Both nurses and patients reported a reluctance to waste a doctor’s time [37]. Registered Nurse Alliance. Twenty articles reporting the experiences of 486 participants were included in the review. St Leonards: Allen & Unwin; 1989. Positive results have been found in older people in long-term care settings, although it is difficult to discern the specific effect attributable to them because they are inserted in multidisciplinary teams. This situation has the potential to create environments where there is a reliance on standing orders and protocols, which only diminishes opportunities for independent practice by advanced practice nurses. The critical appraisal score sheets for the excluded studies is also provided in an additional file [see Additional file 4]. Some nurses were content with their current duties and chose not to participate in further education with a participant stating ‘(we have to) accept that there’s a lot of nurses that don’t want any more responsibility, or they don’t want to extend their roles. To identify, assess and summarize available scientific evidence about the effect of interventions deployed by advanced practice nurses when providing care to older people in different care settings, and to describe the roles and components of the interventions developed by these professionals. Keywords: Advanced practice, General practice, Systematic review, Qualitative research Background There is an absence of clear agreement regarding the con-cept of advanced practice nursing both in Australia and overseas [1–5]. Twenty articles reporting the experiences of 486 participants were included. Description of data: A consolidated document detailing the results of critical appraisal for excluded studies. Google Scholar. 891.]. Additionally, advanced practice nurses struggle to negotiate and clarify scopes of practice while general practitioners have trouble justifying the costs associated with advanced practice nursing roles. Experiences of the work of a Nurse Practitioner (NP) were also included in the study. Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice. By continuing you agree to the use of cookies. Aust J Prim Health. No other studies have identified this tension. Collegian (Royal College of Nursing, Australia). Interestingly, seven studies reported that patients did not recognise interactions between the advanced practice nurse and the GP as professional cooperation [10, 15, 28, 30, 31, 34, 36]. Ehrlich C, Kendall E, St John W. How does care coordination provided by registered nurses “fit” within the organisational processes and professional relationships in the general practice context? Blackburn M, Stathi A, Keogh E, Eccleston C. Raising the topic of weight in general practice: perspectives of GPs and primary care nurses. A review by McInnes et al. (DOCX 36 kb), Modified critical appraisal tool. It was also noted that a minority of GPs still doubted that advanced practice nurses had sufficient education to complete their role [25]. J Adv Nurs. However, we argue that the uncertainty surrounding advanced practice nursing in general practice is the result of a complex set of related factors that have sabotaged attempts to gain professional recognition for over a decade. The modified critical appraisal tool is provided in an additional file [see Additional file 2]. 2015;22:183–9. It was accepted that advanced practice nurses were competent in maintaining the flow of patients through the general practice with one GP stating ‘If she thinks someone needs to be seen, and when, and how, I value that. They were classified depending on the type of follow-up (long and short-term care) and the scope of the service (advanced practice nurses interventions focused on multimorbid patients, or focused on a specific disease). Springer Nature. Educational role of nurse practitioners in a family practice centre: perspectives of learners and nurses. It appeared that colleagues either side of the advanced practice nurse, were better placed in this way because they held positions and performed duties that were more easily recognised and understood by patients. (DOCX 80 kb), List of studies contributing to each code and sub-theme. http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/, https://doi.org/10.1186/s12912-016-0198-7, Service organization, utilization, and delivery of care. Main R, Dunn N, Kendall K. Crossing professional boundaries’: barriers to the integration of nurse practitioners in primary care. Nurse participants could be either advanced practice nurses or those being supervised or otherwise interacting with advanced practice nurses. This issue of The Journal of School Nursing is devoted to literature reviews relevant to school nursing practice. [30] found that many NPs were reluctant to fully utilise prescribing rights because they considered themselves to be nurses first and were uncomfortable with being viewed as elitist and acting like a doctor. Nineteen out of twenty included studies contributed to this sub-theme [8–10, 15, 22–36]. This framework simplified the search process and facilitated a more focused assessment of the retrieved studies. This is particularly evident in general practice, where advanced practice role development is more fluid and generally less supported by the hierarchical structures evident in the hospital system [5]. Mitchell J, Brown J, Smith C. Interprofessional education: a nurse practitioner impacts family medicine residents’ smoking cessation counselling experiences. This included computer templates preloaded with pertinent patient information [32], drug initiation and titration algorithms [9, 27] and structured care pathways [10]. Advanced practice nurses were uneasy with performing time-limited consultations because this reduced the amount of time that they could interact with their patients with one advanced practice nurse stating ‘You are booked solid and you have patient after patient, and when you go back to review they want to talk about all things and you really don’t have time’ [27, p. e320]. 2010;56(10):e375–82. The first author was supported by an Australian Government Research Training Program Scholarship. We conducted a systematic review and meta‐analysis. We found that while many GPs were prepared to handover individual tasks, fewer were willing to assign overall case responsibility to the advanced practice nurse. In another case, a GP proposed a funding model where patients paid an ‘upfront practice payment’ for services provided by an advanced practice nurse [9, p. 353]. 2015;16:36. Juan Carlos Morilla-Herrera, Silvia Garcia-Mayor, Francisco Javier Martín-Santos, Shakira Kaknani Uttumchandani, Álvaro Leon Campos, Jorge Caro Bautista, José Miguel Morales-Asencio, A systematic review of the effectiveness and roles of advanced practice nursing in older people, International Journal of Nursing Studies, 10.1016/j.ijnurstu.2015.10.010, 53, (290-307), (2016). Studies were included if they evaluated the effectiveness of integrated working between primary health care professionals and care homes, or identified barriers and facilitators to integrated working. [12] provided worthwhile understandings of challenges to teamwork, collaboration and decision-making in the general practice environment without specifically tackling issues surrounding advanced practice nursing. A diagram showing the relationship of the codes to the sub-themes and major theme is shown in Fig. All authors participated in the critical appraisal process. For example, a review of cognitive remediation may evaluate the effectiveness of training of executive function for different populations, such as those with mild versus moderate traumatic brain injury. J Adv Nurs. Nursing and the Advanced Practice. Jokiniemi K, Haatainen K. Advanced nursing roles: a systematic review. We retrieved the full text of studies that appeared to include relevant data or information. Article  The DNE’s relationship with endocrine specialists, allowed GPs to maintain a professional distance that was not replicated with other advanced practice nurses [35]. Infante F, Proudfoot J, Powell Davies G, Bubner T, Holton C, Beilby J, Harris M. How people with chronic illnesses view their care in general practice: a qualitative study. We discovered that general practitioners and patients continue to have concerns around responsibility, trust and accountability. Int Nurs Rev. Charmaz K. Constructing grounded theory. We conducted a systematic review of qualitative studies that explored the experiences of patients, nurses and doctors who had contact with advanced practice nurses working in general practice. We argue that this uncertainty has constrained the transition to unqualified acceptance, wedging advanced practice nursing into a liminal space with little scope for recognition and expansion. This is done by synthesizing the results of several studies. Senior nurses working towards NP status were in a similar situation [10]. The number of participants has been included to highlight the relative weight of patient, nurse and doctor experiences. Fifteen studies were included. PubMed Google Scholar. We found that issues around accountability negatively affected confidence in advanced practice nurses in general practice. Article  2014;15:1–9. There is an absence of clear agreement regarding the concept of advanced practice nursing both in Australia and overseas [1–5]. http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf. However, advanced practice providers might add value to care in several other ways, but this needs further study. Study selection was completed by the lead author and reviewed by the co-authors. PubMed  Accessed 25 July 2016. The levels of evidence provide a standard by which the field of nursing can evaluate the rigor of research in order to be confident that the findings are worthy of regard and consideration for being embedded in nursing practice. Another study found that patients needed to see that the DNE carried the authority of, and was trusted by, the GP [36]. Patient participants had to have experience of advanced practice nursing as a current or former patient of a general practice. 1997;26(4):729–35. One study reported incidences where GPs believed insulin protocols were only relevant to nurses [31]. Evidence-based practice relies on the clinician’s understanding of how to search for and retrieve valid and high-level evidence. 2013;15:497–503. However, many of the included studies did not report participant quotes within the results section of their papers and we, therefore, had to rely on interpretive data for our synthesis. J Adv Nurs. Objective: An overview of systematic reviews was conducted to develop a broad picture of the dimensions and indicators of nursing care that have the potential to be influenced by the use of ICTs. Philosophies And Theories For Advanced Nursing Practice by Butts and Rich. Mahomed R, St John W, Patterson E. Understanding the process of patient satisfaction with nurse-led chronic disease management in general practice. 2014;15:1–9. Nurse Educ Today. While it could be argued that the intangibility of these higher order skills could lead to errors in recognition, in practice it is relatively straightforward to distinguish what is and what is not advanced practice nursing [1]. Advanced Practice Nurse, Palliative Care, Co‐Director of the University Centre for Palliative Care and Scientific Collaborator, Department of Nursing Development, Directorate of Nursing, Medical‐Technical and Medical‐Therapeutical Areas, Inselspital Bern University Hospital, Bern, Switzerland. reviews [18, 21–23] elucidating advanced nursing practice in the emergency and critical care settings included only stud-ies published before January 2013, which may be dated. In another study, a GP believed that NPs were a waste of money because they always asked for a second opinion [22]. mining’ approaches in the title-abstract screening stage of a ‘case study’ systematic review about undergraduate medical education in UK general practice settings. We found that medicalisation of nursing roles was resisted by both nurses and doctors. (DOCX 21 kb), Critical appraisal of included studies. This only resulted in trivialising the duties of the advanced practice nurse to the extent that they had to be formalised in a more detailed way with protocols. 2006;57(4):382–91. 2011;58(2):225–33. The full text of included studies was exported to the NVivo 11TM software program. Furler J, Blackberry I, Walker C, Manski-Nankervis J, Anderson J, O’Neal D, Young D, Best J. This uncertainty was also evident in three other studies where more experienced GPs stated that the advanced practice nurse scope of practice was ill-defined and ambiguous [15, 30, 31]. To gain respect from GPs, advanced practice nurses felt that they had to display skills that were more medically oriented, however, these skills were not accepted by their less qualified nursing colleagues who themselves felt undervalued and overworked. NURSING Systematic Review Made Simple for Nurses * Leong Siew Teing, RN, Adv Diploma in Critical Care, Bachelor of Health Science (Nursing) ... nursing practice is evidence-based, patients will receive nursing care that is safe, effective, promotes comfort and facilitates best outcomes. Engaging GPs in insulin therapy initiation: a qualitative study evaluating a support program in the Belgian context. The critical appraisal score sheets for each of the included studies is provided in an additional file [see Additional file 3]. Walsh A, Moore A, Barber A, Opsteen J. A between‐group analysis was performed to evaluate the effectiveness of the exercise training. This is particularly evident in general practice where advanced practice role development is more fluid and generally less supported by the hierarchical structures evident in the hospital system. nursing lens in the curricula of advanced practice nursing programs. They resented PNs being given extended duties after they had completed a relatively small amount of training that was mostly funded by the practice. An interesting review from the Netherlands outlines the relationship between sexting, psychological problems, and risk behavior ( Van Ouytsel, Walrave, Ponnet, & Heirman, 2015 ) and addresses the first USPSTF priority, related to mental health. Abstract. 1. The result of this custom was that advanced practice nurses became unsure of what they were supposed to doing and hesitant to assume additional responsibility when it was offered. MJ performed the final edit of the manuscript. Advanced practice nurses were also inclined to default to tasks such as patient flow in the absence of other meaningful work. This article describes the use of systematic literature reviews to recognise appropriate evidence and develop guidelines to inform nursing practice, thereby enabling safe, high quality nursing care. J Adv Nurs. Two studies from the authors’ personal collections were also added to this initial group. 2013;21(6):7. California Privacy Statement, We found that the concept of accountability was used by both GPs and patients to justify an unwillingness to increase the responsibility of advanced practice nurses. Studies were included in the review if questions one, two and three and most of the remaining questions were answered “yes”. Gardner G, Duffield C. Defining advanced practice nursing. Mahomed et al. Search strategies. Emergent codes were collapsed into sub-themes and themes. Medical Subject Headings (MeSH) terms for general practice were combined with MeSH terms and text words for nursing and MeSH terms for qualitative research. Given the similarities between this and broader healthcare contexts, we argue that our findings have implications for efforts to solidify advanced practice nursing outside of general practice. 2004;12(3):201–9. The purpose of this review is to synthesise published qualitative studies reporting experiences of advanced practice nursing in general practice. Google Scholar. Breen A, Carr E, Mann E, Crossen-White H. Acute back pain management in primary care: a qualitative pilot study of the feasibility of a nurse-led service in general practice. The panoramic view provided by patients, nurses and doctors within this novel context, offers a fresh perspective on why advanced practice nurses have struggled to gain acceptance within the healthcare milieu. However, there was a limit to this pattern because nurses are, in the main, salaried from the total earnings of a general practice and recover very little in the way of rebates for their services. © 2020 BioMed Central Ltd unless otherwise stated. Critical appraisal was undertaken and the findings of included studies were analysed using the constant comparative method. Two studies found that visible and ongoing role development was an essential element of trust [23, 31], while another study found that advanced practice nurses wrestled with the expectation of being both autonomous and a team player with a broad range of professional skills [32]. 2013;19:150–8. Stasa H, Cashin A, Buckley T, Donoghue J. One study discovered that despite being supervised by NPs in the initial stages of their training, GP residents were still unclear about the NP’s scope of practice [27]. A total of 27 descriptors were used to code the data. Sociol Health Illn. The findings showed that advanced practice nurses gained confidence from participation in further training and this assurance was noticeable to colleagues and clients. 2013;20(3):127–35. BMC Nurs. 2009;23(4):401–9. Several other behaviours narrowed the gap between GPs and advanced practice nurses. The purpose of a systematic review is to sum up the best available research on that specific question. NPs and DNEs who, by the nature of their position, had more education than other nurses in the practice, believed that the path to recognisable status was increasingly independent practice. Price A, Williams A. Of the 12 codes used in the aggregation of this sub-theme, the following eight codes contributed the greatest amount and are presented below: ambiguity, traditionalising, clarifying, protocolling, reforming, flexibility, collaboration and negotiation. J Interprof Care. While important to the day-to-day running of the practice, this task could have been delegated to more junior nurses or indeed reception staff. DW and GS revised the manuscript for content and structure. Description of data: A consolidated document detailing the results of critical appraisal for included studies. Other studies focused on nurses performing certain roles [13, 14], working in specific contexts [10, 15], or managing particular illnesses [16–18]. Description of data: A table listing the studies that contributed to each code and sub-theme. The Evidence-Based Practice Implementation Guide (Figure 16-1) was developed to assist nurse leaders with planning and use of effective implementation strategies that advance stakeholders (both people and systems) through a process of diffusion: creating awareness and interest, building knowledge and commitment, promoting action and adaptation, and integrating and sustaining use … London: Sage Publications; 2014. A list of preliminary codes was developed after close reading of the findings/results section of a selected article. Preliminary searches revealed that this step was not feasible during the initial search process. The authors declare that they have no competing interests. DARE. The purpose of a systematic review is to deliver a meticulous summary of all the available primary research in response to a research question. Google Scholar. Other GPs were happy to hand off care if they did not have to supervise or otherwise support the advanced practice nurse including answering questions [15, 30]. Despite efforts to achieve conceptual clarity, advanced practice nursing continues to reside in a liminal space, unable to secure ongoing recognition as a viable means of healthcare delivery. In this case, as DNEs became overloaded with additional cases, insulin initiation was delegated to PNs who did not have specialist training and this was viewed as a threat to their status within the practice [35]. McKinlay E, Garrett S, McBain L, Dowell T, Collings S, Stanley J. 2015;71(9):1973–85. 2014;31(3):349–56. Several studies from the United States, a country with a large cohort of advanced practice nurses, were retrieved but subsequently excluded after critical appraisal. We also reported examples where GPs were only happy to handover duties if they were not subsequently called upon by the advanced practice nurse for basic clinical advice, supervision or training. Given that some GPs also resented advanced practice nurses making diagnoses, it is possible that the pushback from specialists was a means of preserving the last bastion of a closed fraternity. We found that on the one hand, GPs were happy to hand over some of the more time-consuming responsibilities of care to nurses to see more patients themselves and, presumably, bring more money into the practice. Qual Prim Care. In many cases, GPs handed over tasks that they had no interest in, did not enjoy performing or took up too much of their consultation time. We were only interested in the experiences (O) of patients, nurses and doctors (P) who had contact with advanced practice nurses working in general practice (E). Jakimowicz, M., Williams, D. & Stankiewicz, G. A systematic review of experiences of advanced practice nursing in general practice. Every included study contributed to this sub-theme [8–10, 15, 22–37]. A NP in this study stated ‘I’m not sure where the resistance emanates from but there’s possibly resistance from the Nursing and Midwifery Council…I think the argument possibly is around the fact that nursing roles are changing so fast that they don’t want to make an elite group’ [30, p. 483]. 2005;13(2):85–90. Part of We found that trust was an important element in establishing and maintaining confidence in advanced practice nurses in general practice. Johnson M, Goyder E. Changing roles, changing responsibilities and changing relationships: an exploration of the impact of a new model for delivering integrated diabetes care in general practice. School of Health Sciences, University of Tasmania, 1 Leichhardt Street, Darlinghurst, NSW, 2010, Australia, School of Health Sciences, University of Tasmania, Private Bag 135, Hobart, TAS, 7001, Australia, School of Health Sciences, University of Tasmania, Locked Bag 5052, Alexandria, NSW, 2015, Australia, You can also search for this author in We discovered that general practitioners and patients continue to have concerns around responsibility, trust and accountability. Assumptions by GPs that they are responsible for everything that transpires within the practice are, therefore, dangerous because they may give colleagues the (wrong) impression that they are somehow absolved from any culpability deriving from their own care decisions. One study found that a lack of flexibility had serious implications for ongoing relationships [15]. Twelve studies reported the development of protocols as a means of avoiding omissions and explicitly stating what duties advanced practice nurses could perform [9, 10, 15, 25, 27, 28, 31–36]. Reviewing research evidence for nursing practice: systematic reviews highlights the key issues involved in conducting different types of systematic reviews - encompassing qualitative studies, quantitative studies and combining quantitative and qualitative studies. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. These codes were further refined during analysis of the remaining articles, using the constant comparative method [21]. PubMed  Mills J, Chamberlain-Salaun J, Christie L, Kingston M, Gorman E, Harvey C. Australian nurses in general practice, enabling the provision of cervical screening and well women’s health care services: a qualitative study. We limited the search to journal articles in English with the full text available. However, the use of meta-analysis method is not necessary in every single systematic review. We found that despite patients, nurses and doctors being able to articulate problems concerning confidence, boundaries and value, there had been scant progress towards organising this niche of practice in any sustainable way. However, many GPs did not believe that advanced practice nurses were capable of being both autonomous and accountable [33]. Manski-Nankervis J, Furler J, Blackberry I, Young D, O’Neal D, Patterson E. Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory. BMC Fam Pract. CAS  An unexpected finding was the dialectic verbalised by GPs concerning the value of their consultation time versus the recovery of costs incurred through the provision of an advanced practice nurse. We also found a tension between the need to undertake professional development and the drive to establish independent practice. Phillips C, Dwan K, Pearce C, Hall S, Porritt J, Yates R, Sibbald B. Text was coded line-by-line and a code tree was used to identify emergent themes. Sixteen electronic databases were consulted (1990–2014). 2015;22(2):225–32. Further investigations are needed to evaluate the cost-effectiveness of the two modalities detected and to compare internationally the interventions developed by advanced practice nurses. 2013;19:131–40. Copyright © 2020 Elsevier B.V. or its licensors or contributors. Cite this article. Patients reported that the nurse was more likely to ask about any additional concerns that they may have [36]. Negotiation was not confined to purely clinical interactions between GPs, advanced practice nurses and patients. Each database are provided in an additional file 5 ] ) Checklist for qualitative studies reporting experiences of advanced nurses... Engagement with the full text of studies contributing to each code and sub-theme is in... Facilitated a more focused assessment of the codes to the general practice the and... J. insulin in general practice involving role expansion [ evaluate the use of systematic reviews to advance nursing practice ] 25, e379..., they struggled to maintain a caseload that was mostly funded by practice! A high-quality systematic review of the exercise training those being supervised or otherwise interacting with advanced practice who... Lens in the review if questions one, two and three and of! “ yes ” with nurse-led chronic disease management in general practice and GPs appreciated flexibility 15! Tm libraries and NVivo TM coding files can be obtained from the literature to a... A paucity of quality studies specifically exploring this phenomenon nursing, Australia ) an tension... Retrieve valid and high-level evidence a diagnosis [ 28 ] and losing control over treatment decisions 31. Practice in the absence of other meaningful work DOCX 80 kb ), critical appraisal tool for this that..., stasa H. trust and decision-making: how district nurses and patients continue to concerns. Drive to establish sustainable legitimacy in general practice strategies for PubMed and CINAHL between nurse and doctor 34... Included allowing the advanced practice nursing in general practice capable of being both autonomous and accountable 33! P. 3 ] the task C. Interprofessional education: a nurse-led model of care for insulin initiation for people type... Authors declare that they may have [ 36 ] S understanding of the practice was devalued [ ]... Supervised or otherwise interacting with advanced practice providers might add value to care in other!: breaking through the role confusion of advanced practice nursing as a current or former of... During the initial search process, you agree to our agreed definition of practice! Negatively affected confidence in advanced practice nursing in general practice - barriers and enablers for timely initiation flexibility 15! In Fig of flexibility had serious implications for ongoing relationships [ 15 ] we found that lack. And abstract with nurses making a diagnosis [ 28 ] and informal communications outside of clinical treatment [. Visit: how nurses in general practice: //doi.org/10.1186/s12912-016-0198-7, DOI: https: //doi.org/10.1186/s12912-016-0198-7 contributed to this [! And evaluate the use of systematic reviews to advance nursing practice their status within the practice in the curricula of advanced practice nurses not. Staff [ 35 ] with established heart disease: lessons from patients ’ experiences conducting a systematic review that. They have no competing interests to systematically review the effects of interventions to improve the implementation of in. Duffield C. making nursing work: breaking through the role confusion of advanced practice nurses ’ roles in Health!, Gallinaro a, Duffield C, Dwan K, Pearce C, H.! Needed to evaluate the cost-effectiveness of the search to journal articles in with... Read and approved the final manuscript © 2020 Elsevier B.V. or its licensors contributors. Questions one, two and three and most of the search process and facilitated a more focused of! B.V. or its licensors or contributors process is provided in an additional file [ see additional file ]... This was also the case with cervical screening, a nurse Practitioner ( NP ) were included., p. 3 ] is described as the most reliable source of evidence to guide clinical.... Feasible during the initial search process answered “ yes ” establish independent practice over treatment [! Software program of guidelines in nursing: a qualitative study evaluating a program! In isolation we will consider documents that describe or evaluate frameworks, or. Management in general practice retained sole responsibility for the excluded studies is in... Patient, nurse and doctor [ 34 ] currently do ’ [ 25 ] were established and! Agree to our Terms and Conditions, California Privacy Statement and cookies policy and nurses by Bettany-Saltikov 19! The cost-effectiveness of the remaining articles, using the Population Exposure Outcome ( )... On the CASP Checklist for qualitative studies reporting experiences of advanced practice nurses who displayed clinical acumen attitudes. 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Number: 6 ( 2017 ) Cite this article therapy initiation: a step-by-step guide exercise training delegated more... Practice providers might add value to care in several other behaviours narrowed gap... A lack of flexibility had serious implications for ongoing relationships [ 15, 22–37 ] that... Concerns that they may have [ 36 ] source of evidence to guide clinical practice revealed this! Step of my DNP project or conceptual model of care for insulin initiation for with! And NVivo TM coding files can be obtained from the authors declare that they have competing. Of clinical treatment spaces [ 37 ] and a study by Merrick al... Empowering practice nurses appreciated training opportunities, they struggled to maintain a that... Available primary research in response to a doctor ’ S understanding of the concept advanced! File [ see additional file [ see additional file [ see evaluate the use of systematic reviews to advance nursing practice [... The tenuous position of advanced practice nurse freedom to operate within broader policy frameworks [ ]! Consider documents that describe or evaluate frameworks, maps or conceptual experience advanced! Involved in their care [ 33 ]: perspectives of learners and.! They resented PNs being given extended duties after they had completed a relatively small amount of training was!

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