NURSING AND HEALTH CARE MANAGEMENT AND POLICY Advanced practice nursing roles: development, implementation and evaluation Denise Bryant-Lukosius PhD RN CON(C) Assistant Professor, School of Nursing, McMaster University Clinical Nurse Specialist, Juravinski Cancer Centre, Hamilton, Ontario and Canadian Health Services Research Foundation, Postdoctoral Fellow, Canada Alba DiCenso PhD RN Professor, School of and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario and Chair in Advanced Practice Nursing, Canadian Health Services Research Foundation/Canadian Institute of Health Research, Canada Gina Browne PhD RN Professor, School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario and Director, Systems Linked Research Unit for Health and Social Service Utilization, Canada Janet Pinelli PhD RNC Professor, School of Nursing and Department of Pediatrics, McMaster University, Hamilton, Ontario and Clinical Nurse Specialist/Neonatal Nurse Practitioner, McMaster Children���s Hospital, Canada Submitted for publication 5 January 2004 Accepted for publication 14 March 2004 Correspondence: Denise Bryant-Lukosius, Room 3H48 ��� Faculty of Health Sciences, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5. E-mail: bryantl@mcmaster.ca BRYANT-LUKOSIUS D., DICENSO A., BROWNE G. & PINELLI J. (2004) BRYANT-LUKOSIUS D., DICENSO A., BROWNE G. & PINELLI J. (2004) Journal of Advanced Nursing 48(5), 519���529 Advanced practice nursing roles: development, implementation and evaluation Aim. The aim of this paper is to discuss six issues influencing the introduction of advanced practice nursing (APN) roles: confusion about APN terminology, failure to define clearly the roles and goals, role emphasis on physician replacement/sup- port, underutilization of all APN role domains, failure to address environmental factors that undermine the roles, and limited use of evidence-based approaches to guide their development, implementation and evaluation. Background. Health care restructuring in many countries has led to substantial increases in the different types and number of APN roles. The extent to which these roles truly reflect advanced nursing practice is often unclear. The misuse of APN terminology, inconsistent titling and educational preparation, and misguided interpretations regarding the purpose of these roles pose barriers to realizing their full potential and impact on health. Role conflict, role overload, and variable stakeholder acceptance are frequently reported problems associated with the introduction of APN roles. Discussion. Challenges associated with the introduction of APN roles suggests that greater attention to and consistent use of the terms of the terms advanced nursing practice, advancement and advanced practice nursing is required. Advanced nursing practice refers to the work or what nurses do in the role and is important for defining the specific nature and goals for introducing new APN roles. The concept of advancement further defines the multi-dimensional scope and mandate of advanced nursing practice and distinguishes differences from other types of nursing roles. �� 2004 Blackwell Publishing Ltd 519

Advanced practice nursing refers to the whole field, involving a variety of such roles and the environments in which they exist. Many barriers to realizing the full potential of these roles could be avoided through better planning and efforts to address environmental factors, structures, and resources that are necessary for ad- vanced nursing practice to take place. Conclusions. Recommendations for the future introduction of APN roles can be drawn from this paper. These include the need for a collaborative, systematic and evidence-based process designed to provide data to support the need and goals for a clearly defined APN role, support a nursing orientation to advanced practice, promote full utilization of all the role domains, create environments that support role development, and provide ongoing evaluation of these roles related to pre- determined goals. Keywords: advanced nursing practice, advanced practice nursing, nursing, role barriers, role implementation, role evaluation Introduction Advanced practice nursing (APN) represents the future frontier for nursing practice and professional development. It is a way of viewing the world that enables questioning of current practices, creation of new nursing knowledge, and improved delivery of nursing and health care services (Patterson & Haddad 1992, Davies & Hughes 1995, Elliott 1995, Sutton & Smith 1995). Therefore, continued development of APN is of paramount importance for society and the nursing profession. In this paper, six issues influencing APN role develop- ment, implementation and evaluation are described, and recommendations for the future introduction of APN roles are proposed. Confusion about the roles is evident in misuse of terms, inconsistent titling and educational preparation, and varied interpretations about the purpose of APN roles (Dunn & Nicklin 1995, Woods 1997, Brown 1998, Styles & Lewis 2000, Chang & Wong 2001). In addressing this issue, the terms ���advanced nursing practice��� and ���advanced practice nursing��� are distinguished, and this provides the basis for examining five other issues: lack of clearly defined APN roles and goal expectations, role emphasis on physician replacement and support, under- utilization of the full scope of APN role domains, environmental factors that undermine APN roles, and the limited use of research and evidence-based approaches to guide the introduction of new APN roles. Global context of APN roles In the last decade, many countries have witnessed unpre- cedented increases in the numbers and types of new APN roles such as acute care nurse practitioners, advanced practice case managers, and clinical nurse specialists/nurse practitioners (Keane & Richmond 1993, Elliott 1995, Alcock 1996, Dillon & George 1997, Pinelli 1997, Offredy 2000, Chang & Wong 2001, Chen 2001, Pulcini & Wagner 2001, White 2001). New APN roles have occurred predominantly in acute care settings. Increasing demand for APN is expected to continue well into the 21st century, with expansion of such roles in ambulatory and community settings. Despite the need for this higher level of nursing practice, there are many challenges to the successful implementation of APN roles (Dunn & Nicklin 1995, Beal et al. 1997, Woods 1998, Irvine et al. 2000, Centre for Nursing Studies and the Institute for the Advancement of Public Policy 2001, Guest et al. 2001, Seymour et al. 2002). Preliminary results of an international survey of the roles indicate variability in legislative and regulatory mechanisms, titling, role autonomy, prescriptive authority, role functions, educational preparation, and extent to which these roles have been evaluated (ICN 2001). Thus, it is unclear which roles truly reflect advanced practice. Confusion about terminology Advanced practice nursing roles can be shaped to address complex and dynamic health care system needs and demands for flexibility in service delivery. While variability among APN roles is expected and desirable, consistency in core characteristics is important for advanced nursing practice to occur. However, within the nursing profession there is confusion about the terminology used to describe APN roles. The terms advanced nursing practice and advanced practice nursing are often used interchangeably (Brown 1998, CNA 2000, Styles & Lewis 2000). Understanding the difference between these related concepts is necessary for defining and then developing the full potential of the roles (Table 1). D. Bryant-Lukosius et al. 520 �� 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 519���529