Development of a conceptual policy framework for advanced practice nursing: an ethnographic study.

Aim: To report on a study examining policy development for advanced practice nursing from intent of policy to realization in practice. Background: Inclusion of advanced practice nursing roles in the healthcare workforce is a worldwide trend. Optimal advanced nursing practice requires supportive policies. Little is known about how policy is developed and implemented. Design: Ethnography using an instrumental case study approach was selected to give an in-depth understanding of the experiences of one country (Singapore) to contribute to insight into development elsewhere. Methods: The four-phase study was conducted from 2008–2012 and included document analysis (n = 47), interviews with key policy decision makers (n = 12), interviews with nursing managers and medical directors (n = 11), interviews and participant observation with advanced practice nurses (n = 15). Results: Key policymakers in positions of authority were able to promote policy development. However, this was characterized by lack of strategic planning for implementation. A vague understanding by nursing managers and medical directors of policies, the role and its position in the healthcare workforce led to indecision and uncertainty in execution. Advanced practice nurses developed their role based on theory acquired in their academic programme but were unsure what role to assume in practice. Lack of clear guidelines led to unanticipated difficulties for institutions and healthcare systems. Conclusion: Strategic planning could facilitate integration of advanced practice nurses into the healthcare workforce. A Conceptual Policy Framework is proposed as a guide for a coordinated approach to policy development and implementation for advanced practice nursing.