This paper surveys the historical development and current scope of advanced practice nursing roles in the United States. It examines four principal roles—nurse practitioner (NP), nurse educator, nurse informaticist, and nurse administrator—describing their distinct functions, required competencies, and contributions to healthcare quality. The paper also addresses the regulatory landscape for NPs in New Jersey, relevant professional organizations, and the leadership attributes associated with participatory leadership. A concluding health-policy section applies these concepts to the childhood obesity epidemic, reviewing current policy, key stakeholders, and the potential impact of evidence-based interventions on healthcare outcomes.
The starting point of all current-day nursing practice is the registered nurse. The standards and policies governing education and legal regulations for attaining a basic first-level nursing credential were not always fixed — and, for that matter, there were not always professional nurses at all.
Specialist nurses can be considered the primary product of nursing's professional evolution. The foundation of today's advanced nurses was established with the advent of specialist nurses in America. They were recognized in practice from the latter part of the 19th century, and by the 1930s and 1940s the number of specialist nurses in the United States had grown substantially. Clinical nurse specialists (CNSs) have been strongly recognized in the field of nursing since the 1960s. The clinical activities of these nurse specialists were usually considered to fall within conventional nursing practice domains, though their expertise was typically extended beyond those boundaries. As a result, CNSs were not regarded as posing any particular threat to the conventional arrangement of the broader healthcare system. More recently, CNSs have become intimately and commonly linked with advanced nursing concepts, a connection that reflects the significant overall growth of advanced nursing (Development of Advanced Nursing Roles, 2012).
Contrary to the relatively gradual evolution of specialist nurses, research scholars initiated the role and concept of nurse practitioner in tandem with the launch of a new pediatric primary healthcare role in 1965 in the United States. The role was built upon the extensive functional capabilities of specialist nurses, but also incorporated conventional therapeutic and diagnostic skills. Researchers note that the necessity for this change arose from practical issues as well as social concerns of the era, including a shortage of pediatricians. Initially, there may have been some concern about the potential repercussions of transcending former professional limits on nursing practice's scope. This was particularly significant during a period when nurses were achieving greater autonomy and moving away from the long-established dominance of medical authority (Development of Advanced Nursing Roles, 2012).
Many other important professional developments in the 1990s and in the early part of the following decade contributed to the future of advanced nursing. These included the government's establishment of consultant nurse roles and the introduction of legislation for non-medical prescribing. Growth during the 1990s contributed in varied and significant ways to the development of advanced nursing (Development of Advanced Nursing Roles, 2012).
One set of definitions describes the nurse practitioner (NP) as a particular type of registered nurse who performs "advanced practice." Generally speaking, NPs are highly educated, holding at least a bachelor's degree in addition to their registered nurse license. They also possess clinical experience and additional education that varies depending on the particular state where they choose to practice. The functional role of the NP is broadly analogous to that of a physician, and generally includes the ability to prescribe pharmaceuticals and order laboratory tests as needed.
Studies indicate that NPs, along with other healthcare providers, are trained to deliver several primary care functions. They may therefore be capable of facilitating increased access to primary healthcare, especially in underserved localities. The term Advanced Practice Registered Nurse (APRN) denotes nurses who, through graduate-level education, have acquired advanced clinical skills and knowledge enabling them to provide direct medical care to patients. APRNs are trained through graduate and postgraduate courses in pharmacology, advanced health assessment, physiology, and other medical sub-disciplines.
NPs constitute the largest cluster of APRNs and practice across various population-focused areas, including family practice, women's health, geriatrics, and pediatrics. They are the most commonly found non-physician providers of primary health care and offer comprehensive services that include disease prevention, counseling, and health promotion. National licensing boards dictate the full range of services NPs may perform, such as hospital admissions, prescribing medications, and diagnosing patient ailments. Individual hospitals and Medicaid agencies can further expand the activities permitted for NPs. Half of U.S. states allow NPs to practice largely independent of supervising physicians, including diagnosis, treatment, and patient referral; however, in some instances significant limitations are imposed on the scope of services NPs are permitted to provide. Laws governing NP licensure, regulations, and certifications pertaining to practice limits differ widely by state and are often less broad than the full extent of APRN training (Schiff, 2010).
Effective clinical training is characterized by specific traits: the ability to act with professional objectivity, genuine enjoyment of clinical teaching, the use of metacognition, and the capacity to serve as both a role model and a source of support. Important personal characteristics include a genuine affinity for the nursing profession, reflective thinking, and empathy. Valued metacognitive traits include knowledge of the curriculum and the clinical environment. Clinical learning can be enriched by putting theory into practice, applying clinical reasoning, and adopting a patient-centered approach to training. Clinical educators are regarded as support providers, particularly when drawing on professional and interpersonal competencies and when building relationships with both staff and students in the clinical setting. The traits of role modeling comprise consistency between words and actions, as well as clinical competency. A professional approach to nursing education has been identified as the central foundation of research in this area (Dahlke et al., 2012).
Nursing informatics emerged over the last two decades to help nurses fully employ information technology for improving healthcare delivery (TIGER Informatics Competencies Collaborative, 2007). Nursing informatics is a specialty that integrates information science, computer science, and nursing science to communicate and manage data, knowledge, and information in nursing practice. The basis of this specialty lies in the concepts of data, knowledge, and information. Data refers to discrete observations that are structured, interpreted, or organized. Information, by contrast, is data that has been structured, interpreted, or organized to acquire meaning — examples include age, weight, disease status, blood pressure, and frequency of home visits. The purpose and potential of nursing informatics lie in supporting and improving individual and community healthcare by collecting, managing, and communicating information about and for patients. Nursing informatics can help make the contribution of nursing visible in medical records, and can support nurses by delivering tools for clinical decision support (Daniel & Oyetunde, 2013).
The goal of nursing informatics is to improve the health of individuals, families, communities, and populations through the optimization of information management and communication. This encompasses the use of technology and information in direct healthcare provision, in the establishment of efficient administrative systems, in the delivery and management of educational experiences, in supporting nursing research, and in facilitating lifelong learning (Daniel & Oyetunde, 2013).
International literature provides supportive evidence that healthcare services benefit when recognized nurse executives are positioned within the leadership structure for the governance of professional nursing. Benefits to healthcare organizations are directly realized through higher quality and standards of care, better patient health outcomes, and positive consumer experience. As the largest workforce in healthcare, nurses and midwives have a considerable impact on the optimization of healthcare service productivity and on efficient patient health outcomes. Executive nurses supervise and lead nursing personnel through professional governance standards to deliver the quality of healthcare and experience the public expects. Nurse executives can create a compelling vision for specialized nursing and midwifery practice through organizational and workforce development, business planning, and strategic thinking — all aimed at delivering safe, reliable healthcare and driving service improvement by engaging the nursing and midwifery workforce. More broadly, executive nurses are capable of creating and leading clinical practice and influencing levels of excellence and innovation at every stage of a healthcare organization (Hughes, 2013).
Nurse executives contribute significantly to ensuring that a professional leader with evident authority is present, accessible, and able to serve as an advocate for nurses and midwives at the board and executive levels of a healthcare service organization. They can balance executive decision-making with the delivery of cohesive consumer healthcare, and can meet primary health service goals related to resource investment and financial integrity. Additionally, nurse executives are capable of driving a system-wide approach to supporting consumer healthcare through strategic monitoring and the maintenance of effective and efficient nursing and midwifery care, while simultaneously supporting the development and application of organizational plans for achieving key service performance targets (Hughes, 2013).
New Jersey State's legal requirements for nursing practice are as follows: the practitioner must be at least 18 years of age, must be of good moral character, and must possess evidence of a current Registered Nurse (RN) license in good standing. The nurse must be registered as a professional nurse, having successfully completed an academic program that includes pharmacology and carries board approval. The applicant must also have passed a written examination approved by the board (State Reg., n.d.).
Professional registered nurses are required to renew their RN licenses once every two years. There are no continuing education requirements specified in New Jersey's nursing regulations or statutes (Systems, 2001).
The New Jersey State Nurses Association (NJSNA) advances the welfare of the state's approximately 110,000 RNs, promotes the nursing profession, and advocates on behalf of consumers and nurses. The NJSNA works in collaboration with fifty-three territorial and state organizations and with the American Nurses Association (ANA), its parent organization, to represent the 2.6 million registered nurses across the United States (NJSNA, 2015).
The Eastern Nursing Research Society (ENRS), a research division of the New England Organization for Nursing (NEON) and the Mid-Atlantic Regional Nursing Association (MARNA), covers the states of Connecticut, Maine, Delaware, Massachusetts, New York, New Jersey, Pennsylvania, New Hampshire, Vermont, Rhode Island, and Washington, D.C. (Nurse Together, 2015).
"NJ licensing requirements, organizations, and NP competencies"
"Participatory leadership skills and professional development"
"Policy strategies for reducing childhood obesity rates"
Nursing may be described from a variety of perspectives: as a role, as a practice level, as being generalist or specialist in nature, and as an area of scope encompassing educational, clinical, research, and managerial skills. In the future, these dimensions must increasingly be viewed through the lens of advanced nursing roles, albeit with distinct and evolving features. The present reality of nursing practice has shifted advanced nursing beyond purely clinical domains and into a broader field where it carries greater overall significance for the profession (Development of Advanced Nursing Roles, 2012).
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