Advanced practice role delineation within Hong Kong: A cross‐sectional study

Abstract A career ladder for nurses, including several levels of nursing practice and specific roles for advanced practice nurses, was introduced in Hong Kong around the start of the 21st century. To date no studies have distinguished the practices of advanced practice nurses in Hong Kong. This cross‐sectional study, conducted between November 2020 and March 2021, aims to identify and differentiate the practice patterns of advanced practice nurses by utilizing the Advanced Practice Role Delineation tool. A total of 191 responses were obtained. Three roles were identified: nurse consultant, advanced practice nurse, and advanced practice nurse in management. Among the five advanced practice nursing domains, nurses were most frequently involved in Education and in Direct Comprehensive Care activities, while least active in Research and in Publication and Professional Leadership. Identifying activities in various nursing roles helps to differentiate their responsibilities and provides new insights for role utilization and support. Although the role characteristics are shaped by country contexts, research evidence on practice patterns may be used to support international discussion and efforts to promote role clarity and effective role introduction and optimization.

match existing nursing position titles to the needs of the services, and by educators to design postgraduate courses responsive to the clinical career ladder of nurses.

| INTRODUCTION
Increasingly, countries are challenged to provide access to high quality care and are seeking ways to optimize provider expertise to meet demands while containing healthcare costs (International Council of Nurses [ICN], 2020; World Health Organization [WHO], 2020). There is a need for clearer understanding of the practice patterns of nurses in advanced roles to assist healthcare managers in clarifying and making effective decisions about how to best utilize and integrate these various roles within organizations. In this article, we will describe the advanced practice nursing workforce within Hong Kong and outline study results identifying and differentiating practice activities among recognized advanced practice nursing roles.

| BACKGROUND
Specialist and advanced practice beyond generalist nursing have become internationally recognized nursing phenomena during the last few decades. However, a great variation among different levels of nursing roles exists between and within countries, as countries are in different stages of advanced practice nursing role development (ICN, 2020;Maier et al., 2017). Although all nurses contribute to the healthcare system through their different roles, those in advanced practice nursing roles build on registered nurse (RN) practice by integrating higher level knowledge, skills, and experience across several clinical and non-clinical role domains with the ultimate aim to meet population health needs and improve health and health system outcomes (Bryant-Lukosius & Wong, 2019;ICN, 2020). One of the most significant barriers to effective advanced practice nursing role implementation and utilization is the lack of role clarity (Mohr & Coke, 2018). The ICN defines an advanced practice nurse (APN) as "a generalist or specialised nurse who has acquired, through additional graduate education (minimum of a master's degree), the expert knowledge base, complex decisionmaking skills and clinical competencies for Advanced Nursing Practice, the characteristics of which are shaped by the context in which they are credentialed to practice" (ICN, 2020, pp. 6).
There are about 46 000 RNs eligible to practice in the Hong Kong (Nursing Council of Hong Kong, 2020b). A career ladder for nurses was introduced around the start of the 21st century to respond to the challenges of complex client care and the advancement of healthcare (Wong & Wong, 2020). The first advanced practice nursing role was piloted in 2003 with the majority of positions occurring in inpatient settings . Currently, there are approximately 5000 APNs in Hong Kong (Hospital Authority, 2021a). While APNs do not have licensure beyond that of RNs, the career ladder of the RN, specialist nurse (SN), APN, and nurse consultant (NC) are clearly set out . The professional career ladder is a three-tier pathway. Tier 1 applies for RNs and SNs, tier 2 applies to the APNs/ ward managers, and tier 3 to NCs (Chan, 2014;. Two streams of career progression are provided through the system: management or clinical  Although a Master's degree is a minimum requirement for APN recognition, some nurses may not meet this standard due to lack of formal credentialing processes and the recent development of educational standards for the APN in Hong Kong (Wong & Wong, 2020).
The NC role was introduced in Hong Kong in 2009 to model the Clinical Nurse Specialist (CNS) role in the United States (Wong et al., 2017). NCs are required to have a master's education, specialty training, and eight years of work experience (Lee et al., 2013), and are seen to practice at the highest level of a clinical nursing career (Gardner et al., 2017;Lee et al., 2013;Wong et al., 2017). Evaluations of the NC in Hong Kong demonstrate their exemplary work and positive impact on patient, nursing profession, and organization outcomes (Wong et al., 2017). NCs are involved in developing and providing complex patient care and leading quality improvement initiatives. Five main categories of roles and responsibilities of NCs have been recognized: expert practitioner, service developer and planner, quality assurer, educator, and researcher (Chan, 2014). The number of NCs in Hong Kong is around 160 and recently the Hospital Authority has announced strategies to retain staff by increasing the number of NCs and associate NCs to 200 and 442, respectively. The introduction of the associate NC rank, as a step prior to NC, helps to facilitate continuous development of nursing talents and promote nursing service standards (Hospital Authority, 2021b).
The APN in management (APN-M) is one of 16 specialties in advanced nursing practice in Hong Kong. This position performs a specialist role in a clinical specialty, providing management in advanced nursing care and acting as a resource person to patients, relatives, staff, and the public, as appropriate. APN-Ms also engage in research activities and promote evidence-based practice for the betterment of service (Hospital Authority, n.d.) APN-Ms and NCs share common competencies developed by the Hong Kong Academy of Nursing in 2018 (Wong & Wong, 2020). These competencies align with international standards for advanced practice nursing and promote role clarity and integration within Hong Kong (Wong et al., 2017). The role activities of APN-Ms cover the scope of five core competence areas comprising (1)  With the development of specialist and advanced practice nursing roles, it is necessary to distinguish and specify these roles in the professional promotion ladders . This comparative descriptive study aimed to identify and distinguish the practice patterns of APNs within Hong Kong by utilizing the Advanced Practice Role Delineation (APRD) tool (Gardner et al., 2013). The APRD tool has been used internationally to distinguish nursing and advanced practice nursing roles  in several countries, for example in the United States, Australia, Finland, Canada, Spain, New Zealand, and Singapore (Carryer et al., 2018;Gardner et al., 2013;Jokiniemi et al., 2018;Jokiniemi, Heikkilä, et al., 2021a;Mick & Ackerman, 2000; Sevilla Guerra, Miranda Salmer on, & Zabalegui, 2018a; Woo et al., 2019).
The results of this study may be used to support evidence-informed decision-making and role optimization through improved understanding about the unique and complementary nature of these roles. This research is aligned with the strategic priorities of the WHO (2015) to effectively introduce advanced roles for nurses within healthcare systems.

| Research design
A cross-sectional study was conducted using an online self-report questionnaire. To report the study, the Strengthening the Reporting of Observation studies in Epidemiology (STROBE) checklist was utilized (File S1 in the Supporting Information).

| Data collection and participants
The data collection was conducted in Hong Kong between November 2020 and March 2021. To be eligible for this study, participants had to be (a) working in a clinical role, and (b) certified in a specialized area of practice with a master's or doctorate degree. To reach a wide range of APNs the invitation to participate in the study, including an information letter and link to the survey, was sent to the members of the Hong Kong Academy of Nursing (n = 2546) and advanced practice nursing postgraduate students (n = 313) through a Hong Kong Academy of Nursing contact person who is also an author of this paper. A total of four remainder e-mails were sent out through the contact person.

| Measurements
The questionnaire had three sections: (1) sociodemographic data on professional (i.e., role title, practice experience, certification, area of practice) and educational (specialty education, highest level of nursing education) qualifications; (2) the 41-item APRD tool identifying practice activities in the five domains of Direct Comprehensive Care, Support of Systems, Education, Research, and Professional Leadership; and (3) perceptions on time spent overall in each of the domains. In Sections 2 and 3, a 5-point Likert-type scale (0 = never, 1 = rarely, 2 = sometimes, 3 = often, and 4 = always) was used to measure the use of nursing activities or overall time spent in domains of practice during a typical month (Gardner et al., 2013).
The content of the APRD tool has been studied in Australia (Chang et al., 2010), Finland (Jokiniemi, Ackerman, et al., 2021b), and Spain (Sevilla Guerra et al., 2018a, b). The construct of the tool has been examined by exploratory factor analysis (Chang et al., 2012) and confirmatory factor analysis Sevilla Guerra, Risco Vilarasau, et al., 2018b). Although some changes have been suggested in previous studies, the original tool was used in this study to allow for comparison across studies using the APRD tool. The Cronbach's alpha scores for the APRD tool have been found to be between 0.90 (Jokiniemi, Heikkilä, et al., 2021a) and 0.94 (Chang et al., 2012), indicating strong internal consistency for the scale. In 2019, a pilot test of the instrument was conducted in Hong Kong (n = 12). Only minor amendments to the questionnaire were required to improve understandability of the language for local readers

| Statistical analysis
The Statistical Package for the Social Sciences (SPSS, version 27.0, 2017) was used to analyze the data. There were no missing data, so therefore raw data could be used to analyze the results. To describe the characteristics of the sample, descriptive statistics were used. Categorical variables are presented as counts and percentages and continuous variables are presented as means. For Section 2 of the questionnaire, the sum of each activity in the APRD tool and the mean scores for each subscale were calculated to illustrate their use. For the purpose of analysis, role titles of the participants were organized into the three categories of NC, APN, and APN-M. Based on role category, role differences related to activities in the five domains were compared using a one-way analysis of variance (ANOVA) with a p-value of less than 0.05 to establish significance. ANOVA between-role effects taking into account respondents' gender, age, education, experience in current position, and type of hospital were explored. Tukey's HSD post hoc test was used to explore the statistically significant differences between role categories. Age was organized into three groups (from lowest to 40 years; 41 to 50 years; and from 51 years and over), and years of experience in current position was categorized into three groups (from 0 to 2 years [novice/beginner]; 2 to 4 years [competent/proficient]; and 5 years and above [approaching expert/ expert]). Prior to analysis the assumptions of ANOVA were tested (homoskedasticity, normality). Data were not normally distributed; however, this was not a critical assumption in multivariable analysis.
Finally, for Section 3 of the questionnaire, we calculated an overall mean score for time spent in each domain of practice.

| Ethical considerations
The study protocol was approved by the University of Eastern Finland Committee on Research Ethics (statement number 22/2018). The Hong Kong Academy of Nurses granted permission to conduct the study with its members. Data were handled in strict confidence and disposed of in accordance with the policy guidelines of the Hong Kong Academy of Nursing. The prospective participants were informed of the study in writing. At the beginning of the survey, participants were asked to indicate their consent to be involved in the study by checking "Yes" to a consent statement. Participants could leave the study at any point.

| Participant characteristics
A total of 2850 questionnaires were distributed, of which 191 were completed for a total response rate of 7%. The majority (81%) of respondents were female with an average age of 47 years. They reported working in different roles involving 13 position titles such as NC, midwife consultant, deputy chief nurse, APN, and ward manager. The position titles were re-grouped into the three role categories of NC (n = 34), APNs (n = 106), and APN-M (n = 51) aligning the two streams of career progression (management or clinical) and accommodating the second (APNs/nurse managers) and third (NCs) tiers of the career ladder. The majority of nurses (92.2%) had a master's or doctoral degree and worked in an acute hospital (81%).
Respondents had worked as a RN for an average of 25.6 years and had been in their current APN position for an average of 6.2 years.
Nurse consultants were most educated and experienced out of the three groups (Table 1). Over 80% of the respondents provided direct patient care with 98 percent working in full-time positions.
Several specialties were recognized with the largest three being critical care (n = 10), cardiac care (n = 9), and community and public health (n = 7).    into account. Eleven percent of the variability in the Education activity could be accounted for by the role category of the respondent.

| Research
Nurse consultants were the most active in the Research domain (mean 2.72), having the highest involvement in all activities (Table 2).
While APNs and APN-Ms were most active in Item 4.2, "Participate in audits to monitor and improve quality of patients care practices," the highest activity score of NCs was for Item 4.4, "Uses research evidence to guide practice and policy changes" (Table 2). Based on Tukey post hoc analysis, statistically significant differences between role categories were found in all six items. APNs and APN-Ms did not differ in any of the items. The ANOVA between-role effect for Research showed statistically significant differences between role categories (p < 0.001) when gender, age, education, experience in current position, and hospital type were taken into account. Fourteen percent of the variability in the Research activity could be accounted for by the role category of the respondent.

| Publication and professional leadership
Finally, NCs were the most active in the Publication and Professional Leadership domain (mean 2.84), and had the highest involvement in all activities across the three groups (Table 2). APN-Ms were more active in each of the Publication and Professional Leadership activities than APNs. For all three groups the highest activity sore was seen on Item 5.2, "Serve as a resource or committee member in professional organisations." There were statistically significant differences between role categories in all six items (Table 2). APNs and APN-Ms did not differ significantly in three of the six items. The ANOVA between-role effect for Publication and Professional Leadership showed statistically significant differences between role categories (p < 0.001) when gender, age, education, experience in current position, and hospital type were taken into account. Nine percent of the variability in the Publication and Professional Leadership activity could be accounted for by the role category of the respondent.   (Donald et al., 2010). Internationally, to improve role clarity and understanding among advanced practice nursing stakeholders and to provide a foundation for nursing career planning and development, standardization of nursing titles within and across countries is needed (Gardner et al., 2017;ICN, 2020). Nursing career ladders may be country specific and therefore consideration needs to be given to extrapolate the discussions to the international advanced practice nursing community. These findings suggest that APN-Ms do meet the international definition for advanced practice nursing within the context of the Hong

| DISCUSSION
Kong healthcare system. Only through discussion and discernment of various advanced practice nursing roles and titling in different countries may we begin to increase our understanding and promote greater clarity and consistency of advanced practice nursing roles internationally.
About 8% of the nurses who participated in this study had not completed an MSc as an expected requirement for advanced practice.
It is possible that some of these nurses were graduate students in master's programs who were already working in an advanced practice nursing role. Although a master's degree is a minimum requirement for APNs in Hong Kong (The Nursing Council of Hong Kong, 2020b), there is no formal credentialing process in place to enforce this requirement in practice (Wong & Wong, 2020). While internationally, a master's degree education is valued within the APN community, many studies report variability in APN education, especially when credential requirements are not in place (see e.g., Gardner et al., 2016;Jokiniemi et al., 2018;Jokiniemi, Heikkilä, et al., 2021a). While research regarding advanced practice nursing education is limited, a few studies have demonstrated that completion of a master's degree is important for promoting the optimal implementation of advanced practice nursing role domains (Kilpatrick et al., 2013;Pauly et al., 2004).
Across the three role categories, APNs were highly involved in activities for each of the five domains of advanced practice. Overall, nurses were most frequently engaged in Education activities. In order to deliver high quality care, nurses are expected to continually update their knowledge and skills to maintain their competency to practice. As APNs are found to focus on educating, precepting, mentoring, and facilitating the professional development of nurses and nursing students (Price & Reichert, 2017) and competence that match population health and practice setting needs, and also systems level health policies that optimize the utilization of APN expertise and scope of practice (Wong & Wong, 2020). Identifying advanced practice nursing activities among different advanced practice nursing roles helps to differentiate their responsibilities and provides new insights for role utilization and support.

| Study limitations and implications for future research
Typical of online surveys, the response rate of the survey was low despite the use of multiple reminders. The low response rate may be attributed to the practice demands on nurses associated with the global COVID-19 pandemic. The sample of the study was, however, adequate for the methodology. Furthermore, the distribution outlined in Table 1  care and service quality. The study results add to the international literature aiming to delineate the varied advanced practice nursing roles.
As career ladders and roles are country specific, consideration needs to be given on the generalizability of the results in the international advanced practice nursing community. However, it is necessary to distinguish and specify various advanced practice nursing roles to ensure the consistent implementation and integration of these roles within the clinical nursing career ladder. Identifying activities in different nursing positions will help to differentiate these roles and responsibilities and aid in the governance and clarity of these roles.