Developing a core competency framework for advanced practice nursing in mainland China: a sequential exploratory study

With the increasing need for improved nursing services and outcomes, APN has spread and accepted worldwide and was proven to have advantages in improving access to care, decreasing waiting time, and cost containment of health care [1]. To date, approximately 70% of nations have some form of advanced practice nursing [2]. APN is the expanded healthcare services and interventions provided by nurses with an advanced capacity [3]. The advanced practice nurse is granted to a nurse who has completed additional education to acquire expert knowledge, complex decision-making skills, and the clinical competencies to provide expanded healthcare services within the context of nursing [4]. Identifying the definition of nursing competencies is the foundation of the conceptualization and development of advanced practice nursing roles [5, 6]. Nursing competency is a mastery of knowledge, clinical, interpersonal and technical skills, which is the basis for good performance in the clinical environment [7]. In 1996, Hamric had put forward core competencies for advanced practice nurses(APNs), which included seven domains that took clinical practice, nursing research, health coaching and education, collaboration, ethical decision making, and leadership into consideration [8]. In 2011, the American Association of Colleges of Nursing (AACN) designed six core competencies for master’s education in nursing, such as changes for quality care, culture of excellence, and translating evidence into practice [9]. In 2010, the Canadian Nurses Association published the core competency framework for nurse practitioners: clinical practice, collaboration, consultation and referral, research, and leadership [10]. In Australia, the Australian Nursing & Midwifery Council (ANMC) included three core competencies for nurse practitioners: dynamic practice, professional efficacy and clinical leadership [11]. In the UK, the Royal College of Nursing (RCN) established the core competency framework for APN [12].

Hong Kong is an area with early development of advanced practice nurses in China, the nurse specialist role was first piloted in 1993 and an advanced practice nursing role piloted in 2003. Nurse practitioner (NP) is the title of advanced practice nurse in Taiwan, who not only have a master's degree or doctor's degree, but also are registered nurses who have received the master's level education of nurse practitioner. Chinese mainland has established certified registered nurse and certified nurse systems to cultivate nurses with different competency levels under accompanying training and certification regulations. Although the current regulations for nurses, launched in 2008, did not have any APN roles or APN-related descriptions, Chinese researchers began to explore the localization of the role of advanced practice nurse based on the foreign concept model, and found that training advanced practice nurse from master level is the trend of the development of nursing specialization in recent years. By the end of March 2015, there were 84 clinical master's programs in nursing in China [13]. This resulted in a significant increase in the number of clinical nurses with master's degrees, which prompted China to establish an advanced practice specialty nursing program to prepare nurses for future work with medical specialists. Review of the literature revealed that advanced practice nurse role with higher consensus in china were clinical practitioner, manager, educator, researcher, coordinator and consultant [14]. This result is consistent with results of the international reasearech [15], but competences required for APN are wide heterogeneity, with a total of 16 was mentioned in the literature [14]. Clinical practice ability, research ability and management ability are higher consensus in the process of developing advanced practice in specialty areas, there is much confusion between Specialist Nurses(SN) and advanced practice nurses. Specialist nurses are probably those who can deal with situations in a specific area of practice. Advanced practice nurses not only perform proficiently and possess specialized knowledge, but also have original thinking, innovation and the ability to analyse complex situations in delivering services and leading changes [13]. APNs are at the frontier of their field and at the top of the clinical ladder [16]. The roles of Specialist Nurses(SN) have been defined and regulated in some organizations of mainland china. Some researchers have explored the core competencies of advanced practice nurses in different specialized fields, such as gastroenterology nursing specialists [6], oncology advanced practice nurses [17], critical care advanced practice nurses [18], and advanced midwifery practitioners [19]. In addition, previous studies in China did not provide a clear definition of specialist nurse or advanced practice nurse. The core competencies for APN role are not clearly defined, with confusion regarding the APN title more prevalent since delineation of the Specialized Nurse roles. Some intuitive or logical methods of categorization were used, with small convenience samples, resulting in validity and reliability. Under this condition, we aimed to identify a competency framework for APNs through sequential exploratory research.

The definition of advanced practice nurses(APN) used in our study is defined as a registered nurse with a master's degree or above and with at least 5 years of working experience who has received academic training and practical training, acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice.

An exploratory sequential study was designed. We conducted a two-phase approach to develop the core competencies for advanced practice nursing: (1) Phase 1: a literature review and qualitative interviews were conducted to draft the initial competency framework; Phase2: The Delphi technique was used to identify the framework.

The core competency framework with six domains and 61 items in this study provided evidence for the role development of APNs, which will prepare a cadre of nurses who have master’s degrees and are consistently ready to face health care delivery challenges and promote health. This study was a first attempt to define the scope of competency for APNs and may accelerate the maturation of the core competency framework for APNs in mainland China.

This study proposed an expert consensual list of the core competencies for APN, which contains six domains: direct clinical nursing practice, research and evidence-based nursing practice, professional development, organization and management, mentoring and consultation, and legal/ethical practice with 61 items. Compared to Hamric’s conceptual model and the ICN’s model, the core competency framework in this study had similar contents but also some differences.

The direct clinical nursing practice domain received the highest score among the six domains, as shown in Table 4, which indicated that providing clinical nursing care was the priority of nursing roles (Fig. 1). This finding was consistent with most previous studies [26, 27]. This domain consisted of patient-focused activities, including assessments, clinical nursing decision-making, nurse–patient relationship establishment and interpretation of data, which was consistent with previous studies [28, 29]. Nurse–patient relationships are critical to effectively implement nursing interventions [30]. The ability to establish therapeutic and collaborative nurse–patient relationships was also required in Hamric’s core competency model for APNs [8]. Comments about this domain led to the removal of ‘making a medical diagnosis’, ‘prescribing routine medications and routine examination for the patient’ as an activity, because nurse prescription has not yet been implemented widely in mainland China. If nurse prescription is widely allowed in the future, this activity should be included. Because nurse prescription has been an important responsibility to distinguish general nurses and nurses working in advanced positions in the USA. A total of 20 items were developed to describe the clinical nursing practice competency in detail.

The research and evidence-based nursing practice competency ranked second among all domains. This competency was also identified in some previous studies [31‐34]. However, neither AMNC nor RCN is reflective of conducting research in their competency framework for APN [11, 12]. AACN only considered translating evidence to practice as a part of the core competencies without emphasizing the research ability of APN [9]. This discrepancy may result from the developing degree of nursing research between Western countries and China. The first master’s degree of nursing programme was not established until 1990 in China [35]. Although the enrolment of master of nursing specialist students has increased gradually since 2010, researchers, policy-makers, and educators think it is critical to have more expectations for the research competency of APNs to improve the nursing discipline in China. In this study, the 10 items in the dimension of research and evidence-based nursing practice pay more attention to the research on clinical problems and the translation of best evidence to clinical practice.

The third identified competency was professional development, which included the development of individuals and the nursing discipline. This confirmed previous results from Anna-Lena et al. [28] Krista et al. [27], and Finnbakk et al. [36]. With the development of health technologies, nurses are certainly required to keep up with the leading edge of specialized knowledge and new health care patterns. Moreover, advanced practice nurses are expected to take responsibility for the development of the nursing discipline. However, it may take a long time to make a difference in the acquisition of professional development competency.

Competency in organization and management was also required for APNs in this study. This competency contained two aspects: communicating and cooperating effectively with colleagues and participating in the organization and coordination of relevant elements of clinical nursing practice. This finding was slightly different from previous results, which only included collaborative or communicative ability [10, 28, 37] or only included mentoring and quality improvement activities [27, 32, 33]. Previous studies in China have found that communication is a time-consuming activity during the nursing process and directly relates to most conflicts and medical errors in the clinical environment [38, 39]. It was important for APN to conduct effective communication with patients, patients’ family members, and colleagues. The contents of this domain are more similar to professional leadership in Hamric’s advanced practice model.

This study also supported previous results, which stated that mentoring and consultation are required competencies for APNs [11, 32, 33, 40]. This competency generally involved health education to patients, professional guidance to peers, and specialized consultation to service subjects in this study, which was a complicated scenario to use clinical knowledge, learning principles, and education tools [41]. This domain covers a broad range of mentoring programs for patients, communities, clinicians, and students. However, the activity within this domain in our research included the large amount of “informal” teaching activities conducted by APN, similar to the result of Chang’s study [24]. It was critical to cultivate the mentoring and consultation competency of APNs to meet the demands of patients about disease management and health resource seeking as well as specialized issues from junior nurses [6].

The legal/ethical practice was another core competency identified in this study, which was rarely mentioned in most previous studies. Patient rights protection is a wide consensus around the world, and strengthening the occupational ethics and legal knowledge of nurses was proven to increase service quality and reduce medical disputes [42]. It is urgent to strengthen the ethical and legal practice competency of APNs in the complicated health environments of China [43].

This study identified some similarities with the competence framework of Hamric’s model, namely, six domains. However, there were several differences, such as the domain delineation and some items, due to the cultural and policy differences between China and Western countries. The engagement of stakeholders in all aspects of APN in this study was the distinguishing characteristic of this emerging field. This study also investigated the opinions of a heterogeneous sample, including nurses with master’s degrees, nursing managers and medical policymakers at multiple clinical sites, which helped to make the findings more reliable and generalizable.

In this study, we identified six core competency domains required for APNs, including direct clinical nursing practice, research and evidence-based nursing practice, professional development, organization and management, mentoring and consultation, and ethical/legal practice. This competency framework can be used in competency-based education to cultivate advanced practice nurses to meet increasing nursing care needs. Additionally, this framework can be used for competency level assessment of APNs. A future study should examine how these competencies are incorporated into nursing curricula and how they affect patient outcomes.