understanding of the form and language of the documents.We sought to explore the program description genre through this process: the implied readers of documents and their distinctive use of linguistic registers (Atkinson & Coffey, 2004).These registers specialize in using language associated with a particular domain of everyday life (Atkinson & Coffey, 2004).This process included recursive discussions between the three authors relating to general impressions while discussing specific excerpts of texts focusing on analytical impressions and ideas.The strict structure of the texts allowed us to compare the same textual elements from each document and identify the differences and similarities related to these analytical ideas.Thus, we chose to use this division of the text in the following steps of the analysis.
Secondly, learning outcomes may be seen as a culmination of HEIs expectation of what the student should know by graduation, and thus, an expression of what the institutions interpret that they offer.Therefore, we analyzed learning outcomes as core building blocks to understand how HEIs position APN in health care services.The analysis focused on coding the content of each learning outcome, and through discussions between the authors, we identified that the learning outcomes represented (i) the nursing practice (nursing), (ii) the recipient of nursing (patient), and (iii) the context in which nursing practice occurs (system).Examples from the coding process are presented in Table 2.These codes occurred either as a single code (example system) or in relationship with another code (example nursing-patient) with each learning outcome.Where no relationship between codes was identified, we marked them single code.The frequencies of codes are presented in Table 3.Finally, we focused on an in-depth analysis of legitimizing discourse in the material (Van Leeuwen, 2007).More precisely, we examine if and why APN education is important and why it should be conducted a certain way.Here, we sought to understand how the broad strokes of HEIs construct legitimizing APN, using Van Leeuwen's (2007) four concepts of legitimization: (1) legitimation by reference to the authority of tradition, customs, and law, or persons; (2) legitimation by reference to value systems; (3) legitimation by reference to goals, institutionalized social action; and (4) legitimation through narratives.Using the material's analytical framework, we identified legitimizing through (1) authority by reference to tradition, customs, and law, and (3) rationalization by reference to goals and institutionalized social action as prominent discourse strategies.We chose to focus on these two concepts in the final analysis.The classification of legitimizing discourses allowed us to explore how HEIs position APN education within an authority and rationalization discourse.
The method employed to answer the aim of this study enabled a combined approach that, first, provided an overview of documentary realities and then allowed scrutiny of text extracts focusing on HEIs' positioning and legitimization of APN in depth.

Results
The presentation of results is structured as follows: First, we provide an overview of the documents' characteristics and the genre they outline.Second, we present the results of an in-depth analysis focusing on legitimization and positioning.

The program description genre
As shown in Table 1, the focus of the included educational programs differs.Their names refer to particular parts of health care, within areas of illness or nursing.From the first outlook, the program descriptions as textual products seem similar and follow the same structure.There is a general part and a specific part for each program, with a rough outline between them.The first paragraph(s) of the text is named introduction, background, presentation of the program, aims of the program, or information on the program.The text that follows ranges from a few sentences to multiple pages and consists of arguments related to current health care descriptions or possible future health care descriptions, often on laws and/or white papers.After the introductory text, expected learning outcomes are outlined, and dispersed between knowledge, skills, and general competence.Between the program descriptions, the number of learning outcomes ranged from 11 to 46.Following the learning outcomes, practical information aimed at students, teachers, and prospective students are outlined, including target group and admission requirements, relevance for work and studies, teaching and assessment methods, and internationalization.The general part ends with a schematic presentation of the courses with the program cycle.The specific part that follows presents each course from the scheme, with content, learning outcomes, teaching and assessment methods, and course requirements.
In content, the textual elements within the documents are characterized by an overall variety in the levels of abstraction.This was identified in all parts of the documents, both in the wording of practical information and in more general argumentation.For example, one of the courses, Health Assessment (15 ECTS), outlines content in nine bullet points, where one is clinical assessment methods, including "inspection, palpation, percussion, and auscultation."Another course, Systematic Documentation and Assessment of the Patient's State of Health (5 ECTS), presents five bullet points as central themes for instruction, including systematic documentation and assessment of the patient's overall state of health.The former concerns particular methods and skills that are commonly associated with medical practice.The latter focuses on systematic assessment without a similarly defined practical skill set.Thus, beyond a similar structure through bullet points concerning content within a similar aspect of APN practice, detailing and the necessity to describe elements in detail among program descriptions differ.We could not identify the reason for this discrepancy within and between program descriptions.
We also observed a similar pattern, beyond the differences in abstraction, regarding how HEIs position themselves differently concerning similar topics.Here, the differences in positioning are exemplified by two learning outcomes from the two HEIs: Interact with patients/users, their next of kin, and other health professionals in planning, organizing, and implementing measures in health care services.Independently plan, implement, document and assess the performance of advanced clinical neonatal nurses in close dialogue and interaction with the child and the family so that the child's caregivers are empowered in the parental role and participate as partners in the child's treatment team.
These two learning outcomes concern the same topic in many aspects, including the patient's and others' presence inpatient care and user participation.However, their positioning toward user participation is different.The first highlights user participation as necessary in delivering health care services overall, and the second places its importance within the scope of nursing practice specifically.Both these learning outcomes exemplify how HEIs construct user participation as an aspect of delivering health care services; however, the first construct its importance within a broader context rather than as a part of nursing practice as the second.
Through exploration of implied readers of the program descriptions, we interpreted it as tied to the formal and informal justification of the document's existence.The law regulates the existence and some of the content, thus pointing to a government control function.Moreover, we identified elements of the text portrayed as an information booklet for students.On the one hand, there are student possibilities, such as internationalization, and on the other, work requirements with possible consequences of not completing them and clarification of expectations toward students: The course is estimated to entail a total of 400 h of work including scheduled teaching, self-study, course requirements, exam preparations, and the exam.
Because of the timing of admission, some courses state the possibility of deviations from the course plans due to the COVID-19 pandemic.In addition, some courses are labeled as examples from earlier years, with the explanation of course descriptions not being finished in time for student admission.Consequently, there is wiggle room in the realization of the plans outlined in the documents; however, these statements point to a traditional understanding, where changes, if made, are already planned for.

Legitimizing APN through a reality description of societal problems and demands
Using Van Leeuwen's (2007) concepts of legitimizing through authority and rationalizations allowed us to analyze documentary realities and learn how HEIs construct an answer as to why there is a need for APN and why it is needed in such a way.The following section presents what we interpreted to represent legitimizing discourses based on authority and rationalization.We utilized quotes from the introductory texts to highlight the findings of our analysis.
Legitimizing arguments based on authority was constructed by establishing a set of demands.These demands originated from presenting laws and white papers or statements on the public's demand for health care.Subsequently, each demand is countered by arguing that the implementation of APN would alleviate these demands.One program description includes the following: A master's degree program in advanced nursing in chronic disease will assist in meeting the competence requirements for public health and organizational changes that the Norwegian Health Service demands; proper treatmentat the right place and right time (White paper on the coordination reform [2008/2009]).
In this excerpt, the argument is closed by explicitly referring to a white paper.Moreover, the sentence's last part following the semicolon is the subheading of the white paper.Thus, legitimizing APN in this example is based on the demand for a general lack of competence in the health care services, as they present the referred white paper to address.We interpret it as HEIs legitimize APN through authority, where they present their description of how authorities have addressed relevant elements of legitimizing APN practice, without the authorities specifically pointing to APN itself.
The same logic is used in legitimization through rationalization.APN is the solution to a patient rooted problem that the program descriptions present, as shown in this example: Diabetes Mellitus is a chronic disease that is very prevalent.Statistics indicate that over 350 000 people in Norway are currently affected by diabetes, with only half of this population being aware that they are diabetic.It is essential for the health service to have the necessary expertise and adequate access to well-qualified personnel who can provide care for this patient group in the future.The expertise gained by candidates who have completed the master's degree program in clinical diabetes nursing allows them to provide the information, support, and guidance to patients and their family members that are central to their care.
First, they present a problem statement (many people have diabetes, and half of them do not know it), followed by the solution (APN-educated candidates).Second, we theorize that the breach in this excerpt, from a patient description to a system need for competence, points to patients being presented as the root cause of problems in the system, where nurses can resolve the system's problem and thus assist the patients' needs.The following example further illustrates this by expressing how the patient is part of a system demanding nurses to focus on systemic improvement for better patient care: An APN will take independent responsibility for clinical assessments and decisions on an individual as well as a system level, as well as taking responsibility for independently evaluating the results of outcomes of procedures and service provisions.

Positioning APN in health care
When coding learning outcomes, we used three codes-patient, nursing, or system-to reflect the perspective from which each learning outcome positioned APN.Moreover, each code was coded once or twice depending on the linguistic structure.We found that 18% of the codes represented the patient, 31% represented nursing, and 51% represented the system.Furthermore, we identified the relationship of codes within each learning outcome.The overall number of learning outcomes related to the system was the most prominent, as outlined in Table 3.The nursing codes show differences in knowledge outcomes and general competence.Nursing-patient-nursing within a patient context-was most frequently characterized as a knowledge learning outcome.Nursing-nursing, which uses nursing competence within a nursing context, and nursing-system, which uses nursing within a system context, were most frequently characterized as a general competence.Thus, APNs are expected to have knowledge of the patient related context while also having the competence to practice in the system context.The patient perspective is overall less frequent.Our analysis points to a systemic HEI construction of the APN position in health care.As the most mentioned elements among knowledge, skills, and general competence in learning outcomes related to the system, we emphasize the need for HEIs to position APNs within the societal perspective of nursing practice.
Based on the analysis above, we explored the course names of the included educational programs, as they were named in the program descriptions.When considering ECTS, most mandatory courses are either the master's theses or research and development subjects (53% of ECTS in total).All of the included educational programs have one or more generically named courses of (something) nursing related to the context of practice or aspects of practice, i.e., Advanced Clinical Nursing in Primary Care and Palliative Nursing 1 (23% of ECTS in total).The remaining mandatory ECTS (24% of ECTS in total) across programs have different foci presented in their names, with some focusing on natural science subjects, such as pharmacology and pathophysiology, and others focusing on health assessment, ethics, communication, and more.The distribution of the themed course names is presented in Table 4.

Assigning societal responsibility and motivation to the individual
Both the legitimizing and learning outcome analyses revealed a strong system focus in program descriptions.Moreover, the analysis provided indications of possibilities and responsibilities for the individual student toward the system: A nurse who holds a master's degree is qualified to meet the ever-increasing demands of nursing practice.These involve meeting the requirements for research-based, independent, and remedy-focused expertise within a health service characterized by changes and task shifting between health professionals.
Legitimizations through authority pointing to requirements of nursing practice, and rationalization pointing to systematic problems, are written as resolved by the individual responsibility to fill this gap.Moreover, by practicing and educating oneself to accommodate given demands and problems, the graduate can and will have a substantially positive impact on multi-level nursing practice according to program descriptions: An advanced practice nurse will, through professional management, be able to assist with and assume shared responsibility in ensuring comprehensive patient trajectories, provide patient care during critical transitions, and contribute to safe, effective, and coordinated services, with the proper use of resources.
The program descriptions underline an underlying personal motivation for prospective students to accommodate the problems, requirements, and gaps of the health care system that affect and are affected by patients: The target group for this program is nurses who wish to increase their levels of competence to meet the requirements within clinical hospital departments and in parts of the primary health service that require specialist knowledge and skills connected with complicated and critical disorders.
Thus, given that the individuals pursue education, we interpret that they are subordinate to the health care system, yet are in a position to reform it as they want to take independent responsibility for matters outside their direct scope.APN education is presented as a solution to several structural problems in the contextual practice of nursing.HEIs construct the individual APN as one that is within a position to reform the health care system, given the earlier presented legitimization, where the focus is beyond the individual nurse, but personalized through his/her ability to have a substantial impact on the system as they wish.

Discussion
This is the first study to explore how HEIs construct APN through program descriptions in Norwegian education.By exploring documentary realities, we identified the text constructing APNs as a solution to several structural problems in health care.Our analysis has demonstrated how the documents position health care services as the intended primary beneficiary of nurses with APN education, despite also arguing the patient-related aspects and overall organization of care requiring change.Legitimizing the existence of the educational programs targets systems more prominently than nurses and patients, suggesting a politicized argumentation.HEIs' construction of APNs as a system actor further raises the question of their understanding of health care systems and their institutional role in this understanding.Despite focusing on the legitimization of APN education, the construction identified through HEI documents in this paper can be seen as an expression of the lack of definition of the role of APN in studies (see Allsop et al., 2021).An important subject related to such a role in APN literature is the possibility and the extent of the task shifting between physicians and APNs (see Maier et al., 2016;Martínez-González et al., 2015).Similarly, when arguing for APN education, the Norwegian Ministry of Health and Care Services (2015) referenced research focusing on comparing APN practice to physician care, arguing that patients are more satisfied with the care they receive and that they do not experience any negative health effects.However, Browne and Tarlier (2008) argue that valuing APNs on their physician replacement value is problematic for the long-term sustainability of the role, based on experiences in early development in Canada.More extensive research focusing on the manifestation and construction of APNs and their role following the education explored here is needed to gain a better understanding of the education's outcome in the Norwegian context.
Hamric's integrative model of APN outlines "seven advanced practice competencies with direct care as the core competency on which the other competencies depend and environmental and contextual factors that must be managed for advanced practice nursing to flourish."(Arslanian-Engoren, 2019, p. 41).Similarly, Fagerström (2021) uses Aristotle's three concepts of knowledge to express an argument of care for and approaching the patient revealing their competence, and thus of centrality to APN education.Our analysis points to implicit patient-related care and the construction of nurses responsible for reforming health care.Direct patient care is mentioned where it can materialize as an example of a grander goal for reformation; thus, our analysis questions whether these concepts of knowledge are equal to the HEI construction of APN or patient care being a matter of course.The International Council of Nurses (2020) problematizes the continuum of APN roles, from professional development, organizational leadership, research, and education to extended clinical functions.Our analysis points to HEIs having a stronger focus on the former than on the latter.
This study reports findings where HEI presents APN graduates as empowered and in a position to impact patient care and general health care significantly.Contandriopoulos et al. (2016) argue that the integration of nurse practitioners can trigger desirable disruptive changes in Canadian primary health care, where nurse practitioners are one of the specific roles under the APN umbrella.Henni et al. (2018) showed that the first APN graduates in Norway recognized that their efforts were essential to obtain the opportunity to apply their knowledge and skills outside the educational institution.Our analysis has shown that the program descriptions construct individual motivation and responsibility for societal issues.Our findings further pose the question of the construction of APN as an enthusiastic patient caring revolutionary or involuntary martyr.Adverse job characteristics are associated with burnout in nursing (Dall'Ora et al., 2020).With the added responsibility of reforming a system and the personal efforts to practice for patients dependent on a few individuals, one can ask about the personal cost of being responsible for the disruptive change.

Limitations
This study aimed to address documentary reality construction in one type of document from an educational pathway for nurses in Norway.First, this study only provides a glimpse into the complexity of written HEI documents and does not intend to provide evidence of the direct social world, even though we argue that the documents are social products (Atkinson & Coffey, 2004).Second, it is crucial to note that the documentary analysis was preformed and based on written material in one language, whereas the results are presented in another.We acknowledge that performing a linguistic analysis, where language is the main subject, impacts the study.However, we find that the results are of importance for the international community.Moreover, in order for the quotes included in the article to allow the reader to assess and interpret our analysis, we commissioned a professional translation service to ensure that a layer of interpretation from the authors was not added in the process.Finally, the educational programs and program descriptions included in this study were collected during a turbulent time between the Ministry of Health, the Directorate of Health, and Education Institutions.During the last few years, an active debate pointing to a closer consensus seems to have been achieved between them regarding what APN should achieve in Norwegian health care.We argue that the public discussion has added an essential viewpoint to the discussion of the direction of APN education and, subsequently, APN implementation in the Norwegian setting, whereas the results for practice need to be examined through additional studies.

Conclusion
By exploring the education institutions' publicly available documents governing clinically-oriented master educational programs for nurses, this analysis revealed an explicit system focus and implicit clinical focus.The forefront of legitimizing APN education in Norway is related to unmet demands from authorities in the health care system, rationalizing system change for patient-induced problems.The positioning of the APN is closely related to the health care system.Health care is described as involving systemic problems and unmet demands with strong expectations that APNs have a responsibility to solve as individuals.

Appendix
Table A1.Links to education program website sourced for the analysis, and the date of download.

Institution
Focus

Table 1 .
Presentation of clinical master program options for nurses in Norway, as included in this study.Focus areas of the programs are based on the names of the program.bThe clinical training in each program is presented inhours.Hours that were not specified beyond weeks or days were calculated using the following formula: day = 7.5 h, week = 30 h, and in interval descriptions (e.g., 5-6 weeks); the highest number was used.Instances where such calculation was performed are marked by *. a

Table 2 .
Example of the coding procedure of learning outcomes.Code relationships within knowledge, skills and general competence, as well as a learning outcome as a single code, are exemplified.

Table 3 .
Presentation of findings from the learning outcome analysis, presenting relationships between codes in the same learning outcome.The table is sorted according to the total instances of each relationship identified across all types of learning outcomes.

Table 4 .
Distribution of subjects within themes, based only on course names.