Collegian
Volume 16, Issue 2 , Pages 55-62, April 2009

Advanced nursing practice: A global perspective

  • Christine Duffield, BScN MHP PhD RN

      Affiliations

    • Centre for Health Services Management, University of Technology, Sydney, Australia
    • Corresponding Author InformationCorresponding author at: University of Technology, Centre for Health Services Management, Office Level 7, 235-235 Jones St, PO Box 123, Broadway (City Campus), Sydney, NSW 2007, Australia. Tel.: +61 2 9514 4831; fax: +61 2 9514 4835.
    • ,
  • Glenn Gardner, RN, BappSc (Adv Nursg), MEdSt, PhD

      Affiliations

    • Queensland University of Technology and Royal Brisbane and Women's Hospital, Australia
    • ,
  • Anne M. Chang, RN, DipNEd, BEdST (Hons) MEdSt, PhD

      Affiliations

    • Queensland University of Technology and Queensland Centre for Evidence Based Nursing & Midwifery, Mater Health Services, Brisbane, Australia
    • ,
  • Christine Catling-Paull, MSc RN RM

      Affiliations

    • Centre for Health Services Management, University of Technology, Sydney, Australia

Received 13 January 2009; accepted 9 February 2009. published online 27 April 2009.

Article Outline

Summary 

Aim

To review the titles, roles and scope of practice of Advanced Practice Nurses internationally.

Background

There is a worldwide shortage of nurses but there is also an increased demand for nurses with enhanced skills who can manage a more diverse, complex and acutely ill patient population than ever before. As a result, a variety of nurses in advanced practice positions has evolved around the world. The differences in nomenclature have led to confusion over the roles, scope of practice and professional boundaries of nurses in an international context.

Method

CINAHL, Medline, and the Cochrane database of Systematic Reviews were searched from 1987 to 2008. Information was also obtained through government health and professional organisation websites. All information in the literature regarding current and past status, and nomenclature of advanced practice nursing was considered relevant.

Findings

There are many names for Advanced Practice Nurses, and although many of these roles are similar in their function, they can often have different titles.

Conclusion

Advanced Practice Nurses are critical for the future, provide cost-effective care and are highly regarded by patients/clients. They will be a constant and permanent feature of future health care provision. However, clarification regarding their classification and regulation is necessary in some countries.

Keywords: Advanced practice, Nurse Practitioners, Clinical nurse specialist, Nurse roles, Work organisation, Literature review

 

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Introduction 

Over the last 20 years or so nursing practice has become more specialised and nurses more highly skilled in response to changing needs of the health care consumer, technological innovations and improved educational opportunities. A key development internationally has been the recognition of advanced skills and knowledge held by many nurses (Sheer & Wong, 2008). Advanced Practice Nurses (APNs) were first recognised in the mid-1960s in the USA, when, predominantly in a response to a shortage of doctors, nurses began performing more medically defined tasks. Internationally, these Advanced Practice Nurses evolved on an ad hoc basis, with different roles, responsibilities and nomenclature. Today, APNs have as many titles as they do roles and there is confusing overlap in many areas. This is particularly relevant in countries like Australia where there are different jurisdictions that govern nursing, and which mandate a variety of names to identify advanced nursing practice roles.

This paper will critique the literature related to the advanced nursing practice in the UK, USA, Canada, New Zealand and Australia. We will draw upon this critique to describe commonalities and differences. Finally we will propose a way forward to inform an international agenda of consistency for future development of the discipline in line with health service demands. The term APN is used here to describe all levels and definitions of nurses working in an advanced and extended capacity. Nurse Practitioners (NPs) and other specifically titled APNs will be referred to when necessary to distinguish these particular roles. It is the intention of this article to highlight the problem of the APN nomenclature both internationally and nationally, and to identify areas where progress towards regulation is underway.

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Search methods 

The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval (MEDLINE) and Cochrane database of Systematic Reviews were accessed and databases from 1987 to 2008 were assessed. Information was also obtained through government health and professional organisation websites. All information in the literature regarding current and past status and nomenclature of advanced practice nursing was considered relevant. Keywords Nurse Practitioner, advanced practice, clinical nurse specialist, nurse roles, work organisation, and literature review were used.

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United Kingdom 

Advanced practice roles for nurses are not a new concept in the UK, but as in the USA and Australia, there have been reports of a lack of consistency and clarity around the roles and titles (Buchan and Calman, 2004, Castledine, 1997, Maylor, 2005). The NP role developed out of the primary nursing method of care delivery in the 1980s, and by the 1990s, titles such as ‘advanced practitioner’ and ‘advanced nurse practitioner’ emerged, but without consistency or uniformity (Wilson-Barnett, Barriball, Reynolds, Jowett, & Ryrie, 2000). The role of nurse consultant was introduced in 1997, and the ‘modern Matron’ introduced in 2001, although this role involves clinical management rather than advanced practice (Scott, Savage, Ashman, & Read, 2005). Midwives have a different route to registration and are not considered advanced nurses in the UK, so will not be examined. The range of classification for Advanced Practice Nurses in the UK is outlined in Table 1.

Table 1. UK Advanced Practice Nurses.
Nurse practitioner (NP) (sometimes called nurse clinician)Clinical nurse specialist (CNS)Specialist practitioner (SP—formerly district nurses and health visitors)Specialist community public heath nursesNurse consultant (NC)

Key documents released prior to the development of advanced nursing roles in the UK include the Vision for the Future (Department of Health, 1993), Post Registration Education and Practice Project [PREP] (United Kingdom Central Council, 1994), and the Scope of Professional Practice (United Kingdom Central Council, 1992). These influential reports provided the momentum for the widespread development of APNs in the early 1990s. The PREP report (1994, p. 3) stated that specialist nursing practice:

‘exercised higher levels of judgement and discretion in clinical care… demonstrated higher levels of clinical decision making… monitored and improved standards of care through supervision of practice, clinical nursing audit, developed and led practice, contributed to research, taught and supported professional colleagues’.

However there are distinct differences between APNs and ‘specialist nurses’. Specialist nurses focus on a specific, well-defined area of nursing whereas APNs operate at an autonomous level in a number of practice settings. A decade ago in their survey of specialist and advanced nursing practice in the UK, McGee and Castledine (1999) found that there were many variations in the definitions. A driving force in the introduction of these advance practice nursing roles related to political influences such as the reduction in junior doctor hours and an emphasis on a more efficient use of the health workforce (Woods, 1997).

The UK regulatory board, the Nursing and Midwifery Council (NMC) (2005, p. 3) defines APNs as “highly experienced, knowledgeable and educated members of the care team who are able to diagnose and treat your healthcare needs or refer you to an appropriate specialist if needed.” They go on to state that APNs are “highly skilled nurses who can:

•take a comprehensive patient history;

•carry out physical examinations;

•use their expert knowledge and clinical judgment to identify the potential diagnosis;

•carry out physical examinations;

•use their expert knowledge and clinical judgement to decide whether to refer patients for investigations and make diagnoses;

•decide on and carry out treatment, including the prescribing of medicines, or refer patients to an appropriate specialist;

•use their extensive practice experience to plan and provide skilled and competent care to meet patients health and social care needs, involving other members of the health care team as appropriate;

•ensure the provision of continuity of care including follow-up visits;

•assess and evaluate, with patients, the effectiveness of the treatment and care provided and make changes as needed;

•work independently, although often as part of a health care team that they will lead; and

•as a leader of the team, make sure that each patient's treatment and care is based on best practice.” (NMC, 2005, p. 3).

It appears the NMC rejects the concept of standardising extended nursing roles and certification as it is seen to limit nurses’ scope of practice and the profession's ability to meet changing healthcare needs (Jowett, Peters, Reynolds, & Wilson-Barnett, 2001). The NMC initiative for extending nurses’ scope of professional practice permits nurses to assume additional clinical tasks or alter the nature of service provision as long as they attain the appropriate education or training, levels of competence, and are prepared to be accountable for their new practices.

The NMC's comprehensive APN competencies were put together after key developments consisting of the Knowledge and Skills Framework (National Health Service, 2003), and the Implementation of a framework for standards for post-registration nursing (NMC, 2005). Currently the NMC, the Royal College of Nursing (RCN) and the Association of Advanced Nursing Practice Educators (AANPE) are working closely to create a new sub-part of the nursing register for APNs. These nurses will have completed advanced level training (possibly to the level of master degree) and would need to maintain registration requirements to remain in practice.

In the UK there is also a perception that the introduction of nurse consultants at the top rank of status and salary in the nursing profession has eroded the position of APNs. It has been argued that nurses at various levels have the same core functions, that these do not differ for nurse consultants, and that the best method of distinguishing between practitioners with the same job description could be by measuring outcomes (Maylor, 2005).

A report by the RCN (2005) catalogued the practices of nurses, their different roles and their job satisfaction. However the report did little to propose any standardisation of the different nursing roles identified, despite calls to do just that (Lankshear, Sheldon, Maynard, & Smith, 2005). Nurse Practitioner training has been described as varied, ranging from short locally organised courses to postgraduate study, with most NPs employed by GPs, some by Community Trusts, but with no agreed definition on what their role encompasses (Ashburner, Birch, Latimer, & Scrivens, 1997). Coombes (2008) describes this as a ‘major road block to better acceptance’ (p. 1522) which affects the credibility of APNs, something which the NMC and the RCN, backed by the British Medical Association, are currently working towards.

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United States of America 

The US Federal government has supported APNs for over 40 years as a response to community requirements for access to affordable, quality health care and the specialised nursing requirements of complex patients. The USA, with its well-established advanced nursing roles, has a large range of expanded and extended nursing roles that vary considerably state by state, but all claiming to be advanced practice. These roles are outlined below in Table 2.

Table 2. Advanced Practice Nurses in the USA (8).
Certified nurse practitioner (NP)Certified nurse–midwife (CNM)Certified registered nurse anaesthetist (CRNA)Clinical nurse specialist (CNS)

It is obvious from these titles that there is a variety of roles and functions of APNs established by various stakeholders and professional associations. The National Council of State Boards of Nursing APRN Advisory Committee and the APRN Consensus Work Group (2008 p. 5) state that APNs (called Advanced Practice Registered Nurses [APRN]) is an ‘nurse who has completed an accredited graduate-level education program preparing him/her for one of the four recognised APRN roles.’ These are: Certified NP, Certified Nurse–Midwife (CNM), Certified Registered Nurse Anaesthetist (CRNA) or Clinical Nurse Specialist (CNS).’ There is also the role of Physician Assistants (PA), which essentially works within a medical model and so excluded from this discussion. APRNs are masters-educated nurses regulated as a separate group, although there is no uniform model of regulation across the states. These nurses operate independently, often with prescribing rights. Educational levels and prescribing rights for APRNs vary between nursing boards (Kenward, 2007).

In the USA, the CNS generally practises in acute care and focuses on nursing specialities, while historically, the NP principally works in primary health care settings dealing with a wider range of health care needs. The National Association of Clinical Nurse Specialists (2004, p. 1) defines the CNS as a:

‘registered professional nurse holding a graduate degree’ who ‘independently provides theory and research-based care to clients facilitating attainment of health goals, and works with nurses to advance nursing practice to improve outcomes cost effectively, and/or provides clinical expertise to affect system wide changes in organisations to improve programs of care’.

A number of CNSs here prescribe medication and medical equipment (e.g. patient care supplies), work as consultants to manage complex patients, and often own and operate their own businesses. However, there is a problem of overregulation in some states as CNSs need to obtain a second licence in order to practise in their advanced role, although there are legislative reforms underway to rectify this (National Council of State Boards of Nursing, 2000).

Licensure for NPs to practise is possible in every state (Carson, 1999), although scope of practice and authorisation to prescribe varies. The Nurse Practice Act in each state protects the title of NP, and NPs may also be credentialed in their local areas. In most areas, NPs will need tertiary education to master degree level in order to practice (American Academy of Nurse Practitioners, 2007); although it has been proposed that future NPs will practise at doctoral level (Nelson, 2005).

In 2007, there were estimated to be approximately 120,000 NPs working in the US and up to 6000 new NPs are trained each year at over 325 colleges and universities (American Academy of Nurse Practitioners, 2008).

The necessity for consensus within the profession has been called for by many (for example, Hanson and Hamric, 2003, Lyons, 2004, Rose et al., 2003). This led to a recent report from the National Council of State Boards of Nursing (Kenward, 2007) to delineate the differences between NPs and CNSs. The report found CNSs focus more on administration, whereas NPs direct more of their energy towards patient care. Despite similar work, different importance was placed on aspects of their roles as well as many areas of overlap.

The National Council of State Boards of Nursing (NCSBN) in its position paper (2002, p. 4), stated that ‘a lack of consistency in education, titling, credentialing, program accreditation, scope of practice and reimbursement have confused the public, legislators, regulators and nurses themselves, and have hindered efforts to make full use of contributions of APRNs to health care.’ The paper makes a series of comprehensive recommendations to deal with these inconsistencies within the jurisdictions of nursing regulatory boards. In addition the joint work by the NCSBN and the APRN Consensus Work Group (2008) is set to improve and standardise the regulation, licensure, education and accreditation of APRNs.

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Canada 

As in the USA, advanced practice for nurses in Canada developed in the 1960s due to shortages of medical staff and the nursing profession's desire for greater autonomy and advancement. The advanced nursing role in Canada today covers mainly CNSs and NPs working under various definitions (CNA, 2006, CNO, 2003, Micevski et al., 2004). NPs work in most provinces and territories in Canada, but are more likely to be employed in rural and remote communities. In the past, there have been few government initiatives and a degree of medical resistance which have hindered the development of the role of the NP. There have also been legal issues due to a lack of standard education programs and regulatory frameworks. However recently there has been renewed interest in an advanced role for nurses focus on education, role definition and development of standards of practice (Pauly et al., 2004).

The most recognised advanced nursing role in Canada is the CNS. These nurses hold either a master or doctoral degree in nursing and also have expertise in a clinical nursing specialty (Canadian Nurses Association, 2006). An expert practitioner, the CNS provides direct care, education and consultation to clients, as well as education and consultation to the health care team. In 2004, the National Association of Clinical Nurse Specialists (NACNS) set out some clear rules and regulations for CNSs in terms of their scope of practice and use of the title. Educational requirements, as well as direct and indirect care services, prescriptive authority, standards of practice, requirements for continuation of practice and more are defined, principally for uniformity across provinces, and to delineate the need for some CNSs to obtain a second license to practice.

Canada also has APNs with titles of Registered Nurse First Assistants (RNFAs) and Nurse Anaesthetists. RNFAs are a growing number of nurses who, similar to the Physician's Assistant in the USA, work with medical staff to improve patient flow by performing more medicalised tasks, especially in community settings that do not have post-graduate trainees. Like nurse anaesthetists in the USA, nurse anaesthetists here have a similar impact on patient waiting times for surgery, and have specific post-registration training (American Association of Nurse Anesthetists, 2006).

In 2002, the Canadian Nurses Association (CNA) developed a national framework for APNs, particularly NPs, recognising their value but also calling for consistency across the country. NPs have recently been defined as having ‘advanced knowledge and decision-making skills in health assessment, diagnosis, therapeutics (including pharmacological, complementary, and counselling interventions), health care management, and community development and planning’ (Ontario Ministry of Health and Long-Term Care, 2005, p. 7) Other titles such as ‘expanded role nurse’, ‘nurse associate’ and ‘physician's assistant’ are only position or role descriptions and are not protected legally.

A recent publication has emphasised the need for Canadian nurses to deliver services to the maximum level of their training and skills in order to help improve access and reduce waiting times (Trypuc & Hudson, 2005). It argues that by utilising the workforce in this way, APNs will free medical staff to concentrate on delivering skilled medical services and increase patient flow and efficiency.

In the past, NPs in Canada have had the same identity crisis as NPs in Australia, the USA and the UK. There has been confusion regarding terminology, failure to clearly define roles, and inconsistencies in education throughout the country (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004). It has been stated that advanced practice nursing continues to be misunderstood by front-line workers, with their roles often confused, creating inefficiencies and work duplication (Urquhart, Roschkov, Rebeyka, & Scherr, 2004). There have been proposals to merge the roles of CNS and NP to avoid confusion and lower costs (Pinelli, 1997). However, there is currently work underway to improve this situation and standardise the NP role. The CNA is implementing the Canadian Nurse Practitioner Initiative, which will comprise Canada-wide nursing stakeholders, including regulatory bodies, professional associations and governments who will work towards optimising the profile of the NP. This initiative will define the NP role and develop recommendations for collaborative practice models, curriculum design, recruitment and retention strategies. It will also develop legislation for regulation and national core competencies and more. This work will do much to raise the profile of NPs in Canada and ensure a more structured and consistent role for NPs in the future (CNA, 2006).

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New Zealand 

In New Zealand, advanced nursing roles were developed as part of a Government policy on primary health care provision and Maori health (Ministry of Health New Zealand, 1988). The report identified advanced nursing roles for the provision of highly skilled care, the coordination of care for certain groups of patients between community and hospital, and a high level of family health care services. The New Zealand Nurses Organisation (2008) has a wide-ranging amount of information available on advanced nursing practice, and the Nursing Council of New Zealand (2002) also has a comprehensive framework available on scope of practice.

The NPAC-NZ (2004) Nurse Practitioner Advisory Committee of New Zealand (NPAC-NZ) (2004) states that all NPs in New Zealand will be educated to master level by 2010, and be given prescribing rights after an approved pharmacology course. There is a lengthy accreditation process to become endorsed as a NP, and because of this a mentor system is in place to assist nurses to apply. NPs from the USA or the UK may have been differently endorsed and may or may not be able to practice in New Zealand (2004). Recently the Nursing Council of New Zealand published NP competencies (2008), and there are eight approved sites for tertiary education to master level around the country. In 2007, there were 38 practising NPs in New Zealand (Anonymous, 2007). It may be that less populated countries such as New Zealand have less difficulty in providing standardised frameworks for nurses, purely because of geography, and the lack of multiple health service regions and jurisdictions.

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Australia 

The Royal College of Nursing, Australia and the Ministerial Advisory Committee on Nursing (MACON) in 1997 are among the few organisations that offer definitions of advanced nursing practice. In 2004, The National Nurses Organisation of Australia defined NPs and, in addition, described what are essentially CNSs and Clinical Nurse Consultants (CNCs) as ‘advanced’ and ‘expert’ registered nurses (NNO, 2004).

There are very few definitions for the roles of CNS and CNC available from the state/territory health departments and professional organisations. The NSW Health Policy Directives (NSW Health, 2005b, NSW Health, 2005c) are the only health department guidelines found that clearly state the award definitions and job description of CNSs, CNCs and NPs. The Department of Health in Victoria has general information on APNs but does not offer specific definitions for these roles. The Australian & New Zealand College of Mental Health Nurses (1995) includes advanced practice standards in its ‘Standards of Practice for Mental Health Nurses in Australia’, and the Australian College of Operating Room Nurses has information on roles that include expanded nursing practice, but no definition of APN as such.

In 1987, the NSW Department of Health developed a new clinical career path which established the position of CNSs (NSW Health, 1987, NSW Health, 2005c). It was proposed as an option for those nurses who wanted to remain by the bedside, rather than move into management or education, historically the only career paths available (Duffield et al., 2001). This new career path for nurses was also designed to provide recognition and remuneration for their status and to enhance recruitment and retention. In 1990, a similar award was promulgated for Clinical Nurse Consultants (CNCs), with skills and experience being the main criteria for eligibility, rather than tertiary qualifications (NSW Health, 2005b, NSW Nurses Association, 1990). This government directive (NSW Health, 2005a) defined the award and specified domains of clinical service and consultancy, leadership, research, education, and clinical services planning and management. There were three grades of CNC described and similar to the CNS directive, an understanding that the roles of these advanced nurses would vary substantially depending on local area health service needs and practices.

In 2001, five years after the initial proposal for implementation (Nurse Practitioner Project Stage 3 Final Report), the first NP was appointed in NSW. The other states/territories followed with reports from Western Australia (2000), Victoria (2000), South Australia (1999), the ACT (2002), Tasmania (2002), Queensland (2003) and the National Rural Health Alliance (2005) which examined the feasibility of implementing the role of the NP. In May 2005, there were NPs working within almost every State and Territory, with 54 in practice throughout NSW (Moyes, 2005). Health authorities, particularly in rural and remote areas where nurses were already working in a similar capacity, have welcomed the NP role. Although not without a degree of opposition, largely from the medical profession (AMA, 2005, Pollard, 2005, RACGP, 1999), the level of health care provided by NPs is proving to be beneficial, cost-effective and highly regarded (Horrocks et al., 2002a, Kinnersley et al., 2000, Sutton and Smith, 1995). There have also been legislative obstacles to prescribing rights of some NPs (Gardner & Middleton, 2008). Table 3 refers to the common roles of APNs in Australia, and worldwide (Table 4).

Table 3. Advanced Practice Nurses in Canada.
Clinical nurse specialist (CNS)Nurse practitioner (NP)
Table 4. Commonalities to Advanced Practice Nurses (country and state specific policies apply) (International Council of Nurses, 2003).
Right to diagnose
Authority to prescribe medication
Authority to prescribe treatment
Authority to refer clients to other professionals
Authority to admit patients to hospital
Legislation or some other form of regulatory mechanism to APNs
Legislation to confer and protect the title ‘Nurse Practitioner/Advanced Practice Nurse’
Officially recognised as nurses working in advanced practice roles

In the past four years Australia has made significant progress in gaining consistency in NP standards across the eight jurisdictions. In 2004 the Australian Nursing and Midwifery Council (ANMC) commissioned a study jointly funded by the ANMC and the Nursing Council of New Zealand to examine the role of the Nurse Practitioner (Gardner, Carryer, Dunn, & Gardner, 2004). The aim was to achieve Australian national and trans-Tasman standards for NP practice and education. Most of the recommendations from this study have been adopted by the ANMC and Australia now has national NP practice competency standards and a national definition. Australia defines a NP as a

‘registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications, and ordering diagnostic investigations.’ (Gardner et al., 2004, Gardner et al., 2004 p. 3).

Despite the Australian progress in NP development there remains some confusion and inconsistency in relation to other advanced practice nursing roles.

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International similarities and differences 


•There is international recognition of the need to have regulated standards of education, titles and scope of practice for advanced nursing roles. Failure to standardise the expectations and definitions of the role of Advanced Practice Nurses creates confusion and possible risks to the public, and does little to further the reputation of the nursing profession generally.

•There is now national consistency in Australia on the definition and competency standards for the NP (Gardner et al., 2004). However, there is no consistency in other APN roles that are defined within local jurisdictions.

•There are similarities between Australian and international standards for entry to NP roles. Minimum educational requirements are set at master degree level in most areas. Those states (Victoria, South Australia and Western Australia) with a lesser entry level have plans to change this in the future. Internationally, there is formal recognition of the necessity for ongoing educational programs and a credentialing system to be in place, although this is not a widespread practice at present.

•All RNs in Australia, including APNs, must re-register with the relevant nursing board in order to practice in each state or territory through the Mutual Recognition Act. In the USA, the ‘Nurse Licensure Compact’ legislation allows states to recognise nurses registered from elsewhere. Similar legislation in Australia has recently been proposed (Productivity Commission, 2005).

•There are differences apparent in the role competencies of a CNS in the UK, USA and Canada. In Australia, CNSs have a direct clinical role in a specialist area of practice, and often spend their time managing wards and staff as well as having a clinical load. The role of a CNS in Canada or USA is more closely aligned with the CNC role in Australia (Ball and Cox, 2003, Duffield et al., 1995).

•Certified Nurse–Midwives are seen as APNs in the USA whereas in the UK, New Zealand and Australia, they are educated differently and are separately identified.

•In the USA, ‘Advanced Practice Nursing’ appears to be a recognised term for a number of roles with scopes of practice defined at state or local level. The National Council of State Boards of Nursing oversees the regulatory boards of the country and are working towards consistency of all APNs (National Council of State Boards of Nursing, 2000).

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Conclusion 

There is little doubt that APNs are, and will continue to be an important provider of cost-effective and accessible healthcare in the 21st century. The expansion of medical technology, the complexity of patients and the specialisation in service delivery have all contributed to the need for more knowledgeable and competent nurses. These nurses have proven themselves to be extremely cost-effective (Brooten & Naylor, 1995), and welcomed by the public (Ball and Cox, 2003, Horrocks et al., 2002b, Mundinger et al., 2000). However, as this review has demonstrated, there is considerable confusion surrounding the notion of advanced practice in nursing. Whilst the role of the NP is gaining some consistency in that the commonalities identified in Table 3 all relate to the NP, there is a lack of clarity and consistency nationally and internationally in other APN roles. This is so not only in Australia but also, internationally and it is important to clarify these issues for APNs to be recognised for the advanced services they are able to provide and to advance in their careers (Lloyd Jones, 2005).

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References 

  1. ACT Department of Health Housing and Community Care. (2002). ACT Nurse Practitioner Project Steering Committee. Canberra: ACT.
  2. American Academy of Nurse Practitioners. (2007). Scope of Practice for Nurse Practitioners. <http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/Scope_of_Practice.pdf> Retrieved 06.01.09.
  3. American Academy of Nurse Practitioners. (2008). What is a Nurse Practitioner? <http://www.aanp.org> Retrieved 12.12.08.
  4. American Association of Nurse Anesthetists. (2006). Education. <http://www.aana.com/education/default.asp> Retrieved 06.02.06.
  5. Anonymous. (2007). New nurse practitioner moves to the beat. New Zealand Nursing Review, 8(5).
  6. Ashburner L, Birch K, Latimer J, Scrivens E. Primary Care Defining Role. 1997;107:32–33
  7. Australian & New Zealand College of Mental Health Nurses . Standards of practice for mental health nursing in Australia. Greenacres, South Australia: ANZCMHN; 1995;
  8. Australian Medical Association. (2005). General practice nurses make perfect sense (but independent nurse practitioners don’t). <http://www.ama.com.au/node/1964> Retrieved 06.01.09.
  9. Ball C, Cox CL. Part one: Restoring patients to health outcomes and indicators of advanced nursing practice in adult critical care. International Journal of Nursing Practice. 2003;9(6):356–367
  10. Brooten D, Naylor D. Nurses effect on changing patient outcomes. Image the Journal of Nursing Scholarship. 1995;27(2):95–99
  11. Bryant-Lukosius D, DiCenso A, Browne G, Pinelli J. Advanced practice nursing roles: Development, implementation and evaluation. Journal of Advanced Nursing. 2004;48(5):519–529
  12. Buchan J, Calman L. Skill-mix and policy change in the health workforce: Nurses in advanced roles Paris: Directorate for employment. Labour and Social Affairs. 2004;
  13. Canadian Nurses Association. (2006). Advanced nursing practice. <http://www.cna-nurses.ca/CNA/practice/advanced/default_e.aspx> Retrieved 23.01.06.
  14. Carson WY. State legislation which affects nursing practice. American Nurse Association. 1999;
  15. Castledine G. Castledine column. The abuse of specialist nursing titles must stop. British Journal of Nursing. 1997;6(19):
  16. College of Nurses of Ontario. (2003). Acute care/speciality nurse practitioner: Policy issues relevant to regulation of the role.
  17. Coombes R. Dr Nurse will see you now. British Medical Journal. 2008;337:a1522
  18. Department of Health. (1993). A vision for the future. London: Department of Health.
  19. Department of Health and Human Services Tasmania. (2002). Tasmanian nurse workforce planning project—final report.
  20. Department of Human Services South Australia. (1999). Nurse practitioner project final report. Adelaide: Department of Human Services South Australia.
  21. Department of Human Services Victorian Government . The Victorian nurse practitioner project: Final report of the taskforce. Melbourne: Policy Development and Planning Division, Victorian Government Department of Human Services; 2000;
  22. Duffield C, Moran P, Beutel J, Bunt S, Thornton A, Wills J, et al. Profile of first-line nurse managers in New South Wales, Australia, in the 1990s. Journal of Advanced Nursing. 2001;36(6):785–793
  23. Duffield C, Pelletier D, Donoghue J. A profile of the clinical nurse specialist in one Australian state. Clinical Nurse Specialist. 1995;9(3):149–154
  24. Gardner, G., Carryer, J., Dunn, S., & Gardner, G. (2004). Nurse practitioner standards project. Canberra
  25. Gardner, G., & Middleton, S. (2008). Nurse practitioners hamstrung and patients disadvantaged: Study, Australia. Medical News Today. <http://www.medicalnewstoday.com/articles/95543.php> Retrieved 10.12.08.
  26. Hanson CM, Hamric AB. Reflections on the continuing evolution of advanced practice nursing. Nursing Outlook. 2003;51(5):203–211
  27. Health Department of Western Australia. (2000). Remote area nurse practitioner project. Perth: Health Department of Western Australia.
  28. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal. 2002;324(7341):819–823
  29. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal. 2002;324:819–823[see comment]
  30. International Council of Nurses. (2003). Definition and Characteristics of Nurse Practitioners/Advanced Practice Nurses. Practice issues. Retrieved 26/07/2005 from http://icn-apnetwork.org.
  31. Jowett S, Peters M, Reynolds H, Wilson-Barnett J. The UKCC's scope of professional practice some implications for health care delivery. Journal of Nursing Management. 2001;9(2):93–100
  32. Kenward K. Role delineation study of nurse practitioners and clinical nurse specialists. Chicago: National Council of State Boards of Nursing; 2007;
  33. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. British Medical Journal. 2000;320(7241):1043–1048[see comment]
  34. Lankshear A, Sheldon T, Maynard A, Smith K. Nursing challenges: Are changes in the nursing role and skill mix improving patient care?. Health Policy Matters. 2005;10:1–7
  35. Lloyd Jones M. Role development and effective practice in specialist and advanced practice roles in acute hospital settings: Systematic review and meta-synthesis. Journal of Advanced Nursing. 2005;49(2):191–209
  36. Lyons B. The CNS regulatory quagmire: We need clarity about advanced nursing practice. Clinical Nurse Specialist. 2004;18(1):9–13
  37. Maylor M. Differentiating between a consultant nurse and a clinical nurse specialist. British Journal of Nursing. 2005;14(8):463–468
  38. McGee P, Castledine G. A survey of specialist and advanced nursing practice in the UK. British Journal of Nursing. 1999;8(16):1074–1078
  39. Micevski V, Korkola L, Sarkissian S, Mulcahy V, Shobbrook C, Belford L, et al. University health network framework for advanced nursing practice: Development of a comprehensive conceptual framework describing the multidimensional contributions of advanced practice nurses. Canadian Journal of Nursing Leadership. 2004;17(3):52–64
  40. Ministry of Health New Zealand. (1988). Report of the ministerial taskforce on nursing. Wellington: Ministry of Health New Zealand.
  41. Moyes B. Nurse practitioners in Australia are we making alphabet soup?. Nurse Practitioner National Network. 2005;
  42. Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PD, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. The Journal of the American Medical Association. 2000;283(1):59–68
  43. National Association of Clinical Nurse Specialists . Model rules and regulations for CNS title protection and scope of practice. Clinical Nurse Specialist. 2004;18(4):178–179
  44. National Council of State Boards of Nursing. (2000). Nurse licensure compact. <https://www.ncsbn.org/nlc.htm> Retrieved 06.01.09.
  45. National Council of State Boards of Nursing. (2002). Regulation of advanced practice nursing. <http://www.ncsbn.org/pdfs/APRN_Position_Paper2002.pdf> Retrieved 06.01.09.
  46. National Council of State Boards of Nursing and APRN Consensus Work Group. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification and education. <http://aanp.org/NR/rdonlyres/56292A59-8240-449D-910D-EF331FC7DC86/0/FinalAPRNJointDialogueReport7708.pdf#search=advanced%20practice%20nurse> Retrieved 06.01.09.
  47. National Health Service . The NHS knowledge and skills framework (NHS KSF) and development review guidance—working draft. Leeds: NHS; 2003;
  48. National Nursing Organisations (NNO) . Glossary of terms: Criteria for specialities in nursing and principles of credentialling for nurses. Canberra: NNO; 2004;
  49. National Rural Health Alliance. (2005). Advanced nursing practice in rural and remote areas. Retrieved 25.3.09 from http://nrha.ruralhealth.org.au/cms/uploads/publications/advanced%20nursing%20practice%206%20july%202005.pdf.
  50. Nelson R. Is there a doctor in the house?. American Journal of Nursing. 2005;105(5):28–29
  51. New Zealand Nurses Organisation. (2008). Advanced nursing practice—NZNO position statement. <http://www.nzno.org.nz/Site/Professional/ANP/ANP_Position_Statement.aspx> Retrieved 17.12.08, 1.
  52. NSW Health. (1987). Public hospital nurses’ (State) award; guidelines for clinical nurse specialist classification [circular No. 87/32]. New South Wales: NSW Health.
  53. NSW Health. (2005a). Clinical nurse consultant–higher grades–public hospital nurses’ (state) award. Sydney: NSW Health.
  54. NSW Health. (2005b). Public hospital nurses’ (state) award – clinical nurse consultant – higher grades [Policy directive PD2005-424]. Sydney: NSW Health.
  55. NSW Health. (2005c). Public hospital nurses’ (State) award – clinical nurse specialist classification [Policy directive PD2005_432]. Sydney: NSW Health.
  56. NSW Nurses’ Association. (1990). Public hospital nurses state award. Sydney: NSW Nurses’ Association.
  57. Nursing and Midwifery Council. (2005). Implementation of a framework for the standard for post registration nursing. <http://www.nmcuk.org/aFrameDisplay.aspx?DocumentID=1669>Retrieved 17.12.08.
  58. Nursing Council of New Zealand. (2002). Criteria for endorsement of practice standards. Wellington: Nursing Council of New Zealand.
  59. Ontario Ministry of Health and Long-Term Care. (2005). Family health teams: Guide to interdisciplinary team roles and responsibilities. Toronto: Ontario Ministry of Health and Long-Term Care.
  60. Pauly B, Schreiber R, MacDonald M, Davidson H, Criekmore J, Moss L, et al. Dancing to our own tune: Understandings of advanced nursing practice in British Columbia. Canadian Journal of Nursing Leadership. 2004;17(2):47–57
  61. Pinelli JM. The clinical nurse specialist/nurse practitioner: Oxymoron or match made in heaven?. Canadian Journal of Nursing Administration. 1997;10(1):85–110
  62. Pollard, R. (2005). Losing patience. Sydney Morning Herald, p. 16, August 30.
  63. Productivity Commission. (2005). Australia's Health Workforce: Research Report. Canberra: Productivity Commission.
  64. Queensland Health. (2003). Nurse practitioner project report. Queensland Health Nurse Practitioner Project Steering Committee: Brisbane.
  65. Rose B, All A, Gresham D. Role preservation of the clinical nurse specialist and the nurse practitioner. The Internet Journal of Advanced Nursing Practice. 2003;5(2):
  66. Royal Australian College of General Practitioners. (1999). Position statement: Nurse practitioners. <http://www.racgp.org.au/policy/Nurse_Practitioners.pdf> Retrieved 17.12.08.
  67. Royal College of Nursing. (2005). Maxi nurses: Advanced and specialist nursing roles (No. 002 756). London: Royal College of Nursing.
  68. Scott C, Savage J, Ashman M, Read S. Evaluating the role of modern matrons. Nursing Management. 2005;12(2):22–26
  69. Sheer B, Wong FKY. The development of advanced nursing practice globally. Journal of Nursing Scholarship. 2008;40(3):204–211
  70. Sutton F, Smith C. Advanced nursing practice: New ideas and new perspectives. Journal of Advanced Nursing. 1995;21(6):1037–1043
  71. The Nurse Practitioner Advisory Committee of New Zealand. (2004). Nurse practitioners in New Zealand: The facts. <http://www.nurseducation.org.nz/documents/NPs%20in%20NZ%20-%20the%20facts.pdf> Retrieved 12.12.08.
  72. Trypuc JM, Hudson AR. Waiting lists and nursing. Canadian Journal of Nursing Leadership. 2005;18(4):
  73. United Kingdom Central Council . The scope of professional practice. London: UKCC; 1992;
  74. United Kingdom Central Council . The report of the post registration education and practice project (PREP). London: UKCC; 1994;
  75. Urquhart G, Roschkov S, Rebeyka D, Scherr K. Clinical nurse specialist or nurse practitioner?. Can Nurse. 2004;100(5):18–22
  76. Wilson-Barnett J, Barriball KL, Reynolds H, Jowett S, Ryrie I. Recognising advancing nursing practice: Evidence from two observational studies. International Journal of Nursing Studies. 2000;37(5):389–400
  77. Woods LP. Conceptualizing advanced nursing practice: Curriculum issues to consider in the educational preparation of advanced nurses in the UK. Journal of Advanced Nursing. 1997;25(4):820–828

PII: S1322-7696(09)00019-5

doi:10.1016/j.colegn.2009.02.001

Collegian
Volume 16, Issue 2 , Pages 55-62, April 2009

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