¶ … Advanced Practice Nursing Framework Following its introduction during the 1960s, the role of the advanced practice nurse (hereinafter alternatively "APN") has expanded greatly into a number of specialty areas (Nwosuocha, 1999). Consequently, the definition of the advanced practice nurse has also experienced significant changes. According to Nwosuocha, "With the expanded roles of advanced practice nursing there are many definitions of what constitute faculty practice. Teaching, service, joint appointments and other forms of practice are included in this definition" (1999, p. 62). Although specific definitions vary, Lachman (2006) reports that, "Nurses with advanced training are licensed, registered nurses with a master's degree who have received specialty credentialing as an advanced practice nurse" (pp. 78-79).

The titles assigned to the advanced practice nursing role also vary from jurisdiction to jurisdiction, but include general terms such as clinical nurse specialist and nurse practitioner, with specialty fields of practice including adult psychiatric clinical nurse specialist, family nurse practitioner, psychiatric mental health nurse practitioner and adult nurse practitioner (Mccabe & Burman, 2006). A useful definition recently provided by McFarland and Eipperle (2008) states that, "Advanced practice nursing, is the application of an expanded range of practical, theoretical, and research-based therapeutics to phenomena experienced by [clients] within a specialized clinical area of the larger discipline of nursing" (2008, p. 48). These authors add an additional qualification that "The core competency of each role is direct clinical practice and that a nurse practitioner is therefore an advanced practice nurse" (McFarland & Eipperle, 2008, p. 48). The American Academy of Nurse Practitioners provides the following information concerning the historical foundation and current status of advanced practice nurses in the United States:

1. Advanced practice nurses provide high-quality healthcare services similar to those of a physician. APNs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, APNs focus on health promotion, disease prevention, health education and counseling. They help patients make wise health and lifestyle choices.

2. With respect to nurse practitioners per se, the first NPs were educated at the University of Colorado in 1965. Programs soon spread across the U.S. As of 2011, there are about 140,000 practicing NPs. Close to 9,000 new NPs are prepared each year at over 325 colleges and universities.

3. NPs have graduate, advanced education and clinical training beyond their registered nurse preparation. Most have master's degrees and many have doctorates.

4. NPs are licensed in all states and the District of Columbia. They practice under the rules and regulations of the state in which they are licensed. Most NPs are nationally certified in their specialty area and are recognized as expert healthcare providers. The faith that patients have in NPs is shown by the almost 600 million visits made to NPs each year (Why choose a nurse practitioner as your healthcare provider?, 2011, p. 1).

Not surprisingly, the expanded role of the advanced practice nurse has allowed these healthcare professionals to make significant contributions to a wider range of patents, including prescriptive authority in many states (Hales, 2002). According to Hales, "Historically in the United States, advanced practice nurses with prescriptive privileges have been nurse practitioners, nurse midwives, and nurse anesthetists. Today, however, clinical nurse specialists have expanded their scope of practice to be eligible for prescriptive privileges that correspond to their clinical expertise" (2002, p. 80). Advanced practice nurses in psychiatric settings are becoming particularly active in the expanded prescribing role (Hales, 2002).

The author's personal philosophy of nursing is loosely based on the tenets of Jean Watson's theory of caring because the holistic approach to the provision of healthcare is a rationale model that can be applied to a wide range of specialties (Perkins, 2004). As Watson emphasizes, "Such a model of caring emerges from nursing and its timeless values and worldview, which guide caring practices to all the people, all the time, transcending differences, whether they be biological, physical, economic, geographic, religious, political, or social" (2008, p. 55). The "whole person perspective" advocated by Watson includes significant cross-cultural issues that must be taken into account when formulating effective treatment protocols (McFarland & Eipperle, 2008). These steps include the following:

1. Framing knowledge and predicting similarities and differences among and between cultures;

2. Providing a means to learn and gather care information about cultures essential for holistic assessment and sound nursing conclusions;

3. Discovery of caring and healing values, beliefs, and practices used by individuals, families, groups;

4. Collaboratively using ethical reasoning, analysis, skill, and decision making relevant to culture;

5. Evaluation through reflective and...

Establishing and maintaining a system of caring and healing system which is essential for holistic assessment, sound nursing conclusions, and appropriate and integrated care (McFarland & Eipperle, 2008, p. 49).
Other aspects of Watson's model are also appealing for personal reasons, such as the combination of caring with conventional allopathic medical interventions. In this regard, Glazer (2000) emphasizes that, "The nursing profession has taken two very different roads to the goal of separate and equal professional status. The first road is the 'Caring plus Science' path. Nurse advocates have argued that 'caring,' rather than curing, is a highly beneficial characteristic of nursing that is often missing from the cold, increasingly technological world of modern Western medicine" (p. 3). Therefore, using the powerful potential for caring combined with modern medicine, the advanced practice nurse is in an excellent position to promote positive clinical outcomes in ways that may not be otherwise achievable.

Conceptual Model

Just as definitions of the advanced practice nursing profession vary, so too do the conceptualizations of their precise role within the larger healthcare environment. Notwithstanding these different perspectives, there are some general commonalities that characterize the profession that can help conceptualize this role. For instance, McCabe and Burman report that, "Advanced practice nurses have become increasingly visible and important providers in America's changing and often unpredictable healthcare system. Evidence exists establishing both the quality and cost-effectiveness of the advanced practice nurse role in meeting the needs of patients" (2006, p. 3).

This expanded role has been met with a concomitant increase in the acceptance and satisfaction of the advanced practice nurse by healthcare consumers (McCabe & Burman, 2006). As a result of this increased acceptance and satisfaction, the role of the advanced practice nurse has expanded into a much wider range of specialty areas of practice (McCabe & Burman, 2006). As Mccabe and Burman point out, though, "Despite the almost meteoric rise in the advanced practice nurse role, the significant increase in students applying to APN programs, and the increased rate of specialization, the APN role development has been haphazard, often externally mediated by changes in healthcare delivery models, and has led to confusion regarding the actual behaviors performed by any given APN" (2006, p. 4).

Despite this confusion concerning the precise services provided by a given advanced practice nursing professional, there are some broad areas that are expected to influence the advanced practice nursing profession in the near future, including the following:

1. Growing competition from other health care providers;

2. A need for demonstrated added value of advanced nursing practice;

3. Changing sites for health care education and practice from acute care to community sites; and,

4. A need for standardizing APN practice and education across states (Beitz & Kost, 2006).

Taken together, these issues and themes can be conceptualized as illustrated in Figure 1 below.

Figure 1. Conceptual schematic of advanced practice nurse's position in the healthcare spectrum

The selection of these primary components is congruent with a number of researchers who emphasize that the recipient of care, goals of are and the environment in which healthcare services are provided as common features of many advanced practice nurse positions today (Levin & Feldman, 2006). For instance, the Academy of Nurse Practitioners emphasizes that, "The role of the nurse practitioner continues to evolve in response to societal and health care needs. As leaders in primary and acute health care, nurse practitioners combine the roles of provider, mentor, educator, researcher, and administrator" (Scope of practice for nursing practitioners, 2010, p. 1). While some advanced practice nurses may specialize in one or more of these capacities, others may be required to function is all of them according to their healthcare setting involved (Scope of practice for nursing practitioners, 2010). Clearly, in their capacity as expert clinicians, advanced practice nurses are on the front-lines of healthcare delivery, but their role frequently includes serving as an educator, researcher and consultant as well, and these issues are discussed further below.

Job Description

Although it is reasonable to suggest that specific job description will differ from healthcare setting to healthcare setting, the general job descriptions provided for four of the main areas of practice, expert clinician, educator, researcher, and consultant, can be operationalized as indicated in Table 1 below.

Table 1

Job description for advanced…