Advanced practice nursing roles development implementation and evaluation

Chapter 4 Role Development of the Advanced Practice Nurse

Karen A. Brykczynski

What is it like to become an advanced practice nurse (APN)? Role development in advanced practice nursing is described here as a process that evolves over time. The process is more than socializing and taking on a new role. It involves transforming one's professional identity and the progressive development of the seven core advanced practice competencies (see Chapter 3 ). The scope of nursing practice has expanded and contracted in response to societal needs, political forces, and economic realities ( Levy, 1968 ; Safriet, 1992 ; see Chapter 1 ). Historical evidence suggests that the expanded role of the 1970s was common nursing practice during the early 1900s ( DeMaio, 1979 ). However, the core of nursing is not defined by the tasks nurses perform. This task-oriented perspective is inadequate and disregards the complex nature of nursing.

In the current cost-constrained environment, the pressure to be cost-effective and to make an impact on outcomes is greater than ever, but studies have shown that the initial year of practice is one of transition ( Brown & Olshansky, 1998 ; Brykczynski, 2009 ; Kelly & Mathews, 2001 ) and an APN's maximum potential may not be realized until after approximately 5 or more years in practice ( Cooper & Sparacino, 1990 ). This chapter explores the complex processes of APN role development, with the objectives of providing the following: (1) an understanding of related concepts and research; (2) anticipatory guidance for APN students; (3) role facilitation strategies for new APNs, APN preceptors, faculty, administrators, and interested colleagues; and (4) guidelines for continued role evolution. This chapter consolidates literature from all the APN specialties—including clinical nurse specialists (CNSs), nurse practitioners (NPs), certified nurse-midwives (CNMs), and certified registered nurse anesthetists (CRNAs)—to present a generic process relevant to all APN roles. Some of this literature is foundational to understanding issues of role development for all APN roles and, although dated, remains relevant. This chapter has been expanded to include international APN role development experiences.

The discussion is separated into (1) the educational component of APN role acquisition and (2) the occupational or work component of role implementation. This division in the process of role development is intended to clarify and distinguish the changes occurring during role transitions experienced during the educational period (role acquisition) and the changes occurring during the actual performance of the role after program completion (role implementation). Strategies for enhancing APN role development are described. The chapter concludes with summary comments and suggestions to facilitate future APN role development and evolution.

Perspectives on Advanced Practice Nurse Role Development

Professional role development is a dynamic ongoing process that, once begun, spans a lifetime. The concept of graduation as commencement, whereby one's career begins on completion of a degree, is central to understanding the evolving nature of professional roles in response to personal, professional, and societal demands ( Gunn, 1998 ). Professional role development literature in nursing is abundant and complex, involving multiple component processes, including the following: (1) aspects of adult development; (2) development of clinical expertise; (3) modification of self-identity through initial socialization in school; (4) embodiment of ethical comportment ( Benner, Sutphen, Leonard, & Day, 2010 ); (5) development and integration of professional role components; and (6) subsequent resocialization in the work setting. Similar to socialization for other professional roles, such as those of attorney, physician, teacher, and social worker, the process of becoming an APN involves aspects of adult development and professional socialization. The professional socialization process in advanced practice nursing involves identification with and acquisition of the behaviors and attitudes of the advanced practice group to which one aspires ( Waugaman & Lu, 1999, p. 239 ). This includes learning the specialized language, skills, and knowledge of the particular APN group, internalizing its values and norms, and incorporating these into one's professional nursing identity and other life roles ( Cohen, 1981 ).

Novice to Expert Skill Acquisition Model

Acquisition of knowledge and skill occurs in a progressive movement through the stages of performance from novice to expert, as described by Dreyfus and Dreyfus (1986 , 2009 ), who studied diverse groups, including pilots, chess players, and adult learners of second languages. The skill acquisition model has broad applicability and can be used to understand many different skills better, ranging from playing a musical instrument to writing a research grant. The most widely known application of this model is Benner's (1984) observational and interview study of clinical nursing practice situations from the perspective of new nurses and their preceptors in hospital nursing services. Although this study included several APNs, it did not specify a particular education level as a criterion for expertise. As noted in Chapter 3 , there has been some confusion about this criterion. The skill acquisition model is a situation-based model, not a trait model. Therefore, the level of expertise is not an individual characteristic of a particular nurse but is a function of the nurse's familiarity with a particular situation in combination with his or her educational background. This model could be used to study the level of expertise required for other aspects of advanced practice, including guidance and coaching, consultation, collaboration, evidence-based practice ethical decision making, and leadership (see Brykczynski [2009] for a detailed discussion of the Dreyfus model).

Figure 4-1 shows a typical APN role development pattern in terms of this skill acquisition model. A major implication of the novice to expert model for advanced practice nursing is the claim that even experts can be expected to perform at lower skill levels when they enter new situations or positions. Hamric and Taylor's report (1989) that an experienced CNS starting a new position experiences the same role development phases as a new graduate, only over a shorter period, supports this claim.

The overall trajectory expected during APN role development is shown in Figure 4-1 ; however, each APN experiences a unique pattern of role transitions and life transitions concurrently. For example, a professional nurse who functions as a mentor for new graduates may decide to pursue an advanced degree as an APN. As an APN graduate student, she or he will experience the challenges of acquiring a new role, the anxiety associated with learning new skills and practices, and the dependency of being a novice. At the same time, if this nurse continues to work as a registered nurse, his or her functioning in this work role will be at the competent, proficient, or expert level, depending on experience and the situation. On graduation, the new APN may experience a limbo period, during which the nurse is no longer a student and not yet an APN, while searching for a position and meeting certification requirements (see later). Once in a new APN position, this nurse may experience a return to the advanced beginner stage as he or she proceeds through the phases of role implementation. Even after making the transition to an APN role, progression in role implementation is not a linear process. As Figure 4-1 indicates, there are discontinuities, with movement back and forth as the trajectory begins again. Years later, the APN may decide to pursue yet another APN role. The processes of role acquisition, role implementation, and novice to expert skill development will again be experienced—although altered and informed by previous experiences—as the postgraduate student acquires additional skills and knowledge. Role development involves multiple, dynamic, and situational processes, with each new undertaking being characterized by passage through earlier transitional phases and with some movement back and forth, horizontally or vertically, as different career options are pursued.

Direct-entry students who are non-nurse college graduates (NNCGs) and APN students with little or no experience as nurses before entry into an APN graduate program would be expected to begin their APN role development at the novice level (see Fig. 4-1 ). Some evidence indicates that although these inexperienced nurse students may lack the intuitive sense that comes with clinical experience, they avoid the role confusion associated with letting go of the traditional RN role commonly reported with experienced nurse students ( Heitz, Steiner, & Burman, 2004 ). This finding has implications for APN education as the profession moves toward the Doctor of Nursing Practice (DNP) as the preferred educational pathway for APN preparation ( American Association of Colleges of Nursing [AACN], 2006 ).

Another significant implication of the Dreyfus model ( Dreyfus & Dreyfus, 1986 , 2009 ) for APNs is the observation that the quality of performance may deteriorate when performers are subjected to intense scrutiny, whether their own or that of someone else ( Roberts, Tabloski, & Bova, 1997 ). The increased anxiety experienced by APN students during faculty on-site clinical evaluation visits or during videotaped testing of clinical performance in

Role Concepts and Role Development Issues

This discussion of professional role issues incorporates role concepts described by Hardy and Hardy (1988) along with the concept that different APN roles represent different subcultural groups within the broader nursing culture ( Leininger, 1994 ). Building on Johnson's (1993) conclusion that NPs have three voices, Brykczynski (1999a) described APNs as tricultural and trilingual. They share background knowledge, practices, and skills of three cultures—biomedicine, mainstream nursing, and everyday life. They are fluent in the languages of biomedical science, nursing knowledge and skill, and everyday parlance. Some APNs (e.g., CNMs) are socialized into a fourth culture as well, that of midwifery. Others are also fluent in more than one everyday language.

The concepts of role stress and strain discussed by Hardy and Hardy (1988) are useful for understanding the dynamics of role transitions ( Table 4-1 ). Hardy and Hardy described role stress as a social structural condition in which role obligations are ambiguous, conflicting, incongruous, excessive, or unpredictable. Role strain is defined as the subjective feeling of frustration, tension, or anxiety experienced in response to role stress. The highly stressful nature of the nursing profession needs to be recognized as the background within which individuals seek advanced education to become APNs ( Aiken, Clarke, Sloan, et al., 2002 ; Dionne-Proulz & Pepin, 1993 ). Role strain can be minimized by the identification of potential role stressors, development of coping strategies, and rehearsal of situations designed for application of those strategies. However, the difficulties experienced by neophytes in new positions cannot be eliminated. As noted, expertise is holistic, involving embodied perceptual skills (e.g., detecting qualitative distinctions in pulses or types of anxiety), shared background knowledge, and cognitive ability. A school-work, theory- practice, ideal-real gap will remain because of the nature of human skill acquisition.

Bandura's (1977) social cognitive theory of self-efficacy may be of interest to APNs in terms of understanding what motivates individuals to acquire skills and what builds confidence as skills are developed. Self-efficacy theory, a person's belief in their ability to succeed, has been used widely to further understanding of skill acquisition with patients ( Burglehaus, 1997 ; Clark & Dodge, 1999 ; Dalton & Blau, 1996 ). Self-efficacy theory has also been applied to mentoring APN students ( Hayes, 2001 ) and training health care professionals in skill acquisition ( Parle, Maguire, & Heaven, 1997 ).

Role Ambiguity

Role ambiguity (see Table 4-1 ) develops when there is a lack of clarity about expectations, a blurring of responsibilities, uncertainty regarding role implementation, and the inherent uncertainty of existent knowledge. According to Hardy and Hardy (1988) , role ambiguity characterizes all professional positions. They have noted that role ambiguity might be positive in that it offers opportunities for creative possibilities. It can be expected to be more prominent in professions undergoing change, such as those in the health care field. Role ambiguity has been widely discussed in relation to the CNS role ( Bryant-Lukosius, Carter, Kilpatrick, et al, 2010 ; Hamric, 2003 ; see also Chapter 14 ), but is also a relevant issue for other APN roles ( Kelly & Mathews, 2001 ), particularly as APN roles evolve ( Stahl & Myers, 2002 ).

Role Incongruity

Role incongruity is intrarole conflict, which Hardy and Hardy (1988) described as developing from two sources. Incompatibility between skills and abilities and role obligations is one source of role incongruity. An example of this is an adult APN hired to work in an emergency department with a large percentage of pediatric patients. Such an APN will find it necessary to enroll in a family NP or pediatric NP program to gain the knowledge necessary to eliminate this role incongruity. This is a growing issue as NP roles become more specialized. Another source of role incongruity is incompatibility among personal values, self-concept, and expected role behaviors. An APN interested primarily in clinical practice may experience this incongruity if the position that she or he obtains requires performing administrative functions. An example comes from Banda's (1985) study of psychiatric liaison CNSs in acute care hospitals and community health agencies. She reported that they viewed consultation and teaching as their major functions, whereas research and administrative activities produced role incongruity.

Role Conflict

Role conflict develops when role expectations are perceived to be contradictory or mutually exclusive. APNs may experience conflict with varying demands of their role, as well as intraprofessional and interprofessional role conflict.

Intraprofessional Role Conflict

APNs experience intraprofessional role conflict for a variety of reasons. The historical development of APN roles has been fraught with conflict and controversy in nursing education and nursing organizations, particularly for CNMs ( Varney, 1987 ), NPs ( Ford, 1982 ), and CRNAs ( Gunn, 1991 ; see also Chapter 1 ). Relationships among these APN groups and nursing as a discipline have improved markedly in recent years, but difficulties remain ( Fawcett, Newman, & McAllister, 2004 ). The degree to which APN roles demonstrate a holistic nursing orientation as opposed to a more disease-specific medical orientation remains problematic (see value-added discussion under collaboration, later).

Communication difficulties that underlie intraprofessional role conflict occur in four major areas: (1) at an organizational level; (2) in educational programs; (3) in the literature; and (4) in direct clinical practice. Kimbro (1978) initially described these communication difficulties in reference to CNMs, but they are relevant for all APN roles. The fact that CNSs, NPs, CNMs, and CRNAs each have specific organizations with different certification requirements, competencies, and curricula creates boundaries and sets up the need for formal lines of communication. Communication gaps occur in education when courses and textbooks are not shared among APN programs, even when more than one specialty is offered in the same school. Specialty-specific journals are another formal communication barrier because APNs may read primarily within their own specialty and not keep abreast of larger APN issues. In clinical settings, some APNs may be more concerned with providing direct clinical care to individual patients, whereas staff nurses and other APNs may be more concerned with 24-hour coverage and smooth functioning of the unit or institution. These differences may set the stage for intraprofessional role conflict.

During the 1980s and 1990s, when there was more confusion about the delineation of roles and responsibilities between RNs and NPs, RNs would sometimes demonstrate resistance to NPs by refusing to take vital signs, obtain blood samples, or perform other support functions for patients of NPs ( Brykczynski, 1985 ; Hupcey, 1993 ; Lurie, 1981 ), and they were not admonished by their supervisors for these negative behaviors. These behaviors are suggestive of horizontal violence (a form of hostility), which may be more common during nursing shortages ( Thomas, 2003 ). Roberts (1983) first described horizontal violence among nurses as oppressed group behavior wherein nurses who were doubly oppressed as women and as nurses demonstrated hostility toward their own less powerful group, instead of toward the more powerful oppressors. Recognizing that intraprofessional conflict among nurses is similar to oppressed group behavior can be useful in the development of strategies to overcome these difficulties ( Bartholomew, 2006 ; Brykczynski, 1997 ; Farrell, 2001 ; Freshwater, 2000 ; Roberts, 1996 ; Rounds, 1997 ; see Chapter 11 ). According to Rounds (1997) , horizontal violence is less common among NPs as a group than among RNs generally. Over the years, as the NP role has become more accepted by nurses, there appear to be fewer cases of these hostile passive-aggressive behaviors, often currently referred to as bullying, toward NPs. However, they are still reported in APN transition literature ( Heitz et al., 2004 ; Kelly & Mathews, 2001 ).

One way to address these issues would be to include APN position descriptions in staff nurse orientation programs. Curry's claim (1994) that thorough orientation of staff nurses to the APN role, including clear guidelines and policies regarding responsibility issues, is an important component of successful integration of NP practice in an emergency department setting is also applicable to other roles and settings. Another significant strategy for minimizing intraprofessional role conflict is for the new APN, and APN students, to spend time getting to know the nursing staff to establish rapport and learn as much as possible about the new setting from those who really know what is going on—the nurses. This action affirms the value and significance of nurses and nursing and sets up a positive atmosphere for collegiality and intraprofessional role cooperation and collaboration. In Kelly and Mathews' study (2001) of new NP graduates, such a strategy was exactly what new NPs regretted not having incorporated into their first positions.

Interprofessional Role Conflict

Conflicts between physicians and APNs constitute the most common situations of interprofessional conflict. Major sources of conflict for physicians and APNs are the perceived economic threat of competition, limited resources in clinical training sites, lack of experience working together, and the historical hierarchy. The relationship between anesthesiologists and CRNAs is an ongoing exemplar for examination of the issues of interprofessional role conflict between physicians and APNs.

One way to promote positive interprofessional relationships is to provide education and practice experiences that include APN students, medical students, and both physician and APN faculty to enhance mutual understanding of both professional roles ( Kelly & Mathews, 2001 ). Developing such interprofessional education (IPE) experiences is difficult because of different academic calendars and clinical schedules. However, these obstacles can be overcome if these interdisciplinary activities are considered essential for improved health care delivery and if they have sufficient administrative support. Some programs attempt to overcome these scheduling issues by mandating IPE for APNs while it remains an elective experience for medical students, thereby reinforcing an optional and not important perspective among medical students.

The issues of professional territoriality and physician concern about being replaced by APNs were reported by Lindblad and colleagues (2010) from an ethnographic study of the first four APNs to graduate in 2005 from the first CNS program in Sweden. The APNs and general practitioners (GPs) agreed that the usefulness of the APNs would have been greater if the APNs had been able to prescribe medications and order treatments. After working with the APNs, the GPs saw them more as an additional resource and complement rather than a threat. By 2009, there were 16 APNs working in the new role in primary health care. Further clarification and definition of APN role responsibilities and collaboration will be forthcoming from Sweden.

The complementary nature of advanced practice nursing to medical care is a foreign concept for some physicians, who view all health care as an extension of medical care and see APNs simply as physician extenders. This misunderstanding of advanced practice nursing underlies physicians' opposition to independent roles for nurses because they believe that APNs want to practice medicine without a license (see Chapters 1 and 3 ). In fact, numerous earlier studies of APN practice have demonstrated that advanced practice roles incorporate a holistic approach that blends elements of nursing and medicine ( Brown, 1992 ; Brykczynski, 1999a , b ; Fiandt, 2002 ; Grando, 1998 ; Johnson, 1993 ). However, when APNs are viewed by physicians as direct competitors, it is understandable that some physicians would be reluctant to be involved in assisting with APN education ( National Commission on Nurse Anesthesia Education, 1990 ). In addition, some nurse educators have believed that physicians should not be involved in teaching or acting as preceptors for APNs. Improved relationships between APNs and physicians will require redefinition of the situation by both groups. The Interprofessional Education Collaborative's ( IPEC, 2011 ) advocacy for an interprofessional vision for all health professionals and the Institute of Medicine's ( IOM, 2003 ) recommendation that the health professional workforce be prepared to work in interdisciplinary teams underscore the imperative of interprofessional collaboration (see Chapter 12 ). Competency in interprofessional collaboration is critical for APNs because it is central to APN practice. This content is incorporated into the leadership and interprofessional partnership components of The Essentials of Doctoral Education for Advanced Nursing Practice ( AACN, 2006 ).

Some interesting research has recently emerged on this issue in Canada and Europe. A participatory action research study conducted in British Columbia, Canada ( Burgess & Purkis, 2010 ) indicated that NPs viewed collaboration as both a philosophy and a practice. “They cultivated collaborative relations with clients, colleagues, and health care leaders to address concerns of role autonomy and role clarity, extend holistic client-centered care and team capacity, and create strategic alliances to promote innovation and system change” ( p. 300 ). Of particular importance is the fact that the NP participants described themselves as being nurses first and practitioners second. This is significant because when role emphasis is on physician replacement and support rather than on the patient-centered, health-focused, holistic nursing orientation to practice, the nursing components of the role become less valued and invisible ( Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004 ). Medically driven and illness-oriented health systems tend to devalue these value-added components of APN roles and reimbursement mechanisms for including these aspects of care are lacking. Fleming and Carberry (2011) reported on a grounded theory study of expert critical care nurses transitioning to the role of APN in an intensive care unit (ICU) setting in Scotland. Initial perceptions were that the APN role was closely aligned with medical practice, but later perceptions supported earlier studies that the APN role was characterized by an integrated, holistic, patient-centered approach to care, which was close to the medical model, but different because it was carried out within an expert nursing knowledge base. They identified that further research is needed to explore the outcomes of this integrated practice. This is the research imperative for APNs—to demonstrate the impact of the holistic nursing approach to care on patient outcomes.

Nurse-midwives have been in the forefront of developing collaborative relationships with physicians for many years. All APN groups would benefit from attention to the progress that CNMs have made in collaboration with physicians. The joint practice statement of the American College of Nurse Midwives (ACNM) and the American College of Obstetricians and Gynecologists (ACOG) can be used as a model for other APN groups (ACOG/ ACNM, 2011 ). It highlights key principles for improving communication, working relationships, and seamlessness in the provision of women's health services (see also the ACNM's website, www.acnm.org ). Problems with previous joint practice statements were that they included varying interpretations of physician supervision. According to the most recent statement, “OB-GYNs and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed, independent providers who may collaborate with each other based on the needs of their patients. Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and accountability” (ACOG/ ACNM, 2011 ).

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