evidence & practice / advanced practice
REGULATION
Development and regulation of
advanced nurse practitioners in
the UK and internationally
King R, Tod A, Sanders T (2017) Development and regulation of advanced nurse practitioners in the UK and internationally.
Nursing Standard. 32, 14, 43-50. Date of submission: 2 March 2017; date of acceptance: 14 September 2017. doi: 10.7748/ns.2017.e10858
Rachel King
Doctoral research student,
Faculty of Medicine,
Dentistry and Health,
University of Sheffield,
Sheffield, England
Angela Tod
Professor of older people
and care, Faculty of
Medicine, Dentistry
and Health, University
of Sheffield, Sheffield,
England
Tom Sanders
Senior research fellow,
Faculty of Medicine,
Dentistry and Health,
University of Sheffield,
Sheffield, England
Correspondence
rlking1@sheffield.ac.uk
Conflict of interest
None declared
Peer review
This article has been
subject to external
double-blind peer
review and checked
for plagiarism using
automated software
nursingstandard.com
Abstract
The NHS in the UK is under increasing pressure as a result of financial and recruitment
issues, as well as an ageing population. Nursing has continued to adapt to this challenging
time. Over the past few years, the advanced nurse practitioner (ANP) role has been
implemented widely in primary and secondary care. However, the ANP role has lacked
consistency in scope of practice, training and regulation. This article summarises the
development of the ANP role in the UK and internationally, and issues relating to
regulation. Globally, ANPs are regulated by one of three different bodies: nationally
by central government or a professional body, or locally by employers. In the UK, the
role is regulated by local procedures, relying on employers to make decisions about
the scope and preparation for practice. Some of the challenges in the UK in relation to
ANP regulation are discussed, including variations in scope, organisational constraints
and lack of support. These challenges are exacerbated by a lack of role clarity, thereby
indicating there is a need to improve regulation of ANPs. The Royal College of Nursing
has responded to these challenges by introducing ‘credentialing’, a system for recording
qualifications, skills and experience, but the uptake of this process is yet to be evaluated.
Therefore, employers and ANPs should be aware of their collective responsibility for
ensuring appropriate role regulation.
Keywords
advanced clinical skills, advanced nurse practitioners, advanced practice, autonomous
practice, clinical competencies, credentialing, professional issues, regulation
THIS ARTICLE REFLECTS on the discharge decision-making by ANPs in
potential contribution of regulation of emergency care. This article is not based
advanced nurse practitioners (ANPs) in on the PhD data; it is based on findings
the UK. National regulation of ANPs from a narrative literature review,
has been repeatedly discussed since discussions with clinicians and recent
these roles first emerged, but it has never debates in the nursing press (Heale and
been implemented. However, the recent Rieck Buckley 2015, Maclaine 2017,
introduction of ‘credentialing’ by the Pearce 2017). In this article, the umbrella
Royal College of Nursing (RCN) (2017) term ANP is used to describe advanced
has brought the issue of regulation to the nursing roles (RCN 2012).
fore again.
This article was prompted by the Advanced nurse practitioner roles
first author’s experience as an ANP in The NHS in the UK is reaching capacity
primary care, as well as observations and and emergency departments (EDs) have
discussions she has had while conducting a been described as ‘close to tipping point’
doctoral study. The author’s PhD examines (Evans 2016). In these times of limited
volume 32 number 14 / 29 November 2017 / 43
evidence & practice / advanced practice
Online resources, the nursing profession has
For related articles visit continued to adapt to meet local demands.
the archive and search One response has been the increase in ANP
using the keywords. roles (Sheer and Wong 2008). ANPs have
Guidelines on writing for been defined as ‘registered nurses who
publication are available have acquired the expert knowledge base,
at: rcni.com/writeforus complex decision-making skills and clinical
competencies for expanded practice’
Acknowledgements (International Council of Nurses (ICN)
This doctoral study is 2017). The RCN (2017) stated that ANPs
funded by the National are ‘educated at master’s level… and have
Institute for Health the freedom and authority to act, making
Research (NIHR) autonomous decisions in the assessment,
Collaboration for diagnosis and treatment of patients’.
Leadership in Applied This article summarises the variations in
Health Research and the scope of the ANP role and discusses the
Care (CLAHRC) Yorkshire requirement for clarity of titles, training
and Humber. The views and regulation. National regulation of
expressed are those of the ANPs has been a topic of debate among
authors, and not those of policymakers in the UK for the past
the NHS, the NIHR or the 20 years. The system in the UK relies
Department of Health. on employers taking responsibility for
Rachel King would like to ANP regulation, from initial workforce
thank Professor Angela planning, to providing education, role
Tod and Dr Tom Sanders clarity and supervision. At a time when
for their continued regulation of all UK healthcare workers
support is being reviewed (Professional Standards
Authority for Health and Social Care
2016), this is a prime opportunity to
consider the challenges to employment
processes and reconsider national
regulation, in line with many other
countries (Sheer and Wong 2008).
Literature review
A narrative literature review was
undertaken in November 2016 and
updated in July 2017 to explore
information relating to the regulation of
ANP roles. Narrative literature reviews
offer a snapshot of prevalent knowledge
at a particular point in time (Booth et al
2016). The aim of this literature review
was to understand current processes of
regulation relating to the ANP role in the
UK. The Cumulative Index to Nursing and
Allied Health Literature and MEDLINE
databases were searched using the
keywords ‘regulation’ and ‘advanced nurse
practitioner’. Articles published from 2001
to 2017 were identified. Reference lists
were scanned for further relevant articles.
The articles were appraised by searching
44 / 29 November 2017 / volume 32 number 14
the titles followed by the full text for
discussions about the global regulation of
ANPs. Relevant grey literature was also
reviewed from the Nursing and Midwifery
Council (NMC), RCN, Royal College of
Emergency Medicine (RCEM), Department
of Health (DH), NHS England, NHS
Scotland and NHS Wales.
Development of the advanced nurse
practitioner role
Over the past few years there has been
a political drive to provide increasingly
cost-effective healthcare, leading to
the expansion of non-medical roles
(Abraham et al 2016). This has been
accompanied by nurses’ desire to
further their careers by increasing their
knowledge and clinical skills (Schober
and Affara 2006).
The ANP role was first introduced in
the US and Canada in the mid-1960s, the
UK in the mid-1980s, and New Zealand
and Australia in the 1990s (Pearson and
Peels 2002a, Furlong and Smith 2005,
Griffin and Melby 2006). Several factors
influenced the introduction of the ANP role
worldwide, including (Ketefian et al 2001,
Schober and Affara 2006):
»» Shortage of doctors.
»» Requirement to improve access to
primary care.
»» Requirement to improve care for
particular patient groups.
»» Government policy.
»» Interprofessional and intraprofessional
collaboration.
»» Nurse education.
»» Positive evaluations of the ANP role.
In the UK, factors influencing the
development of the ANP role included a
requirement to reduce healthcare costs,
improve access to healthcare and respond
to the reduced availability of doctors
(Pearson and Peels 2002a). ANPs in
the US and UK were first employed in
primary care to reduce doctors’ workloads;
however, they are now more prevalent in
secondary care (Pulcini et al 2010). Early
policy drivers of ANP role development in
the UK included a proposed redesign of the
health service outlined in The NHS Plan:
A Plan for Investment, A Plan for Reform
nursingstandard.com
(DH 2000), which aimed to provide
flexible services and put an end to the fixed
boundaries between doctors and other
healthcare professionals.
Several studies have explored
the effectiveness of the ANP role.
Williamson et al (2012) undertook a
ward-based ethnographic study of ANPs
and found they enhanced communication
and practice, thus improving the patient
journey. In research that used a case
study approach to explore the ANP role,
McDonnell et al (2015) concluded that
ANPs have a positive effect on patients,
other staff and organisational outcomes.
Griffin and Melby (2006) examined nurses’
and doctors’ perceptions of the ANP role
in a survey study. They found that it was
generally viewed positively, although
less so by GPs. They suggested that
multidisciplinary acceptance would
be improved by accredited, standardised
ANP training.
Since implementation, there has been
much ambiguity about advanced nursing
titles. A survey of 32 countries identified
13 different titles, including: nurse
practitioner, advanced practice nurse,
clinical nurse specialist, nurse specialist,
professional nurse, expert nurse and nurse
consultant (Pulcini et al 2010). Despite
recommendations for standardisation of
role and educational preparation, there
remains confusion and wide variation in
the use of the ANP title (Pearson and Peels
2002b, Marsden et al 2003, Furlong and
Smith 2005, Hoskins 2012).
Advanced nurse practitioner scope
of practice
Scope of practice describes the role to be
undertaken, including knowledge, attitudes
and skills required by the healthcare
practitioner, as well as mechanisms of
accountability (Schober and Affara 2006).
The ANP role varies globally depending
on the particular healthcare requirements
of the population; however, it commonly
includes roles that were traditionally
undertaken by physicians (Schober and
Affara 2006, Heale and Rieck Buckley
2015). In the UK, the ANP role involves:
practising autonomously; taking a patient
nursingstandard.com
history; using advanced clinical skills to KEY POINT
assess, order and interpret tests; giving There has been much
diagnoses; and deciding on the most ambiguity about advanced
appropriate management, including nursing titles. A survey
prescribing medicines (Latter et al 2007, of 32 countries identified
DH 2010, Brook and Rushforth 2011). 13 different titles, including:
In a literature review conducted by nurse practitioner,
Mantzoukas and Watkinson (2007), advanced practice
important themes related to the ANP nurse, clinical nurse
role were outlined, including: the use of specialist, nurse specialist,
knowledge in practice; critical thinking and professional nurse, expert
analytical skills; clinical judgement; and nurse and nurse consultant
decision-making. (Pulcini et al 2010)
ANPs work in a range of healthcare
settings. For example, in ophthalmology
they provide emergency care, perform
minor surgery and run glaucoma clinics
(Marsden et al 2013). In EDs, they take
a patient history, perform a physical
examination, order and interpret relevant
tests, prescribe treatments, and discharge or
refer patients (Fawdon and Adams 2013).
One study found the variation in scope
of practice was related to individual
competence and the preferences of medical
colleagues (Maddox et al 2016). Jones
(2005) stated that clear role definitions
and expectations are important to the
success of the ANP role. Although previous
literature has identified wide variations in
scope of practice, this article focuses on
those roles with significant overlap with
medicine, suggesting that improving role
regulation would provide further clarity.
Four pillars of advanced practice
In referring to advanced practice, the
term ‘level of practice’ rather than
‘scope of practice’ is used (RCN 2012).
NHS Wales (2010) stated: ‘Advanced
practice should be viewed as a “level of
practice” rather than a specific role and
it is not exclusively characterised by the
clinical domain but may also include
those working in research, education,
management/leadership roles.’
NHS Scotland (2010) outlined four
important characteristics of the ANP role:
clinical practice, leadership, education
and research. These were adapted
to devise a framework for advanced
practice incorporating four ‘pillars’ or
characteristics – clinical, management
volume 32 number 14 / 29 November 2017 / 45
evidence & practice / advanced practice
KEY POINT and leadership, research, and education
The DH (2010) has outlined (NHS Wales 2010). Each pillar of the ANP
several competencies role will be evident in different degrees for
for ANPs, including each ANP. However, they are all essential
critical thinking, applying to advanced practice (RCN 2012).
knowledge and skills to
a range of clinically and Educational preparation
professionally challenging Educational preparation of ANPs differs
situations, and working between countries and within the UK,
across professional with programmes being developed
boundaries. These independently of each other (Griffin and
competencies are broad Melby 2006, Schober and Affara 2006,
and open to interpretation Heale and Rieck Buckley 2015). Master’s
by nurses, employers level preparation is a minimum standard
and educators for the ANP role in many countries.
However, although there is a consensus
among UK health departments that
master’s level education for ANPs will be
compulsory in the future (RCN 2012),
this is not presently the case (Schober and
Affara 2006, Pulcini et al 2010). One
survey found that less than one third of
ANPs in the UK had a master’s degree
(Gerrish et al 2011). Some pre-registration
nursing courses in the UK now include
more advanced skills in their content,
particularly those at master’s level, leading
to a blurring of the academic boundaries
between junior and advanced nurses. It is
here that the value of nursing experience
should also be taken into consideration
when appointing nurses to ANP positions
(Benner 1984).
The DH (2010) outlined several
competencies for ANPs, including critical
thinking, applying knowledge and skills
to a range of clinically and professionally
challenging situations, and working
across professional boundaries. These
competencies are broad and open to
interpretation by nurses, employers and
educators. The RCN (2012) designed a
framework of standards and competencies
that higher education institutions may
use to develop educational programmes
for ANPs. Nurses who complete such
accredited programmes can receive a
certificate from the RCN. However, this
training is not a requirement for all ANP
practice, and not all nurses are members of
the RCN.
In the UK, some clinical specialties have
developed their own bespoke training
46 / 29 November 2017 / volume 32 number 14
courses. For example, the RCEM (2015)
developed a training programme for
advanced clinical practitioners, aimed at
training advanced nurses and paramedics
in emergency care. The course involves
demonstrating proficiency in a range of
competencies, which are assessed locally
by a medical consultant supervisor,
followed by a final external assessment.
This scheme, although supported by
the RCN, is regulated by the medical
profession. It is not a requirement of all
ANPs in all EDs. This raises the question
of who should oversee the regulation of
ANPs: national governance, nursing or
medical professional bodies, employers or
individuals.
UK regulation procedures
The ICN (2017) recommends regulation
of the ANP role; however, there is
widespread variation in how this is
achieved. Surveys exploring regulation of
ANP roles internationally have identified
three main areas, including government
regulation, professional body regulation
or local regulation by employers (Heale
and Rieck Buckley 2015, Maier 2015).
Many countries require national
regulation of ANP titles, scope of practice
and registration, including Ireland,
the Netherlands, Australia, Canada
and the US (Maier 2015). The UK and
Finland have adopted local governance
of the ANP role by employers; however,
they do regulate prescriptive authority
nationally (Maier 2015). The lack of
national role regulation in the UK has
added to the wide discrepancy in practice,
challenges associated with role clarity
and issues in tracking workforce data,
especially since the ANP role is developing
opportunistically (Maier 2015). However,
NHS Scotland (2010) has argued that a
change to more formalised regulation is
not necessary; it maintains that advanced
practice merely reflects the next step on the
nursing career ladder.
NHS Wales (2010) stated that
organisations should ensure robust
governance arrangements are in place
before establishing the ANP role, and in
relation to all types and levels of practice.
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Similarly, the RCN (2012) emphasised
that improving employer-led governance is
important in providing guidance to ANPs
and ensuring patient safety. The RCN
(2012) is opposed to the use of the ANP
title where a nurse has not completed the
appropriate educational preparation. The
NMC (2007) outlined its concerns about
the confusion resulting from the plethora
of advanced nursing job titles, several of
which may imply a level of knowledge and
competence not possessed by the nurse.
The NMC (2017) implemented a process
of revalidation that must be undertaken
by all registered nurses every three years.
In the revalidation process, registrants
must demonstrate that they have met the
following requirements (NMC 2017):
»» 450 practice hours or 900 hours if
revalidating as a nurse and midwife.
»» 35 hours of continuing professional
development, of which 20 hours must
be participatory.
»» Five pieces of practice-related feedback.
»» Five written reflective accounts.
»» A reflective discussion.
A health and character declaration is
also required, as well as a professional
indemnity agreement and an interview with
a confirmer (NMC 2017). Revalidation
may improve local ANP regulation because
it requires the registrant to have a reflective
discussion with a clinical supervisor,
providing opportunities to highlight
learning requirements.
The RCN (2017) introduced
credentialing for ANPs: a system where
ANPs can formally log their experience,
competence and qualifications.
Credentialing was introduced to provide
formal recognition of ANPs’ skills and
experience for ANPs, employers, colleagues
and the public (RCN 2017). This process
has been piloted in two phases to test the
assessment criteria and was introduced
nationally in spring 2017 (Pearce 2017).
The requirements for credentialing are
outlined in Box 1.
There will be a transitional period until
2020 where nurses who do not meet all
of the criteria in Box 1 may still meet the
credentials by submitting a portfolio of
evidence. Those who meet the standard
nursingstandard.com
are included on a publicly available list KEY POINT
of ANPs (RCN 2017). This process of Credentialing was
credentialing is voluntary, so although it introduced to provide
will identify those who are meeting the formal recognition of ANPs’
RCN (2017) requirements of advanced skills and experience
practice, it will not mean that those for ANPs, employers,
who are not listed are not meeting the colleagues and the
requirements. Therefore, it still leaves the public (RCN 2017). This
ANP title open to misuse and confusion. process has been piloted
The NMC governance procedures require in two phases to test the
nurses to adhere to The Code: Professional assessment criteria and
Standards of Practice and Behaviour for was introduced nationally
Nurses and Midwives (NMC 2015) by in spring 2017 (Pearce 2017)
employer governance and self-governance.
The introduction of credentialing, although
voluntary, could be seen as a step towards
a structured and formalised process of
regulation of the ANP’s expanded roles and
responsibilities (Pearce 2017). National
regulation would provide further clarity on
the required educational standards, scope
of practice and titles (Brook and Rushforth
2011, Carney 2016).
Compulsory national regulation
A review of the similarities and differences
of international regulation of ANPs found
that national regulation occurs in Ireland,
Japan, New Zealand, Singapore, Hong
Kong, Australia and the US, but not in the
UK (Carney 2016). This raises the question
of why the UK has not followed suit.
Brook and Rushforth (2011) stated that
UK national regulation of the ANP role is
crucial for public protection because of the
high-risk nature of the diagnostic aspect
of the role. They stated that the public
should expect nurses performing advanced
autonomous roles to work under similar
regulated standards as medicine, especially
BOX 1. Advanced nurse practitioner
credentialing requirements
»» A relevant master’s degree
»» An independent non-medical prescribing
qualification registered with the Nursing and
Midwifery Council (NMC)
»» An active member of the NMC
»» A relevant job plan that reflects the four pillars of
advanced level practice: clinical practice, leadership,
education and research
(Royal College of Nursing 2017)
volume 32 number 14 / 29 November 2017 / 47
evidence & practice / advanced practice
KEY POINT since all doctors are required to meet
The ANP role is different minimum standards of education regulated
from other advanced and by the General Medical Council (2011).
traditional nursing roles The Council for Healthcare Regulatory
because of the nature Excellence (CHRE) (2009), now the
of its expanded scope Professional Standards Authority for
(Brook and Rushforth Health and Social Care, defended the
2011). This includes decision not to introduce national
assessing, diagnosing regulation of the ANP role on the basis
and treating patients with that it was an extension of the skills
undifferentiated conditions assessed at initial registration. However,
(Fawdon and Adams 2013) the counterargument is that the role has
changed significantly in recent years in the
UK; there is increasing and considerable
overlap with the medical profession
and thus the argument against national
regulation is weakened. The CHRE (2009)
also suggested that national regulation
should be considered if the risks to
patients differed from those ordinarily
associated with the profession. The ANP
role is different from other advanced and
traditional nursing roles because of the
nature of its expanded scope (Brook and
Rushforth 2011). This includes assessing,
diagnosing and treating patients with
undifferentiated conditions (Fawdon and
Adams 2013). For some, this supports a
stronger argument for national regulation
and may partly explain why the RCN
(2017) adopted the credentialing approach.
However, the NMC and CHRE appear
to remain unconvinced that regulation
is required.
A report by the Professional Standards
Authority for Health and Social Care
(2016) proposed a transformation of
the regulation of all health and social
care professionals, making it easier
for these individuals to work across
professional boundaries. This would
provide an important opportunity to
incorporate the ANP role into a national
regulatory system.
If national regulation is to be
reconsidered, it would be essential to
maintain standards and prevent harm,
be clear, address the full scope of practice,
and enable flexible roles in the workforce
so as not to pose a further barrier to
ANP practice (Heale and Rieck Buckley
2015, Maier 2015, Professional Standards
Authority for Health and Social Care 2016).
48 / 29 November 2017 / volume 32 number 14
Challenges associated with local
regulation of the advanced nurse
practitioner role in the UK
Although the nursing profession has
embraced the new challenges of advanced
practice, several studies have identified
issues that may be related to a lack of
national regulation. Heale and Rieck
Buckley (2015) reported that a lack of
title protection and regulation provide
a barrier to ANPs working within their
full scope of practice. Others have
suggested that ANPs experience a lack
of standardised educational preparation,
organisational constraints, a lack of
cooperation from colleagues and no
freedom to refer patients and order
investigations (Marsden et al 2003,
Pulcini et al 2010, Barton and Mashlan
2011, Lloyd-Rees 2016).
Variation in remuneration has also been
identified as a barrier to ANP working.
Since 2004, NHS staff in the UK, except
doctors, dentists and senior managers,
have been paid according to the Agenda
for Change (AfC) pay scale, guided by
a knowledge and skills framework (DH
1999). The RCN (2012) recommended
that a nurse working autonomously as
an ANP should be paid at AfC band 8a.
Employers are not always adhering to
these guidelines, with pay varying from
AfC band 6 to band 8a (Fawdon and
Adams 2013, Marsden et al 2013). The
RCN (2012) stated that caution was
required when applying for ANP jobs
since some prospective employers persist
in ‘offering so-called ANP posts for which
no specific educational preparation is
required, and for which the remuneration
on offer is not appropriate for a nurse
as competent and highly qualified as
an ANP’.
The process of RCN credentialing is
voluntary and will cost nurses a fee every
three years (Pearce 2017). It is in the early
stages of implementation and uptake of
the process is yet to be evaluated. It may
also be unclear to ANPs whether they
should credential with the RCN or
one of the specialist medical colleges,
of which the RCEM is the only one
offering this service.
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Discussion
This article has outlined the scope of
expanded practice of ANPs and the
variations in regulation globally and
locally. It has emphasised a requirement
for employers and ANPs to take
responsibility for their own professional
regulation to ensure they are adequately
prepared for the roles they are expected
to undertake. This process is supported
by revalidation (NMC 2017), as well as
credentialing opportunities by medical and
nursing colleges (RCN 2012, RCEM 2015,
Pearce 2017).
In light of the increasing number
of ANPs in the UK, and challenges
related to local regulation, the nursing
profession should reconsider the most
effective mechanism for supporting staff
in the ANP role and ensuring patient
safety. Employers, clinical managers
and educators have to respond to
developments in nursing careers to
provide the most relevant training and
support. In the UK, the responsibility for
ANP regulation lies with local employers
in primary and secondary care. This
literature review has revealed that, as
a result of local governance, there are
wide variations in scope and educational
preparation of ANPs (Heale and Rieck
Buckley 2015).
Ideally, employers should adhere to
guidelines developed by professional
bodies on the appropriate training, pay,
working conditions and support for
ANPs. One way that employers and
ANPs could do this is to use the RCN
credentialing system (Pearce 2017), and
potentially use it in the future as evidence
of fitness to practise and working at
an ANP level. The Code (NMC 2015)
indicates that ANPs themselves have a
responsibility to regulate their practice.
As before, the RCN (2017) credentialing
system could be useful for them. However,
if this joint employer-ANP led governance
is not routinely occurring in practice,
or is found to be inconsistent, national
regulation by the NMC may need to be
reconsidered. The argument to support
this is to provide standardised support
for nurses, as well as an increased
nursingstandard.com
understanding of the role by other KEY POINT
healthcare professionals, and increased In light of the increasing
public awareness of the service provided number of ANPs in the UK,
by ANPs. and challenges related
The challenge for policymakers, to local regulation, the
educators and researchers is to identify nursing profession should
what type of roles and skills nurses are reconsider the most
undertaking in practice, and provide effective mechanism for
optimum ways to train and support them. supporting staff in the
Future research should explore the scope ANP role and ensuring
of practice of ANPs in various contexts patient safety
across the UK, and how consistent the
mechanisms of regulation are in different
healthcare settings.
Conclusion
After summarising the international
literature on the development and support
of the ANP role, it is suggested that
the increase in implementation of this
role in the UK should be accompanied
by sound regulatory processes. There
needs to be effective understanding and
sharing of local regulatory procedures
by employers. The RCN (2017) system
of credentialing may also become a
requirement by employers as evidence of
ANP-level working. This will enhance
public protection and ensure adequate
preparation for practice. There are also
arguments for reconsidering national
regulation of the ANP role in the UK,
which, in some cases, significantly
overlaps with medicine.
Regardless of process, regulation
should continue to enable flexibility
in meeting the demands of the ever-
changing healthcare context, while
providing structured training and
support for nurses.
IMPLICATIONS FOR PRACTICE
»» ANPs and employers should aware of their
current responsibilities in ensuring local
ANP regulation.
»» In supporting local regulation,
‘credentialing’ could be used by employers
and ANPs as evidence of ANP level of
practice.
»» If ambiguity of ANP education, scope
of practice and regulation persist, then
national regulation in the UK should be
reconsidered, in line with many other
countries.
volume 32 number 14 / 29 November 2017 / 49
evidence & practice / advanced practice
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