Advanced practice nurses: our unmet challenge

Section: Editorial

How to quote

Zabalegui Yárnoz A. Enfermeras de práctica avanzada: nuestro reto pendiente. Metas Enferm nov 2018; 21(9):3


Adelaida Zabalegui Yárnoz

Advanced Practice Nurses (APNs) work in the intersection between Nursing and Medicine. Their development is due to an increase in patient care needs and an improvement in nurse training. An APN is defined as “a nurse with expert knowledge, the skills to make complex decisions and clinical competence for advanced practice, depending on the setting and/or country where these are implemented”. They conduct clinical practice directly on patients, integrating patient care, education for patients and/or professionals, and research. Besides, they perform actions of guidance, counseling, evidence-based practice, leadership, interdisciplinary and intradisciplinary collaboration, and they make ethical decisions. Advanced Practice Nurses require post-graduate master training, though in the United States they might need a doctorate in some areas; specialist clinical nurses, consultants and practitioners are included within this profile. Outside Spain, practitioners can prescribe medications; in the United States, since 1965, and currently also in Australia, Canada, United Kingdom, the Netherlands and Sweden.

Advanced Practice Nurses are essential in the new healthcare models, in order to increase the efficacy of response to current and future healthcare problems, derived of an increase in ageing, chronicity and multimorbidity, and to promote healthy lifestyles, prevention and health promotion, and home / community care vs. hospitalization. There is an international growth of the APN role, and competences previously assigned to doctors (substitution) are being transferred to nurses, when there is an insufficient number of physicians (1). There is also a growth of APNs in order to improve access to the healthcare system, by incorporating nursing competences in new clinical areas (supplementation); this is represented by case managers, liaison nurses, e-Health monitoring, and counseling on healthy lifestyles. The conclusion of a comprehensive review of clinical trials on APNs “substituting” physicians in Primary Care (2) was that the intervention of APNs in recurrent, urgent or chronic health issues provides equal or better quality of care and health outcomes than physicians, while patient satisfaction is higher with the care received from APNs.

In Spain, we must capitalize on the higher academic and clinic training of post-graduate nurses, creating new positions that will strengthen their role is Advanced Practice Nurses. Their activity will allow to give a more efficient response to healthcare needs, including care, within cost-efficient healthcare models that optimize resources and make the system sustainable. However, the implementation of Advanced Practice in Spain has met with barriers, such as the high workload or lack of clarity about the APN role, their leadership, teamwork or funding (3). Its implementation requires strategic improvements that will clearly define their role within the multidisciplinary team, encourage their visibility, promote their role and document their added value.

In order to incorporate Advanced Practice Nurses in our setting, we must identify the existing ones (for example, specialist nurses) who conduct their activity in the majority of healthcare centers, and create specific APN positions for each specialty, supported by new legislation. In this sense, we can use in our setting the Modified Advanced Practice Role Delineation (APRD) tool, which is valid, reliable and easy to use (4). In Australia, it is used to evaluate APN activity in terms of expert care planning, comprehensive care, interprofessional collaboration, education, research, evidence-based practice and professional leadership. The data obtained will allow governments, managers, Nurse Managers and Advanced Practice Nurses to follow up their activity and professional development, in order to establish a portfolio of services and assess their impact on patient care.

The increasing complexity in healthcare and patient care setting cannot be questioned. On the other hand, the lack of nurses and physicians in the overall setting is creating opportunities to incorporate nurses with specialist or advanced training. We need commitment by politicians, managers and leaders for their detection and acknowledgement, which will lead to a higher benefit for patients and the healthcare system.


  1. Maier CB, Barnes H, Aiken LH, Busse R. Descriptive, cross-country analysis of the nurse practitioner workforce in six countries: size, growth, physician substitution potential. BMJ Open. 2016; 6(9).
  2. Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJAH. Nurses as substitutes for doctors in primary care. Cochrane Library. 2018, 7:CD001271.
  3. Kilpatrick K, Lavoie-Tremblay M, Ritchie JA, Lamothe L, Doran D. Boundary work and the introduction of acute care nurse practitioners in healthcare teams. J Adv Nurs. 2012; 68(7):1504-15.
  4. Sevilla Guerra S, Risco Vilarasau E, Galisteo Giménez M, Zabalegui A. Spanish version of the modified Advanced Practice Role Delineation tool, adaptation and psychometric properties. J Nurs Pract. 2018 Jun; 24(3): e12635.