This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Advanced practice nursing has emerged worldwide in response to the need for improved services and outcomes for specific priority groups, improved access to care, decreased wait times, and cost containment of health care [1]. Advanced practice nursing (APN) is an umbrella term that encompasses various APN roles (based on country of origin) that share at their core direct care of patients and families [2,3]. APN roles have expanded in numbers and scope of practice over the past several decades with APN roles being highly valued and an integral part of the health care system. Due to the benefits of APN in meeting the current and future health needs of patients, the concept of APN (and the components of the role) needs to be effectively identified in order to continue to ensure patient safety while expanding patient access to APN care. The International Council of Nurses (ICN) defines an APN role as a “registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice [4].” However, there is still no international agreement with respect to minimum educational preparation for APN, title protection for various APN roles, education, scope of practice, and accreditation system, and performance evaluation system [[5], [6], [7], [8], [9], [10]].
Efforts to clarify the uncertainty in many countries have occurred. In the United States of America (USA), a national consensus model for APN was developed in 2008, which identifies the titles to be used, describes the regulatory model, identifies licensure, accreditation, certification and education of different APN roles (Certified Registered Nurse Anesthetist, Certified Nurse-Midwife, Clinical Nurse Specialist, and Certified Nurse Practitioner) [11]. In 2011, the Canadian Nurses Association suggested that a pan-Canadian collaborative integration plan was required for the integration of APN roles (Nurse Practitioner and Clinical Nurse Specialist) in primary and tertiary health care in Canada [12]. Recently, four strategic directions and actions were proposed by the China Medical Board China Nursing Network, including developing standards for advanced nursing practice, developing master's level curricula based on the standards, commencing pilot projects across a number of university affiliated hospitals, and prepare clinical tutors and faculty [13].
Bryant-Lukosius and DiCenso (2014) developed a framework of Participatory, Evidence-based, Patient-focused Process for APN (PEPPA framework) [14]. The PEPPA framework has been widely used to support the development of various APN roles [15]. It is shaped by the underlying principles and values consistent with APN, namely, a focus on addressing patient health needs through the delivery of coordinated care and collaborative relationships among health care providers and systems and included three main stages: development, implementation, and evaluation [15]. The overall goal of this special issue, “Advanced Practice Nursing”, is to disseminate novel scholarship on APN development, implementation, and evaluation. We have included 9 articles, selected from the multiple manuscripts submitted, that together provide insightful understanding of the breadth and depth of scholarship in APN. These articles discussed the APN role generally (n = 2) and specific roles including Clinical Nurse Specialist (n = 3), Nurse Practitioner (n = 3) and Certified Registered Nurse Anesthetist (n = 1). We hope that in reading these articles, you deepen your philosophical understanding, as well as discover methodological and innovative strategies that resonate with you, your practice, and inform the growth of knowledge to support APN.
The issue begins with three discussion articles on developing APN. In the first article, Wong, the chief editor of the first APN book in China, synthesized the historical development of APN in China in the context of global development and identified the differences between APN roles and specialty nurses in terms of competencies, education and regulation. This topic is of particular interest in China, or other developing countries, because there is no officially certified APN role on the Chinese Mainland and the education and policies required for supporting APN are evolving. In the second article, Liu and Wang looked further into one specific APN role and reviewed the current status and directions in the development of wound ostomy continence nurses in China, including the origin, training and accreditation system, roles, values and policy. They provided a clear example of how specialty nurses could develop and evolve into an APN role. In the third article, Delvin reviewed the social and political contexts in which the Canadian NP role has evolved in primary care and used various theories, which included Abbott's theory on the system of professions, a feminist philosophical framework, and Foucauldian analysis of the concepts of governmentality, parrhesia and care of self, to understand why we need to reflect on the professional identity of APN and define the APN role. This discussion is particularly noteworthy as it provides a philosophical foundation to support further research on APN development, especially when a new APN role, or a new scope of practice in an existing APN role, is emerging and integrated within the healthcare system.
Next, we present a set of three articles focused on the hot topics in the implementation of the APN role. The first, by Staples and Sangster-Gormley, surveyed Nurse Practitioner programs in all ten Canadian provinces to understand their preceptorship structures, how they support preceptorship for NP students, and to identify gaps and challenges to the recruitment and retention of preceptors. As clinical training is an important component of Nurse Practitioner education, they suggested a systematic and intraprofessional collaborative approach to facilitate the recruitment and retention of clinical preceptors, which could be adapted and applied into other APN areas. The second and the third article focused on implementation of APN and explores the competencies of APN roles dealing with complex situation, as APN requires significant role autonomy to support greater complexity of decision making in various organizations and environments. Wands examined the relationship between ethical decision making skills of Certified Registered Nurse Anesthetists in the USA and their moral distress that may causes feelings of fatigue, frustration, job burnout, anger, and a fear of job loss that then can lead to changes in patient care. The findings showed that Certified Registered Nurse Anesthetists who perceived a higher skill level of ethical decision-making experienced lower levels of moral distress when addressing ethical issues. Raghubir analyzed the concept of emotional intelligence in APN using Rodger's evolutionary approach. She identified antecedents, four common attributes of emotional intelligence and its consequence related to the well-being of nurses as working professionals and the quality of patient care and outcomes. These articles both suggested the importance of integrating non-technical competencies training (e.g. ethical decision making, emotional intelligence) in APN education.
Finally, the remaining three articles included in this issue evaluating the effectiveness of APN on health care for patients and families. Mallow et al. used e-health technology to deliver a 12-week Nurse Practitioner led intervention to patients with multiple chronic conditions in a rural community primary care clinic in the USA. Keenan et al. evaluated the impact of an APN role on patient flow, documentation, communication and satisfaction in a neurosurgery unit in a Canadian tertiary care center. Eman developed an education intervention to support family caregivers of patients receiving hemodialysis in Jordan and found that the intervention significantly reduced caregivers' burden associated with the responsibility of caring for their family member by addressing the physical and mental health care needs of caregivers. These studies illustrated the core direct care of patients and families, which is the competency central to APN, and how this competency improved health care outcomes for individuals and populations.
Taken together, the articles in this special issue provide understanding of the philosophical and conceptual perspectives of APN, development and implementation of APN roles and evidence for the impact of APN. These findings help to inform solutions to three major inter-related issues influencing the introduction and integration of APN roles: failure to define clearly the roles and goals of APN care, failure to address environmental factors that undermine the roles, and limited use of evidence-based approaches to guide their development, implementation and evaluation [16]. We hope this special issue will stimulate nurse scholars to conduct more studies advancing the art and science of APN for individuals across lifespan and their families in both primary and tertiary health care.
This Special Issue would not be possible without the support of Professor Huaping Liu, the editor-in-chief of International Journal of Nursing Sciences, who kindly offered us the opportunity to serve as guest editors for this special issue. Her advice, insights, and exceptional editorial knowledge and skills have been indispensable. We would also like to thank Hongli Wang, the journal's managing editor, whose knowledge, patience, and constant support made this issue a reality. We greatly appreciate the work of all the contributors whose work and dedication to increasing the scholarly knowledge in the area of advanced practice nursing will help move the field forward.
Peer review under responsibility of Chinese Nursing Association.