A Definition of Advanced Practice Nursing Ann B. Hamric This chapter considers two central questions that provide the foundation for this text: ?Why is it important to define carefully and clearly what is meant by the term advanced practice nursing?
?What distinguishes the practices of advanced practice nurses (APNs) from those of other nurses and other health care providers? Advanced practice nursing is considered here as a concept, not a role, a set of skills, or a substitution for physicians. Rather, it is a powerful idea, the origins of which date back more than a century. Such a conceptual definition provides a stable core understanding for all APN roles (see Chapter 2), it promotes consistency in practice that can aid others in understanding what this level of nursing entails, and it promotes the achievement of value-added patient outcomes and improvement in health care delivery processes. Advanced practice nursing is a relatively new concept in nursings evolution (see Chapter 1). Although debates and dissention are necessary and even healthy in forging consensus, ultimately the profession must agree on the key issues of definition, education, credentialing, and practice. This agreement is critically important to the survival, much less the growth, of advanced practice nursing. In this chapter, advanced practice nursing is defined and the scope of practice of APNs is discussed. Various APN roles are differentiated and key factors influencing advanced practice in health care environments are identified. The importance of a common and unified understanding of the distinguishing characteristics of advanced practice nursing is emphasized. The advanced practice of nursing builds on the foundation and core values of the nursing discipline. APN roles do not stand apart from nursing; they do not represent a separate profession, although references to ?the nurse practitioner (NP) profession,? for example, are seen in the literature. It is the nursing core that contributes to the distinctiveness seen in APN practices. According to the American Nurses Association (ANA, 2010), contemporary nursing practice has seven essential features: ? provision of a caring relationship that facilitates health and healing; attention to the range of human experiences and responses to health and illness within the physical and social environments; integration of assessment data with knowledge gained from an appreciation of the patient or the group; application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking; advancement of professional nursing knowledge through scholarly inquiry; influence on social and public policy to promote social justice; and, assurance of safe, quality, and evidence-based practice (p. 9). These characteristics are equally essential for advanced practice nursing. Core values that guide nurses in practice include advocating for patients, respecting patient and family values and informed choices, viewing individuals holistically within their environments, communities, and cultural traditions, and maintaining a focus on disease prevention, health restoration, and health promotion (ANA, 2001; Creasia & Friberg, 2011; Hood, 2010). These core professional values also inform the central perspective of advanced practice nursing. Efforts to standardize the definition of advanced practice nursing have been ongoing since the 1990s (American Association of Colleges of Nursing [AACN], 1995, 2006; ANA, 1995, 2003, 2010; Hamric, 1996, 2000, 2005, 2009; National Council of State Boards of Nursing [NCSBN], 1993, 2002, 2008). However, full clarity regarding advanced practice nursing has not yet been achieved, even as this level of nursing practice spreads around the globe. The growing international use of APNs with differing understandings in various countries has only complicated the picture (see Chapter 6). Different interpretations of advanced practice (AACN, 2006; ANA, 2005), debates about who is and is not an APN, and discrepancies in educational preparation for APNs remain issues for the international community, even as they are being standardized within countries. In spite of this lack of clarity (Ruel and Motyka, 2009; Pearson, 2011), emerging consensus on key features of the concept is increasingly evident. The definition that I have developed has been relatively stable throughout the five editions of this book. The primary criteria used in this definition are now standard elements used in the United States and, increasingly, elsewhere to regulate APNs. Similarly, consensus is growing in understanding advanced practice nursing in terms of core competencies. Even authors who deny a clear understanding of the concept propose competencies?variously called attributes, components, or domains?that are generally consistent with, although not always as complete as, the competencies proposed here. It is important to distinguish the conceptual definition of advanced practice nursing from regulatory requirements for any APN role (in the regulatory arena, the alternative term advanced practice registered nurse [APRN] is most commonly used; NCSBN, 2008). Of necessity, regulatory understandings focus on the more basic and measurable primary criteria of graduate educational preparation, advanced certification in a particular population focus, and practice in one of the four common APN roles: nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), and certified nurse-midwife (CNM). This approach is clearly seen in the APRN definition outlined in the Consensus Model (NCSBN, 2008) and has been very helpful and influential in standardizing state requirements for APRN licensure across the United States. Although necessary for regulation, however, this approach does not constitute an adequate understanding of advanced practice nursing. Limiting the professions understanding of advanced practice nursing to regulatory definitions can lead to a reductionist approach that results in a focus on a set of concrete skills and activities, such as diagnostic acumen or prescriptive authority. Understanding the advanced practice of the nursing discipline requires a definition that encompasses broad areas of skilled performance (the competency approach). As Chapter 2 notes, conceptual models and definitions are also useful for providing a robust framework for graduate APN curricula and for building an APN professional role identity. Distinguishing Between Specialization and Advanced Practice Nursing Before the definition of advanced practice nursing can be explored, it is important to distinguish between specialization in nursing and advanced practice nursing. Specialization involves the development of expanded knowledge and skills in a selected area within the discipline of nursing. All nurses with extensive experience in a particular area of practice (e.g., pediatric nursing, trauma nursing) are specialized in this sense. As the profession has advanced and responded to changes in health care, specialization and the need for specialty knowledge have increased. Thus, few nurses are generalists in the true sense of the word (Kitzman, 1989). Although family NPs traditionally represented themselves as generalists, they are specialists in the sense discussed here because they have specialized in one of the many facets of health care?namely, primary care. As Cockerham and Keeling note in Chapter 1, early specialization involved primarily on-the-job training or hospital-based training courses, and many nurses continue to develop specialty skills through practice experience and continuing education. Examples of currently evolving specialties include genetics nursing, forensic
