Calkin's model of advanced nursing practice

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What is the Difference in Advance Nursing Practice (ANP) and Advance Practice Nursing (APN)?
It is critical that all nurses, regardless of their educational preparation understand differences in nursing specialties. Likewise, recognizing similarities and finding the nexus of shared competencies is paramount to maximizing the impact nursing will have on patient outcomes. According to Hamric et al (2014), advanced practice nursing and advanced nursing practice are distinguishable and are not interchangeable (p 69). However, the Doctor of Nursing Practice degree is available to all nurses practicing at the highest levels.

Advanced practice nursing includes both providing direct clinical care providers like nurse practitioners, clinical nurse specialist, nurse midwives and nurse anesthetist and indirect care nurses in administrative or executives roles, those working as nurse informaticists, and nurses in public health. The nurse educator stands alone currently and will be discussed in more detail in Week 2.

To provide a refined answer to the question, Advanced nursing practice is an umbrella term for many different nursing specialties in which advanced practice nursing is one. The Doctoral Essentials broadly defines advanced nursing practice as “any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy” (p.4).

APNs provide direct care to individual patients and families. APN roles involve expanded clinical knowledge, skills and abilities and require a different level of regulation than non-APN roles. This course will focus on the many roles of the advanced practice nurse and the varied roles of advanced nursing practice. The text will be your primary reference for APN roles, and the articles and other reference material will provide additional knowledge in advance nursing practice roles.

(Hamric, p. 68-70)

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We wish to acknowledge the previous chapter author, Judith A. Spross, PhD, RN, FAAN, for her excellent work in previous editions.

Concepts, models, and theories are used by advanced practice registered nurses (APRNs) to elicit histories, perform physicals, plan treatment, evaluate outcomes, and develop interpersonal relationships, as well as to help patients and families improve their health, cope with illnesses, and die with dignity. All APRNs, regardless of their years of experience and practice, rely on common processes and language to communicate with colleagues about patient care and to explain clinical situations. As such, it is important that the nursing profession and APRNs understand the language of advanced practice nursing to communicate it to each other, clients, and stakeholders.

Understanding the conceptualization of advanced practice nursing, APRN practice, similarities and differences among APRNs, and how APRNs contribute to affordable, accessible, and effective care is central to actualizing a patient-centered, interprofessional health care system that maximizes patient outcomes and minimizes negative consequences. Conceptualizations of advanced practice nursing include models and theories that guide the practice of APRNs. The use of theory is fundamental to the sound progress in any practice discipline. Common language and mutually understood conceptual and theoretical frameworks support communication, guide practice, and are used to evaluate practice, education, policy, and research.

Such a foundation is essential for APRNs given the proposed changes in the US health care system, as seen in the Patient Protection and Affordable Care Act (ACA) (2010), the Consensus Model for APRN Regulation (APRN Joint Dialogue Group, 2008), and The Future of Nursing (Institute of Medicine [IOM], 2011). Other forces driving a common understanding of APRNs are the increasing numbers of programs offering the Doctor of Nursing Practice (DNP) degree, accountable care organizations, and the promulgation of interprofessional competencies (Canadian Interprofessional Health Collaborative [CIHC], 2010; Health Professions Network Nursing and Midwifery Office, 2010; Interprofessional Education Collaborative [IPEC] Expert Panel, 2011), as well as recommendations to the US Congress to increase funding for interprofessional education and practice (National Advisory Council on Nurse Education and Practice, 2015).

In addition to efforts in the United States, nursing associations, councils, and regulatory agencies in other countries have clarified, established, and/or regulated APRN roles and practice (Canadian Nurses Association [CNA], 2007, 2008, 2009a, 2009b; ICN Nurse Practitioner/Advanced Practice Nursing Network, 2016; International Council of Nurses [ICN], 2009; Nursing and Midwifery Board of Australia, 2014). In countries in which APRN roles exist, in addition to studies of the distinctions among roles (Gardner, Chang, Duffield, & Doubrovsky, 2013; Gardner, Duffield, Doubrovsky, & Adams, 2016; Lowe, Plummer, O'Brien, & Boyd, 2012), APRN educational programs are being established, for example, in Israel (Kleinpell et al., 2014), mainland China (Wong et al., 2010), and Singapore (National University of Singapore Yong Loo Lin School of Medicine, 2016). Country-specific frameworks are being developed to clarify education, scope of practice, registration and licensing, and/or credentialing (Fagerström, 2009). Although contextual factors may differ from those in the United States, global opportunities exist for clarifying and advancing APRN practice specific to a country's culture, health system, professional standards, and regulatory requirements. A sample of conceptual and theoretical models of APRN practice from various countries is presented in this chapter along with US and international conceptualizations of APRN roles.

Professional organizations with interests in licensing, accreditation, certification, and educational (LACE) issues regarding APRNs also operate from a conceptualization of advanced practice nursing, whether implicit or explicit. In this chapter, models promulgated by APRN stakeholder organizations that describe the nature of advanced practice nursing and/or differentiate between advanced and basic practice, and selected models, including international, that have guided APRN practice are discussed. Problems associated with lack of a unified definition of advanced practice and imperatives for undertaking this important work exist. When practical, consensus on advanced practice nursing models should be beneficial for patients, society, and the profession. The APRN Consensus Model (APRN Joint Dialogue Group, 2008) and core competencies of APRN practice brought needed conceptual clarity to the regulation of advanced practice nursing in the United States. However, variations in scope of practice still remain between states in the United States (Pearson, 2014) and around the world (Kleinpell et al., 2014). Additionally, work is still needed to differentiate basic and advanced nursing practice and the practice of APRNs from that of other disciplines. Therefore the purposes of this chapter are as follows:

1. 1. Lay the foundation for thinking about the concepts underlying advanced practice nursing by describing the nature, purposes, and components of conceptual models.

2. 2. Identify conceptual challenges in defining and operationalizing advanced practice nursing.

3. 3. Describe selected conceptualizations of advanced practice nursing.

4. 4. Make recommendations for assessing existing models and developing, implementing, and evaluating conceptual frameworks for advanced practice.

5. 5. Outline future directions for conceptual work on advanced practice nursing.

It is important to note that, because of the dynamic and evolving nature of health care and nursing organizations activities in this arena, nationally and globally, readers are encouraged to consult the websites cited in this chapter for up-to-date information.

Nature, Purposes, and Components of Conceptual Models

A conceptual model is one part of the structure of nursing knowledge. Ranging from most abstract to most concrete, this structure consists of metaparadigms, philosophies, conceptual models, theories, and empirical indicators (Fawcett & Desanto-Madeya, 2013). Traditionally, key concepts in the metaparadigm of nursing are humans, the environment, health, and nursing (Fawcett & Desanto-Madeya, 2013).

Fawcett and Desanto-Madeya (2013) described a conceptual model as “a set of relatively abstract and general concepts that address the phenomena of central interest to a discipline, the propositions that broadly describe these concepts, and the propositions that state relatively abstract and general relations between two or more of the concepts” (p. 13). In addition, they noted that a conceptual model is “a distinctive frame of reference … that tells [adherents] how to observe and interpret the phenomenon of interest to the discipline” and “provide[s] alternative ways to view the subject matter of the discipline; there is no ‘best’ way” (p. 13). Although there is no best way to view a phenomenon, evolving a more uniform and explicit conceptual model of advanced practice nursing benefits patients, nurses, and other stakeholders (IOM, 2011) by facilitating communication, reducing conflict, and ensuring consistency of advanced practice nursing, when relevant and appropriate, across APRN roles, and by offering a “systematic approach to nursing research, education, administration, and practice” (Fawcett & Desanto-Madeya, 2013, p. 15).

Models may help APRNs articulate professional role identity and function, serving as a framework for organizing beliefs and knowledge about their professional roles and competencies, providing a basis for further development of knowledge. In clinical practice, APRNs use conceptual models in the delivery of their holistic, comprehensive, and collaborative care (Carron & Cumbie, 2011; Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011; Elliott & Walden, 2015; Musker, 2011). Models may also be used to differentiate among and between levels of nursing practice—for example, between staff nursing and advanced practice nursing (Gardner et al., 2013) and between clinical nurse specialists (CNSs), nurse-midwives, and nurse practitioners (NPs) (Begley et al., 2013).

Conceptual models are also used to guide research and theory development by focusing on a given concept or examining the relationships among select concepts to elucidate testable theories. For example, Gullick and West (2016) evaluated Wenger's Community of Practice framework to build research capacity and productivity for CNSs and NPs in Australia. Faculty, in the preparation of students for APRN roles, use conceptual models to plan curricula, to identify important concepts and their relationships, and to make choices about course content and clinical experiences (Perraud et al., 2006; Wong et al., 2010).

Fawcett and Graham (2005) and Fawcett, Newman, and McAllister (2004) have challenged us to think about conceptual questions of advanced practice:

· • What do APRNs do that makes their practice “advanced”?

· • To what extent does incorporating activities traditionally done by physicians qualify nursing practice as “advanced”?

· • Are there nursing activities that are also advanced?

Because direct clinical practice is viewed as the central APRN competency, this begs the question: What does the term clinical mean? Does it refer only to hospitals or clinics? These questions are becoming more important given the APRN Consensus Model and given the role that APRNs are expected to play across the continua of health care as a result of ongoing changes to health care legislation. From a regulatory standpoint, the emphasis on a specific population as a focus of practice will lead, when appropriate, to reconceptualizing curricula to ensure that graduates are prepared to succeed in new or revised certification examinations. Hamric and Tracy (see Chapter 3) have noted that although some APRN competencies (e.g., collaboration) may be performed by nurses in other roles, the expression of these competencies by APRNs is different. For example, although all nurses collaborate, a unique aspect of APRN practice is that APRNs are authorized to initiate referrals and prescribe treatments that are implemented by others (e.g., physical therapy). Innovations and reforms arising from changes in health care legislation will ensure that APRNs are explicitly engaged in the delivery of care across care settings, including in nursing clinics and palliative care settings, and as full participants in interprofessional teams. Changes in regulations and in the delivery of health care may be the impetus that leads to new or revised conceptualizations of advanced practice nursing (e.g., defining theoretical and evidence-based differences between the care provided by APRNs and other providers and clinical staff, the role of APRNs in interprofessional teams, and specialization and subspecialization in advanced practice nursing). Working together, nursing leaders and health policymakers will be able to design a health care system that delivers high-quality care at reasonable cost, based on disciplinary and interdisciplinary competencies, outcomes, effectiveness, efficacy, and efficacy.

In addition to a pragmatic reevaluation of advanced practice nursing concepts based on the evolution of APRN regulation and health care reform, important theoretical questions are being raised about the conceptualization of advanced practice nursing. Issues range from the epistemologic, philosophical, and ontologic underpinnings of advanced practice (Arslanian-Engoren, Hicks, Whall, & Algase, 2005) and the extent to which APRNs are prepared to apply nursing theory to their practices (Algase, 2010; Arslanian-Engoren et al., 2005; Karnick, 2011) to the questions about the nature of advanced practice knowledge, discerning the differences between and among the notions of specialty, advanced practice, and advancing practice (Allan, 2011; Christensen, 2009, 2011; MacDonald, Herbert, & Thibeault, 2006; Thoun, 2011).

In summary, questions arising from a changing health policy landscape and from theorizing about advanced practice nursing underscore the need for well thought-out, robust conceptual models to guide APRN practice. Conceptual clarity of advanced practice nursing, what it is and is not, is important not only for patients and those in the nursing profession but also for interprofessional education (CIHC, 2010; Health Professions Network Nursing and Midwifery Office, 2010; IPEC Expert Panel, 2011) and practice (American Association of Nurse Anesthetists [AANA], 2012). Conceptual clarity of advanced practice nursing will also inform the creation of accountable care organizations and support efforts to build teams and systems in which effective communication, collaboration, and coordination will lead to high-quality care and improved patient, institutional, and fiscal outcomes.

Conceptualizations of Advanced Practice Nursing: Problems and Imperatives
Despite the usefulness and benefits of conceptual models, conceptual confusion and uncertainty remain regarding advanced practice nursing. One noted issue is the lack of a well-defined and consistently applied core stable vocabulary used for model building. Despite progress, this challenge remains. For example, in the United States advanced practice nursing is the term that is used, but the ICN and CNA use the term advanced nursing practice. Considerable variation is noted between the conceptual definition of advanced practice nursing and that of advanced nursing practice as used in Australia, Canada, New Zealand, the United States, Canada, and the United Kingdom (Stasa, Cashin, Buckley, & Donoghue, 2014). Adding to this opacity is the use of the term advanced practitioner to describe the role of non-APRN experts in the United Kingdom and internationally (McGee, 2009). The role and functions of APRNs need to be clearly and consistently conceptualized.

The APRN Consensus Model (APRN Joint Dialogue Group, 2008) represents a major step forward in promulgating a uniform definition of advanced practice in the United States, for the purpose of regulation. However, the lack of a core vocabulary continues to make comparisons difficult because the conceptual meanings vary. Competencies are more commonly used to describe concepts of APRN practice, but reflection on and discussion of other terms such as roles, hallmarks, functions, activities, skills, and abilities continue and may contribute to the urgent need for clarification of conceptual models and a common language.

Few models of APRN practice address nursing's metaparadigm (person, health, environment, nursing) comprehensively. The problem in comparing, refining, or developing models is that concepts are often used without universal meaning or consensus and, occasionally, with no or inconsistent definitions. It is rightly anticipated that conceptual models of the field and its practice change over time. However, the evolution of advanced practice nursing and its comprehension by nurses, policymakers, and the public will be enhanced if scholars and practitioners agree on the use and definition of fundamental concepts of APRN practice.

Another challenge is the paucity of conceptual models describing the practice and outcomes of APRNs. Although the numbers of models are increasing, they remain small. Further compounding this issue is the scarcity of international and global models of APRN practice. Models are needed that address the diverse health and cultural needs of individuals, families, and communities worldwide.

Another issue is a lack of clarity in the conceptualizations that differentiate the clinical practice of APRNs from that of registered nurses (RNs) without graduate degrees in advanced practice. Conceptual models can help to identify key concepts and variables that distinguish the focus, levels of practice, and outcomes between and among nurses with different levels and types of academic preparation and specialty certification.

Of additional importance is clarifying and distinguishing the differences in practice of APRNs and physician colleagues. Some graduate APRN students may struggle with this issue as part of role development. The lack of conceptual clarity is apparent in advertisements that invite both NPs and physician assistants to apply for the same position. Organized medicine continues to expend resources trying to limit or discredit advanced practice nursing, even as some physician leaders work on behalf of advocating for APRNs. Barriers to APRNs' ability to practice to the full extent of their education and training as recommended by the IOM (2011) may be the result of lack of conceptual clarity between nursing at the advanced practice level and the practice of medicine. To this end, the philosophical underpinnings of conceptual models of APRN practice need explication.

The emphasis on interprofessional education and practice is another issue in need of clarification. Interprofessional education and practice is central to accountable, collaborative, coordinated, and high-quality care. Graduate education of APRNs alongside other health professionals is beginning to take place. For example, at the University of Michigan, an interprofessional clinical decision-making course with graduate students from nursing (APRN students), pharmacy, dentistry, medicine, and social work is one of the first of its kind in the nation. Students learn together and from each other about their roles, preparation, and disciplinary foci (Sweet, Madeo, Fitzgerald, et al., 2017). The development of interprofessional competencies for health professionals (CIHC, 2010; Health Professions Network Nursing and Midwifery Office, 2010; IPEC Expert Panel, 2011) indicates the need for high-functioning, interprofessional teams of health care experts to maximize patient outcomes. The existence of interprofessional competencies and emergence of promising conceptualizations of interprofessional work are critical contextual factors for elucidating and advancing conceptualizations of advanced practice nursing (Barr, Freeth, Hammick, Koppel, & Reeves, 2005; Reeves et al., 2011). Conceptual models for APRN practice on interprofessional teams are needed to explicate the unique and critical contributions of APRNs to patient outcomes and system resources.

Among many imperatives for reaching a conceptual consensus on advanced practice nursing, most important are the interrelated areas of policymaking, licensing and credentialing, and practice, including competencies. In the policymaking arena, for example, not all APRNs are eligible to be reimbursed by insurers, and even those activities that are reimbursable are often billed incident to a physician's care, rendering the work of APRNs invisible. The APRN Consensus Model (APRN Joint Dialogue Group, 2008), the ACA (2010), and the IOM's call for changes to enable APRNs to work within their full scope of practice (IOM, 2011) will make it easier for US policymakers to recommend and adopt changes to policies and regulations that now constrain APRN practice, eventually making the contributions of APRNs to quality care visible and reimbursable. Agreement on vocabulary and concepts such as competencies that are common to all APRN roles will maximize the ability of APRNs to work within their full scope of practice.

Although some progress has been made, there are compelling reasons for continuing dialogue and activity aimed at clarifying advanced practice nursing and the concepts and models that help stakeholders understand the nature of APRN work and the contributions of APRNs. Reaching consensus on concepts and vocabulary will serve theoretical, practical, and policymaking purposes. As the work of health care reform and implementing interprofessional competencies, education, and practice moves forward, there will be opportunities for the profession to conceptualize advanced practice nursing more clearly. Box 2.1 presents outcomes that come from clarification and consensus on conceptualization of the nature of advanced practice nursing.

Conceptualizations of Advanced Practice Nursing Roles: Organizational Perspectives

Practice with individual clients or patients is the central work of the field; it is the reason for which nursing was created. The following questions are the kinds of questions a conceptual model of advanced practice nursing should answer:

· • What is the scope and purpose of advanced practice nursing?

· • What are the characteristics of advanced practice nursing?

· • Within what settings does this practice occur?

· • How do APRNs' scopes of practice differ from those of other providers offering similar or related services?

· • What knowledge and skills are required?

· • How are these different from those of other providers?

· • What patient and institutional outcomes are realized when APRNs deliver care? How are these outcomes different from those of other providers?

· • When should health care systems employ APRNs, and what types of patients particularly benefit from APRN care?

· • For what types of pressing health care problems are APRNs a solution in terms of improving outcomes, quality of care, and cost-effectiveness?

Of the conceptual models presented in this chapter, some are more narrowly focused than others, and some are more homogeneous or mixed with respect to the phenomenon studied. Models may be seen as micromodels in terms of the unit of analysis or as metamodels incorporating a number of conceptual frameworks. Still other models explain systems and the relationships between and among systems. All these foci are important, depending on the purposes to be served. However, in the development of conceptual models, the phenomenon to be modeled must be carefully defined. For example, a model may encompass the entire field of advanced practice nursing or be confined to distinctive concepts (e.g., collaborative practice between APRNs and physicians or the difference between APRN practice and the practice of non-APRN nurses). If a phenomenon and its related concepts are not clearly defined, the model could be so inconsistent as to be confusing or so broad that its impact will be diluted.

In addition to describing concepts and how they are related, assumptions about the philosophy, values, and practices of the profession should be reflected in conceptual models. The discussion of conceptualizations of advanced practice nursing is guided by these assumptions:

1. 1. Each model, at least implicitly, addresses the four elements of nursing's metaparadigm: persons, health and illness, nursing, and the environment.

2. 2. The development and strengthening of the field of advanced practice nursing depends on professional agreement regarding the nature of advanced practice nursing (a conceptual model) that can inform APRN program accreditation, credentialing, and practice.

3. 3. APRNs meet the needs of society for advanced nursing care.

4. 4. Advanced practice nursing will reach its full potential to the extent that foundational conceptual components of any model of advanced practice nursing framework are delineated and agreed on.

Consensus Model for Advanced Practice Registered Nurse Regulation
In 2004, an APRN Consensus Conference was convened to achieve consensus regarding the credentialing of APRNs (APRN Joint Dialogue Group, 2008; Stanley, Werner, & Apple, 2009) and the development of a regulatory model for advanced practice nursing. Independently, the APRN Advisory Committee for the National Council of State Boards of Nursing (NCSBN) was charged by the NCSBN Board of Directors with a similar task of creating a future model for APRN regulation and, in 2006, disseminated a draft of the APRN Vision Paper (NCSBN, 2006), a document that generated debate and controversy. Within a year, these groups came together to form the APRN Joint Dialogue Group, with representation from numerous stakeholder groups, and the outcome was the APRN Consensus Model (APRN Joint Dialogue Group, 2008).

The APRN Consensus Model includes important definitions of roles, titles, and population foci. Furthermore, it defines specialties and describes how to make room for the emergence of new APRN roles and population foci within the regulatory framework. A timeline for adoption and strategies for implementation were put forth, and progress has been made in these areas (see Chapter 22 for further information; only the model is discussed here). Fig. 2.1 depicts the components of the APRN Consensus Model, the four recognized APRN roles and six population foci. The term advanced practice registered nurse refers to all four APRN roles. An APRN is defined as a nurse who meets the following criteria (APRN Joint Dialogue Group, 2008):