Stages of APN Role Development

Introduction

The purpose of the IAPN website is to help promote the international role of Advanced Practice Nursing, particularly to be a resource to help give a glimpse into the constantly evolving role on a macro level. In order to facilitate a bigger picture and to assist with a glimpse into the varying role internationally, a scale utilized throughout the world is to assist the international community in clearly identifying the state of role APN role development for easier reference, and to allow international communities that may already have a more advanced role to be able to assist in the role development of those that are in earlier developing stages (Heale & Rieck Buckley, 2015).

For those particularly interested in developing an APN role in their nation, I would encourage you to look for the already validated and accepted models in use. Of those, the Strong Model of APN Practice (NP / APN Network, 2019), and variations of similar models exist to help guide the development of APN program development and are much more comprehensive. Another helpful tool for APN role understanding is the Consensus Model to help differentiate the roles within the same nation. Such models often use objective data coming from questionnaires of programs, health systems, and individual nurses that provide the basis of much of the content presented in IAPN.

However, much of the information presented in the IAPN website also relies on grey literature and non primary resources as information because of a significant gap in published literature. In order to quantify the grey literature and provide one uniform model based on the information received, the below model was created to provide a glimpse as to the current state of advancement of the APN role in a given country. By no means is this validated as a research proven model, but gives a basic framework for the content of this website.

Bias

The focus of this model is based on defining “advancement” on increasing formal role recognition and autonomy. Not every nation has the need or interest in prioritizing advancement of the APN role. The end purpose of APN role advancement is not to “become independent clinicians” but rather to meet the needs of the population. Additionally, this model has a significant bias that nursing presents additional health care qualities not met by other health clinician roles, suggesting an APN not only exists to meet a gap in medical care by any clinician, but uniquely contributes to the population’s greater health care needs.

The Model of APN Role Advancement

[IMAGE: MODEL OF STAGES OF APN DEVELOPMENT]

The model utilized on the IAPN website is as follows:

STAGE 0: Registered Nursing Role In Development

This role is identified as the registration not being formally identified with a bachelor level formal curriculum for nursing.  Particularly, if the country does not have formal standardization of the nursing role, there is not adequate foundational support to develop an advanced practice nursing role.  As the international standard set by the International Council of Nurses for Advanced Practice Nurses reflects a master’s level education, if the does not have a comparable bachelor’s level education for their nursing staff, consequentially there is also a gap in the ability for advancement toward a master’s level role.

Examples: entity does not have formal role of nursing established and will accept health care management from individuals in varying educational preparation without regulation to practice nursing.

Gap to next stage: Lack of registered nurse role establishment, lack of bachelor’s level education for registered nursing.

STAGE 1: Potential Stage

In this stage, there is a formal registered nurse role, however there is no known significant identification of role advancement.  This stage largely focuses on feasibility, as the foundation to developing advancement of the nursing role is largely drawn on the potential for it to develop.  Entities in this stage reflects no known formal interest or inquiry.  However, it may have individuals or small groups that have begun to explore the concept of advancing nursing practice at the grassroots level.  

Examples: recent establishment of standardized registered nurse role or establishment of the bachelor degree as a competency standard.

Gap to next stage: Informal inquiry to develop the role of the APN

STAGE 2: Investigative Stage

This stage reflects any element of informal inquiry to determine the feasibility of the role development.  Entities in this stage begin to explore the barriers including health policies, health care systems including need for increased nursing role, or gaps in traditionally physician directed health care.

Examples: publications describing need or support of role advancement, nursing representation in international advanced practice nursing forums, consultation with subject matter experts to discuss the role development.

Gap to next stage: Formal development of role advancement.

STAGE 3: Development Stage

This stage is marked by the formal development of an initiative to create advancement for nursing practice.

Examples:  pilot programs, educational institutions with formalized curriculum to advance nursing, organizations that establish their own advanced protocols for specialized nurses not regulated by legal policies with intent to expand nursing scope of practice further over time.

Gap to next stage:  does not have formal establishment of the advanced nursing role in bylaws and does not currently have any formal or concerted effort to develop an advanced practice role.

STAGE 4: Establishment Stage

This stage is marked by formal proposal of cross-organizational or governmental entity collaboration with the interest to develop more universal role advancement.

Examples: Ministry of health within a country creating formal role that is beyond that of a single health facility, collaborative of various key stakeholders developing policies with intent to develop legislation for more universal implementation of an advanced practice nurse role.

Gap to next stage: Formal recognition of advanced practice nursing role. Legislation has been adapted at the policy level.

STAGE 5: Implemented Without Autonomy Stage

This stage reflects formal recognition of the advanced practice nurse.  There is legal protection and recognition of the role including standardization of curriculum to become an advanced practice nurse.  This role however does not allow for autonomy of practice and still requires supervision for any additional role expansion.

Examples: Entity that has formal name recognition however requires additional medical supervision or collaboration to perform treatments, prescriptions, changes in plan of care.

Gap to next stage: Provision of at least one element of role autonomy.

STAGE 6: Partial Autonomy Stage

In this stage the role is formally acknowledged and has autonomy in at least one key component of the key practice elements.  The role reflects no supervision or requirement of another individual to must sign off on the decision of practice and the individual’s independent license permits practice to that element.

Examples: Role that allows for autonomous diagnosis for urinary tract infection, but requires physician colleague to prescribe or sign-off on medication to treat infection.  Nursing protocol that is developed and implemented by advanced practice nurse that does not require any superior clinical medical supervision for approval.

Gap to next stage: Complete autonomy of role.

STAGE 7: Full Autonomy Stage

In this stage, the advanced practice nurse is able to independently perform their role.

Examples: Advanced practice nurse attended clinic without other discipline.

Additional Considerations

The following considerations are factors that are not reflected in the above proposed model.  However, they are important to note and acknowledge as they may contribute to the advancement of the APN role.

Varying Scope of Practice

As laid out by the ICN APN Network (Schober et al., 2020, p.10), clinical characteristics are identified but based on varying healthcare systems, the scope of practice may vary.  This leaves some ambiguity of when a legal entity may cross the threshold between having an established APN role versus a specialized registered nurse.

Cross Country Compatibility

An additional gap that would greatly assist with the development of the APN role internationally would be to provide a state of universal accord between host nation roles, allowing for some level of cross-country role compatibility.  In theory, this role would only be possible for nations with roles in stages 5 through 7, and while would indicate significant establishment of the role, is separate from the actual development of role autonomy.

Form of Standardized Practice Competency

Standards of competence often vary based on entity.  Key means of that of establishing standardized training can vary by entity based on feasibility and cultural practice.  The scale above does not differentiate between the different forms of certification, as they may have variable rigor depending on policy.  Examples of forms of standardization may include core curriculum for educational institutions, board certification with a standardized competency test, and/or institutional licensure.

Level of Role Embracement

While there may be very influential individuals and entities that have developed the role, there is the potential for the role to be regionally more or less accepted despite legal and policy-level support.  As a result some entities have the potential to meet the criteria for a specific stage but that does not ensure that all components under the purview of that entity mutually embrace the role.

References:
Heale, R. & Reick Buckley, C. (2015). An international perspective of advanced practice nursing regulation. International Nursing Review. 62, 421-429. doi:10.1111/inr.12193

NP / APN Network (2019). Mapping of advanced practice nursing competencies from nineteen respondent countries against the Strong Model of Advanced Practice Nursing (2000) and the International Council of Nurses (2008) advanced practice nursing competencies. Online Publication. Retrieved June 5, 2022 from: https://international.aanp.orghttps://international.aanp.org/Content/docs/MappingOfAdvPracNursingCompetencies.pdf

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