Advanced practice

Reflections on the continuing evolution of advanced practice nursing

Abstract

While the concept of advanced practice nursing (APN) is still relatively new, distinct patterns of evolution from specialty practice to advanced practice nursing are evident over the last 100 years. The purpose of this article is to describe 3 stages in this evolutionary process, as well as discuss several internal and external issues that represent challenges facing APN educators and clinicians who seek to strengthen advanced practice in the current healthcare system. We clarify our definition of advanced practice nursing, and note the critical need for cohesion within the profession regarding the definition and core competencies of advanced practice. Our aim is to suggest a preferred vision for advanced credentialing. We encourage dialogue among our nursing colleagues to move this agenda forward.

Section snippets

Historical patterns in the evolution of APN roles

While specialties in nursing have existed since the 1900s, specialization in nursing is different from advanced practice nursing, which is a relatively recent development in the history of the profession. Indeed, the phrase "advanced practice nursing" only began to appear in the literature in the 1970s and 1980s.5 Every specialty in nursing is not necessarily advanced practice nursing, as is clear when considering nurse educators, nurse administrators, or expert clinicians who have not attained

Commentary

We believe that each of these phases is part of the natural evolution towards advanced practice nursing that occurs as a practice specialty matures.

Interestingly, however, not all specialties evolve into advanced practice nursing, so this is not an inevitable progression. Dietetics was an early nursing specialty that matured into a separate discipline. Some specialties have evolved away from clinical practice as a central defining focus. Administration is an early example of this, as

Definition of advanced practice nursing

Before raising issues that must be addressed for the continuing evolution of advanced practice nursing, we need to clarify our understanding of the concept. Hamric4 developed a two-part definition of advanced practice, based on three seminal documents: ANA's Nursing's Social Policy Statement,16 the National Council of State Boards of Nursing's Position Paper on the Regulation of Advanced Nursing Practice,17 the National Organization of Nurse Practitioner Faculties' (NONPF) Advanced Nursing

Issues involved in evolving APN roles

We submit that a number of issues must be addressed for a given nursing specialty to evolve to an advanced level of practice and become incorporated into the larger arena of advanced practice nursing. As we move to strengthen advanced practice nursing, it is helpful for the profession to address these important issues in a unified and proactive fashion, rather than in the somewhat haphazard way that many roles have historically developed. These issues are outlined in Table 2.

Two visions for the future

At least two visions of the future are possible to discern in the present turbulence in the health care system. In the first, advanced practice nursing fades as a definable level of practice and merges into "mid-level provider" status along with physician assistants (PAs) and others. In this bleak (from our perspective) vision, physician substitution becomes the primary activity of APNs, and the emphasis in outcomes is on medical outcomes such as the diagnosis and cure of illness only. Advanced

Conclusion: creating our preferred vision for the future

For advanced practice nursing to continue to evolve as a unique phenomenon in health care it is necessary to look carefully at the way APNs are educated and credentialed for practice. To this end, the need to adhere to core competencies and to standardize APN curricula and national certification exams are a critical imperative. Attention to these basic structures will place APNs in a positive position to be able to negotiate the legal and regulatory issues that will continue to be an integral

Charlene M. Hanson is a Professor Emerita at Georgia Southern University, Statesboro, GA USA.

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Charlene M. Hanson is a Professor Emerita at Georgia Southern University, Statesboro, GA USA.

Ann B. Hamric is an Associate Professor at University of Virginia School of Nursing, Charlottesville, VA USA.

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