The evolving roles of the Advanced Practice Nurse in postgraduate studies

. Advanced Practice Nurses (APNs) are key to improving access to timely care at the local level and to ensuring quality, innovation, and developments in healthcare in Europe and worldwide. As we begin the process of implementing APNs in the Estonian healthcare system, it is necessary to understand what roles are attributed to APNs within the nursing profession in order to distinguish them from the roles of other healthcare professionals in the country. Therefore, qualitative longitudinal research was conducted to describe and understand how APN students identify their higher-level roles in their specialities and positions. 183 narrative essays written by the APN students in the second semester of their master’s studies in Health Sciences at Tallinn Health Care College were analysed using inductive content analysis. Eight roles of APNs were revealed as observed by the students themselves: the continuously evolving direct care provider, the experience counsellor, the improving practitioner, the team player, the fighter and the advocate, the developer and the promoter, the leader, and the advancer on the move. From this we can conclude that APN students are already experienced and focused on clinical practice and evidence-based activities as a Clinical Nurse Specialist (CNS) while they have acquired and apply all the other core competencies of an Advanced Practise Nurse. The period of the COVID-19 pandemic and developing advanced practice has significantly increased the APN students’ ability to work in and lead teams, and their courage to protect the rights of patients and nurses.


INTRODUCTION
Historically, the expansion of the boundaries of nursing roles has emerged from society's need in times of war and other crises. It is likely that the first specialist nurse was an anaesthetist in the United States of America during the Civil War in the second half of the 19th century, but even then, fights with physicians over specialist nurses' rights went on for decades (Tracy and O'Grady 2017). In Europe, nurses in Finland, Hungary, Ireland, Spain, and the United Kingdom have all reported the establishment and extensive implementation of APN roles. However, this is a time-consuming process of change, and many countries are still in the early stages of developing APN roles, including Romania, Cyprus, Slovenia, and Estonia (Unsworth et al. 2022).
After more than 60 years of global development, there is a growing recognition of the importance of APNs and their impact on increasing access to health services and improving the quality of health services and health outcomes, especially for disadvantaged populations. Moreover, in the current labour and economic crisis, the only way out for the sustainability and development of healthcare is to introduce new healthcare models with APNs (Bryant-Lukosius et al. 2017). Therefore, APNs are one of the fastest-growing groups of health professionals worldwide. Particularly during the COVID-19 pandemic, APNs proved that their role in patient care, treatment, and survival has been critical. Internationally there is a growing recognition of their importance in innovating health systems to improve access to health services, improve people's health, and reduce healthcare costs (ICN annual report 2021).
While the need for APNs is internationally recognised, the roles of both nurses and APNs in different countries, and sometimes in different organisations within the same country, have often moved in different directions and can therefore vary significantly between organisations and countries. In addition to the lack of clarity about roles, there is a lot of confusion about job titles, which can be misleading, especially for patients and carers, without know ing the context or local healthcare arrangements (Bryant-Lukosius et al. 2017). For example, an international study identified 52 different advanced practice nursing role titles with wide variations in regulations in 26 countries, the most common being clinical nurse specialist (CNS), nurse practitioner (NP), and APN (Heale and Buckley 2015). For this reason, research has focused on role descriptions rather than titles because they cause more confusion, and it is then more difficult to understand what a person's tasks are and how they differ from each other. Bryant-Lukosius et al. (2017) reviewed the literature on APN roles -clinical nurse specialist and nurse practitioner -in low/middle income countries (Latin America and the Caribbean). The literature reveals that the roles of APNs are usually described as follows.
• The APN's most important role, with the highest intensity, is related to the clinical practice, which involves the direct and indirect care of patients, families, specific patient groups, communities or popu lations. With in-depth knowledge, the CNS keeps abreast of developments in treatment and technology, and specialises in caring for populations with more complex health problems, either in acute care or in long-term care and primary care. Society today needs APNs to focus on chronic disease prevention and disease progression management for their patients' journeys in order to reduce the burden of disease and mortality in an ageing population, particularly for chronic diseases such as mental health and cardiovascular disease, cancer, and diabetes. APNs, therefore, have a broader remit than registered nurses, which also means a more holistic approach to health assessment, disease and injury prevention and care management, and more direct contact with patients. Depending on national legislation, APNs may also be authorised to diagnose, prescribe medicines and treatment, admit patients to hospital, and refer them to other health professionals (Bryant-Lukosius et al. 2017;Dowling et al. 2013).
In addition, APNs have heightened responsibilities for nursing and health system improvement and innovation to provide more sustainable models of healthcare by combining many higher-level roles: • educating all healthcare professionals, • researching and promoting evidence-based practice, • leading innovation and healthcare improvement in the organisation, • developing profession (Bryant-Lukosius et al. 2017).
Finally, regardless of the country, title or combination of roles, the most common characteristic of APNs includes the completion of an accredited education programme for APNs and formal recognition with the license, registration, certificate and/or credentialling (Schober et al. 2020).
Since 2008, the International Council of Nurses (ICN) de fines an Advanced Practice Nurse as 'the one who has acquired, through additional education, the expert knowl edge base, complex decision-making skills and clinical competencies for expanded nursing practice, the characteristics of which are shaped by the context in which they are credentialed to practice.' (Schober et al. 2020). In Estonia, the definition of an APN and the minimum competences required in general were established and approved by the Council of the Estonian Nurses Union in 2020 as follows: 'A nurse who has completed the nurses' professional training curriculum or has a master's degree in Health Sciences in one of the nursing specialities and has acquired greater clinical competence and decisionmaking skills and the ability to work both individually and in an interdisciplinary team and to lead research and development.' (Liivet 2020).
The growing need to expand the role of nurses in the Estonian healthcare system initially led health colleges in Tartu and Tallinn, in interdisciplinary cooperation with employers, to establish a curriculum for the professional training of graduate nurses between 2006 and 2009. As a master's degree is recommended for entry into advanced practice nursing based on the latest recommendations of the ICN, both health colleges in Estonia started a master's programme in Health Sciences in 2018, which aims to provide 'op portunities for deepening knowledge in health sciences, readiness for independent and interdisciplinary col laboration, to conduct research and development work and continuing studies at doctoral level.' (EKKA 2021). Currently, there are two professional master's degree programmes for educating APNs in Estonia. The duration of study for master's students is 1.5 years (90 European Credit Points), after which they obtain the MSc degree and the title of APN with specialisation in one of the four areas of nursing: clinical nursing, health nursing, intensive care nursing or mental health nursing. Barriers to the introduction of APN roles in Estonia are similar to those reported in the international literature, including role clarity, legislation, regulation, education programmes and resources, funding, and physicians' resistance (Bryant-Lukosius et al. 2017;Unsworth et al. 2022). Although we have agreed at national level on the need of advanced practice nursing, and established the definition, minimum competences and the internationally accredited curriculum of APN, the developments at political and legislative level are time-consuming because of the need to develop consensus and clarity about the roles, qualifications, and rights of APNs in the national health system (Unsworth et al. 2022). As there is currently some intra-and interprofessional resistance to expanding the boundaries of nursing in Estonia (Ministry of Social Affairs 2022), and empirical evidence is needed to convince stakeholders of the value of APN roles (Unsworth et al. 2022), it is necessary to first understand what the roles of APNs mean within the profession. The best way to obtain the necessary information is to ask the master's students selected to become the first APNs in Estonia as most of them are already leaders in nursing and their studies and developments have been mostly supported by their employer. Tallinn Health Care College admitted 240 master's students in 2018-2022, 161 of whom have already graduated as APNs with master's degrees in Health Sciences.

MATERIALS AND METHODS
The aim of this empirical research was to describe and understand APN students' identification with their higherlevel roles in their specialty. Answers were sought to five research questions: • What higher-level roles do APN students identify in their professional lives? • How do they profile these roles? • What is the frequency of these roles among APN students in 2019-2022? • What are the possible trends in the frequency of roles among APN students over the years? • What is the overall distribution of different roles among APN students for all four years combined? Data collection was carried out within the framework of the APN national study programme -master's programme in Health Sciences of Tallinn Health Care Collegeby the first author of the article in educational (informal) agreement with the students and the college. The data collection and analysis were not a stand-alone research project but a part of the learning process in which students wrote a narrative essay with the aim of making sense of their role in professional development through the narration of a personal experience/event. Following a verbal agreement with the students at the beginning of the subject, the essays were read only by the subject lecturer, who provided summative feedback to the entire group in the form of content analysis results. This is referred to as a reflexive approach to personal and professional learning (Moon 2001), where the student writes a self-reflection on their role in the workplace, and the lecturer, in giving feedback, reflects non-judgmentally and non-personally on the information read from the student's individual homework. By sharing feedback with the whole group in the seminar, each student further had the opportunity to compare themselves anonymously with their peers. In addition, this form of feedback was also a practical example for the students on how to carry out a content analysis and present the results.
For four consecutive years between 2019 and 2022, as part of the Development Project subject, first-year APN students were asked to write a narrative essay as an individual homework assignment to decipher their role in the professional development of their specialty through the narration of a personal experience/event.
A total of 183 Health Sciences master's students' (hereinafter APN students) narrative essays about their role in professional development were included in data analysis. The number of essays per year was as follows: in 2019 N = 55, in 2020 N = 50, in 2021 N = 38, in 2022 N = 40. The lengths of written essays varied from one to four pages, with most being up to three pages long.
This qualitative data was analysed both qualitatively and quantitatively in pursuit of the answers to the five research questions. Among all the textual material, an inductive content analysis was conducted to search for students' expressions of their higher-level roles in nursing and in their specialty. Although students often described themselves as performing multiple roles simultaneously, a single role was identified from each student's essay to take precedence. In each text, phrases or paragraphs describing the author's role were selected and coded for analysis. In total, 29 substantive codes of roles were categorised into eight categories of different roles of APNs. To describe these roles in more detail, the researcher quoted most of the characteristic expressions from the database in the results anonymously, so that all details that could identify the author were replaced by three dots.
To quantify the resulting role prevalence among APN students, the frequency distribution of each role concept was calculated for the total number of essays and for each year. To identify possible trends in role development across the four years, comparisons were made between years based on the number of research participants (n). To estimate the proportion of roles among all participants, the percentage (%) was calculated.
No personal details of the research participants were asked, although some of the students' narratives were very personal. Therefore, the researcher made every effort to ensure that the students could not be identified when the research findings were published. The essays were deliberately only viewed by the lecturer, the first author of this article, who was the only person entrusted by the students to read and give feedback on their essays, personally analyse them and provide the students with a summary of the role codes with citations to each course. During the analysis process, the researcher added the initials of the author of the essay in parentheses to the original citations in the summary so that she could return to the original data if needed and so that she could explain to the students the definition of their role during the course. Each year's summary was shared with the course students only to teach and discuss the different roles of the APN and to check that the researcher had understood the essay writers correctly. Prior to this seminar, students were informed orally and by writing in the summary slides that there was a possibility that they might be recognised in the quote in the summary, and that those who did not wish their quote to be shared should inform the lecturer immediately. The quotes that the authors did not allow to be shared were removed from the summary, but all quotes were included in the data analysis as no one objected. Citations from student essays published in this article are anonymous. The author wrote to the owners of the individual quota tions, informed them of the article and obtained written permissions to publish them anonymously in this article.

Qualitative descriptions of the higher-level roles among APN students
Out of 183 APN students' essays, 29 codes and 8 categories of APN roles were identified between 2019-2022, shown in Table 1. The continuously evolving direct care provider is dedicated to helping patients as well as to nursing and to one's profession. He/she carries and passes on the core values of nursing through continuous development of self and others. He/she leads change in the health, well-being, safety, and experience of patients and their families.
'... just being a good nurse is not enough. It takes indepth learning, skill, and continuous self-improvement. ... I believe that the role of nursing today is to link all these elements together and provide a better service to patients and society. A caring nurse is a valuable asset, because he/she contributes to one's own knowledge and development, cares about one´s work and profession, takes on new challenges, and in doing so is keen to be heard and valued.' (Translation of a quote from an APN student essay, 2020) The experience counsellor has had a difficult personal experience as a patient or healthcare professional. He/she faced and came out of the crisis on one's own and works with passion to prevent or alleviate others from having the same negative experience. Such person understands and can support others in the same situation.
'I didn't want to accept vague justifications: that's just the way it is and that's all. And those moments of doubt made me look for answers again, and there were no exceptional times when ... I had done the groundwork by already looking for scientific information that had been published in the world. ... I made the decision that I now wanted to go on learning and use that to offer sciencebased help to others.' (Translation of a quote from an APN student essay, 2022) The improving practitioner works as a practitioner in nursing or midwifery. He/she sees problems in their working environment and/or in the patient journey and wants to help and make a difference. Each improving practitioner seeks solutions and intervenes on one's own initiative to make the world a better place through small steps.
'I believe that each of us should improve our working environment along the lines of the Estonian saying "Where you see a mistake, come and help!". ... During my master's studies, I was introduced to the principles of shared governance and realised that this is exactly the kind of approach that is lacking in our system...' (Translation of a quote from an APN student essay, 2019) The team player understands the importance of teamwork to realise his/her ideas. He/she gives his/her best and empowers others in the team. Team player is an equal partner who also takes on the role of leader in a crisis and leads the team when necessary.
'... no health professional acts alone. ... At some point, you may be the strongest member of the team and you must make decisions or lead the team; I have been in that situation and after that event I realised the importance of developing teamwork and team skills.' (Translation of a quote from an APN student essay, 2022) The fighter and advocate sees the big picture of health and wellbeing and highlights the challenges. He/she advocates for the rights of nurses and patients and calls for fundamental (revolutionary) changes in the attitudes, knowl edge, skills, and practises of health professionals. He/she is fierce in his/her statements and actions.
'Today, these professional boundaries are clearly unde fined in terms of day-to-day tasks, and issues related to treatment are increasingly becoming mixed with ... nursing. As a specialty developer, I see myself seeking clearer answers to these questions. ... As an ardent debater on these issues, I have also been called a "disobedient nurse" ...' (Translation of a quote from an APN student essay, 2022) The developer and promoter has vision, commitment, and responsibility. He/she values the professional development of self and others and shares his/her attitude, knowledge, and skills with health professionals as a mentor, coach, trainer, or development facilitator. Influencer, initi -ator, and leader of change in healthcare, he/she serves as a role model for colleagues.
'My role in professional development is to guide others to be curious, to help them set goals and relate (new) knowledge, sometimes to create intrigue to show a different perspective. ... we influence the most powerful ones to change. We are more -we ask questions, we mediate and advocate, we investigate, we educate, we problem- The leader with a clear vision, strong will and a strategy to drive change is decisive and determined. He/ she systematically develops his/her leadership skills and professional competence and is a role model for his/her colleagues.
'Achieving change and development is not an individual effort, it takes the whole team. Everyone needs to have a common purpose and will. Through self-development I can develop and lead the team. As a leader, I need to be able to manage the whole process. This is my role in professional development.' (Translation of a quote from an APN student essay, 2020) The advancer on the move prioritises individual and professional development. He/she focuses on the journey and is in the moment, seeking his/her own path and seeing where it leads. He/she knows what to do and how to do it and focuses on the task at hand, accepting the challenges that life offers.
'It's important for me to keep evolving ... I believe that one day it will be time for me to move on and find a new path in healthcare, where I can find opportunities to develop and realise myself. In the meantime, I'm developing myself through academic studies...' (Translation of a quote from an APN student essay, 2019)

Quantitative prevalence of higher-level roles among APN students in 2019-2022
Figure 1 presents the distribution of roles among APN students (n) from different years. An upward trend is visible in the number of team players, leaders, and especially fighters and advocates among APN students. While 2019 had the highest number of improving practitioners, and developers and promoters, the following year 2020 had the equal number of continuously evolving di rect care providers with improved practitioners. The number of students with the improving practitioner's role has decreased each year, starting with 19 students in 2019 and ending with 4 students in 2022. Compared to previous years, there were more fighters and advocates in 2022 but no advancers on the move. At the same time, the number of continuously evolving direct care providers, and developers and promoters increased by two or three times in 2022 compared to 2021. Figure 2 presents the overall percentage of different roles among four (different) groups of APN students altogether during 2019-2022, mainly comprised of improving practitioners, developers and promoters, continuously evolv ing direct care providers, followed by leaders, team players, and advancers on the move. The role of ex perience counsellor as well as the role of fighter and advocate were the least represented among APN students.

DISCUSSION
Advanced practice nursing students in Estonia focus on the patient and the provision of a higher level of direct patient care in their specialty while having acquired and applying all the other core competencies of an APN. Most APN students described their role in line with Hamric and Hamson's description (Tracy and O'Grady 2017) of a higher-level role for APNs with a direct focus on clinical practice and evidence-based ac tivities as a CNS, who is a clini cal expert in his/her specialty, provides direct care to pa tients with complex health problems, is a skilled coun sellor for patients and colleagues, develops supportive and educating members of the healthcare team, improves the quality of patient care, manages change in a complex organisation, facilitates better advocacy for pa tients and nurses.
At the start of the APN education in Estonia, the abundance of improving practitioners and the lack of team players and leaders among the first-year APN students in 2019 suggests that the development activities for direct care nurses at that time were more individual, local, and driven by external circumstances rather than a strategy. It can be assumed that prior to the official adoption of the definition and minimum competences of APNs in Estonia in 2020, the role of developer and promoter was seen as separate from the role that the direct care nurse or practitioner should perform in their daily work. However, over the years, the improving practitioner has been replaced by continuously evolving direct care providers, leaders, team players, fighters and advocates, in addition to the already working developers and promoters, indicating that among APN students, practitioner roles are increasingly blending with development and leadership roles. The fact that there are more fighters and advocates among APN students suggests, on the one hand, that APN students have become increasingly aware of the various quality issues after establishing APN status and feel more responsible and empowered to deal with them. On the other hand, it may also indicate that the rights of both patients and professionals have suffered due to the pandemic and the worsening socio-economic crises in the health sector and require more attention from APNs than in the past.
Based on this research, we have evidence that the role of APNs in Estonia is evolving in line with European best practices and ICN guidelines (Schober et al. 2020). However, there is much to be achieved to educate APNs and provide advanced practice nursing to all those in need in Estonia. Therefore, strong nursing leadership is needed to align the APN role with policy priorities and to work with other healthcare providers and policy makers to successfully implement the role. Taking into account the differences in each country, it is important to systematically assess the health needs of the country and population to provide evidence-based and human-centred judgments on which combination of APN roles should be implemented (Bryant-Lukosius et al. 2017).
Close collaboration between clinical service managers, practitioners, and educators is essential for the successful role development of APNs (Unsworth et al. 2022). Education is important for defining and designing the roles of APNs as well as for the effective implementation of these roles in healthcare practice (Briant-Lukosius et al. 2017). Both health care colleges have compiled and developed the master's programme for APNs in accordance with the ICN competence require ments (Schober et al. 2020) and the Estonian Nursing and Midwifery Development Strategy 2021-2030(Estonian Nurses Union et al. 2020. Lecturers and graduates from Tallinn and Tartu health care colleges as well as lecturers from the master's programme in Health Sciences (Nursing Science) at the University of Tartu, employers and the Estonian Nurses Union worked together to create the cur riculum. Therefore, the Health Sciences curriculum was one step ahead in securing the requirements by involving practitioners, educators, and managers in the development of the APN role. (EKKA 2021). In addition, we need to evaluate the effectiveness of the APN role in achieving better health outcomes to analyse how this education enables APNs to achieve their professional goals and meet the demands, expectations, and needs of patients.
Some of the APN roles were piloted in six Estonian hospitals in 2022. Consensus decisions based on the results of these pilot studies defining the new healthcare model and the roles of APNs in it have not yet been made. According to the PEPPA implementation and evaluation framework (Bryant-Lukosius and DiCenso 2004), for successful implementation and optimal use of APN roles in any country, in addition to APN students, all other stakeholders such as patients, physicians, and other healthcare providers as well as educators, managers, and policy makers need to be involved to define the goals and boundaries of APN roles according to population health needs and human resources (Briant-Lukosius et al. 2017).
A limitation of the study is that the data were collected at a specific point in time, and it is acknowledged that students' views on the advanced practice role may and probably will change during their studies. However, it must also be acknowledged that students enter the master's programme with completely different experiences of advanced practice, role models, and (nursing) organisa tional cultures. Linked to this is also a culture clash be tween what students experience in higher education and what they see and experience in the workplace in relation to advanced practice and the value placed on it.

CONCLUSIONS
APN students in Estonia link their higher-level role to clinical work, helping patients directly or by developing others and the environment at every stage of the care pathway. Their in-depth knowledge and evidence-based approach to the profession in their speciality is particularly evident when helping patients with chronic and complex diseases and dealing with situations that require improvement of existing health services or even the development of a new healthcare model.
In light of the developments in the four years since APN training began, together with the introduction of the APN definition and core competencies, and considering that the first APNs graduated just in time for the start of the COVID-19 pandemic in January 2020, it is possible to conclude that the roles identified by APN students have remained the same, but that their proportion has changed in line with the deepening crisis in healthcare. Comparing the distribution of APN roles in different years, it can be concluded that the worsening socio-economic challenges and the pandemic in the last four years have strengthened the willingness of APN students to work in a team, to build and lead a team, and to advocate for nursing practise and patients' rights in order to improve the quality of care.
Further research and development should involve the already experienced APN nurses, patients, and other health professionals in Estonia to identify priority issues and goals for improving the model of care with APNs. The development of implementation strategies will require consensus building with different disciplines and patient associations, institutional and national leaders, and health policy makers. Educators of APNs, employers and professional associations of nurses and midwives will continue to work together to achieve this.