scholarly articles on advanced practice nursing

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Study Protocol

A global perspective of advanced practice nursing research: A review of systematic reviews protocol

Roles Conceptualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Susan E. French Chair in Nursing Research and Innovative Practice, Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal (CIUSSS-EMTL), Montréal, Québec, Canada

Contributed equally to this work with: Isabelle Savard, Li-Anne Audet, Abby Kra-Friedman

Affiliation Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada

Affiliations Henrietta Szold School of Nursing, Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Ein Kerem, Jerusalem, Israel, School of Nursing, Duquesne University, Pittsburgh, Pennsylvania, United States of America

Affiliation Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal (CIUSSS-EMTL), Montréal, Québec, Canada

Affiliation Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore

Affiliation College of Nursing, University of Kentucky, Lexington, Kentucky, United States of America

Affiliation School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts, United States of America

Affiliation School of Nursing, Old Dominion University, Virginia Beach, Virginia, United States of America

Affiliation School of Health Sciences, University of Dundee, Dundee, Scotland, United Kingdom

Affiliation Louise Herrington School of Nursing, Baylor University, Dallas, Texas, United States of America

Affiliation St James Public Health Services, Montego Bay, St James, Jamaica

Affiliation Department of Nursing and Midwifery, University of Huddersfield, Queensgate, Huddersfield, United Kingdom

• Kelley Kilpatrick, 
• Isabelle Savard, 
• Li-Anne Audet, 
• Abby Kra-Friedman, 
• Renée Atallah, 
• Mira Jabbour, 
• Wentao Zhou, 
• Kathy Wheeler, 
• Elissa Ladd, 

• Published: January 24, 2023
• https://doi.org/10.1371/journal.pone.0280726
• Reader Comments

Introduction

In 2020, the World Health Organization called for the expansion and greater recognition of all nursing roles, including advanced practice nurses (APNs), to better meet patient care needs. As defined by the International Council of Nurses (ICN), the two most common APN roles include nurse practitioners (NPs) and clinical nurse specialists (CNSs). They help ensure care to communities as well as patients and families with acute, chronic or complex conditions. Moreover, APNs support providers to deliver high quality care and improve access to services. Currently, there is much variability in the use of advanced practice nursing roles globally. A clearer understanding of the roles that are in place across the globe, and how they are being used will support greater role harmonization, and inform global priorities for advanced practice nursing education, research, and policy reform.

To identify current gaps in advanced practice nursing research globally.

Materials and methods

This review of systematic reviews will provide a description of the current state of the research, including gaps, on advanced practice nursing globally. We will include reviews that examine APNs, NPs or CNSs using recognized role definitions. We will search the CINAHL, EMBASE, Global Health, HealthStar, PubMed, Medline, Cochrane Library Database of Systematic Reviews and Controlled Trials Register, Database of Abstracts of Reviews of Effects, Joanna Briggs Institute, and Web of Science electronic databases for reviews published from January 2011 onwards, with no restrictions on jurisdiction or language. We will search the grey literature and hand search the reference lists of all relevant reviews to identify additional studies. We will extract country, patient, provider, health system, educational, and policy/scope of practice data. We will assess the quality of each included review using the CASP criteria, and summarize their findings. This review of systematic reviews protocol was developed following the PRISMA-P recommendations.

PROSPERO registration number

CRD42021278532.

Citation: Kilpatrick K, Savard I, Audet L-A, Kra-Friedman A, Atallah R, Jabbour M, et al. (2023) A global perspective of advanced practice nursing research: A review of systematic reviews protocol. PLoS ONE 18(1): e0280726. https://doi.org/10.1371/journal.pone.0280726

Editor: Xian-liang Liu, Charles Darwin University, AUSTRALIA

Received: October 1, 2021; Accepted: January 8, 2023; Published: January 24, 2023

Copyright: © 2023 Kilpatrick et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data is included in the paper and/or Supporting information .

Funding: This work is supported by the McGill University Faculty of Medicine and Health Sciences and the Newton Foundation via the Susan E. French Chair in Nursing Research and Innovative Practice held by KK. KK is also supported by a Fonds de recherche du Québec-Santé ( https://frq.gouv.qc.ca/en/health/ ) Research Scholar Senior (Award Number 298573) salary award. There was no additional external funding received for this study, and the authors received no specific funding for this work. All the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

In 2020, the World Health Organization [ 1 ] called for the expansion and greater recognition of all nursing roles, including nurses in advanced practice, to better meet patient care needs. Nurses in advanced practice roles, as defined by the International Council of Nurses (ICN), are most often identified as advanced practice nurses (APNs), with the two most common APN roles being nurse practitioners (NPs) and clinical nurse specialists (CNSs) [ 2 ]. They help ensure care to communities as well as patients and families with acute, chronic or complex conditions [ 2 ]. In addition to providing direct care, NPs and CNSs support care providers to deliver high quality care and improve access to services [ 3 – 5 ]. Nurses in these roles have educational preparation at the Master’s level or above in addition to in-depth clinical expertise and complex decision-making skills [ 6 ]. A global analysis of advanced practice nursing policy, regulation and practice by Ladd et al. [ 7 ] highlighted that advanced practice nursing roles are growing at an accelerated rate. However, these authors argue that advanced practice nursing roles have emerged unequally across the globe in response to local care needs without clear supports to develop consistent expanded roles for nurses. A recent review of systematic reviews of primary healthcare NP roles identified 396 primary studies included in the 40 systematic reviews representing on average 3 countries (range not reported to 9) [ 8 ]. Although there are several systematic reviews of APN and CNS roles in other clinical settings [ 4 , 5 , 9 ], no synthesis of this body of evidence is available for other recognized advanced practice roles, making it challenging to compare advanced practice nursing roles across jurisdictions.

Currently, there is much variability in the use of advanced practice nursing roles globally [ 1 , 7 , 10 , 11 ]. A clearer understanding of the roles that are in place across the globe, how they are being used and the outcomes that are being assessed would support greater role harmonization, and inform global priorities for advanced practice nursing education, research, and policy reform.

To identify current gaps in advanced practice nursing research globally, we propose to conduct of review of systematic reviews of studies examining APNs, NPs or CNSs using recognized advanced practice nursing role definitions [ 2 ]. We will seek to answer the question: Do current systematic reviews that include APNs, NPs or CNSs represent countries where these roles are found globally? To do so, we will address the following three aims:

• Identify the countries included in systematic reviews of APNs, NPs or CNSs;
• Describe the types of included studies, study population, role definitions, and context of care identified in the systematic reviews; and
• Examine the types of outcomes of APN, NP or CNS roles included in systematic reviews globally.

This review of systematic reviews will provide a description of the current state of the research, including gaps, on advanced practice nursing globally. We adapted methods used in an umbrella review that sought to identify indicators sensitive to the practice of primary healthcare NP practice [ 12 ]. The protocol for the review of reviews was developed following the PRISMA-P recommendations by Shamseer et al. [ 13 ]. The review of reviews is registered with the PROSPERO International Prospective Register of Systematic Reviews (Prospero ID CRD42021278532).

Inclusion criteria

Types of studies..

We will include all relevant published and unpublished systematic reviews reported from January 2011 onwards, with no restrictions on jurisdiction or language. For a review to be identified as systematic, a specific research question must be present or sufficient information must be provided so reviewers can identify the components of a research question (i.e., PICOS) related to advanced practice nursing. Additionally, the review must use prespecified inclusion and exclusion criteria, as well as systematic methods to identify relevant published and unpublished evidence to minimize the risk of bias in the retained studies [ 14 ]. Systematic reviews will be included provided the advanced practice nursing role is clearly defined and the APN, NP or CNS has decision-making autonomy [ 2 ].

Types of participants.

Participants will include patients and providers. Patients of any age, health condition, groups or communities receiving care from an APN, NP or CNS in all types (e.g., public/private; teaching/non-teaching,), sizes (e.g., small/medium/large) and locations (e.g., urban/rural) of community or care agencies (e.g., acute, long-term care, primary care, home care) will be retained. Providers will include all members of the healthcare team in all types, sizes, and locations of organizations. We will extract data to describe the country, number of participants, patient health conditions (e.g., diabetes, mental health), type of care (e.g., post-operative care), organizational characteristics, provider roles in the team, reason of APN, NP or CNS intervention (e.g., educational offering), and type of outcome.

Types of interventions.

We will include studies of APNs, NPs or CNSs in all sectors. To capture the countries where the roles that are implemented, we will identify studies in acute care and primary healthcare settings. Acute care will be defined as in-hospital or specialized ambulatory care to address specific health conditions [ 15 ]. Primary care will refer to the entry point of the healthcare system where patients receive comprehensive healthcare services for common health concerns [ 16 ].

Advanced practice nursing includes clinical and non-clinical activities related to education, research, and administration [ 17 , 18 ]. According to the International Council of Nurses, APNs are nurses prepared at the graduate level who have acquired in-depth expertise, complex decision-making skills and advanced clinical competencies [ 2 ]. Master’s or doctoral educational preparation is recommended and in many countries is required with national board certification for licensure and entry-level practice [ 2 ]. Given the diversity of terms used globally to identify APNs, NPs, and CNSs, members of the research team will help identify role titles specific to their region. For example, CNSs may be identified as nurse consultants in some regions in the United Kingdom. We will be attentive to the countries and geographical distribution of the systematic reviews that are identified and adjust our search strategy as needed.

NPs are autonomous clinicians who practice in ambulatory, acute and long-term care as primary and/or specialty care providers, both independently and in coordination with healthcare professionals and others. NPs assess, diagnose, treat, and manage acute episodic and chronic illnesses. NPs are experts in health promotion and disease prevention. They order, conduct, supervise, and interpret diagnostic and laboratory tests, prescribe pharmacological agents and non-pharmacologic therapies, as well as teach and counsel patients, among other services. In addition to clinical practice, they may serve as healthcare researchers, interdisciplinary consultants, and patient advocates. NPs provide a wide range of services to individuals, families, groups, and communities [ 3 ]. For nurses to be considered as NPs in our review of reviews, the review must specify that they completed a formal post-baccalaureate or graduate NP education program.

CNSs have expertise in a nursing specialty and perform a role that includes practice, consultation, collaboration, education, research and leadership. CNSs assist in providing solutions for complex healthcare issues and are leaders in the development of clinical practice guidelines, promoting the use of evidence, and facilitating system change [ 2 ]. CNSs specialize in a specific area of practice that may be defined in terms of a population, setting, disease or medical subspecialty, type of care or type of problem. For nurses to be considered as CNSs, the review has to specify that they completed a graduate degree and the role described must be reflective of the CNS role definition.

Types of comparators.

We will extract data related to the comparator (i.e., control) group to provide a brief description of the group to which care is being compared. Comparator groups can include the following, among others: usual care, best care, care provided by other healthcare professionals (e.g., physicians), or adherence to clinical practice guidelines.

Types of outcomes.

The outcomes of interest for this review of reviews will include any outcome of an advanced practice nursing role. We will document measures at the levels of the patient (e.g., health status, patient satisfaction, quality of life), the provider (e.g., job satisfaction, quality of care), the health system (e.g., costs, length of hospital stay, rehospitalisation, resource utilisation), education, or policy/scope of practice. Outcomes will be categorized as clinical, provider, health system, educational, policy/scope of practice.

Exclusion criteria

We will exclude reviews developed to address broad research questions (e.g., integrative reviews, literature reviews, scoping reviews).

We will exclude from the review of reviews studies related to physician assistants. Certified registered nurse anesthetists are excluded because, as of yet, they do not have global APN presence in the majority of countries with APN roles. We will also exclude nurse midwives since, across the different countries, not all regulatory requirements require these roles to be filled by nurses and nor are these roles consistently identified as advanced practice nursing roles. In reviews that include a mix of APN, NP and CNS roles and other provider roles, we will extract only data related to APNs, NPs and CNSs.

Moreover, we will exclude reviews where the impact of the APNs, NPs or CNSs cannot be teased out and is not reported separately from that of other types of nurses or healthcare team members. We will develop a list of all excluded reviews, along with the reasons justifying their exclusion.

Database search

We will limit our search to January 2011 onwards to capture the most up-to-date trends, as evidence is outdated after five years in about half of published reviews [ 19 ]. We will search the following electronic databases: CINAHL, EMBASE, Global Health, HealthStar, PubMed, Medline, Cochrane Library Database of Systematic Reviews and Controlled Trials Register, Database of Abstracts of Reviews of Effects (DARE), Joanna Briggs Institute, and Web of Science. We will combine subject headings and keywords related to advanced practice nursing (e.g.: advanced practice nursing, nurse-led), APN (e.g., advanced practice nurse, advanced practice clinician, advanced practitioner, nurse prescriber), NP (e.g., nurse practitioner, advanced practice registered nurse, family nurse practitioner, primary healthcare nurse practitioner, adult gerontology nurse practitioner, pediatric nurse practitioner, oncology nurse practitioner, emergency nurse practitioner, mental health nurse practitioner, neonatal nurse practitioner), and CNS (e.g., nurse specialists, clinical nurse specialist, infection control practitioner, nurse consultant, specialist nurse) roles/titles, along with a search filter based on the CADTH systematic reviews and meta-analyses search filter and that developed by Lunny et al. for reviews of systematic reviews to capture a broad range of roles across settings [ 20 , 21 ]. Subject headings and keywords will also include more general roles/titles, as well as those specific to primary and acute care settings, and corresponding acronyms where applicable. The full preliminary search strategy developed for the PubMed database, which will subsequently be adapted to each electronic database, is presented in S1 Appendix . We will adapt strategies reviewed by an academic librarian that have been used successfully in previous reviews [ 21 ]. In addition, we will hand search the reference lists of all relevant reviews to identify additional studies.

Moreover, we will search the grey literature will for the period of January 2011 onwards using the following websites and tools: World Health Organization, Organization for Economic Co-operation and Development (OECD), International Council of Nurses, CADTH Information Services, CADTH Grey Matters Tool, and ProQuest Dissertation and Theses. We will search the PROSPERO International Prospective Register of Systematic Reviews to identify registered review protocols, and will contact authors of registered PROSPERO reviews to ascertain study status. For each website, the content will be searched using the same search terms as those used for the published literature, e.g.: (Advanced practice nurs* OR Nurse practitioner* OR Clinical nurse specialist*) AND (Primary care OR Acute care) AND Systematic review*. If there is not an inherent search function on the website, a search will be conducted of all webpages and weblinks. The preliminary search strategy for the grey literature is presented in S2 Appendix .

Study selection

To enhance inter-rater agreement, all reviewers will be trained to use the screening instrument and inclusion/exclusion criteria. We will upload the retained studies into the EndNote and RAYYAN software [ 22 ], after which duplicates will be removed. Two reviewers will independently screen titles and abstracts using the predefined inclusion/exclusion criteria, and recommend exclusion or further full-text review. Any discrepancies will be discussed among the reviewers. Inter-rater agreement will be estimated using the kappa statistic. Additional training sessions will be planned if inter-rater agreement is low and Cohen’s kappa is below 60% [ 23 ].

To be included in our review of reviews, each paper must be identified as a systematic review, and focus on an advanced practice nursing role or intervention. If the abstract contains insufficient information or there is no abstract available, we will complete a full-text review. We will complete a full-text review for all the reviews retained after the initial screening, again using the predefined inclusion/exclusion criteria. Any coding discrepancies will be discussed among the reviewers until agreement is reached on the inclusion or exclusion of the review. In the event they are unable to reach a consensus, a third reviewer will act as tie-breaker.

Data extraction

Data from included full-text papers will be extracted by one coder and subsequently reviewed by a second coder. Any discrepancies will be resolved by consensus. A structured tool developed for a previous review of reviews will be adapted and pilot-tested by the investigators [ 12 ]. We will extract data from the methods and results section of each full-text paper. The data we will extract will include: review aim or focus; review characteristics (e.g., publication year); name and number of electronic databases searched; participant and intervention characteristics; number and types of studies included in the review; countries where studies were conducted; specification of patient, provider, health system, educational, policy, and scope of practice outcomes; and funding source [ 24 ]. Additionally, we will document APN, NP or CNS and non-APN involvement in the research team who conducted the review by extracting data related to the professional designation of the research team members.

Design of included studies

Because the addition of APNs, NPs and CNSs is a complex healthcare system intervention, different types of information are needed to inform research about advanced practice nurses [ 25 ]. Systematic reviews included in our review of systematic reviews may include the results of randomized controlled trials, prospective controlled observational studies and cohort studies, retrospective controlled observational and cohort studies, and surveys. We will develop a summary table to present key findings.

Assessment of review quality

Two reviewers will independently rate each systematic review using the 10-item Critical Appraisal Skills Programme (CASP) criteria [ 26 ] to assess the systematic review’s methodologic quality. As described above, inter-rater agreement will be assessed using Cohen’s kappa, and any disagreements will be discussed among the reviewers until they come to a consensus. We will generate a summary table with the CASP ratings.

The primary outcome of the review of reviews is to document APNs, NPs or CNSs research globally to identify gaps in current research. We will examine each advanced practice nursing role separately.

Data synthesis

A narrative synthesis of the findings will be compiled. We will use an iterative process to identify patterns and relationships emerging across the different reviews and years when they were conducted [ 27 ]. We will develop summary tables outlining the key review characteristics (e.g., publication year, countries where primary studies were conducted), outcomes (i.e., patient, provider, health system, educational, policy/scope of practice), type of advanced practice nursing role, and quality assessment. We will keep a record of all review-related decisions. No additional quantitative analyses are planned as this is not recommended for overviews because of the potential risk of overlap in studies that appear in more than one review [ 28 ].

The identification of advanced practice nursing roles that are currently in place, the countries where these nurses practice and the outcomes being used to examine practice will shed light on current gaps in the literature, and identify stronger and weaker areas of evidence related to advanced practice nursing globally. The review of systematic reviews builds on a recently completed umbrella review of NPs in primary healthcare. The current review of reviews will synthesize the characteristics of advanced practice nursing roles, study populations, contexts and outcomes to determine how closely these roles align with ICN definitions. In contexts where the roles are not optimally implemented or utilized, the findings will support the development of recommendations at the clinical, educational, and regulatory levels to improve role clarity, role implementation and access to high quality care. In addition, the development of an international strategic plan for APN role development will aid countries hoping to further expand APN practice.

Supporting information

S1 checklist. prisma-p 2015 checklist..

https://doi.org/10.1371/journal.pone.0280726.s001

S1 Appendix. Preliminary search strategies (PubMed) for the published literature.

https://doi.org/10.1371/journal.pone.0280726.s002

S2 Appendix. Preliminary search strategies for the grey literature.

https://doi.org/10.1371/journal.pone.0280726.s003

• 1. World Health Organization. State of the World’s Nursing Report 2020- Investing in education, jobs and leadership. Health Workforce. 6 April 2020. Available from: https://www.who.int/publications/i/item/9789240003279 .
• 2. International Council of Nurses, Schober M, Lehwaldt D, Rogers M, Steinke M, Turale S, et al. Guidelines on Advanced Practice Nursing. 2020. Available from: https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf .
• 3. American Association of Nurse Practitioners (ANNP). Discussion paper: Quality of nurse practitioner practice. 2020. Available from: https://storage.aanp.org/www/documents/advocacy/position-papers/Quality-of-NP-Practice-Bib_11.2020.pdf .
• View Article
• PubMed/NCBI
• Google Scholar
• 6. Canadian Nurses Association, Almost J. Regulated Nursing in Canada: The Landscape in 2021. February 2021. Available from: https://www.cna-aiic.ca/en/nursing-practice/the-practice-of-nursing/regulated-nursing-in-canada .
• 11. Schumann L, Bird B, Pilane C, Duff E, Geese F, Jelic M, et al. Mapping of advanced 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 (2013–2017). International Council of Nurses NP/APN Network Research Subgroup Publication. March 2019. Available from: https://internationalaanporg/Research/SG .
• 21. CADTH. CADTH search filters database. Ottawa. 2022. Available from: https://searchfilters.cadth.ca/list?q=&p=1&ps=20&topic_facet=systematic%20reviews%20000000%7CSystematic%20reviews .
• 26. Critical Appraisal Skills Programme (CASP). CASP Checklist: 10 questions to help you make sense of a systematic review. 2018. Available from: https://casp-uk.net/casp-tools-checklists/ .

• Open access
• Published: 11 September 2017

The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review

• Brigitte Fong Yeong Woo   ORCID: orcid.org/0000-0002-7640-6002 1 ,
• Jasmine Xin Yu Lee 2 &
• Wilson Wai San Tam 1  

Human Resources for Health volume  15 , Article number:  63 ( 2017 ) Cite this article

127k Accesses

212 Citations

83 Altmetric

Metrics details

The prevalence of chronic illness and multimorbidity rises with population aging, thereby increasing the acuity of care. Consequently, the demand for emergency and critical care services has increased. However, the forecasted requirements for physicians have shown a continued shortage. Among efforts underway to search for innovations to strengthen the workforce, there is a heightened interest to have nurses in advanced practice participate in patient care at a great extent. Therefore, it is of interest to evaluate the impact of increasing the autonomy of nurses assuming advanced practice roles in emergency and critical care settings on patient outcomes.

The objectives of this study are to present, critically appraise, and synthesize the best available evidence on the impact of advanced practice nursing on quality of care, clinical outcomes, patient satisfaction, and cost in emergency and critical care settings.

Review methods

A comprehensive and systematic search of nine electronic databases and a hand-search of two key journals from 2006 to 2016 were conducted to identify studies evaluating the impact of advanced practice nursing in the emergency and critical care settings. Two authors were involved selecting the studies based on the inclusion criteria. Out of the original search yield of 12,061 studies, 15 studies were chosen for appraisal of methodological quality by two independent authors and subsequently included for analysis. Data was extracted using standardized tools.

Narrative synthesis was undertaken to summarize and report the findings. This review demonstrates that the involvement of nurses in advanced practice in emergency and critical care improves the length of stay, time to consultation/treatment, mortality, patient satisfaction, and cost savings.

Conclusions

Capitalizing on nurses in advanced practice to increase patients’ access to emergency and critical care is appealing. This review suggests that the implementation of advanced practice nursing roles in the emergency and critical care settings improves patient outcomes. The transformation of healthcare delivery through effective utilization of the workforce may alleviate the impending rise in demand for health services. Nevertheless, it is necessary to first prepare a receptive context to effect sustainable change.

Peer Review reports

While people of all ages receive emergency and critical care services across the world, the elderly population continues to exhaust a greater proportion of these services [ 1 ]. The complexity and acuity of care have heightened with greater prevalence of chronic illness and multimorbidity among older adults [ 2 ]. Correspondingly, the demand for emergency and critical care services has increased [ 1 ], alongside a concomitant increase in the forecasted workforce requirements for such services [ 3 ]. The Accreditation Council for Graduate Medical Education regulations in 2006 in the United States of America (USA) recommends a high-intensity model of care involving 24-h physician coverage [ 3 , 4 ]. This implementation accentuates inadequacies of the healthcare workforce to provide emergent and critical care services. In the USA, it is predicted that, compared to healthcare system’s demands, there will be a 22% shortfall of critical care physicians by 2020 and a subsequent 35% shortfall by 2030 [ 1 ].

With the impending rise in demand for health services, an effective utilization of the workforce is paramount to ensure high-quality yet cost-effective health service delivery [ 5 ]. Across some countries, healthcare workers’ wages account for approximately 50% of the total healthcare expenditure [ 6 ]. Hence, cost containment strategies will inevitably involve the workforce [ 7 ]. Efforts are underway for measures to enhance productivity through increasing the capacity of the workforce.

One potential measure is a greater utilization of nurses in advance practice. The global annual growth of the nurse practitioner (NP) workforce has been estimated to be between three to nine times greater compared to physicians; therefore, of interest to health policymakers is the utilization of NPs and advanced practice nurses (APNs) [ 8 , 9 ]. The nomenclature varies internationally. The “NP” title is used in Australia, Belgium, Canada, Sweden, the United Kingdom (UK), and the USA whereas the “APN” title is used in Switzerland, Singapore, and South Korea [ 10 ]. Nonetheless, NPs and APNs (NP/APNs) are registered nurses “who acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice” ([ 4 ], p. 26) and enter the workforce with a master’s degree [ 11 ].

This advanced practice role was first introduced in the 1960s as a solution to the lack of primary care physicians, to meet the primary care needs of the rural and underserved populations [ 12 ]. Primary care has first contact with patients and, subsequently, provides continuity of care within the healthcare system through the coordination of care according to patients’ needs [ 13 ]. Studies to evaluate the quality of primary care provided by NP/APNs have been shown to be comparable to that of physicians in terms of effectiveness and safety [ 14 ]. To fulfill primary care needs, NP/APNs in this setting are trained generalists who have a breadth of knowledge to render a wide scope of care.

Since the inception of advanced nursing practice in primary care, its role has extended to other healthcare settings such as the acute care. Acute care provides short-term restorative stabilization to patients in unstable chronic conditions and with complex acute and critical illnesses. Acute care encompasses emergency and critical care [ 15 ]. Emergency and primary care advanced nursing practice do share similarities in that they serve as first-contact access to healthcare, but the acuity of the patient manifestations delineates the two. Unlike in primary care NP/APNs, emergency NP/APNs are trained to manage patients with acute life- or limb-threatening conditions [ 15 ]. In the past decade, greater practice autonomy has been given to NP/APNs in emergency and critical care. This expanded practice allows nurses to assume some medical tasks typically performed by physicians, aiming at not only increasing the access to healthcare and service efficiency but also eventually mitigating the cost of health services.

The development of advanced nursing practice contributed to a service model aiming to respond flexibly to the ever-changing needs of patients [ 16 ]. Systematic reviews of studies on the effectiveness and safety of NP/APN-led primary care have reported positive effects of NP/APN service on clinical outcomes, patient satisfaction, and costs [ 14 , 17 ] These reviews focused on the primary care setting, it may be inappropriate to extrapolate their findings to the emergency and critical care settings since the patient acuity and clinical needs differ among settings.

Nonetheless, reviews evaluating NP services in the emergency and critical care settings exist. However, they have three shortcomings, the first of which concerns their generalizability. Over the past decade, studies have evaluated whether the delegation of medical tasks to NP/APNs in the emergency and critical care settings was feasible and safe. A review of 31 studies on the impact of NPs and physician assistants in such settings reported that their practice was safe and, in some cases, the quality of care was higher than that of physicians [ 18 ]. However, only two of the studies were randomized controlled trials (RCTs) [ 19 , 20 ] whereas the rest had small sample sizes and questionable study methodology; these limit the generalizability of the review. A more recent review [ 21 ] also reported that NPs do have a positive impact on the quality of care. Nonetheless, the reviews included both NPs and non-nursing healthcare providers, thereby introducing heterogeneity in the synthesis of evidence, making it difficult to assess the true effect of NPs in the intensive care settings [ 18 , 21 ].

The second shortcoming centers on the inconclusiveness of the reviews. One review suggested although NP services in the emergency setting did reduce waiting time and provide care comparable to that of a midgrade physician, the cost of NP services was higher than that of resident physicians [ 22 ]. In contrast, another review concluded that the use of NPs reduced the cost of emergency and intensive care services. Further complicating the picture is a recent systematic review that reported an inadequacy of evidence to determine the cost-effectiveness of NP services in emergency departments (EDs) [ 23 ]. Consequently, the cost-effectiveness of advanced nursing practice in the emergency and critical care settings has remained inconclusive. Lastly, all existing reviews [ 18 , 21 , 22 , 23 ] elucidating advanced nursing practice in the emergency and critical care settings included only studies published before January 2013, which may be dated.

Considering the existing literature, it is of interest to undertake an updated systematic review on the latest evidence to determine whether advanced practice nursing in emergency and critical care have an impact on the quality of care, clinical outcomes, patient satisfaction, and cost savings. If NP/APNs can indeed provide competent and safe care in these settings, greater access to emergency and critical care services will be available, thereby strengthening the workforce to fulfill the escalating healthcare demands.

Therefore, the main objective of this systematic review is to present, critically appraise, and synthesize the best available evidence on the impact of advanced nursing practice on patients’ length of stay, time to treatment or consult, mortality, patient satisfaction, and cost in emergency and critical care settings.

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to in the conduct and reporting of this systematic review [ 24 ].

Study selection

Published studies and studies which have yet to be published were searched using PubMed, CINAHL, The Cochrane Library, Scopus, Embase, Web of Science, ScienceDirect, Wiley Online Library, and ProQuest Dissertations and Theses Global databases from January 2006 up to September 2016. Only English studies were considered. The search strategy included the keywords, as shown in Table  1 , in various combinations for a systematic database search. The search terms and search strategies for each database are included in Additional file  1 . The reference lists of all identified studies were also screened. Corresponding authors were contacted for additional information where necessary.

Study eligibility

This review included RCTs, quasi-experimental studies, prospective and retrospective cohort studies. Cross-sectional studies and studies without comparison groups were excluded.

The PICO (Population-Intervention-Comparison-Outcome) framework guided the selection process [ 25 ]. This review considered studies that included the following:

Patients: at least 16 years of age, presenting in EDs, trauma centers, intensive care unit (ICU), or high dependency units, requiring emergency or critical care

Nurses: registered nurses in advanced practice role, i.e., APNs or NPs

Physicians: emergency physicians, intensivists, residents, medical officers, hospitalists, or house officers in the ED or ICU or high dependency units

Excluded from the review were studies that examined both adult and pediatric patients requiring emergency or critical care services. Excluded from the review were also studies that examined services provided by physician assistants. This review included studies with interventions which compared the outcomes of the APN-/NP-directed emergency or critical care services with those of the physician-directed care. This review also included studies with interventions which compared the physician-only model of care with APN-physician or NP-physician collaborative model of care.

Studies that had the following outcome measures were included:

Patients’ length of stay in the emergency or critical care setting

Patient mortality

Time to consultation or treatment

Patients’ satisfaction

Cost of care

The selection of studies was done independently by two of the authors (BW and JL) based on the eligibility criteria. Disagreement during selection was resolved by discussion with a third-party arbiter (WT). The selection process is illustrated in the flow diagram in Fig.  1 .

Systematic review search flow diagram

Data extraction

Data was extracted by one author (BW) and crosschecked by another (JL) for accuracy. Resolution of disagreement was done by discussion with a third-party arbiter (WT). The Joanna Briggs Institute’s (JBI) “Data Extraction Form for Experimental/Observational Studies” [ 26 ] was adapted to tabulate the characteristics and findings of the studies.

Quality assessment

Two authors (BW and JL) performed the methodological quality assessment independently, based on the “JBI Critical Appraisal Checklist for Randomized Controlled Trials,” and “JBI Critical Appraisal Checklist for Cohort Studies” [ 21 ]. The RCTs were assessed for their randomization methods, treatment allocation, concealment of treatment groups, and homogeneity of the participants’ baseline demographics upon entry of the study. In addition, all studies were appraised for their control of confounding factors, reliability of outcome measures, and suitability of statistical analyses. For this review, a low methodological quality refers to a score assigned to a study of less than 40%, a medium quality refers to one between 40 and 70%, and a high quality refers to one greater than 70%. The findings of any systematic review are only as reliable as the primary data source, upon which the review is based [ 27 ]. Hence, studies rated to have low methodological quality (see Additional file  2 ) were excluded to avoid potentially erroneous conclusions based on the synthesis of poorly conducted studies.

Given the heterogeneity of the interventions and findings in the studies, no meta-analysis was performed. Instead, a narrative synthesis of the studies was done: the analysis was conveyed in prose, alongside tables to outline and explain the results.

Study characteristics

This review included 15 studies with 23 681 participants across five countries including Australia [ 28 , 29 , 30 ], Canada [ 31 , 32 ], New Zealand [ 33 ], UK [ 34 ], and USA [ 35 , 36 , 37 , 38 , 39 , 40 , 41 ], where the nomenclature for nurses in advanced practice was “NP.” A total of 14 studies [ 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ] were published while one was an unpublished manuscript (Roche T, Gardner GE, Jack L: The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study. In preparation.) at the point of the search. The previously unpublished manuscript was subsequently published in 2017 [ 42 ]. All included studies were conducted between 2006 and 2016. As regards the setting, six studies [ 28 , 29 , 30 , 32 , 33 ] focused on the EDs, six [ 31 , 34 , 35 , 37 , 38 , 41 ] on the ICU, two [ 36 , 40 ] on the trauma centers, and one on the stroke center [ 39 ]. The sample sizes ranged from 103 [ 31 ] to 9066 [ 38 ]. The characteristics of the studies are detailed in Table  2 .

Methodological quality

The assessment details of each study’s methodological quality are presented in Table  3 . In this review, only three studies were RCTs [ 29 , 30 , 31 ] whereas 12 were cohort studies [ 28 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 42 ]. The included studies had low to medium risk of bias.

In two of the three RCTs, true randomization was used to assign patients to study groups by using computer-generated sequence, thus incurring only low risk of selection bias. In the other RCT, a triage coordinator was present to randomly assign the patients at a planned ratio to either NP-directed care or physician-directed care. Two of three RCTs, took measures to blind the outcome assessors to treatment assignment, minimizing detection bias. Out of the 15 studies, 14 measured their outcomes in a reliable and valid manner using pre-decided criteria, minimizing reporting bias. The presence of confounding factors was acknowledged in 11 of the 12 cohort studies but only five of them described strategies to deal with it. All the included studies fared poorly in reducing attrition bias. Only three of the 15 studies had complete follow-up or strategies to address incomplete follow-up. Appropriate statistical analyses were chosen in all included studies.

The study results and statistical conclusions are summarized in Table  4 . The details of the individual studies can be found in Table  5 . The findings were categorized according to the studies’ setting. Studies conducted in emergency and critical care settings measured outcomes such as length of stay, waiting, and patient satisfaction. Outcomes such as mortality and cost were measured only in the critical care setting.

Emergency setting

Length of stay.

Four out of the 15 studies examined the impact of the advanced nursing practice roles on the length of stay in the emergency setting [ 28 , 32 , 33 , 42 ].

NP-directed management of care

Two studies [ 28 , 33 ] reported a significant reduction in the length of stay in EDs of patients who were reviewed and treated by NPs when compared to those seen by physicians. However, the shorter time was attributed to the baseline difference in patients’ acuity between the groups. The physicians handled patients of higher acuity and complexity than NPs. On the contrary, a multisite study [ 42 ], with comparison groups of similar baseline patient acuity, found comparable lengths of stay in EDs when patients with chest pain were managed by either NPs or physicians.

Length of stay in collaborative care involving nurse practitioners

One study [ 32 ] compared NP-physician collaborative model of care with usual physician-only model of care and found similar lengths of stay in ED between the comparison groups.

Waiting time

Of the 15 studies, six studies [ 28 , 29 , 30 , 32 , 33 ] examined the impact of advanced nursing practice roles on waiting time in the emergency setting.

Time to consultation

Only one study [ 33 ] reported that patients with minor injuries experienced shorter waiting time (median 14 min) when reviewed by emergency NPs than those reviewed by physicians (median 50 min). The other three studies [ 28 , 30 ] comparing NP-directed care with physician-only care found similar waiting time to consultation in EDs. Another study [ 32 ] comparing the NP-physician collaborative care with physician-only care also found similar waiting time to consultation in EDs.

Time to treatment

One RCT [ 29 ] illustrated that a greater proportion of patients (15.4%) managed by emergency NPs received analgesia within 30 min of arrival at the ED compared to patients managed by physicians (1.6%) ( P  < 0.001).

Patient satisfaction

Of the 15 studies, two examined patient satisfaction in the emergency setting [ 30 ]. The two used previously validated questionnaires to measure patient satisfaction. One of which [ 42 ] found similar patient satisfaction scores when comparing NP-directed care with physician-only care while the other [ 30 ] reported NPs to receive higher patient satisfaction scores than physicians (NP median score 23 [IQR 20–24] vs. physician median score [IQR 16–24]; P  = 0.002).

Critical care setting

Seven out of the 15 studies examined the impact of the advanced nursing practice roles on the length of stay in the critical care setting [ 31 , 35 , 36 , 37 , 38 , 40 , 41 ].

Comparable lengths of stay in a trauma center was reported in one study [ 40 ] where the comparison groups had similar baseline patient acuity. A RCT [ 31 ] conducted in a post-cardiac surgery unit where patients required critical care found comparable lengths of stay in hospital between the comparison groups (NP-directed care versus physician-only care). Despite the higher acuity of care required by patients under NP-directed care than those under physician-only care, the discharge outcomes were similar. In addition, a large cohort study [ 38 ] reported a significantly shorter length of stay in medical ICUs for patients whose management were led by NPs than those under physician-only management. Patients in the NP-directed group also had lower odds (odds ratio 0.87, P  < 0.001) of longer hospital stays. Interestingly, a higher patient-to-provider ratio was observed in the NP-directed group but the authors [ 38 ] were judicious in inferring greater efficiency in NP-directed care given the differences in the patients’ characteristics between comparison groups.

Collaborative care involving nurse practitioners

All included studies that compared NP-physician collaborative model of care with usual physician-only model of care found similar lengths of hospital stay [ 35 , 36 , 37 , 41 ] between the comparison groups. However, in one study [ 36 ], after subgroup analysis, a significantly shorter length of stay was found in the physician-NP collaborative group for patients transferred from another service (mean difference 6.54 days, P  < 0.0001), patients discharged to rehabilitation facility (mean difference 2.63 days, P  = 0.0024), patients older than 60 years (mean difference 1.80 days, P  = 0.0369), or patients discharged on intravenous antibiotics/wound therapy (mean difference 3.93 days, P  = 0.0171). The management of such patients warrants greater communication with multidisciplinary teams, discharge planning, care coordination, and administrative work were required; in this niche, NPs are familiar with such tasks and can competently perform them [ 43 ].

Only one study [ 39 ] examined the impact of advanced nursing practice roles on waiting time in the critical care setting. The study [ 39 ] demonstrated that a 24/7, on-site coverage with an acute care NP as first responders for acute ischemic stroke significantly reduced the time to treatment (median 45 min; IQR 35–58 min) in comparison to the usual service model (median 53 min; IQR 45–73 min) ( P  < 0.001).

Five [ 34 , 37 , 38 , 39 , 41 ] out of the 15 studies analyzed the impact of the advanced nursing practice roles on hospital and ICU mortality. Two studies [ 38 , 39 ] comparing NP-directed care with physician-only care found comparable patient mortality. One of them, a large cohort study ( n  = 9066) conducted in the medical ICU [ 38 ], suggested NP-directed care had the same quality as physician-only care. The patients under NP-directed care had lower ICU mortality (6.3%) than those under physician-only care (11.6%; adjusted OR 0.77; 95% CI 0.63–0.94; P  = 0.01) whereas hospital mortality between groups were similar (10 vs. 15.9%; adjusted OR 0.87; 95% CI 0.73–1.03; P  = 0.11). This finding was consistent with that in the other three studies conducted in ICUs [ 34 , 37 , 41 ] which compared the NP-physician collaborative care with physician-only care.

Of the 15 studies, only one examined patient satisfaction in the critical care settings [ 31 ]. The study developed a new self-reported tool to measure patient satisfaction and found similar scores when comparing NP-directed care with physician-only care. Nonetheless, the study [ 31 ] reported that NPs performed better than physicians in teaching, answering questions, listening, and pain management. This finding was akin to the study [ 30 ] conducted in the ED which assessed the healthcare provider for completeness of care, politeness of service provider, explanation and advice given, waiting time, and comprehension of discharge instruction.

Three of the 15 studies reviewed the impact of the advanced nursing practice roles on cost [ 34 , 36 , 41 ], all of which compared NP-physician collaborative care with physician-only care in the critical care setting. One study [ 41 ] reported that despite a longer ICU stay for patients in the NP-physician group than for those in physician-only group, there was no significant difference in the observed charges between them. This supports the contention that involving NPs in the management of the critically ill can lead to cost savings. The other two studies [ 34 , 36 ] had results that demonstrated cost savings in the NP-physician group compared to physician-only group. One of them concluded that an annual staffing cost of approximately £170 000 could be saved when physicians worked with NP in managing ICU patients.

With population aging and the consequent global epidemic of chronic diseases, healthcare demands will only rise. Accordingly, nurses in advanced practice can add value and increase access to healthcare by, potentially strengthening the healthcare workforce. Nonetheless, the expansion of role and autonomy of nurses will lead to concerns of patient safety and clinical outcomes. Through the narrative synthesis of the available evidence from Australia, Canada, New Zealand, UK, and USA, nurses in advanced practice appear to generate clinical outcomes comparable to those of physicians in the emergency and critical settings.

Generally, in the ICU setting, the involvement of NPs in managing the critically ill allowed for greater continuity of care [ 37 ], as NPs did not have to be on frequent rotation coverage as junior physicians. Hence, NPs developed greater familiarity with the environment and patient demands than the physicians who were constantly on rotation. The involvement of NPs also provided the unit’s staff with a consistent point of contact for the multidisciplinary team [ 35 ]. When daily multidisciplinary rounds were initiated by NPs, the coordination of care was shown to improve [ 40 ]. Providing effective care coordination is a forte of nurses [ 10 ]. Care coordination requires interpersonal communication and collaboration. As nurses can establish more personal and tangible relationships with patients than do physicians [ 44 ], they perform better in care coordination. The value of NPs was exemplified when the patient care required cross-disciplinary communication, discharge planning, follow-up care, and administrative work. With NPs’ involvement, patients’ length of stay was shortened [ 36 ]. Apart from delivering efficient care, nurses in advanced practice will get to develop expertise for managing specific groups of patients through assigned responsibilities [ 35 ].

One of the prioritized quality-of-care indicators in the emergency setting is the time from arrival to first assessment by physician [ 45 ]. This review has demonstrated that NPs were capable of rendering emergency care services as timely [ 28 , 32 ] as, if not faster [ 33 ] than, physicians. The addition of nurses in advanced practice in the emergency settings enabled physicians to pay greater attention to patients of higher complexity and acuity, thereby, improving access to prompt emergency care.

Time to treatment is also a priority in emergency care. The time to first administration of analgesia is an important quality-of-care indicator in EDs [ 45 ]. There are national targets in place to improve this aspect of care. In Australia, New Zealand, and the USA, the national target for time to analgesia is 30 min from time of arrival [ 46 , 47 ] and, in the UK, it is 20 min [ 48 ]. When compared with physicians, NPs were observed to have greater adherence to the recommended targets for administering analgesia in a timely fashion [ 29 ]. In their provision of a hybrid model of care amalgamating nursing and medical tasks, NPs are trained to perform patient assessment and, in some countries, have prescription rights. These factors contributed to a shortened time to treatment in the emergency setting for patients [ 29 ].

The experience of the patient is highly valued in the healthcare system [ 49 ]. This review showed that patients’ level of satisfaction was not dependent on whom but how the care was delivered [ 30 , 31 ]. NPs were rated to perform better at patient education, answering queries, listening, and pain management than physicians [ 31 ]. These are the strengths of NPs, consistent with the NP goals and education, which are grounded in nursing [ 43 , 50 ].

Cost savings are an important outcome measure in evaluating the feasibility of any new service model [ 51 ]. Findings from this review suggest greater cost savings with the implementation of the advanced nursing practice role in emergency or critical care [ 34 , 36 , 41 ]. However, judicious interpretation of the evidence is recommended. A fair synthesis of the cost savings in the included studies could not be performed as they had been done in different countries. The varying financial and funding models make it difficult to synthesize the findings. Furthermore, none of the studies in this review performed any cost-effectiveness analysis.

The existing evidence has demonstrated the positive impact of advanced nursing practice roles in the emergency and critical setting, it is then of benefit to examine the necessary conditions for its implementation and receptivity. According to Pettigrew et al.’s “receptive contexts for change” framework (Fig.  2 ), there are eight dynamically linked factors which influence the receptivity to change [ 52 ]. Three of which are especially apparent in the studies featured in this review. They are namely the presence of environmental pressure, supportive organizational culture, and managerial-clinical relations.

Receptive contexts for change framework

Environmental pressure can be especially pivotal in creating favorable conditions for change. When considering environmental pressure, besides the entire healthcare system, the political context of the country has an integral role in defining the environment [ 53 ]. Political influence, a large environmental pressure, was evident in the studies conducted in the USA [ 35 , 36 , 37 , 38 , 39 , 40 , 41 ] and UK [ 34 ]. In the USA, the implementation of the Affordable Care Act in 2010 was a catalyst for the development of more efficient healthcare delivery models to cope with the projected influx of new patients. In the UK study [ 34 ] featured in this review, political influence was also observed. The enactment of provisional immigration laws for physicians outside of the European Union and the European Working Time Directive has make it more difficult to support safe staff-to-patient ratios in the critical care setting. The political context of the country created an environmental pressure which consequently compelled the institutions [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ] cited in this review to capitalize on nurses in advanced practice and experiment with new models of care delivery.

The environmental pressures trigger the development of a supportive organizational culture to effect change to ease the pressure [ 52 ]. A supportive organizational culture strives to promote staff engagement [ 53 ]. Staff engagement involves autonomy to be extended, and it was apparent in the included studies. In this review, the NPs were given greater autonomy to either practice independently [ 28 , 29 , 30 , 31 , 33 , 34 ] or collaborate [ 32 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ] with physicians at greater extents in the emergency and critical care settings. In these studies, the institutions’ willingness to take risks and evaluate new workforce utilization strategies possibly led to the successful implementation of the advanced practice nursing role [ 53 ].

Effective managerial-clinical relations is also a crucial factor in leveraging institutional change [ 53 ]. In the study conducted in Canada [ 31 ], the authors attributed the success observed in the NP role implementation in the post-operative cardiac surgery unit to the support from and collaboration between the administrators and clinical staff. As the NP role was fairly new in the study’s [ 31 ] setting then, it was necessary to involve individuals at all levels in the NP role implementation to optimize its success [ 54 ]. One approach to facilitate effective managerial-clinical relations is through adopting a distributed model of leadership [ 55 ], which encourages collaboration between the administrators and clinical staff. The distributed leadership approach is known to be most efficacious where job roles are mutually dependent [ 56 ]. The implementation of advanced practice nursing roles in the emergency and critical care settings involves mutually dependent job roles and so will benefit from the distributed leadership approach. The distributed leadership approach utilizes a bottom-up process, where individuals working in the setting-of-interest participates in decision-making [ 55 ]. Using this approach creates the notion of co-construction, which avoids the overreliance on a dominant individual, increasing the likelihood for sustainable change [ 54 ].

The quality and coherence of policy is one factor in the receptive context framework [ 52 ] which was not discussed in the included studies but is vital in the implementation of the NP/APN role. The lack of coherent policy to define the roles and professional boundaries of advanced nursing practice can cause healthcare administrators to be apprehensive about the implementation of healthcare models where NP/APNs are given more autonomy and responsibilities [ 57 , 58 , 59 ]. State law governs advanced nursing practice and define supervisory requirements [ 60 ]. Often, the legal frameworks lack clarity on the legal accountability of physicians, should nurses under the physicians’ supervision commit errors harmful to patients [ 61 , 62 ]. Professional indemnity is closely associated to legislative boundaries [ 63 ]. The successful implementation of the NP/APN role hinges on the institution of relevant regulatory frameworks and credentialing systems to guide policy implementations and educational establishments [ 64 ]. It, therefore, reiterates the importance of having coherent policies to define roles and professional independence of nurses in advanced practice.

Limitations

The meta-analysis of the outcomes was not done to present the combined effect of estimates on the impact of advanced nursing roles in the emergency and critical care settings. Yet, to perform a meta-analysis would be inappropriate as the included studies were heterogeneous in designs, interventions, and outcome measures. The heterogeneity of studies was expected as the professional boundaries of nurses differ across countries. However, a review of the impact of advance nursing practice across countries is still valuable.

A limitation in all studies is the poor definition and description of the scope of advanced nursing practice. In addition, preparatory training for nurses to assume advanced practice was rarely discussed. The level of theoretical knowledge and clinical competence of the nurses might differ across the studies; hence, the comparison might not have been fair.

Finally, despite the search across nine international databases, this review included papers in only English; relevant papers not published in English might have been omitted.

Capitalizing on nurses in advanced practice to increase patients’ access to emergency and critical care is appealing and beneficial. This review suggests that the implementation of the NP/APN role in the emergency and critical care settings improves patient outcomes. The transformation of healthcare delivery through effective utilization of the workforce may alleviate the impending rise in demand for health services. Nevertheless, it is necessary to first prepare a receptive context to effect sustainable change.

Abbreviations

Advanced practice nurses

Emergency department

Intensive care unit

Joanna Briggs Institute

Nurse practitioners

Population, Intervention, Comparison, and Outcome

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Randomized controlled trial

United Kingdom

United States of America

Angus DC, Kelley MA, Schmitz RJ, White A, Popovich JJ. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762–70.

Article   CAS   PubMed   Google Scholar  

Marengoni A, Winblad B, Karp A, Fratiglioni L. Prevalence of chronic diseases and multimorbidity among the elderly population in Sweden. Am J Public Health. 2008;98(7):1198–200. doi: 10.2105/AJPH.2007.121137 .

Article   PubMed   PubMed Central   Google Scholar  

Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34(4):1016–24. doi: 10.1097/01.ccm.0000206105.05626.15 .

Article   PubMed   Google Scholar  

Gordon CR, Axelrad A, Alexander JB, Dellinger RP, Ross SE. Care of critically ill surgical patients using the 80-hour Accreditation Council of Graduate Medical Education work-week guidelines: a survey of current strategies. Am Surg. 2006;72(6):497–9.

PubMed   Google Scholar  

Ozcan S, Taranto Y, Hornby P. Shaping the health future in Turkey: a new role for human resource planning. Int J Health Plann Manag. 1995;10(4):305-19. doi: 10.1002/hpm.4740100406 .

Article   CAS   Google Scholar  

Guilbert JJ. The World Health Report 2006: working together for health. Educ Health (Abingdon). 2006;19(3):385–7.

Article   Google Scholar  

Lopes MA, Almeida ÁS, Almada-Lobo B. Handling healthcare workforce planning with care: where do we stand? Hum Resour Health. 2015;13(1):38. doi: 10.1186/s12960-015-0028-0 .

Maier CB, Barnes H, Aiken LH, Busse R. Descriptive, cross-country analysis of the nurse practitioner workforce in six countries: size, growth, physician substitution potential. BMJ Open. 2016;6(9):e011901. doi: 10.1136/bmjopen-2016-011901 .

Maier T, Afentakis A. Forecasting supply and demand in nursing professions: impacts of occupational flexibility and employment structure in Germany. Hum Resour Health. 2013;11(1):24. doi: 10.1186/1478-4491-11-24 .

Pulcini J, Jelic M, Gul R, Loke AY. An international survey on advanced practice nursing education, practice, and regulation. J Nurs Scholarsh. 2010;42(1):31–9. doi: 10.1111/j.1547-5069.2009.01322.x .

Schober M, Affara FA. International council of nurses: advanced nursing practice. Oxford: Blackwell Pub; 2006.

Google Scholar  

Savrin C. Growth and development of the nurse practitioner role around the globe. J Pediatr Health Care. 2009;23(5):310–4. doi: 10.1016/j.pedhc.2008.10.005 .

World Health Organization (WHO). A summary of the 2008 World Health Report. 2008. http://www.who.int/whr/2008/summary.pdf . Accessed 31 July 2017.

Swan M, Ferguson S, Chang A, Larson E, Smaldone A. Quality of primary care by advanced practice nurses: a systematic review. Int J Qual Health Care. 2015;27(5):396–404. doi: 10.1093/intqhc/mzv054 .

Hirshon JM, Risko N, Calvello EJ, Ramirez SSD, Narayan M, Theodosisa C, O’Neill J. Health systems and services: the role of acute care. Bull World Health Organ. 2013;91:386–8. doi: 10.2471/BLT.12.112664 .

Comiskey C, Coyne I, Lalor J, Begley C. A national cross-sectional study measuring predictors for improved service user outcomes across clinical nurse or midwife specialist, advanced nurse practitioner and control sites. J Adv Nurs. 2014;70(5):1128–37. doi: 10.1111/jan.12273 .

Martínez-González NA, Djalali S, Tandjung R, Huber-Geismann F, Markun S, Wensing M, Rosemann T. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:214. doi: 10.1186/1472-6963-14-214 .

Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36(10):2888–97. doi: 10.1097/CCM.0b013e318186ba8c .

Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet. 1999;354(9187):1321–6.

Cooper MA, Lindsay GM, Kinn S, Swann IJ. Evaluating emergency nurse practitioner services: a randomized controlled trial. J Adv Nurs. 2002;40(6):721–30. doi: 10.1046/j.1365-2648.2002.02431.x .

Edkins RE, Cairns BA, Hultman CS. A systematic review of advance practice providers in acute care: options for a new model in a burn intensive care unit. Ann Plast Surg. 2014;72(3):285–8. doi: 10.1097/sap.0000000000000106 .

CAS   PubMed   Google Scholar  

Carter AJ, Chochinov AH. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. CJEM. 2007;9(4):286–95. doi: 10.1017/S1481803500015189 .

Jennings N, Clifford S, Fox AR, O’Connell J, Gardner G. The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review. Int J Nurs Stud. 2015;52(1):421–35. doi: 10.1016/j.ijnurstu.2014.07.006b .

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISM A statement. Ann Intern Med. 2009;151(4):264–9. https://doi.org/10.7326/0003-4819-151-4-200908180-00135 .

Sackett DL. Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone; 2000.

The Joanna Briggs Institute. Joanna Briggs Institute reviewers’ manual: 2016 edition. Adelaide: The Joanna Briggs Institute; 2016.

Bown MJ, Sutton AJ. Quality control in systematic reviews and meta-analyses. Eur J Vasc Endovasc Surg. 2010;40(5):669–77. doi: 10.1016/j.ejvs.2010.07.011 .

Jennings N, O’Reilly G, Lee G, Cameron P, Free B, Bailey M. Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia. J Clin Nurs. 2008;17(8):1044–50. doi: 10.1111/j.1365-2702.2007.02038.x .

Jennings N, Gardner G, O’Reilly G, Mitra B. Evaluating emergency nurse practitioner service effectiveness on achieving timely analgesia: a pragmatic randomized controlled trial. Acad Emerg Med. 2015;22(6):676–84. doi: 10.1111/acem.12687 .

Dinh M, Walker A, Parameswaran A, Enright N. Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors. Australas Emerg Nurs J. 2012;15(4):188–94. doi: 10.1016/j.aenj.2012.09.001 .

Goldie CL, Prodan-Bhalla N, Mackay M. Nurse practitioners in postoperative cardiac surgery: are they effective? Can J Cardiovasc Nurs. 2012;22(4):8–15.

Steiner IP, Nichols DN, Blitz S, Tapper L, Stagg AP, Sharma L, Policicchio C. Impact of a nurse practitioner on patient care in a Canadian emergency department. CJEM. 2009;11(3):207–14.

Colligan M, Collins C, Foley B, Jones P, Miles J, Zeng I. Emergency nurse practitioners: do they provide an effective service in managing minor injuries, compared to emergency medicine registrars? N Z Med J. 2011;124(1344):74–80.

Skinner H, Skoyles J, Redfearn S, Jutley R, Mitchell I, Richens D. Advanced care nurse practitioners can safely provide sole resident cover for level three patients: impact on outcomes, cost and work patterns in a cardiac surgery programme. Eur J Cardiothorac Surg. 2013;43(1):19–22. doi: 10.1093/ejcts/ezs353 .

David D, Britting L, Dalton J. Cardiac acute care nurse practitioner and 30-day readmission. J Cardiovasc Nurs. 2015;30(3):248–55. doi: 10.1097/JCN.0000000000000147 .

Hiza EA, Gottschalk MB, Umpierrez E, Bush P, Reisman WM. Effect of a dedicated orthopaedic advanced practice provider in a level I trauma center: analysis of length of stay and cost. J Orthop Trauma. 2015;29(7):e225–30. doi: 10.1097/BOT.0000000000000261 .

Hoffman LA, Miller TH, Zullo TG, Donahoe MP. Comparison of 2 models for managing tracheotomized patients in a subacute medical intensive care unit. Respir Care. 2006;51(11):1230–6.

Landsperger JS, Semler MW, Li W, Byrne DW, Wheeler AP, Wang L. Outcomes of nurse practitioner-delivered critical care: a prospective cohort study. Chest. 2016;149(5):1146–54. doi: 10.1016/j.chest.2015.12.015 .

Moran JL, Nakagawa K, Asai SM, Koenig MA. 24/7 neurocritical care nurse practitioner coverage reduced door-to-needle time in stroke patients treated with tissue plasminogen activator. J Stroke Cerebrovasc Dis. 2016;25(5):1148–52. doi: 10.1016/j.jstrokecerebrovasdis.2016.01.033 .

Morris DS, Reilly P, Rohrbach J, Telford G, Kim P, Sims CA. The influence of unit-based nurse practitioners on hospital outcomes and readmission rates for patients with trauma. J Trauma Acute Care Surg. 2012;73(2):474–8. doi: 10.1097/TA.0b013e31825882bb .

Scherzer R, Dennis MP, Swan BA, Kavuru MS, Oxman DA. A comparison of usage and outcomes between nurse practitioner and resident-staffed medical ICUs. Crit Care Med. 2016;45(2):e132–7. doi: 10.1097/CCM.0000000000002055 .

Roche TE, Gardner G, Jack L. The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study. BMC Health Serv Res. 2017;17(1):445. doi: 10.1186/s12913-017-2395-9 .

Sidani S, Doran D, Porter H, LeFort S, O’Brien-Pallas LL, Zahn C, Laschinger H, Sarkissian S. Processes of care: comparison between nurse practitioners and physician residents in acute care. Nurs Leadersh. 2006;19(1):69–85.

Badger TA, McArthur DB. Academic nursing clinic: impact on health and cost outcomes for vulnerable populations. Appl Nurs Res. 2003;16(1):60–4.

Schull MJ, Guttmann A, Leaver CA, Vermeulen M, Hatcher CM, Rowe BH, Zwarenstein M, Anderson GM. Prioritizing performance measurement for emergency department care: consensus on evidence-based quality of care indicators. CJEM. 2011;13(5):300–9.

Hatherley C, Jennings N, Cross R. Time to analgesia and pain score documentation best practice standards for the emergency department: a literature review. Australas Emerg Nurs J. 2016;19(1):26–36. doi: 10.1016/j.aenj.2015.11.001 .

Patrick PA, Rosenthal BM, Iezzi CA, Brand DA. Timely pain management in the emergency department. J Emerg Med. 2015;48(3):267–73. doi: 10.1016/j.jemermed.2014.09.009 .

Keating L, Smith S. Acute pain in the emergency department: the challenges. Rev Pain. 2011;5(3):13–7. doi: 10.1177/204946371100500304 .

Muntlin A, Gunningberg L, Carlsson M. Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement. J Clin Nurs. 2006;15(8):1045–56. doi: 10.1111/j.1365-2702.2006.01368.x .

Sidani S, Irvine D. A conceptual framework for evaluating the nurse practitioner role in acute care settings. J Adv Nurs. 1999;30(1):58–66.

Jamison DT. Priorities in health. Washington, DC: World Bank; 2006.

Book   Google Scholar  

Pettigrew AM, Ferlie E, McKee L. Shaping strategic change: making change in large organizations, the case of the National Health Service. London: Sage Publications; 1992.

World Health Organization (WHO): Health system transformation: making it happen. 2016. http://www.euro.who.int/__data/assets/pdf_file/0014/318020/Madrid-Report-HST-making-it-happen.pdf?ua=1 . Accessed 31 July 2017.

Western S. Leadership: a critical text. London: SAGE; 2008.

Bengoa R. Transforming health care: an approach to system-wide implementation. Int J Integr Care. 2013;13:e039.

Hartley J, Benington J. Leadership for healthcare. Bristol: Policy Press; 2010.

Kaasalainen S, Martin-Misener R, Carter N, DiCenso A, Donald F, Baxter P. The nurse practitioner role in pain management in long-term care. J Adv Nurs. 2010;66(3):542–51. doi: 10.1111/j.1365-2648.2009.05206.x .

Lindblad E, Hallman E-B, Gillsjö C, Lindblad U, Fagerström L. Experiences of the new role of advanced practice nurses in Swedish primary health care: a qualitative study. Int J Nurs Pract. 2010;16(1):69–74. doi: 10.1111/j.1440-172X.2009.01810.x .

Tye CC, Ross FM. Blurring boundaries: professional perspectives of the emergency nurse practitioner role in a major accident and emergency department. J Adv Nurs. 2000;31(5):1089–96. doi: 10.1046/j.1365-2648.2000.01380.x .

Pearson L. Sixteenth annual legislative update: how each state stands on legislative issues affecting advanced nursing practice. Nurs Pract. 2004;29(1):26–31.

Middleton S, Gardner A, Gardner G, Della PR. The status of Australian nurse practitioners: the second national census. Aust Health Rev. 2011;35(4):448–54. doi: 10.1071/AH10987 .

Wilson A, Pearson D, Hassey A. Barriers to developing the nurse practitioner role in primary care—the GP perspective. Fam Pract. 2002;19(6):641–6.

Niezen MG, Mathijssen JJ. Reframing professional boundaries in healthcare: a systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain. Health Policy. 2014;117(2):151–69. doi: 10.1016/j.healthpol.2014.04.016 .

Lehmann U, Damme WV, Barten FJMH, Sanders D. Task shifting: the answer to the human resources crisis in Africa? Hum Resour Health. 2009;7:49. doi: 10.1186/1478-4491-7-49 .

Richardson G, Maynard A, Cullum N, Kindig D. Skill mix changes: substitution or service development? Health Policy. 1998;45(2):119–32.

Download references

Acknowledgements

The authors would like to acknowledge Ms. Wong Suei Nee, Senior Librarian of National University of Singapore, for her guidance in fine-tuning the search strategy for the review.

The study was funded by the last author’s (WT) University Start-up Grant. The publication fee is supported by the University Start-up Grant of the last author WT (Ref. No.: NUHSRO/2014/101/SU/01).

Availability of data and materials

N.A. This article is based on a review of existing literature.

Author information

Authors and affiliations.

Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore, 117597, Singapore

Brigitte Fong Yeong Woo & Wilson Wai San Tam

National University Heart Centre Singapore, National University Hospital, 5 Lower Kent Ridge Road, Main Building 1, Level 2, Singapore, 119074, Singapore

Jasmine Xin Yu Lee

You can also search for this author in PubMed   Google Scholar

Contributions

BW conducted the literature search, completed the study selection, critically appraised the studies, extracted data, analyzed, interpreted the data, and drafted the manuscript. JL participated in the study selection, critically appraised the studies, and checked the data extracted. WT provided supervision for all stages of the review, analyzed, and interpreted the data. All authors (BW, JL, and WT) contributed to the conception and critical review of the manuscript and have agreed to its submission for publication.

Corresponding author

Correspondence to Brigitte Fong Yeong Woo .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional files

Additional file 1:.

Search strategy.

Additional file 2:

List of studies excluded after critical appraisal.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Woo, B.F.Y., Lee, J.X.Y. & Tam, W.W.S. The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review. Hum Resour Health 15 , 63 (2017). https://doi.org/10.1186/s12960-017-0237-9

Download citation

Received : 25 April 2017

Accepted : 31 August 2017

Published : 11 September 2017

DOI : https://doi.org/10.1186/s12960-017-0237-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Advanced Practice Nurses (APNs)
• Critical Care Setting
• Impending Rise
• Advanced Practice Nursing Roles
• Receptive Context

Human Resources for Health

ISSN: 1478-4491

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

• Research article
• Open access
• Published: 18 January 2017

A systematic review of experiences of advanced practice nursing in general practice

• Michael Jakimowicz   ORCID: orcid.org/0000-0002-3122-4176 1 ,
• Danielle Williams 2 &
• Grazyna Stankiewicz 3  

BMC Nursing volume  16 , Article number:  6 ( 2017 ) Cite this article

24k Accesses

44 Citations

7 Altmetric

Metrics details

Despite efforts to achieve conceptual clarity, advanced practice nursing continues to reside in a liminal space, unable to secure ongoing recognition as a viable means of healthcare delivery. This is particularly evident in general practice where advanced practice role development is more fluid and generally less supported by the hierarchical structures evident in the hospital system. This review synthesises published qualitative studies reporting experiences of advanced practice nursing in general practice. The panoramic view provided by patients, nurses and doctors within this novel context, offers a fresh perspective on why advanced practice nurses have struggled to gain acceptance within the healthcare milieu.

We conducted a systematic review of qualitative studies that explored the experiences of patients, nurses and doctors who had contact with advanced practice nurses working in general practice. Published work from 1990 to June 2016 was located using CINAHL and PubMed. The full text of relevant studies was retrieved after reading the title and abstract. Critical appraisal was undertaken and the findings of included studies were analysed using the constant comparative method. Emergent codes were collapsed into sub-themes and themes.

Twenty articles reporting the experiences of 486 participants were included. We identified one major theme: legitimacy; and three sub-themes: (1) establishing and maintaining confidence in the advanced practice nurse, (2) strengthening and weakening boundaries between general practitioners and advanced practice nurses and (3) establishing and maintaining the value of advanced practice nursing.

Conclusions

We set out to describe experiences of advanced practice nursing in general practice. We discovered that general practitioners and patients continue to have concerns around responsibility, trust and accountability. Additionally, advanced practice nurses struggle to negotiate and clarify scopes of practice while general practitioners have trouble justifying the costs associated with advanced practice nursing roles. Therefore, much work remains to establish and maintain the legitimacy of advanced practice nursing in general practice.

Peer Review reports

There is an absence of clear agreement regarding the concept of advanced practice nursing both in Australia and overseas [ 1 – 5 ]. Efforts to clarify this uncertainty have concentrated on nomenclature [ 1 ], scope [ 6 , 7 ] and domains of practice [ 2 – 5 ]. We argue that this uncertainty has constrained the transition to unqualified acceptance, wedging advanced practice nursing into a liminal space with little scope for recognition and expansion. This is particularly evident in general practice, where advanced practice role development is more fluid and generally less supported by the hierarchical structures evident in the hospital system [ 5 ].

Within the general practice arena, nurses perform advanced practice duties including diabetes education, chronic disease management and mental health casework, supplanting work performed previously by a general practitioner [ 8 – 10 ]. It is generally agreed that this range of responsibilities meets the international expectations of advanced practice nursing in terms of comprehensive care, systems support, education, research and professional leadership [ 3 , 4 ].

Most research in the general practice area has focused on either (1) Nurse Practitioners, a subset of advance practice nurses with legislative status or (2) Practice Nurses, a larger set of nurses who work in general practice that includes advance practice nurses. A review by McInnes et al. [ 11 ] and a study by Merrick et al. [ 12 ] provided worthwhile understandings of challenges to teamwork, collaboration and decision-making in the general practice environment without specifically tackling issues surrounding advanced practice nursing. Other studies focused on nurses performing certain roles [ 13 , 14 ], working in specific contexts [ 10 , 15 ], or managing particular illnesses [ 16 – 18 ].

The purpose of this review is to synthesise published qualitative studies reporting experiences of advanced practice nursing in general practice. The panoramic view provided by patients, nurses and doctors within this novel context, offers a fresh perspective on why advanced practice nurses have struggled to gain acceptance within the healthcare milieu. This new data will inform wider debates concerning the establishment and continuity of advanced practice roles, independent of setting.

Research question

Our research question was framed using the Population Exposure Outcome (PEO) method as described by Bettany-Saltikov [ 19 ]. This framework simplified the search process and facilitated a more focused assessment of the retrieved studies.

We were only interested in the experiences (O) of patients, nurses and doctors (P) who had contact with advanced practice nurses working in general practice (E). We were cognisant of international variations in the use of the term ‘advanced practice’, so we agreed to use Roche et al.’s [ 5 ] broader and, therefore, more inclusive definition which was the display of a skill set beyond generic nursing work. While in no way discounting the importance of basic nursing tasks, it was important to establish that advanced practice nursing involved additional responsibilities incorporating sophisticated critical reasoning than would not normally be expected of a nurse working at a more junior level. While it could be argued that the intangibility of these higher order skills could lead to errors in recognition, in practice it is relatively straightforward to distinguish what is and what is not advanced practice nursing [ 1 ]. In the case of advanced practice nurses working in general practice, this additional work includes, but is not limited to, case management, peer education, chronic disease management, counselling and health promotion. Table  1 provides two examples common to the general practice setting to highlight this delineation.

Experiences of the work of a Nurse Practitioner (NP) were also included in the study. Patient participants had to have experience of advanced practice nursing as a current or former patient of a general practice. Nurse participants could be either advanced practice nurses or those being supervised or otherwise interacting with advanced practice nurses. Doctors could be located within the practice in the case of general practitioners (GPs) or extrinsic in the case of specialists.

Search methods

We located published work from 1990 to June 2016 using the CINAHL and PubMed databases. Preliminary searches revealed that the terms “advanced practice” and “advanced practice nursing” did not capture relevant literature, so we decided to use the broader term of “nursing”. Medical Subject Headings (MeSH) terms for general practice were combined with MeSH terms and text words for nursing and MeSH terms for qualitative research. We limited the search to journal articles in English with the full text available. The search strategies for each database are provided in an additional file [see Additional file 1 ]. In total, we located 143 studies from PubMed and 45 from CINAHL. Two studies from the authors’ personal collections were also added to this initial group. After discarding duplicate studies, we read the title and abstract of the located articles. Studies reporting survey results needed to include themes derived from “free text” responses. We retrieved the full text of studies that appeared to include relevant data or information. Forty-five studies were retrieved and examined for eligibility.

Study selection

We developed a critical appraisal tool for this study that focused on methods, analysis and interpretation. The tool was based on the Critical Appraisal Skills Programme (CASP) Checklist for Qualitative Studies [ 20 ]. We included an additional screening question that referred to our agreed definition of advanced practice nursing (provided above). Preliminary searches revealed that this step was not feasible during the initial search process. The modified critical appraisal tool is provided in an additional file [see Additional file 2 ]. Studies were included in the review if questions one, two and three and most of the remaining questions were answered “yes”. Study selection was completed by the lead author and reviewed by the co-authors. The critical appraisal score sheets for each of the included studies is provided in an additional file [see Additional file 3 ]. The critical appraisal score sheets for the excluded studies is also provided in an additional file [see Additional file 4 ]. A flow chart describing the results of the search and selection process is provided in Fig.  1 .

Summary of search process

Synthesis of findings

The full text of included studies was exported to the NVivo 11 TM software program. A list of preliminary codes was developed after close reading of the findings/results section of a selected article. These codes were further refined during analysis of the remaining articles, using the constant comparative method [ 21 ]. Text was coded line-by-line and a code tree was used to identify emergent themes. Sub-themes were derived from direct participant quotes and synthesised interpretations. These sub-themes were further analysed and collapsed into one major theme.

Twenty articles reporting the experiences of 486 participants were included in the review. Studies were conducted in Australia (10), New Zealand (1), Canada (3), the United Kingdom (5) and continental Europe (1). A summary of these studies is provided in Table  2 . The number of participants has been included to highlight the relative weight of patient, nurse and doctor experiences. Overall, we found that there was a paucity of quality studies specifically exploring this phenomenon. Several studies from the United States, a country with a large cohort of advanced practice nurses, were retrieved but subsequently excluded after critical appraisal. Twenty-five studies were excluded in total.

A total of 27 descriptors were used to code the data. We identified three sub-themes: (1) establishing and maintaining confidence in the advanced practice nurse, (2) strengthening and weakening boundaries between general practitioners and advanced practice nurses and (3) establishing and maintaining the value of advanced practice nursing. These were aggregated into one major theme: legitimacy. A diagram showing the relationship of the codes to the sub-themes and major theme is shown in Fig.  2 . A list of the studies that contributed to each code and sub-theme is provided in an additional file [see Additional file 5 ].

Sub-theme 1 - Establishing and maintaining confidence in the advanced practice nurse

Nineteen out of twenty included studies contributed to this sub-theme [ 8 – 10 , 15 , 22 – 36 ]. Of the eight codes used in the aggregation of this sub-theme, the following six codes contributed the greatest amount and are presented below: development, relinquishing, responsibility, trust, accountability and referrals.

Establishing confidence in the advanced practice nurse through development

We found that confidence in advanced practice nurses in general practice was established through development activities. Professional development included formal education [ 22 ], self-directed learning [ 23 ], structured learning pathways [ 10 ] and research activities [ 22 ]. One study reported that funding of professional activities was an issue [ 24 ]. Some nurses were content with their current duties and chose not to participate in further education with a participant stating ‘(we have to) accept that there’s a lot of nurses that don’t want any more responsibility, or they don’t want to extend their roles. They are happy to work within…what they currently do’ [ 25 , p. 3]. Others used the knowledge provided to help them to develop their role further [ 24 , 26 ]. In some cases, this involved conducting their own development activities within the general practice as part of staff training and mentoring [ 27 – 29 ] and in the community as part of public health programs [ 25 ].

We also found a tension between the need to undertake professional development and the drive to establish independent practice. Some nurse practitioners were adamant that professional status would not result from more education, but from a wider scope of practice [ 30 ]. Other advanced practice nurses went so far as to claim that skilling less qualified nurses devalued their own training that, in many cases, had cost them thousands of dollars [ 9 ]. It was also noted that a minority of GPs still doubted that advanced practice nurses had sufficient education to complete their role [ 25 ].

General practitioners relinquishing control to display confidence in the advanced practice nurse

We found that over time, GPs became satisfied that they could relinquish certain duties and hand over full or partial responsibility for a range of care activities to advanced practice nurses [ 28 , 31 ]. This included allowing the advanced practice nurse freedom to operate within their scope of practice [ 24 ]. Indeed, GPs considered themselves quite peripheral to the advanced practice nurses in the context of diabetes care, who, they argued had more time to educate patients about glycaemic control [ 9 ]. This was also the case with cervical screening, a task that many GPs felt uncomfortable about performing [ 25 ]. However, McKinlay et al. [ 10 ] found that GPs were reluctant to share the care of mental health patients with advanced practice nurses because it was not an effective use of the nurses’ time. Other GPs were happy to hand off care if they did not have to supervise or otherwise support the advanced practice nurse including answering questions [ 15 , 30 ]. One nurse stated ‘I think they (doctors) are very happy to leave us to our own devices and I think they are sometimes a little bit unhappy…when we…ask them to look at things we are not happy about and that can cause conflict’ [ 15 , p. 891.]

Establishing and maintaining confidence by transferring and accepting responsibility

We found that while many GPs were prepared to handover individual tasks, fewer were willing to assign overall case responsibility to the advanced practice nurse. Two studies found that this only occurred when there were established routines and sustainable structures in place [ 32 , 33 ]. It was accepted that advanced practice nurses were competent in maintaining the flow of patients through the general practice with one GP stating ‘If she thinks someone needs to be seen, and when, and how, I value that. I follow her advice, and if she disagrees with me then she’ll say so’ [ 23 , p. e379]. However, many GPs did not believe that advanced practice nurses were capable of being both autonomous and accountable [ 33 ]. This was reflected in the hesitancy of many nurses to assume full responsibility for patient care [ 30 ].

Displaying trust to establish and maintain confidence in the advanced practice nurse

We found that trust was an important element in establishing and maintaining confidence in advanced practice nurses in general practice. One study found that trust was the bridge between professional cultures which ultimately benefitted patients [ 34 ], while two studies highlighted the importance of medical mentorship in maintaining trust [ 28 , 35 ]. Diabetic Nurse Educators (DNE) were uniquely placed in this respect because they demonstrated skills regarding insulin initiation and titration that were, in many cases, superior to a GP [ 35 ]. The DNE’s relationship with endocrine specialists, allowed GPs to maintain a professional distance that was not replicated with other advanced practice nurses [ 35 ]. Another study found that patients needed to see that the DNE carried the authority of, and was trusted by, the GP [ 36 ].

Patients also trusted advanced practice nurses who displayed clinical acumen and attitudes by behaving in similar ways to a doctor [ 23 ]. Mahomed et al. [ 8 ] discovered that patients who had their care needs met were more likely to recognise the level of education, training and experience required to achieve the advanced practice nurse role. A patient in this study stated ‘I presume they’ve all got the same training, they all know what they’re doing and they know what they’ve got to do for me’ [ 8 , p. 2545]. Two studies found that visible and ongoing role development was an essential element of trust [ 23 , 31 ], while another study found that advanced practice nurses wrestled with the expectation of being both autonomous and a team player with a broad range of professional skills [ 32 ].

Advanced practice nurses maintaining confidence by accepting accountability

We found that issues around accountability negatively affected confidence in advanced practice nurses in general practice. One study found that while the scope and responsibility of advanced practice was negotiated locally, there was universal agreement between doctors, nurses and patients that the GP was ultimately accountable for decisions made by the nurse [ 9 ]. Main et al. [ 30 ] found that many NPs were reluctant to fully utilise prescribing rights because they considered themselves to be nurses first and were uncomfortable with being viewed as elitist and acting like a doctor. A NP in this study stated ‘I’m not sure where the resistance emanates from but there’s possibly resistance from the Nursing and Midwifery Council…I think the argument possibly is around the fact that nursing roles are changing so fast that they don’t want to make an elite group’ [ 30 , p. 483]. Senior nurses working towards NP status were in a similar situation [ 10 ].

Many patients appreciated having both a GP and an advanced practice nurse involved in their care [ 33 ]. Patients reported that the nurse was more likely to ask about any additional concerns that they may have [ 36 ]. Advanced practice nurses were also more willing to share information about themselves which put them at ease [ 8 ]. This communication style inspired patient confidence in the advanced practice nurse, however, patients did not resonate with approaches that were censorial or dictatorial [ 8 ].

Doctors maintaining confidence by respecting referrals from advanced practice nurses

We found that some GPs were reluctant to endorse referrals made by NPs to specialists outside the practice on their behalf [ 28 – 30 , 36 ]. Some specialists refused to recognise the referral at all and berated the responsible GP for allowing the normal protocol to be bypassed [ 28 ]. This gave advanced practice nurses the impression that they were trusted within the walls of the general practice, but not in a way that was visible to the outside world [ 30 ]. Of note, was an effort by one advanced practice nurse to reclaim stature by declaring that her role was central to the operation of the practice. She stated ‘we’re, you know running the ship, meaning we’re not able to free up time’ [ 27 , p. e320].

Sub-theme 2 - Strengthening and weakening boundaries between general practitioners and advanced practice nurses

Every included study contributed to this sub-theme [ 8 – 10 , 15 , 22 – 37 ]. Of the 12 codes used in the aggregation of this sub-theme, the following eight codes contributed the greatest amount and are presented below: ambiguity, traditionalising, clarifying, protocolling, reforming, flexibility, collaboration and negotiation.

Strengthening the boundary between general practitioners and advanced practice nurses by maintaining the ambiguity of advanced practice nursing roles and responsibilities

One study discovered that despite being supervised by NPs in the initial stages of their training, GP residents were still unclear about the NP’s scope of practice [ 27 ]. This uncertainty was also evident in three other studies where more experienced GPs stated that the advanced practice nurse scope of practice was ill-defined and ambiguous [ 15 , 30 , 31 ]. Without a clear understanding of the roles and responsibilities of the advanced practice nurse, some general practitioners lost interest in the position and became disconnected from the advanced practice nurse. This vacuum acted as a boundary between the two areas of practice.

Strengthening the boundary between general practitioners and advanced practice nurses by traditionalising doctor-nurse relationships

In an attempt to narrow this gap, some GPs resorted to traditionalising their relationship with the nurse [ 10 , 15 , 25 , 27 , 28 , 30 – 32 , 34 , 35 , 37 ]. Speed et al. [ 15 ] noted incidences of GPs disciplining nurses over the standard of their paperwork. One study reported a case where a GP rationalised role demarcation to who earned the income to pay the nurses [ 30 ]. Three studies found that this discordance came down to the initial limited understanding of patients’ needs by the GP [ 10 , 32 , 34 ] which subsequently restricted the capabilities of the advanced practice nurse downstream.

We found that medicalisation of nursing roles was resisted by both nurses and doctors. Some doctors were uncomfortable with nurses making a diagnosis [ 28 ] and losing control over treatment decisions [ 31 ]. Advanced practice nurses were uneasy with performing time-limited consultations because this reduced the amount of time that they could interact with their patients with one advanced practice nurse stating ‘You are booked solid and you have patient after patient, and when you go back to review they want to talk about all things and you really don’t have time’ [ 27 , p. e320].

Strengthening and weakening the boundary between general practitioners and advanced practice nurses through clarifying and protocolling

Clarification both strengthened and weakened the divide between advanced practice nurses and GPs. Within environments that were micro-managed by the GP, seven studies reported that nurses began to doubt their care decisions and sought clarification for increasingly simple matters [ 10 , 15 , 28 , 30 , 31 , 34 , 36 ]. One study reported incidences where overt patient requests were overlooked because of this unnecessary interplay between nurse and doctor [ 34 ]. Twelve studies reported the development of protocols as a means of avoiding omissions and explicitly stating what duties advanced practice nurses could perform [ 9 , 10 , 15 , 25 , 27 , 28 , 31 – 36 ]. This included computer templates preloaded with pertinent patient information [ 32 ], drug initiation and titration algorithms [ 9 , 27 ] and structured care pathways [ 10 ]. In one case a nurse stated ‘…it was tick the boxes, spit out the care plan, spit out the health assessment…we are not dealing with the patient as a holistic person…’ [ 32 , p. 131]. One study reported incidences where GPs believed insulin protocols were only relevant to nurses [ 31 ]. Over time, advanced practice nurses lost decision-making skills and felt their status within the practice was devalued [ 15 ]. One study found that nurses in this situation preferred to operate within broader policy frameworks [ 25 ]. Reassuringly, however, clarification was reported to improve teamwork [ 30 ] develop relationships [ 26 ] and overcome uncertainty regarding responsibility [ 31 ].

Weakening the boundary between general practitioners and advanced practice nurses through reforming

Several other behaviours narrowed the gap between GPs and advanced practice nurses. Three studies reported that more experienced GPs were prepared to reform the way care was delivered and expand the role of the advanced practice nurse [ 25 , 28 , 32 ]. One study reported that the ease of implementation was directly correlated with the sustainability of this reorganisation with a GP stating ‘We have to make it easy…we have to make it user friendly’ [ 32 , p. 131]. Another study found that GPs were sceptical of expansion when their own workload pressures increased [ 31 ]. One study discovered an interesting tension between DNEs and PNs involving role expansion [ 35 ]. In this case, as DNEs became overloaded with additional cases, insulin initiation was delegated to PNs who did not have specialist training and this was viewed as a threat to their status within the practice [ 35 ]. Three studies found that nurses had always been trying to expand their roles, citing instances where nurses provided independently organised groups to support patients with chronic illnesses [ 9 , 25 , 26 ]. In another study, patients understood the limitations of care led by advanced practice nurses and realised that they would be referred to a GP if their condition became complicated [ 8 ].

Weakening the boundary between general practitioners and advanced practice nurses through flexibility

Five studies found that advanced practice nurses and GPs appreciated flexibility [ 15 , 23 , 27 , 28 , 37 ]. This included balancing multiple priorities [ 23 ] and informal communications outside of clinical treatment spaces [ 37 ]. A nurse in one study stated ‘It’s a real skill in family practice nursing, identifying those red flags of who needs to be seen – that triaging function’ [ 23 , p. e379]. One study found that a lack of flexibility had serious implications for ongoing relationships [ 15 ].

Weakening the boundary between general practitioners and advanced practice nurses through collaboration and negotiation

In six studies, advanced practice nurses viewed interactions with GPs as opportunities for collaboration [ 9 , 26 , 30 , 32 , 34 , 35 ]. A further six studies reported negotiation during these exchanges [ 10 , 15 , 28 , 30 , 34 , 36 ]. One study reported that the key components of collaborative relationships were shared knowledge, mutual respect and acceptance [ 35 ], while another highlighted the importance of mentoring and supportive networks [ 32 ]. In one study, a nurse stated ‘…you do work in isolation. As far as I am aware I am the only primary mental health nurse in (the area)…so I’ve tried to make links with a mental health nursing adviser who provides professional oversight…’ [ 10 , p. 229].

Negotiation was not confined to purely clinical interactions between GPs, advanced practice nurses and patients. One study reported that understanding and utilising key power relationships within the practice, particularly involving those with financial control, was an important skill [ 32 ]. Another study found that clinical negotiation skills included overstating a patient’s condition to expedite treatment and challenging/counter-challenging [ 15 ]. Interestingly, seven studies reported that patients did not recognise interactions between the advanced practice nurse and the GP as professional cooperation [ 10 , 15 , 28 , 30 , 31 , 34 , 36 ]. One patient stated ‘she had to get permission from Dr Ken to put me on insulin, but it was her that decided and he had to say yes’ [ 9 , p. 619].

Sub-theme 3 - Establishing and maintaining the value of advanced practice nursing

Nineteen out of twenty included studies contributed to this sub-theme [ 8 – 10 , 15 , 22 – 28 , 30 – 37 ]. Of the seven codes used in the aggregation of this sub-theme, the following three codes contributed the greatest amount and are presented below: cost, funding and resources.

Establishing and maintaining the value of advanced practice nursing by measuring cost, funding and resources

Ten studies reported tensions regarding the cost of advanced practice nurses [ 9 , 10 , 24 , 25 , 30 – 34 , 37 ]. Another five studies reported anxieties around recouping this expense [ 9 , 24 , 31 , 32 , 34 ]. Sixteen studies found that as salaried employees, advanced practice nurses measured their worth to the practice in terms of the extra services they offered and the additional time they could give to their patients [ 8 – 10 , 22 , 23 , 25 – 27 , 30 – 37 ]. One study found that advanced practice nurses believed that the process of establishing a connection with a patient was time consuming in the beginning but reaped dividends in terms of patient compliance [ 34 ]. However, a GP in one study stated ‘the nurses can afford to spend a little bit more time with the patients than we can’[ 37 , p. 140] implying that a GP’s time was more valuable in dollar terms.

Both nurses and patients reported a reluctance to waste a doctor’s time [ 37 ]. One study found that GPs were more conscious of the time versus cost considerations of advanced practice nurses than they were of other services within the general practice, including their own [ 30 ]. In another study, a GP believed that NPs were a waste of money because they always asked for a second opinion [ 22 ]. In another case, a GP proposed a funding model where patients paid an ‘upfront practice payment’ for services provided by an advanced practice nurse [ 9 , p. 353]. Many GPs believed that it was not their role to provide patient education or engage in health promotion and this task was better left to the advanced practice nurse [ 15 , 24 – 28 , 30 , 32 , 34 , 35 , 37 ]. Some GPs did concede, however, that the advanced practice nurse was an effective means of providing continuity of care to vulnerable patients and many patients suffering chronic illnesses supported this view [ 8 , 9 , 24 , 25 , 28 , 30 – 32 , 34 ].

Major theme - Legitimacy

The three sub-themes were related by the concept of legitimacy. While GPs, in the main, accepted the place of the advanced practice nurse in the general practice milieu, there was disagreement on how to best utilise this model of care [ 10 , 25 – 28 , 33 , 34 , 36 ]. On the one hand, GPs enjoyed handing over what they perceived to be mundane duties to advanced practice nurses, but resented having to pay for the audits that accompanied these tasks [ 32 ].

Eleven studies reported that advanced practice nurses stated that they were in a constant battle to be recognised professionally by their colleagues and patients [ 8 , 9 , 23 , 25 , 26 , 28 , 30 – 32 , 34 , 35 ]. Another study reported that this was also true in relation to other, less qualified, nursing staff [ 35 ]. While advanced practice nurses appreciated training opportunities, they struggled to maintain a caseload that was commensurate with their training [ 31 ].

Patients, particularly those who viewed their condition as serious, were reluctant to allow an advanced practice nurse to have a prominent role in their care [ 8 ]. In two studies, patients viewed the advanced practice nurse as more available than the GP in terms of appointment times, interaction style and spatial positioning within the general practice [ 23 , 33 ]. While mindful of the need to maintain accessibility, many advanced practice nurses wanted to be accommodated within the general practice in a similar way to the GP, viewing this as a public display of their increased stature within the general practice [ 15 , 22 , 27 , 28 , 31 , 32 , 34 , 37 ].

Establishing and maintaining confidence in the advanced practice nurse

The findings showed that advanced practice nurses gained confidence from participation in further training and this assurance was noticeable to colleagues and clients. However, we found that professional development played virtually no part in solidifying the role of the advanced practice nurse within general practices. NPs and DNEs who, by the nature of their position, had more education than other nurses in the practice, believed that the path to recognisable status was increasingly independent practice. They resented PNs being given extended duties after they had completed a relatively small amount of training that was mostly funded by the practice. They also believed that this devalued their on-the-job training and more comprehensive, self-funded education, giving the advanced practice nurses the impression that practice decision makers did not value the nurse’s overall worth to the general practice particularly highly.

We found that there was a tendency for GPs to relinquish duties to advanced practice nurses for reasons other than the skills and abilities of the nurse. This also applied to situations where the GP retained sole responsibility for the task. In many cases, GPs handed over tasks that they had no interest in, did not enjoy performing or took up too much of their consultation time. This created an uneasy tension between GPs and advanced practice nurses because it appeared that GPs were the sole arbiter of what the nurse could or could not do.

We also reported examples where GPs were only happy to handover duties if they were not subsequently called upon by the advanced practice nurse for basic clinical advice, supervision or training. While this could be interpreted that the GP had confidence in the ability of the advanced practice nurse, pragmatically, it meant that tasks of lower clinical importance were delegated. The result of this custom was that advanced practice nurses became unsure of what they were supposed to doing and hesitant to assume additional responsibility when it was offered. Advanced practice nurses were also inclined to default to tasks such as patient flow in the absence of other meaningful work. While important to the day-to-day running of the practice, this task could have been delegated to more junior nurses or indeed reception staff.

Our findings showed that advanced practice nurses were not automatically bestowed with the level of trust that their skills and abilities demanded. It appeared that colleagues either side of the advanced practice nurse, were better placed in this way because they held positions and performed duties that were more easily recognised and understood by patients. To gain respect from GPs, advanced practice nurses felt that they had to display skills that were more medically oriented, however, these skills were not accepted by their less qualified nursing colleagues who themselves felt undervalued and overworked. NPs, who had statutory and nominal advantage over their advanced practice nursing counterparts, still prioritised the nursing component of their practice and were dismayed when their consultations were time restricted.

We found that the concept of accountability was used by both GPs and patients to justify an unwillingness to increase the responsibility of advanced practice nurses. Interestingly, we found that patients, nurses and doctors agreed that the GP was ultimately responsible for a patient’s care in the general practice. While this view could appear to be reasonably justified, today’s healthcare environment demands that every person charged with the care of patients is ultimately answerable for their own practice. Assumptions by GPs that they are responsible for everything that transpires within the practice are, therefore, dangerous because they may give colleagues the (wrong) impression that they are somehow absolved from any culpability deriving from their own care decisions. If patients also expect GPs to retain final say over their care, the advanced practice nurse is, in effect, performing a function that has little relevance. This situation has the potential to create environments where there is a reliance on standing orders and protocols, which only diminishes opportunities for independent practice by advanced practice nurses.

Referral practice was another area of our findings which further exposed the tenuous position of advanced practice nurses in general practice. This traditional view of peer-to-peer referrals is supported by time honoured practices such as referral letters written in standardised, long winded formats that act to exclude newcomers to the arena who do not have a solid grasp of the nuances involved. Given that some GPs also resented advanced practice nurses making diagnoses, it is possible that the pushback from specialists was a means of preserving the last bastion of a closed fraternity.

Strengthening and weakening boundaries between general practitioners and advanced practice nurses

We found that clarification was both a means of strengthening and weakening boundaries between GPs and advanced practice nurses. In practices where there was a mature relationship between the two, clarification was an empowering force that kept communication channels open and provided opportunities for wider consultation about matters central to the running of the practice. However, other associations were not so productive. In these relationships, advanced practice nurses used clarification as a means of rebuilding their own confidence. This only resulted in trivialising the duties of the advanced practice nurse to the extent that they had to be formalised in a more detailed way with protocols.

Establishing and maintaining the value of advanced practice nursing

An unexpected finding was the dialectic verbalised by GPs concerning the value of their consultation time versus the recovery of costs incurred through the provision of an advanced practice nurse. We found that on the one hand, GPs were happy to hand over some of the more time-consuming responsibilities of care to nurses to see more patients themselves and, presumably, bring more money into the practice. However, there was a limit to this pattern because nurses are, in the main, salaried from the total earnings of a general practice and recover very little in the way of rebates for their services. This balancing act placed the advanced practice nurse at a considerable disadvantage when compared to a revenue earning GP in terms of justifying their position in the long term. No other studies have identified this tension.

Legitimacy of advanced practice nursing in general practice

It is clear from our study, that advanced practice nursing does not have a legitimate foothold in general practice. We found that despite patients, nurses and doctors being able to articulate problems concerning confidence, boundaries and value, there had been scant progress towards organising this niche of practice in any sustainable way. Critical theorists such as Willis [ 38 ] would claim that this maelstrom is subtly encouraged by the medical profession as a means of asserting and supporting their dominance in the general practice sphere. However, we argue that the uncertainty surrounding advanced practice nursing in general practice is the result of a complex set of related factors that have sabotaged attempts to gain professional recognition for over a decade.

Implications

Our findings demonstrate that given recent pressures to lower healthcare costs, any attempt to reposition advanced practice nursing as a viable adjunct to medical care will be met with hesitancy by patients and GPs alike. The risk with this paralysis is that without imminent clarification, advanced practice nurses in general practice may be unprepared to accept increasing responsibility as the healthcare burden increases over the next few decades.

Limitations

We limited this review to qualitative literature to gain a deeper sense of the experiences of advanced practice nursing in general practice. However, many of the included studies did not report participant quotes within the results section of their papers and we, therefore, had to rely on interpretive data for our synthesis. We argue, however, that this does not diminish the ability to generalise our results because all the included studies were subjected to rigorous methodological peer review prior to publication and met our own critical appraisal standards.

We set out to describe experiences of advanced practice nursing in general practice. We discovered that general practitioners and patients continue to have concerns around responsibility, trust and accountability. Additionally, advanced practice nurses struggle to negotiate and clarify scopes of practice while general practitioners have trouble justifying the costs associated with advanced practice nursing roles. The qualitative literature around advanced practice nursing has shown that this form of nursing has yet to establish sustainable legitimacy in general practice. Given the similarities between this and broader healthcare contexts, we argue that our findings have implications for efforts to solidify advanced practice nursing outside of general practice.

Abbreviations

Cumulative Index to Nursing and Allied Health Literature

Diabetic Nurse Educator

Diabetic Nurse Specialist

A reference management software package

General practitioner

Medical Literature Analysis and Retrieval System Online

Medical Subject Heading

Nurse Practitioner

A qualitative data analysis computer software package

A free search engine accessing the MEDLINE database

Type 2 Diabetes Mellitus

Dowling M, Beauchesne M, Farrelly F, Murphy K. Advanced practice nursing: a concept analysis. Int J Nurs Pract. 2013;19:131–40.

Article   PubMed   Google Scholar  

Por J. A critical engagement with the concept of advanced nursing practice. J Nurs Manag. 2008;16:84–90.

Gardner G, Chang A, Duffield C. Making nursing work: breaking through the role confusion of advanced practice nursing. J Adv Nurs. 2006;57(4):382–91.

Article   Google Scholar  

Gardner G, Duffield C. Defining advanced practice nursing. Aust Nurs Midwifery J. 2013;21(6):7.

Google Scholar  

Roche M, Duffield C, Wise S, Baldwin R, Fry M, Solman A. Domains of practice and Advanced Practice Nursing in Australia. Nurs Health Sci. 2013;15:497–503.

Jokiniemi K, Haatainen K. Advanced nursing roles: a systematic review. Nurs Health Sci. 2012;14:421–31.

Stasa H, Cashin A, Buckley T, Donoghue J. Advancing advanced practice - Clarifying the conceptual confusion. Nurse Educ Today. 2014;34:356–61.

Mahomed R, St John W, Patterson E. Understanding the process of patient satisfaction with nurse-led chronic disease management in general practice. J Adv Nurs. 2012;68(11):2538–49.

Furler J, Blackberry I, Walker C, Manski-Nankervis J, Anderson J, O’Neal D, Young D, Best J. Stepping up: a nurse-led model of care for insulin initiation for people with type 2 diabetes. Fam Pract. 2014;31(3):349–56.

McKinlay E, Garrett S, McBain L, Dowell T, Collings S, Stanley J. New Zealand general practice nurses’ roles in mental health care. Int Nurs Rev. 2011;58(2):225–33.

Article   CAS   PubMed   Google Scholar  

McInnes S, Peters K, Bonney A, Halcomb E. An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. J Adv Nurs. 2015;71(9):1973–85.

Merrick E, Fry M, Duffield C, Stasa H. Trust and decision-making: How nurses in Australian general practice negotiate role limitations. Collegian (Royal College of Nursing, Australia). 2015;22(2):225–32.

Hamirudin A, Charlton K, Walton K, Bonney A, Potter J, Milosavljevic M, Hodgkins A, Albert G, Ghosh A, Dalley A. Feasibility of implementing routine nutritional screening for older adults in Australian general practices: a mixed-methods study. BMC Fam Pract. 2014;15:1–9.

Lorch R, Hocking J, Guy R, Vaisey A, Wood A, Lewis D, Temple-Smith M. Practice nurse chlamydia testing in Australian general practice: a qualitative study of benefits, barriers and facilitators. BMC Fam Pract. 2015;16:36.

Article   PubMed   PubMed Central   Google Scholar  

Speed S, Luker K. Getting a visit: how district nurses and general practitioners ‘organise’ each other in primary care. Sociol Health Illn. 2006;28(7):883–902.

PubMed   Google Scholar  

Breen A, Carr E, Mann E, Crossen-White H. Acute back pain management in primary care: a qualitative pilot study of the feasibility of a nurse-led service in general practice. J Nurs Manag. 2004;12(3):201–9.

Infante F, Proudfoot J, Powell Davies G, Bubner T, Holton C, Beilby J, Harris M. How people with chronic illnesses view their care in general practice: a qualitative study. Med J Aust. 2004;181(2):70–3.

Wiles R. Empowering practice nurses in the follow-up of patients with established heart disease: lessons from patients’ experiences. J Adv Nurs. 1997;26(4):729–35.

Bettany-Saltikov J. How to do a systematic literature review in nursing: a step-by-step guide. London: McGraw-Hill Education; 2012.

Critical Appraisal Skills Programme (CASP). Checklist for qualitative studies. http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf . Accessed 25 July 2016.

Charmaz K. Constructing grounded theory. 2nd ed. London: Sage Publications; 2014.

Blackburn M, Stathi A, Keogh E, Eccleston C. Raising the topic of weight in general practice: perspectives of GPs and primary care nurses. BMJ Open. 2015;5(8):e008546.

Oandasan I, Hammond M, Conn L, Callahan S, Gallinaro A, Moaveni A. Family practice registered nurses: the time has come. Can Fam Physician. 2010;56(10):e375–82.

PubMed   PubMed Central   Google Scholar  

McKenna L, Halcomb E, Lane R, Zwar N. An investigation of barriers and enablers to advanced nursing roles in Australian general practice. Collegian (Royal College of Nursing, Australia). 2015;22:183–9.

Mills J, Chamberlain-Salaun J, Christie L, Kingston M, Gorman E, Harvey C. Australian nurses in general practice, enabling the provision of cervical screening and well women’s health care services: a qualitative study. BMC Nurs. 2012;11(1):23–30.

Johnson M, Goyder E. Changing roles, changing responsibilities and changing relationships: an exploration of the impact of a new model for delivering integrated diabetes care in general practice. Qual Prim Care. 2005;13(2):85–90.

Walsh A, Moore A, Barber A, Opsteen J. Educational role of nurse practitioners in a family practice centre: perspectives of learners and nurses. Can Fam Physician. 2014;60(6):e316–21.

Price A, Williams A. Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice. J Interprof Care. 2003;17(3):239–50.

Mitchell J, Brown J, Smith C. Interprofessional education: a nurse practitioner impacts family medicine residents’ smoking cessation counselling experiences. J Interprof Care. 2009;23(4):401–9.

Main R, Dunn N, Kendall K. Crossing professional boundaries’: barriers to the integration of nurse practitioners in primary care. Educ Prim Care. 2007;18(4):480–7.

Sunaert P, Willems S, Feyen L, Bastiaens H, De Maeseneer J, Jenkins L, Nobels F, Samyn E, Vandekerckhove M, Wens J, et al. Engaging GPs in insulin therapy initiation: a qualitative study evaluating a support program in the Belgian context. BMC Fam Pract. 2014;15:1–9.

Ehrlich C, Kendall E, St John W. How does care coordination provided by registered nurses “fit” within the organisational processes and professional relationships in the general practice context? Collegian (Royal College of Nursing, Australia). 2013;20(3):127–35.

Eley E, Patterson E, Young J, Fahey P, Del Mar C, Hegney D, Synnott R, Mahomed R, Baker P, Scuffham P. Outcomes and opportunities: a nurse-led model of chronic disease management in Australian general practice. Aust J Prim Health. 2013;19:150–8.

Ehrlich C, Kendall E, Muenchberger H. Spanning boundaries and creating strong patient relationships to coordinate care are strategies used by experienced chronic condition care coordinators. Contemp Nurse. 2012;42(1):67–75.

Manski-Nankervis J, Furler J, Blackberry I, Young D, O’Neal D, Patterson E. Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory. BMC Fam Pract. 2014;15:1–10.

Furler J, Spitzer O, Young D, Best J. Insulin in general practice - barriers and enablers for timely initiation. Aust Fam Physician. 2011;40(8):617–21.

Phillips C, Dwan K, Pearce C, Hall S, Porritt J, Yates R, Sibbald B. Time to talk, time to see: changing microeconomies of professional practice among nurses and doctors in Australian general practice. Contemp Nurse. 2007;26(1):136–44.

Willis E. Medical dominance. St Leonards: Allen & Unwin; 1989. Revised edn.

Download references

Acknowledgements

The first author was supported by an Australian Government Research Training Program Scholarship.

Availability of data and materials

Relevant EndNote TM libraries and NVivo TM coding files can be obtained from the first author.

Authors’ contributions

MJ conceived the study. MJ performed the data search and retrieval. All authors participated in the critical appraisal process. MJ drafted the manuscript. DW and GS revised the manuscript for content and structure. MJ performed the final edit of the manuscript. All authors have read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Author information, authors and affiliations.

School of Health Sciences, University of Tasmania, 1 Leichhardt Street, Darlinghurst, NSW, 2010, Australia

Michael Jakimowicz

School of Health Sciences, University of Tasmania, Private Bag 135, Hobart, TAS, 7001, Australia

Danielle Williams

School of Health Sciences, University of Tasmania, Locked Bag 5052, Alexandria, NSW, 2015, Australia

Grazyna Stankiewicz

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Michael Jakimowicz .

Additional files

Additional file 1:.

Search strategies. Description of data: Detailed search strategies for PubMED and CINAHL. (DOCX 36 kb)

Additional file 2:

Modified critical appraisal tool. Description of data: Critical appraisal form based on the CASP Checklist for Qualitative Studies. (DOCX 21 kb)

Additional file 3:

Critical appraisal of included studies. Description of data: A consolidated document detailing the results of critical appraisal for included studies. (DOCX 70 kb)

Additional file 4:

Critical appraisal of excluded studies. Description of data: A consolidated document detailing the results of critical appraisal for excluded studies. (DOCX 80 kb)

Additional file 5

List of studies contributing to each code and sub-theme. Description of data: A table listing the studies that contributed to each code and sub-theme. (DOCX 20 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Jakimowicz, M., Williams, D. & Stankiewicz, G. A systematic review of experiences of advanced practice nursing in general practice. BMC Nurs 16 , 6 (2017). https://doi.org/10.1186/s12912-016-0198-7

Download citation

Received : 30 September 2016

Accepted : 27 December 2016

Published : 18 January 2017

DOI : https://doi.org/10.1186/s12912-016-0198-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Advanced practice
• General practice
• Systematic review
• Qualitative research

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Advanced Practice Nursing

Clark, Angela P. PhD, RN, CNS, FAAN, FAHA

Angela P. Clark is an associate professor of nursing at the University of Texas at Austin and a clinical nurse specialist in cardiopulmonary and diabetes care.

Contact author: [email protected] .

A master's degree lets you choose among four career paths.

Whether they are drawn to caring for children or older adults, working in a primary care practice, or providing emergency or critical care, nurses have many career options. No matter what path is chosen, having clinical experience and additional education are musts for all nurses. Some opt to expand their professional capabilities by becoming an advanced practice nurse (APN).

In the United States, there are four roles for an APN: clinical nurse specialist, NP, certified nurse midwife, and certified registered nurse anesthetist. A master's degree is required for each role, and further education may be necessary. The American Association of Colleges of Nursing recommends that by 2015 all APNs be required to have a doctorate in nursing practice (see www.aacn.nche.edu/DNP/DNPFAQ.htm ), although the nursing profession as a whole hasn't yet embraced this concept; vigorous debate continues.

If you're considering an APN role, it's important that you understand what each position entails. Also see “Your Guide to Certification” on page 32 and online at https://links.lww.com/A600 .

CLINICAL NURSE SPECIALIST

The clinical nurse specialist (CNS) provides advanced nursing care to specialty or subspecialty populations with complex health problems. Employment settings vary. A CNS focuses on improving the quality of care across the organization, as well as strengthening a culture of patient safety.

For example, a CNS may work in a hospital or acute care facility to improve patient outcomes for a particular population, such as critical care or pediatric patients. Another popular setting is a specialty clinic—such as for diabetes, heart failure, or wound care—in which the CNS performs focused patient assessment, patient and family education, and care management. Providing mental health care is another option that combines counseling, medication oversight, and other care that improves patients' lives.

In many states, a CNS is authorized to prescribe medications and other supplies as part of a collaborative practice with physicians.

In the United States most NPs are educated to provide primary care, and they can specialize with populations such as adults, children, or families. They may be employed by hospitals or physician groups. NPs can also work in acute care, sometimes filling a role similar to that of a hospital resident by providing care for a select group of patients during hospitalization. NPs can perform procedures such as lumbar puncture or central line insertion, and they may go on rounds for particular types of acutely ill patients.

CERTIFIED NURSE MIDWIFE

Providing holistic maternal health care, the scope of practice of the certified nurse midwife (CNM) varies by state, but she or he typically works independently to provide care to low-risk patients. In cases of high-risk pregnancy, such as patients with certain chronic diseases or pregnancy-related complications, the CNM may work collaboratively with physicians. CNMs offer prenatal care, delivery in the home or hospital, and postpartum care, all while focusing on family-centered care. They also often provide maternal health care for expectant mothers in underserved populations, which makes their service even more valuable. CNMs' outcomes, which are well documented, demonstrate lower rates of cesarean sections and patient complications, and shorter hospital stays.

CERTIFIED REGISTERED NURSE ANESTHETIST

Often working collaboratively with physician anesthesiologists to improve the care of patients undergoing surgery, certified registered nurse anesthetists (CRNAs) provide care to thousands of patients who receive anesthesia every year. This role has existed for more than 125 years. In rural settings, CRNAs may be the only providers who administer anesthesia, and numerous studies have demonstrated their safe patient outcomes. 1,2 CRNAs today have a strong educational background in both science and practice. Their care has been shown to result in outcomes similar to those of anesthesiologists in decreasing postoperative complications and patient mortality. 2

BECOMING AN APN

If you think you want to expand your career and become an APN, consider the following suggestions as you research the role you are interested in:

• talk with APNs about what they like and don't like about their jobs
• check out a variety of master's degree programs to see if the curricula interests you
• meet with students in the master's degree programs to see what it's like from their perspective
• remain informed about the potential requirement change to a clinical doctorate degree. Obviously, the program of study for a clinical doctorate would be longer and more expensive; however, distance learning programs for completing at least part of the course work are becoming more common.

Most importantly, think about what you want to be doing in, for example, 10 years. Explore the options and follow your dreams. Advanced practice nursing could change your life in unexpected and exciting ways.

Supplemental Digital Content

• CERTIFICATION.pdf; [PDF] (287 KB)
• + Favorites
• View in Gallery

Readers Of this Article Also Read

Considering an advanced degree, artificial intelligence and nursing: promise and precaution, taking charge of your career, kombucha tea: not always a health drink, geriatric nurse practitioner in nursing homes.

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Advanced practice registered nurse roles.

Annie P. Boehning ; Lorelei D. Punsalan .

Affiliations

Last Update: March 1, 2023 .

• Definition/Introduction

The advanced practice registered nurse (APRN) role has existed for over half a century. APRN role has evolved to provide health care needs to different populations and sub-specialties throughout the United States and its territories. APRNs are registered nurses with master’s and/or doctorate degrees with advanced education and training beyond registered nurses. Therefore, they have additional scopes of practice over and above traditional nursing duties.

A call for APRNs to provide health care to the full extent of their education in the 2010 Institute of Medicine Report on the Future of Nursing rapidly accelerated the production of APRNs. The APRN scopes of practice vary between states because of the rules and regulations governed by the board of nursing at the state level. The National Council of State Boards of Nursing identifies a need to align the APRN scopes of practice with increasing practice mobility for the APRNs to fulfill the increase in access to health care by the public. [1]

• Issues of Concern

An APRN is a registered nurse with at least a master's degree in nursing who has completed graduate-level education and training from a nationally accredited program. Training must be based on a specific specialty, such as midwives or anesthesia. It can also be based on a population, such as pediatric or family practice. APRNs must pass a national certification examination that measures the role and specialty-specific or population-focused competencies. Their knowledge and skills are built upon the foundation of nursing to bridge the gap in medical and allied health, providing direct care to patients and focusing on individuals and families. [2]  

These advanced-trained registered nurses are prepared educationally to bear the responsibilities and accountabilities of providing health maintenance and preventive care to the public. License to practice is privileged by the individual state the APRN applies to after receiving a conferred degree from an accredited institution.  

Four APRN roles exist with a license to practice in all US states and territories: 

• Certified registered nurse anesthetist (CRNA)
• Certified nurse-midwife (CNM)
• Clinical nurse specialist (CNS) 
• Certified nurse practitioner (NP)

Traditionally, surgical doctors trained nurses to provide anesthesia care for surgical patients until the establishment of anesthesiology as a medical specialty in the US. [3]  During the Civil War, American surgeons trained nurses to help provide anesthesia care to the thousands wounded in the war. Due to the shortage of anesthetists and the physicians' reluctance to provide anesthetics in remote rural areas, more nurses began to take on this role. [4]  The American Association of Nurse Anesthetists (AANA) was founded in 1931, originally as The National Association for Nurse Anesthetists. [3]  Nurse anesthetists also practiced anesthesia care in both World War I and World War II. [5]

CRNA credentialing came into existence in 1956. [6]  Formal educational programs using simulation, didactics, and full clinical subspecialty rotations are structured to train nurses to provide anesthesia. CRNAs are privileged at the state level to provide anesthesia services, depending on the regulatory stipulation of independent practice or under an anesthesiologist's supervision. Each year, CRNAs have provided anesthesia care to more than 40 million patients in the United States [7] .

The practice of midwifery has existed in many cultures on the continents for millennia. [8]  Traditionally, women were trained to assist in birthing and caring for the babies and mothers through apprenticeship from experienced older midwives. In remote villages, midwives were often the only skilled providers to exist, providing health care services with great emphasis on physical, emotional, mental, and spiritual care. In the 1800s, male physicians took great interest in exploring childbirth processes, with a focus on the physical aspect of the entire pregnancy's wellbeing. By the turn of the 1900s, many doctors opposed midwife-assisted births, promoting the science of pain relief that hospitals could offer. [8]  However, in the Southern states, midwives attended up to 75% of births among the Black communities until the 1940s.

The American Association of Nurse-Midwives (AANM) was founded in 1928, originally known as the Kentucky State Association of Midwives. Certification and credentialing processes began in 1971 after formal educational programs and accreditation were established in the US. [9]  Midwife training focuses on a primary commitment to caring for mothers and babies with ancillary services, including annual woman health exams, nutritional counseling, parenting education, and preventive health care. Currently, CNMs are privileged with licenses to independent practice with prescriptive authority in all 50 US states. [10]

Customarily, nurses were trained to work in hospitals to care for unique populations with various healthcare conditions. With the consistency of day-in and day-out caring for patients with similar medical conditions, this line of work enabled the nurses to develop specialized and advanced skills to provide specific healthcare needs to these unique populations. In 1943, the term nurse-clinician was coined by Frances Reiter,  who acknowledged that nurses comfort, teach, protect, encourage, and nurture patients back to health. [11]  Since then, the National League for Nursing Education began to advocate for advanced nursing training in universities to prepare nurse clinicians to serve patients with empowerment.

Initially, the CNS specialty was started at a graduate level of the nursing training program, responding to the need to care for patients in psychiatric settings. CNS expansion to other healthcare settings grew rapidly during the 1960s to reciprocate the need to care for complex patients, particularly after the Vietnam War. [11]  In 1965, the American Association of Nurses (ANA) proposed in a position statement to allow nurses who received a Master's Degree or higher to claim the role of CNS, emphasizing clinical expertise in selective populations. CNS was not widely adopted to practice with full potential until the 1990s during the health care reform in response to reducing costs and shorter hospital stays. [12]  CNS has been providing health care to patients throughout the US, consistently achieving high-quality, cost-effective outcomes with evidence-based practices. Current CNS certification examinations are based on population-specific: Adult/Gerontology, Pediatrics, and Neonatal through the American Nurses Credentialing Center or the American Association of Critical Care Nurses Certification Corporation. [13]

NP role was started in the 1960s by Dr. Loretta Ford, a nurse, and Dr. Henry Silver, a doctor, with a vision to serve the needs of the poor pediatric population in rural Colorado. The role was a disruptive innovation to bridge between a nurse and a doctor. With a strong belief that nurses can provide high-quality primary care to the ailing populations in the remote countryside, the NP role was created to widen healthcare access to the masses. With advanced training and education, nurses can specialize in a population-specific field of study to provide primary care to patients. Looking back in history, nurses were providing primary care to patients independently and autonomously before the rise in regulated medical practices. [14]

In 1965, a formal educational nursing program was first established at the University of Colorado to train nurses on advanced skills to care for patients outside the hospital setting. During the early years of the NP role, NPs were required to work under a physician's supervision with regulatory stipulations, such as prescriptive authority. As the healthcare landscape evolves, particularly after the implementation of the comprehensive healthcare reform Affordable Care Act in 2010 and the Institute of Medicine Report findings on APRN barriers in 2011, NPs are empowered to deliver health care to the extent of their advanced training. [15]

More and more states in the US are granting NPs full authority in rendering health care services. The American Association of Nurse Practitioners (AANP) provides credentialing certification for the

• Family Nurse Practitioner (FNP),
• Adult-Gerontology Primary Care Nurse Practitioner (AGPNP), and
• Emergency Nurse Practitioner (ENP).

The American Nurses Credentialing Center provides certification examinations for the

• Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP),
• Adult-Gerontology Acute Care Nurse Practitioner (AGACNP), and   
• Psychiatric-Mental Health Nurse Practitioner (PMHNP).

The Pediatric Nursing Certification Board provides certification exams for the

• Certified Pediatric Nurse Practitioner Primary Care (CPNP-PC) and
• Certified Pediatric Nurse Practitioner Acute Care (CPNP-AC).

The National Certification Corporation provides credentialing certification exams for the

• Women's Health Care Nurse Practitioner (WHNP),
• Obstetrics and Gynecology Nurse Practitioner (OB/GYN NP), and
• Neonatal Nurse Practitioner (NNP).

APRNs are registered nurses with many clinical hours of nursing experience prior to the start of graduate school. APRNs are educated and trained on specific core competencies in graduate schools. [16]  Learning domains include knowledge of practice, person-centered care, population health, scholarship for nursing discipline, quality, safety, interprofessional partnerships, system-based practice, informatics, healthcare technologies, professionalism, and leadership. There are also sub-competencies specific to specialties versus populations.

Different APRN roles have different requirements in clinical training hours and competency-based requirements. In addition, some states have specific regulatory requirements on training topics and clinical hours. Besides the training on the specialty-specific and/or population-specific required competencies, advanced educational programs also prepare APRNs for systems thinking and policy advocacy that empower them to promote changes. [17]  Many APRN training programs are moving toward a doctorate level, phasing out the master's level preparation. [18]

APRNs are educated and trained to provide health care utilizing evidence-based practice (EBP). The value and the importance of EBP utilization among APRNs provide guidance for standardizing patient care and ensuring high-quality care at a minimum cost. [19]  EBP guidelines for patient care are the standards in APRN training and practice. This facilitates collaborative efforts among allied health professionals. EBP by APRNs promotes autonomy and professional parameters in providing medical care to patients. 

Many states require APRNs to have protocols approved by a medical director to deliver structural plans of care to a specific patient population or specialty based on the APRNs' training. APRNs are employed in various healthcare systems, including outpatient and inpatient environments. However, 26 states in the US have adopted a full practice authority to allow APRNs to practice to the full extent of their education and training without any medical supervision. [20]  Full practice authority granted to APRNs has improved access to primary care providers in the health professional shortage areas. This privilege has increased APRN ownership of medical practices as approved by state regulations. [21]

APRNs have advanced training and higher education; hence, autonomy is crucial to allow APRNs to provide medical care to the extent of their training. They are licensed and authorized to (1) evaluate patients, (2) diagnose patient problems, (3) order and interpret diagnostic tests, and (4) initiate and manage treatments, including prescribing medications and controlled substances under the licensure authority of a state board of nursing. [22]

APRNs have been recognized widely at the federal and state levels of medical billing practices. [23]  While medical billing and reimbursement is a complex subject, services provided by APRNs are reimbursable at both the state Medicaid and federal Medicare systems. [24]  However, third-party payers tend to follow federal rulings on medical service reimbursements. [25]  APRNs follow the same rules as other clinicians in billing and reimbursement, such as fees for services or the Merit-based Incentive Payment System. However, a major gap in reimbursement exists in APRNs compared to other practicing clinicians. [26]

• Clinical Significance

APRNs play a critical role in providing healthcare access to the public, especially in many rural areas and underserved populations. They utilize their knowledge and skills in nursing to provide holistic plans of care to patients and families, with an emphasis on disease prevention.

APRNs also deliver much-needed healthcare education to laypeople on diverse topics, inclusive of whole-person care. APRNs’ roles are important in the US health care system, continuing to provide increased access and preventive medical care to the public.

• Nursing, Allied Health, and Interprofessional Team Interventions

APRNs are part of the interprofessional team providing health care to patients and families, depending on the area of their training. The majority of APRNs in the US are in primary care as nurse practitioners. [21]  These advanced trained nurses are forefront healthcare providers, expanding healthcare access, especially in the rural and underserved areas, to the American public. They provide much-needed education in preventive care to patients and families to keep them healthy.

All APRNs are privileged with a license to practice, and most have the autonomy and the authority to furnish medications and therapies in direct patient care. All interprofessional healthcare providers should work closely to ensure safe, quality patient care and provide cost-effective treatments. Barriers should be eliminated to allow APRNs to practice to the extent of their education and training to benefit the patient's care and health costs. [27]

• Nursing, Allied Health, and Interprofessional Team Monitoring

The collaboration of APRNs and physicians has been ongoing to provide quality, safe, and cost-effective health care to patients. They are part of the health care team. The addition of APRNs has increased healthcare access to the public. APRNs are registered nurses with advanced education and specialized training to provide health care to patients. They are always malleable to adapt to practice changes and push the boundaries to benefit patients, communities, organizations, systems, society, and humanity.

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

Disclosure: Annie Boehning declares no relevant financial relationships with ineligible companies.

Disclosure: Lorelei Punsalan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Boehning AP, Punsalan LD. Advanced Practice Registered Nurse Roles. [Updated 2023 Mar 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

In this Page

Bulk download.

• Bulk download StatPearls data from FTP

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Similar articles in PubMed

• Review Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses [ 2014] Review Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses McCleery E, Christensen V, Peterson K, Humphrey L, Helfand M. 2014 Sep
• Blueprint for a Palliative Advanced Practice Registered Nurse Fellowship. [J Palliat Med. 2021] Blueprint for a Palliative Advanced Practice Registered Nurse Fellowship. Reville B, Foxwell AM. J Palliat Med. 2021 Sep; 24(10):1436-1442. Epub 2021 Jul 9.
• Operational Readiness: Redesigning Advanced Practice Registered Nurse (APRN) Curriculum for an Evolving Battlefield. [Mil Med. 2019] Operational Readiness: Redesigning Advanced Practice Registered Nurse (APRN) Curriculum for an Evolving Battlefield. D'Angelo MR, Seibert D, Wanzer L, Johnson H, Alguire K, Dillon D, Welder MD, Romano C. Mil Med. 2019 Mar 1; 184(3-4):e156-e162.
• Commentary on Potential Crisis in Nurse Practitioner Preparation in the United States. [Policy Polit Nurs Pract. 2019] Commentary on Potential Crisis in Nurse Practitioner Preparation in the United States. Bellflower B, Likes W. Policy Polit Nurs Pract. 2019 Nov; 20(4):186-187. Epub 2019 Oct 22.
• Review Integrative review of graduate entry programs in nursing. [J Nurs Educ. 2012] Review Integrative review of graduate entry programs in nursing. Pellico LH, Terrill E, White P, Rico J. J Nurs Educ. 2012 Jan; 51(1):29-37. Epub 2011 Nov 30.

Recent Activity

• Advanced Practice Registered Nurse Roles - StatPearls Advanced Practice Registered Nurse Roles - StatPearls

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Policy advocacy and health equity: Implications for advanced practice nurses

Affiliation.

• 1 Janice Phillips is Director of Nursing Research and Health Equity at Rush University Medical Center and Associate Professor at Rush University College of Nursing, both in Chicago, Ill.
• PMID: 36006819
• DOI: 10.1097/01.NPR.0000855316.18930.08

Advanced practice nurses are key partners in achieving health equity and are encouraged to use their advocacy skills and policy acumen in doing so. While conducting social determinants of health screenings and providing referrals are important elements in our quest to achieve health equity, meaningful advancements in this area are dependent on the enactment of public policies that yield equitable solutions.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

PubMed Disclaimer

Similar articles

• Defining the social determinants of health for nursing action to achieve health equity: A consensus paper from the American Academy of Nursing. Kuehnert P, Fawcett J, DePriest K, Chinn P, Cousin L, Ervin N, Flanagan J, Fry-Bowers E, Killion C, Maliski S, Maughan ED, Meade C, Murray T, Schenk B, Waite R. Kuehnert P, et al. Nurs Outlook. 2022 Jan-Feb;70(1):10-27. doi: 10.1016/j.outlook.2021.08.003. Epub 2021 Oct 8. Nurs Outlook. 2022. PMID: 34629190
• A policy pathway: Nursing's role in advancing diversity and health equity. Nickitas DM, Emmons KR, Ackerman-Barger K. Nickitas DM, et al. Nurs Outlook. 2022 Nov-Dec;70(6 Suppl 1):S38-S47. doi: 10.1016/j.outlook.2022.03.013. Nurs Outlook. 2022. PMID: 36446539
• Advocacy for health equity: a synthesis review. Farrer L, Marinetti C, Cavaco YK, Costongs C. Farrer L, et al. Milbank Q. 2015 Jun;93(2):392-437. doi: 10.1111/1468-0009.12112. Milbank Q. 2015. PMID: 26044634 Free PMC article. Review.
• Examining Whether The Health-In-All-Policies Approach Promotes Health Equity. Hall RL, Jacobson PD. Hall RL, et al. Health Aff (Millwood). 2018 Mar;37(3):364-370. doi: 10.1377/hlthaff.2017.1292. Health Aff (Millwood). 2018. PMID: 29505382
• Addressing Health Equity Through Action on the Social Determinants of Health: A Global Review of Policy Outcome Evaluation Methods. Lee J, Schram A, Riley E, Harris P, Baum F, Fisher M, Freeman T, Friel S. Lee J, et al. Int J Health Policy Manag. 2018 Jul 1;7(7):581-592. doi: 10.15171/ijhpm.2018.04. Int J Health Policy Manag. 2018. PMID: 29996578 Free PMC article. Review.
• Joynt Maddox KE, James CV. How the Biden Administration can improve health equity for racial and ethnic minority populations. JAMA . 2021;325(14):1387–1388. doi:10.1001/jama.2021.3046.
• Robert Wood Johnson Foundation. What is health equity? www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html .
• U.S. Department of Health and Human Services. Healthy People 2020: Disparities. www.healthypeople.gov/2020/about/foundation-health-measures/Disparities .
• U.S. Department of Health and Human Services. Healthy People 2030: Social Determinants of Health. https://health.gov/healthypeople/objectives-and-data/social-determinants... .
• The University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps, 2021. www.countyhealthrankings.org
• Search in MeSH

LinkOut - more resources

Full text sources.

• Ovid Technologies, Inc.
• Wolters Kluwer

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.