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.