Conceptualizations of the Nature of Advanced Practice Nursing
Conceptualizations of the Nature of Advanced Practice Nursing
The APRN role-specific models promulgated by professional organizations raise several questions, such as:
· • What is common across APRN roles?
· • Can an overarching conceptualization of advanced practice nursing be articulated?
· • How can one distinguish among basic, expert, and advanced levels of nursing practice?
Several authors have attempted to discern the nature of advanced practice nursing and address these questions. The extent to which all APRN roles are considered is not always clear; some only focus on CNS and NP roles.
Select frameworks are presented here that address the nature of advanced practice nursing. From the present review of a number of frameworks, the concepts of roles, domain, and competency are among those most commonly used to explain advanced practice nursing. However, meanings are not consistent. Hamric’s model, which uses the terms roles and competencies, is the only one that is integrative—that is, it explicitly considers all four APRN roles. Because it is integrative, has remained relatively stable since 1996, has informed the development of the DNP Essentials (AACN, 2006) and CNS competencies, and is widely cited, it is discussed first, enabling the reader to consider the extent to which other models address important concepts. Otherwise, the models are discussed chronologically and include examples from US and international conceptual models of APRN practice.
Models
Hamric’s Integrative Model of Advanced Practice Nursing
One of the earliest efforts to synthesize a model of advanced practice that would apply to all APRN roles was developed by Hamric (1996). Hamric, whose early conceptual work was done on the CNS role (Hamric & Spross, 1983, 1989), proposed an integrative understanding of the core of advanced practice nursing, based on literature from all APRN specialties (Hamric, 1996, 2000, 2005, 2009, 2014; see Chapter 3). Hamric proposed a conceptual definition of advanced practice nursing and defining characteristics that included primary criteria (graduate education, certification in the specialty, and a focus on clinical practice with patients) and a set of core competencies (direct clinical practice, collaboration, guidance and coaching, evidence-based practice, ethical decision making, consultation, and leadership). This early model was further refined, together with Hanson and Spross in 2000 and 2005, based on dialogue among the editors. Key components of the model (Fig. 2.4) include the primary criteria for advanced nursing practice, seven advanced practice competencies with direct care as the core competency on which the other competencies depend, and environmental and contextual factors that must be managed for advanced practice nursing to flourish.
The revisions to Hamric’s original model highlight the dynamic nature of a conceptual model, and that essential features remain the same. Models are refined over time according to changes in practice, research, and theoretical understanding. Hamric’s model’s inherent stability and robustness are noteworthy, particularly in light of the many potentially transformative advanced practice nursing initiatives being developed. This model forms the understanding of advanced practice nursing used throughout this text and has provided the structure for each edition of the book. Hamric’s model has been used by contributors to this text to further elaborate specific competencies such as guidance and coaching (Spross, 2009; see Chapter 8), consultation (see Chapter 9), and ethical decision making (see Chapter 13). It has also informed the development of the DNP Essentials (AACN, 2006) and the revised CNS competencies and is widely cited in the advanced practice literature, which provides further evidence of its contribution to conceptualizing advanced practice nursing.
In addition, integrative literature reviews provide further support for Hamric’s integrative conceptualization of advanced practice nursing. Mantzoukas and Watkinson’s (2007) literature review sought to identify “generic features” of advanced nursing practice; seven generic features were identified: (1) use of knowledge in practice, (2) critical thinking and analytic skills, (3) clinical judgment and decision making, (4) professional leadership and clinical inquiry, (5) coaching and mentoring, (6) research skills, and (7) changing practice. The first three generic features are consistent with the direct care competency in Hamric’s model; these three characteristics seem directly related to clinical practice, which supports direct care as a central competency. The remaining four features are consistent with the three competencies of leadership, guidance and coaching, and evidence-based practice competency in Hamric’s model.
Similarly, an integrative literature review of CNS practice by Lewandowski and Adamle (2009) affirmed the direct care, collaboration, consultation, systems leadership, and coaching (patient and staff education) competencies in Hamric’s model. Their review represented ten countries, and their findings were organized using NACNS’s three spheres of influence. Within the first sphere, management of complex or vulnerable populations, they found three essential characteristics—expert direct care, coordination of care, and collaboration. In the sphere of educating and supporting interdisciplinary staff, substantive areas of CNS practice were education, consultation, and collaboration. Within the system sphere of influence, CNSs facilitate innovation and change. These findings lend support for the integration of Hamric’s model with the NACNS model of CNS core competencies (NACNS/National CNS Competency Task Force, 2010).
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