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Role delineation study of advanced practice nursing, a cross-sectional study of practice domains and trends in role functions


Sonia Sevilla Guerra ,

Adelaida Zabalegui


Introduction: The expansion of professional roles has been probed as an innovative solution across some countries in order to help address healthcare integration, coordination, continuity, access and health care sustainability. The development and implementation of different roles in Advanced practice Nursing (APN) has been considered one of those innovations in pioneering healthcare system reforms. The need for nurses to take a leadership role in all settings has been a necessary step to meet the demands of our changing health care system and to contribute to address objectives and sustainable development goals set by different international strategies on human resources for health. However, considerable confusion exists within the international nursing profession about the terminology used to describe these new APNs roles, their role function and their scope of practice. This ambiguity in nomenclature and role definition could lead to difficulties in the introduction and identification of new roles and is often associated with negative staff, patient and organizational outcomes. In Spain, some expert nurses have evolved and adapted to international standards without the official acknowledgment in professional and academic terms that other countries have. The evolution of these expert nurses shares the confusion with the international nursing profession regarding functions and activities in the health care system that could affect the continuity and integration of healthcare services and patients´outcomes.

Methods: The main purpose of this original research was to collect information on the work activities those working in advanced roles perform in practice. The research had two Phases. PHASE I: Cross-cultural equivalence and psychometric properties of the Spanish version of the Modified Advanced Practice Role Delineation (APRD) tool which translated, adapted and validated the Spanish version of the Modified APRD tool. PHASE II Role delineation study of advanced practice nursing, a cross-sectional survey of practice domains and trends in role functions; cross-sectional, descriptive, exploratory, web-based pilot study. The study population were all Spanish specialist nurses (including midwifes, mental health nurses, occupational health nurses and geriatric nurses) and all expert nurses that have been previously identified by the authors as nurses with a more advanced practice competency profile than a general nurse in Spain. The study had a convenience sample of 151 nurses employed by a dual tertiary and community hospital in Barcelona, Spain. The data was collected over six months in 2015 -2016. The original Modified APRD tool comprised 41 items across five domains of advanced practice nursing (direct comprehensive care, support of systems, research, education and publication and professional leadership). Variables used in the second phase of the study were length of nursing experience, educational qualifications, context of practice, level in professional career ladder and role implication on other disciplines, services and patients.

Results: The Spanish version of the Modified APRD tool provided support for the instrument´s validity and reliability among APNs in a Spanish nursing/midwifery population in a dual tertiary and community hospital. A few differences were found between the original English version of the modified APRD tool and its Spanish translation. No acceptable agreement was achieved in three items of the original as they were found not meaningful, repetitive or culturally irrelevant in our context. A Pilot test was conducted among 39 participants who rated the instructions, items and response format. The I-CVI and S-CVI was calculated through the responses of the expert panel which was completed by 8 expert raters. The tool showed an acceptable internal consistency. The PCA analysis, a difference of the original tool, showed a simple structure, with six factors. Results for phase II are being analyzed to determine the instrument capacity to delineate APNs roles by the level of activities undertaken across the six domains of practice in our context.

Discussion: The need to differentiate advanced practice roles and classify an advanced level of practice persists and is becoming increasingly urgent in the international landscape. This study represents the first attempt to examine the reliability and the validity of a Spanish tool capable to delineate APN domains and activities. The results provided support the instrument´s validity and reliability among APNs in a Spanish nursing/midwifery population in a dual tertiary and community hospital. There is an extensive body of scholarly work in the international literature attesting to the role ambiguity related to APN roles. Role delineation studies, or job analysis, are a necessary step in describing current practice expectations, performance requirements, and job environments accordingly with social and health needs. In many cases, it involves collaboration between multiple factors, changes in professional roles and restructuring of organizations to provide a better integrated care between organizations. Hence, by using the newly adapted tool, better quality data could be collected in clinical practice that could assist in improving international comparability and quality of information.

Conclusion: Innovative APN roles are of greater relevance in terms of transforming the model of care such as orientation towards long-term conditions, greater resolution, accessibility, quality in high specialization and interdisciplinary public health. Greater clarity around these roles may assist in optimizing workforce utilization, meeting new service delivery requirements and enabling greater internal organizational cohesion, consistency and professional clarity. These are important factors in optimizing favorable outcomes for staff, patients and the organizations in general. Clarification of role expectations is an important issue for the nursing profession, as well as employers who may be unsure about the precise scope of responsibilities of these innovative roles.

How to Cite: Sevilla Guerra S, Zabalegui A. Role delineation study of advanced practice nursing, a cross-sectional study of practice domains and trends in role functions. International Journal of Integrated Care. 2016;16(6):A62. DOI:
Published on 16 Dec 2016.


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