Advanced Nurse Practitioners' (Emergency) perceptions of their role, positionality and professional identity: A narrative inquiry

Abstract

Aims To explore Advanced Nurse Practitioners' (ANP) (Emergency) perceptions of their role, positionality and professional identity. Background Advanced nursing practice was formally established in the Republic of Ireland in 2001 with 336 ANPs currently registered, projection increasing to a critical mass of 750 by 2021. Advanced practitioners (Emergency) give full emergency care for a specific cohort of clients with unscheduled, undifferentiated and undiagnosed conditions. Design Qualitative narrative inquiry using Bourdieu's concepts of habitus, field and capital as the theoretical framework was undertaken. Methods Data were collected in 10 in‐depth interviews and thematic analysis applied. Results Five key themes emerged: participants' career pathways, personal and professional transitions, role dimensions and core concepts, and position in the organization and emergent professional identity. Role transitioning and a change in habitus, field and capital revealed the uniqueness of their nursing role. Minimizing waiting times, timely patient care and patient satisfaction were key performance indicators. A heightened awareness regarding higher‐level decision‐making, autonomy and accountability is integral to advanced practice. Conclusion This study presents unique insights into the ANP role covering recruitment, organizational culture changes required and support to ease transition emerged. Impact Better understanding the motivation to undertake the role, the transition experience and use of advanced practice skills sets will inform the targets for the future recruitment and retention of ANPs are met nationally and internationally. Dissatisfaction with previous management roles and wanting to be clinically close to patients were motivations to follow an advanced practice clinical career trajectory. Positionality and emergent professional identity are key enablers ensuring that advanced practitioners' roles demonstrate the attributes of advanced practice. Educators could use the findings to develop recruitment, retention and progression strategies. Disseminating the role and scopes of practice could positively influence collaborative models of service delivery and policy development.

An exploration of the levels of clinical autonomy of advanced nurse practitioners: A narrative literature review

“…Ten papers referred to the inclusion of medical and nursing activities for patients as one major part of ANP stepping up, including independent history taking, diagnosis, independent prescribing of medications and ionising radiation, referral and discharge of patients without the need of a physician's consultation or assessment (Anderson et al, 2019; Bahadori & Fitzpatrick, 2009; Cowley & Cooper, 2016; Kerr & Macaskill, 2020; MacLellan et al, 2016; Park et al, 2018; Ryder et al, 2019; Spetz et al, 2017; Turner et al, 2007; Weiland, 2015). Eight papers similarly included ANP stepping up as physical examination, diagnostic and curative intervention, prescribing, admission rights, patient referral and discharge (Anderson et al, 2019; Cowley & Cooper, 2016; Kerr & Macaskill, 2020; MacLellan et al, 2016; Poghosyan & Liu, 2016; Ryder et al, 2019; Sangster‐Gormley et al, 2011; Weiland, 2015).…”

“…Additionally, on referral or discharge of a patient, ‘stepping up’ ANPs clinical autonomy was discoursed as completing full episodes of care, including making the clinical decisions without conferring with a physician and commencing a treatment plan and diagnosis collaboratively or entirely without a physician independently (Anderson et al, 2019; Bahadori & Fitzpatrick, 2009; Burgess & Purkis, 2010; Cowley & Cooper, 2016; Kerr & Macaskill, 2020; Ryder et al, 2019; Weiland, 2015).…”

“…Four studies described the overarching goal of stepping up as providing timely care to patients, improving patient flow, initiating care pathways and continuity of services, which is cost‐effective and ensures quality patient care (Athey et al, 2016; Fox et al, 2018; Kerr & Macaskill, 2020; Ryder et al, 2019). Additionally, nine studies reported ANPs clinical autonomy as stepping up regarding diagnosis, completion of full episodes of care with or without a physician's oversight (Athey et al, 2016; Fox et al, 2018; Kerr & Macaskill, 2020; Maylone et al, 2011; Park et al, 2018; Ryder et al, 2019; Schadewaldt et al, 2016; Spetz et al, 2017; Weiland, 2015).…”

“…Eleven of the 19 papers included in this review explore the use of complex decision‐making skills as part of stepping up (Athey et al , 2016; Bahadori & Fitzpatrick, 2009; Cajulis & Fitzpatrick, 2007; Cowley & Cooper, 2016; Fox et al, 2018; Park et al, 2018; Poghosyan & Liu, 2016; Spetz et al, 2017; Turner et al, 2007; Weiland, 2015; Yee et al, 2013). Seven papers referred to ANPs clinical autonomy as practising from a deeper level of experience and understanding to support their clinically autonomous decision‐making in clinical practice (Anderson et al, 2019; Bahadori & Fitzpatrick, 2009; Cowley & Cooper, 2016; Fox et al, 2018; Kerr & Macaskill, 2020; Ryder et al, 2019; Weiland, 2015). Finally, 12 studies reported continuing professional development as a key factor in developing clinical decision‐making associated with ANPs' clinical autonomy (Anderson et al, 2019; Athey et al, 2016; Bahadori & Fitzpatrick, 2009; Cajulis & Fitzpatrick, 2007; Fox et al, 2018; Kerr & Macaskill, 2020; Park et al, 2018; Poghosyan & Liu, 2016; Ryder et al, 2019; Turner et al, 2007; Weiland, 2015; Yee et al, 2013).…”

“…However, six studies reported ANP clinical autonomy as complex within the organisation when implementing the role with interprofessional and intraprofessional relationships and role territory enforcing restrictions to ANPs living their clinical autonomy (Anderson et al, 2019; MacLellan et al, 2016; Sangster‐Gormley et al, 2011; Schadewaldt et al, 2016; Turner et al, 2007; Weiland, 2015). Seven studies reported a fundamental lack of recognition of ANP clinical autonomy by other health professionals as an incapacitating factor of living it (Bahadori & Fitzpatrick, 2009; Burgess & Purkis, 2010; Schadewaldt et al, 2016; Weiland, 2015; Cowley & Cooper, 2016; Anderson et al, 2019; Kerr & Macaskill, 2020).…”