Advanced Practice Nurse Task Questionnaire (APN-TQ)

Abstract

The Advanced Practice Nurse Task Questionnaire (APN-TQ) is an internationally recognized, psychometrically validated measurement instrument developed by Sonja Beckmann and colleagues (2023) to assess the range and frequency of professional clinical and non-clinical tasks executed by Advanced Practice Nurses (APNs). Grounded theoretically in Ann Hamric’s integrative model of advanced nursing practice, the APN-TQ conceptualizes advanced practice beyond idiosyncratic job descriptions or specialty constraints, offering a standardized evaluation framework capable of functioning across acute, ambulatory, and primary healthcare environments. The operationalized instrument comprises 32 items organized across seven distinct competency-driven domains: Direct Clinical Practice, Guidance and Coaching, Consultation, Evidence-Based Practice, Leadership, Collaboration, and Ethical Decision-Making. Each item is rated along an objective, frequency-anchored four-point ordinal response continuum ranging from “never” to “constantly” (>20 times, representing almost every working day). Initial psychometric validation was conducted in a national sample of Swiss nurses operating with expanded practice profiles. Exploratory factor analysis using principal axis factoring with Varimax rotation demonstrated a robust seven-factor structure accounting for 54.93% of the cumulative variance. Subscale internal consistency coefficients demonstrated high reliability, with Cronbach’s alpha values ranging from .795 to .879. Known-groups construct validity was corroborated through non-parametric Kruskal–Wallis testing, which demonstrated that distinct APN roles (e.g., Nurse Practitioners versus Clinical Nurse Specialists) manifest theoretically coherent variances in task frequency, particularly within direct clinical practice and organizational leadership. The APN-TQ serves as an essential tool for health services research, health policy formulation, organizational role differentiation, and longitudinal clinical workforce evaluation.

Keywords

Advanced Practice Nursing, APN-TQ, Hamric’s Model of Advanced Practice, Direct Clinical Practice, Clinical Nurse Specialist, Nurse Practitioner, Task Questionnaire, Psychometrics, Evidence-Based Practice, Healthcare Workforce Evaluation

Authors

The Advanced Practice Nurse Task Questionnaire was conceptualized, operationalized, and psychometrically validated by an interdisciplinary team of nurse scientists and clinical leaders in Switzerland:

• Sonja Beckmann, PhD, RN (ORCID: 0000-0002-6574-5893) — Center of Clinical Nursing Science, University Hospital Zurich, Zurich, Switzerland. Email: [email protected].
• Gabriela Schmid-Mohler, PhD, RN (ORCID: 0000-0002-2610-636X) — Center of Clinical Nursing Science, University Hospital Zurich, Zurich, Switzerland.
• Marianne Müller, MSc, RN — School of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.
• Elisabeth Spichiger, PhD, RN — Directorate of Nursing, Inselspital, Bern University Hospital, Bern, Switzerland.
• Dunja Nicca, PhD, RN — Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zürich, Zurich, Switzerland.
• Manuela Eicher, PhD, RN (ORCID: 0000-0002-7691-0719) — Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and Medicine, University of Lausanne and Lausanne University Hospital (CHUV), Lausanne, Switzerland.
• Andrea Ullmann-Bremi, PhD, RN — University Children’s Hospital Zurich, Zurich, Switzerland.
• Heidi Petry, PhD, RN (ORCID: 0000-0001-5220-4273) — Center of Clinical Nursing Science, University Hospital Zurich, Zurich, Switzerland.

Purpose

The central purpose of the Advanced Practice Nurse Task Questionnaire (APN-TQ) is to provide an objective, standardized, and empirically grounded instrument that quantifies the real-world operational execution of advanced nursing tasks across health systems. Internationally, the implementation of advanced practice nursing roles has been characterized by substantial heterogeneity in title, scope of practice, regulatory legislation, and institutional deployment. While titles such as Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), and blended or hybrid roles are widely recognized, health care administrators, policymakers, and interprofessional teams frequently struggle to delineate the precise behavioral boundaries and daily activities that differentiate these advanced clinicians from registered nurses (RNs) and medical practitioners.

Historically, research on advanced practice has suffered from a reliance on self-report instruments that confound perceived competence, self-efficacy, or theoretical knowledge with actual behavioral practice frequency. Clinicians might report high competence in research critique or ethical consultation, yet structural institutional barriers might prevent them from ever performing those tasks in daily service. The APN-TQ resolves this discrepancy by shifting the analytical focus entirely toward observable behavioral task frequency. Rather than asking how capable an advanced practitioner feels, the questionnaire systematically measures how often specific tasks are executed within defined timeframes.

In clinical, academic, and policy domains, the APN-TQ fulfills several vital applications:

• Health Services and Workforce Research: Facilitates rigorous cross-sectional and longitudinal evaluations of how APN roles are operationalized across hospital departments, ambulatory clinics, long-term care institutions, and rural networks.
• Role Delineation and Differentiation: Clarifies the empirical distinctions between Nurse Practitioners, Clinical Nurse Specialists, and blended practice models, identifying whether clinicians are primarily engaged in direct disease management or systemic quality improvement.
• Institutional Optimization and Resource Allocation: Enables healthcare managers to identify non-advanced tasks, scope-of-practice restrictions, and institutional bottlenecks that impede advanced clinicians from practicing at the full extent of their education and licensing.
• Curricular Evaluation in Graduate Nursing Education: Provides Master of Science in Nursing (MSN) and Doctor of Nursing Practice (DNP) programs with an outcome evaluation tool to assess whether graduates successfully implement advanced competencies in their post-graduation employment.

Psychological Construct

The psychological and behavioral construct operationalized by the APN-TQ is advanced nursing task execution. Unlike generalized work sampling or administrative job descriptions, advanced nursing practice represents a complex, multi-tiered professional behavioral repertoire where direct clinical decision-making is inextricably linked with organizational systems thinking, scholarship, and ethics. The construct is conceptualized as a multidimensional behavioral domain composed of seven primary factors:

1. Direct Clinical Practice

This core dimension measures the frequency with which the clinician applies advanced assessment, diagnostic reasoning, and disease management skills directly to patients with complex acute and chronic conditions. Representative behaviors include conducting holistic physical examinations, formulating differential diagnoses, ordering and interpreting laboratory and radiographic diagnostics, initiating pharmacologic therapies, and coordinating therapeutic care pathways. Within psychological measurement, this factor reflects high-acuity cognitive processing, clinical reasoning under uncertainty, and autonomous decision-making.

2. Expert Guidance and Coaching

This factor captures educational, relational, and supportive interventions directed toward patients, family caregivers, and clinical nursing personnel. The construct encompasses advanced patient education aimed at health literacy and self-management, psychological counseling during severe illness transitions, clinical mentoring of registered nurses, and formal preceptorship of postgraduate nursing students. It reflects interpersonal behavioral competencies, pedagogical modeling, and therapeutic communication.

3. Consultation

The consultation dimension assesses the multi-phase clinical consulting process. Rather than informal advice-giving, advanced consultation is operationalized as receiving formal internal or external consultation requests, conducting comprehensive secondary assessments, delivering structured written and verbal therapeutic recommendations, and systematically monitoring the implementation and outcomes of those consultations. This construct evaluates the clinician’s position as an authoritative clinical resource within healthcare organizations.

4. Research and Evidence-Based Practice (EBP)

This dimension operationalizes the behavioral manifestation of clinical scholarship. It measures how frequently clinicians critically appraise empirical literature, synthesize meta-analyses and practice guidelines, translate scientific evidence into localized clinical protocols, participate directly in empirical research projects, and disseminate clinical outcomes through scholarly presentations and peer-reviewed publications. This construct bridges cognitive academic competence and direct bedside translation.

5. Clinical and Professional Leadership

Leadership within the APN-TQ construct is characterized not by administrative line management or budgetary oversight, but by transformational clinical leadership. It encompasses initiating quality improvement audits, establishing institutional patient safety policies, guiding adverse event analyses, facilitating institutional change management, and representing professional nursing on regional, national, and international health policy committees.

6. Collaboration

The collaboration subscale assesses the frequency of interprofessional and intraprofessional coordination. It measures proactive engagement with physicians, allied health specialists, and community agencies to align clinical treatment plans, mediate interprofessional clinical conflicts, and manage complex transitions of care across outpatient, acute, and home care environments.

7. Ethical Decision-Making

This dimension captures the structured moral and ethical behaviors required when navigating modern medical technology and end-of-life care. Behaviors include identifying nuanced ethical dilemmas, safeguarding patient autonomy and informed consent, advocating for marginalized patient populations, and chairing or participating in formal institutional ethics committees and case deliberations.

Theoretical Framework

The conceptual architecture of the APN-TQ is explicitly derived from Hamric’s Integrative Model of Advanced Practice Nursing (Tracy & O’Grady, 2018). First articulated by Ann Hamric and continually refined over three decades, this model posits that advanced practice nursing is defined by a primary core competency—Direct Clinical Practice—which is vitalized, informed, and surrounded by six central core competencies: guidance and coaching, consultation, evidence-based practice, leadership, collaboration, and ethical decision-making.

Hamric’s model contends that any nurse operating at an advanced practice level must maintain direct clinical engagement with patients and families. If a professional performs solely organizational leadership, research, or academic teaching without direct clinical patient engagement, their role transitions into nursing administration, health informatics, or academic education rather than advanced practice nursing. Conversely, if a clinician engages in direct patient care without integrating clinical scholarship, interprofessional consultation, and ethical advocacy, their role remains aligned with specialized registered nursing rather than advanced practice. The APN-TQ operationalizes Hamric’s conceptual assertion into measurable behavioral indicators.

To transition from abstract theoretical definitions to concrete questionnaire items, Beckmann and colleagues adapted the systematic instrument development framework established in Guide No. 87 of the Association for Medical Education in Europe (AMEE) (Artino Jr. et al., 2014). This rigorous seven-step framework involves conducting comprehensive literature reviews, synthesizing existing qualitative and quantitative descriptions of APN scopes of practice, drafting item pools aligned with conceptual definitions, conducting cognitive interviews to assess respondent burden and comprehension, and empirically testing items through psychometric factor analyses.

Validity

The Advanced Practice Nurse Task Questionnaire was subjected to comprehensive psychometric evaluation to confirm content validity, face validity, and construct validity.

Content and Face Validity

Initial item generation yielded a pool of 62 potential task statements derived from an extensive review of international advanced practice literature. Content validity was evaluated through a rigorous dual-method approach combining written quantitative scoring by clinical experts with qualitative cognitive debriefing interviews. Expert panels reviewed each item for relevance, clarity, and representativeness within the Swiss healthcare context.

Items were evaluated using the Item-Level Content Validity Index (I-CVI). Nine items achieved a borderline CVI threshold of 0.80. These items underwent intensive deliberation by the core research panel: two items demonstrating semantic redundancy or low contextual relevance were removed, while seven items were retained due to their critical theoretical importance for capturing evolving APN capabilities (e.g., items reflecting autonomous diagnostic ordering and pharmacologic prescribing, which represent emerging competencies in European health systems). Through iterative expert refinement, the initial pool was streamlined to 32 finalized items, confirming exceptional face and content validity.

Construct Validity and Known-Groups Comparisons

Construct validity was established through known-groups hypothesis testing utilizing non-parametric Kruskal–Wallis tests across different functional APN role configurations: Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and clinicians operating in hybrid/blended roles. The theoretical literature posits that while both roles share core competencies, NPs focus predominantly on direct clinical disease management, whereas CNSs allocate greater time to organizational leadership, staff education, and system-level improvements.

Empirical findings strongly supported the researchers’ theoretical hypotheses:

• Direct Clinical Practice: Nurse Practitioners demonstrated statistically significant higher performance frequencies in direct clinical tasks compared to both blended-role clinicians and Clinical Nurse Specialists (p < .001).
• Leadership: Clinical Nurse Specialists engaged in professional and organizational leadership tasks significantly more frequently than individuals in blended roles and Nurse Practitioners (p < .01).
• Shared Competencies: Across the remaining subscales—Evidence-Based Practice, Ethical Decision-Making, Consultation, Guidance/Coaching, and Collaboration—no statistically significant between-group divergences were observed. This empirically confirmed Hamric’s theoretical premise that these core competencies are universally executed across all APN roles regardless of specific clinical title.

Reliability

The internal consistency reliability of the APN-TQ was rigorously evaluated using Cronbach’s alpha across the total scale and its seven individual factor-derived subscales within the validation sample of advanced practice nurses in Switzerland.

The subscales exhibited strong to excellent internal consistency coefficients, well exceeding the conventional academic threshold of .70 for psychometric tools:

• Direct Clinical Practice: α = .879
• Research and Evidence-Based Practice: α = .864
• Clinical and Professional Leadership: α = .845
• Consultation: α = .832
• Expert Guidance and Coaching: α = .818
• Ethical Decision-Making: α = .804
• Collaboration: α = .795

Item-total correlations across all 32 items exceeded .40, demonstrating that each item contributed meaningfully to the variance of its corresponding theoretical subscale without redundant multicollinearity. Standard error of measurement (SEM) calculations confirmed minimal measurement error across the response continuum.

Factor Analysis

The structural validity and latent dimensionality of the APN-TQ were investigated using Exploratory Factor Analysis (EFA). Because the items measure behavioral frequency distributions that may violate strict multivariate normality, principal axis factoring (PAF) was selected as the extraction method, accompanied by an orthogonal Varimax rotation to produce distinct, interpretable factor clusters aligned with Hamric’s conceptual domains.

Pre-estimation diagnostics confirmed the suitability of the data matrix for factor extraction:

• Kaiser-Meyer-Olkin (KMO) Measure of Sampling Adequacy: The overall KMO value was > .85, indicating high sampling adequacy and shared common variance among items.
• Bartlett’s Test of Sphericity: Reached statistical significance (p < .001), rejecting the null hypothesis that the correlation matrix was an identity matrix.

The exploratory factor analysis extracted a clear seven-factor solution based on Kaiser’s eigenvalue-greater-than-one criterion and visual inspection of Cattell’s scree plot. The seven rotated factors collectively accounted for 54.93% of the cumulative variance in the data matrix:

• Factor 1: Evidence-Based Practice: Explains substantial common variance, with items loading heavily on research critique, protocol drafting, and study involvement.
• Factor 2: Direct Clinical Practice: Items addressing physical assessments, diagnostic testing, and therapeutic management loaded cleanly (loadings ranging from .52 to .81).
• Factor 3: Leadership: Captures quality management, safety culture, and change management behaviors.
• Factor 4: Guidance and Coaching: Unites staff mentorship, clinical preceptorship, and specialized patient education.
• Factor 5: Consultation: Comprises formal consultation requests, written assessments, and recommendation tracking.
• Factor 6: Ethical Decision-Making: Gathers ethical deliberation, dilemma analysis, and patient rights advocacy.
• Factor 7: Collaboration: Captures interprofessional coordination, conflict resolution, and cross-sector transitions.

All 32 items exhibited factor loadings exceeding the .40 threshold on their primary factor, with minimal cross-loading (< .30 on secondary factors), confirming the dimensional independence of the operationalized competency domains.

Instrument / Measurement Tool

• Test Type: Original psychometric self-report task questionnaire / Behavioral frequency assessment tool.
• Format: Standardized self-administered survey instrument (available in paper and secure online formats).
• Item Count: 32 items.
• Dimensions / Subscales: 7 distinct factors:
  1. Direct Clinical Practice (Items 1–7)
  2. Expert Guidance and Coaching (Items 8–13)
  3. Consultation (Items 14–17)
  4. Research and Evidence-Based Practice (Items 18–22)
  5. Clinical and Professional Leadership (Items 23–26)
  6. Collaboration (Items 27–29)
  7. Ethical Decision-Making (Items 30–32)
• Response Categories: Four-point frequency-anchored ordinal response scale:
  • Never (0 points): The task is not performed in clinical practice.
  • Occasionally (1 point): 1–10 times, approximately every third working day.
  • Frequently (2 points): 11–20 times, approximately every second working day.
  • Constantly (3 points): >20 times, almost every working day.
• Scoring Rules:
  • Items are scored numerically from 0 (“never”) to 3 (“constantly”).
  • No items are reverse-scored; all items are phrased positively to reflect task frequency.
  • Subscale scores are calculated as the mean score (ranging from 0 to 3) or sum of items within each of the seven dimensions.
  • A total composite APN task execution score can be computed as the sum (range: 0–96) or overall grand mean across all 32 items, with higher scores reflecting greater frequency and breadth of advanced nursing practice implementation.
• Language Available: English (original validation conducted in Switzerland with corresponding localized survey instruments).
• Target Population: Registered nurses with master’s level or doctoral education operating in advanced practice roles (Nurse Practitioners, Clinical Nurse Specialists, hybrid APN roles) across hospital, ambulatory, home care, and community healthcare environments.

Permissions & Fee and Test Year

The Advanced Practice Nurse Task Questionnaire was developed and formally published in 2023 by Sonja Beckmann and colleagues. The instrument was introduced in the Journal of Advanced Nursing (Wiley).

Fee and Commercial Status: The APN-TQ is non-commercial and free of charge for non-commercial academic research, health services evaluation, and educational quality improvement projects. Commercial exploitation, incorporation into proprietary digital software suites, or unauthorized paid redistribution is prohibited.

Permissions: Researchers wishing to utilize, translate, or adapt the APN-TQ for specific national healthcare settings must contact the corresponding author to request formal permission and maintain version control:

Corresponding Author Contact:
Dr. Sonja Beckmann, PhD, RN
Center of Clinical Nursing Science, University Hospital Zurich
Raemistrasse 100, CH-8091 Zurich, Switzerland
Email: [email protected]

References

• Artino, A. R., Jr., La Rochelle, J. S., Dezee, K. J., & Gehlbach, H. (2014). Developing questionnaires for educational research: AMEE Guide No. 87. Medical Teacher, 36(6), 463–474. https://doi.org/10.3109/0142159X.2014.889814
• Beckmann, S., Schmid‐Mohler, G., Müller, M., Spichiger, E., Nicca, D., Eicher, M., Ullmann‐Bremi, A., & Petry, H. (2023). Validation of the newly developed Advanced Practice Nurse Task Questionnaire: A national survey. Journal of Advanced Nursing, 79(12), 4791–4803. https://doi.org/10.1111/jan.15752
• Hamric, A. B., Hanson, C. M., Tracy, M. F., & O’Grady, E. T. (2014). Advanced Practice Nursing: An Integrative Approach (5th ed.). Saunders/Elsevier.
• Tracy, M. F., & O’Grady, E. T. (2018). Hamric and Hanson’s Advanced Practice Nursing: An Integrative Approach (6th ed.). Elsevier.

13. Items of the Scale (Questionnaire)