Factors influencing the development of advanced practice nursing in Singapore

The development of advanced practice nursing (APN) roles has become a worldwide trend as healthcare planners explore innovative options for the provision of healthcare services. The integration of these new nursing roles presents a dynamic change for healthcare professionals and the systems in which they practice. Suitable policies should ideally support the inclusion of APN roles and their practice potential, however, a review of the literature found no evidence that demonstrated relevant policymaking, these policy processes and subsequent implementation of the intent of policy. The aim of the research was to investigate APN policy development from the beginning periods of discussion through various stages of decision making to realisation in practice. An ethnographic design with an instrumental case study approach selecting Singapore as the case was chosen to examine policy development associated with the processes of integrating APN roles into the healthcare workforce. The study consisted of four phases. The first phase involved a review of Singapore documents associated with APN development (N=47). The second phase consisted of interviews with government officials, university dignitaries and academic staff (N=12) who had knowledge of the APN initiative. The third phase included interviews with nursing managers, medical directors and medical consultants (N=11) who were associated with APN implementation. The fourth phase was comprised of interviews and participant observation with APNs (N=15) to ascertain the realities of putting the intent of policy into practice. A systematic approach using NVIVO computer-assisted qualitative data software for coding the data and organizing the coded data led to a classification of categories and subcategories. Identification of relationships between the categories resulted in an account of policy development and implementation. The findings of the ethnography present a comprehensive and in-depth account of the complexities of policy decision making and the challenges of introducing a new healthcare professional such as an APN. Based on study findings it is argued that an understanding of pivotal stages in policy making could lead to a strategic and coordinated approach supportive of APN development and implementation. Knowledge gained from this research led to the creation of an innovative conceptual policy framework. Critical points to consider when launching an APN initiative emerged from the research and are included in the framework. Although the research was conducted in Singapore the study contributes to a wider understanding of the development of APN roles and relevant policies.