By Jane Wray, Associate Editor EBN @livinginhope

The International Council of Nurses (ICN) has recently updated its position statement on Advanced Practice Nursing (APN)¹, an acknowledgment of the significant evolution of this role since its previous statement of 2008. Growing demands on healthcare as a consequence of changing population health needs coupled with service re-design has provided opportunities for the nursing profession to develop and expand roles, scope and practice. The World Health Organisation (WHO)² in the recent ‘State of the Worlds Nursing’ Report indicated that 78 countries (53% of those who responded to the survey) had advanced nursing roles. The most common type being ‘Nurse Practitioner’(NP). The ICN stated that the APN “is fundamentally a nursing role, built on nursing principles”¹ (pg. 11) and identify Clinical Nurse Specialist (CNS) and NP as the two most common. However, you might also see titles such as Advanced Clinical Practice Nurse, or Advanced Practice Registered Nurse (APRN – the US preferred title).

Ambiguity persists amid a plethora of titles³ and there is little correlation between job title and pay⁴. In the UK “being an APN still means vastly different things in different places”⁴ (pg. 965). The ICN¹ draws a clear distinction between the roles of CNS and NP (both of which are APN roles), but acknowledge the confusion suggesting that these are best understood as being on a ‘continuum’. The CNS as expert clinician has a focus on clinical excellence, a specialist area of practice and is more likely to engage in non-clinical and indirect care activities. Whereas the NP has greater direct involvement in patient care particularly in relation to activities such as diagnosis, prescription and treatment of conditions. So – different scope of practice and focus, although both are expected to be educated to at least masters level, practice autonomously and are accountable to an advanced level. Some countries, however such as Germany and The Netherlands do use a blended approach.

APN roles are found more in those countries with a low concentration of doctors¹. This is not to say that APNs replace doctors, nor that they are plugging gaps in the medical workforce. Indeed, it is likely that opportunities for increased professional autonomy and expanded scope of practice may flourish in those countries. Evidence has continued to amass of the relevance of the APN role to care quality, patient safety and service efficiency⁵ and it is evident that the role has evolved to better meet changing population needs and demands. ANP roles are not a simple case of ‘task-shifting’^6,7 or ‘doctor-nurse substitution’⁸– a debate I would hope we have moved on from. The ICN¹ has attempted to shine a light on the development of the APN role, explain some of the complexities and also highlight the opportunities these roles offer to enhance population health and develop the nursing profession.

There is one issue that there is consistent agreement on – the importance of future regulation and governance of APN roles through education, policy and professional standards. There is an opportunity to learn from countries with established educational and regulatory frameworks and it is reassuring to see guidance and frameworks are being developed^9,10,11. As healthcare reform continues at a pace “New solutions are required to deliver healthcare to meet the changing needs of the population. This will need new ways of working, new roles and new behaviours”⁹ (pg. 1). There is evidently enthusiasm for the APN role to be one of the future solutions.

1. International Council of Nurses (ICN) (2020) Guideline on Advanced Practice Nursing. Available at; https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf
2. World Health Organisation (WHO) (2020) State of the world’s nursing 2020: investing in education, jobs and leadership. Available at; https://www.who.int/publications/i/item/nursing-report-2020
3. Leary A, Maclaine K, Trevatt P, Radford M, Punshon G. Variation in job titles within the nursing workforce. J Clin Nurs. 2017;26(23-24):4945-4950.
4. Woods E, King R, Roberson S, Allmark P, Senek M, To A and Ryan T (2020) Advanced practice nurses’ experiences and well-being: Baseline demographics from a cohort study, J Nurs Manag. 2020;28:959–967.
5. Candace Imison, Sophie Castle-Clarke and Robert Watson (2016) Reshaping the Workforce. The Nuffield Trust in association with NHS Employers. Available at; https://www.nuffieldtrust.org.uk/files/2017-01/reshaping-the-workforce-web-final.pdf
6. Maier, C.B., Köppen, J., Busse, R. et al. Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries. Hum Resour Health 16, 24 (2018) https://doi.org/10.1186/s12960-018-0285-9
7. Leary A, MacLaine K (2019) The evolution of advanced nursing practice: past, present and future. Nursing Times [online]; 115: 10, 18-19.
8. Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJ (2018). Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev. 2018;7(7):CD001271. doi:10.1002/14651858.CD001271.pub3
9. Health Education England (HEE) (2017) Multi-professional framework for advanced clinical practice in England (With NHS Improvement and NHS England). Available at; https://www.hee.nhs.uk/sites/default/files/documents/Multi-professional%20framework%20for%20advanced%20clinical%20practice%20in%20England.pdf
10. Royal College of Nursing (2018) Advanced level nursing practice competencies. Available at; https://www.rcn.org.uk/professional-development/publications/pub-006896
11. Royal College of General Practitioners (2020) Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice / Primary Care in England. Available at; https://www.skillsforhealth.org.uk/images/services/cstf/ACP%20Primary%20Care%20Nurse%20Fwk%202020.pdf