Integrating Advanced Practice Nurses into the Health System: Views from Nurses and Healthcare Managers – A Qualitative Study

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Despite the pivotal role that nurses occupy within the Lithuanian healthcare system, the potential of Advanced Practice Nurses remains largely unrealized, due to the absence of clearly defined formal roles and structured pathways that would enable Advanced Practice Nurses to practise autonomously and apply their advanced competencies to their full extent. This study aimed to examine the perspectives of selected nurses and healthcare managers on the integration of Advanced Practice Nurses into health system. Methods A qualitative descriptive design employing semi-structured interviews was utilised in Lithuania with Advanced Practice Nurses (n=6) and healthcare managers (n=6). Participants were recruited based on inclusion criteria. The interviews covered six main topics. The average duration of the interviews was 67.5 minutes. Data were analyzed using thematic analysis. Results The analysis yielded twelve themes each for the nurses and healthcare managers. The results indicated that Advanced Practice Nurses and healthcare managers have differing perspectives on how Advanced Practice Nurses should be integrated, yet both regard it as a necessary evolution of the health system. Motivations were both personal and professional, driven by a commitment to holistic, patient-centred care and the desire to apply advanced clinical knowledge autonomously. Managers perceived successful integration as dependent on role clarity, mutual trust, and professional autonomy. Integration barriers are chiefly structural and cultural—unclear legislation, insufficient funding, low public awareness, and professional resistance—but can be addressed through policy reform, education, public engagement, and investment in collaborative models. Conclusions There is a clear and increasing need for Advanced Practice Nurses to strengthen healthcare, alleviate physician workload, manage chronic conditions, and expand access in underserved regions. Advanced Practice Nurses demonstrate strong motivation to apply their competencies and assume broader roles, yet this is constrained by limited institutional pathways, recognition, and role definition. Further national-level research is needed in Lithuania to assess the effectiveness, safety, patient satisfaction, health outcomes, service utilization, and economic impact of Advanced Practice Nurse-led care. Clinical trial number Not applicable. Advanced Practice Nurses Healthcare Managers Quality of Care Lithuanian Health System Qualitative Study Background As healthcare systems grow more complex, many countries are expanding the roles of nurses to enhance access, improve outcomes, and increase system efficiency [ 1 ]. Advanced Practice Nurses (APNs)—including Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives, and Nurse Anesthetists—are increasingly acknowledged for their expert knowledge, clinical autonomy, and decision-making capabilities, usually supported by a master's degree or higher [ 2 , 3 ]. While the concept of APNs is broadly accepted, implementation differs due to variations in legislation, system readiness, and professional recognition. The International Council of Nurses (ICN) provides global benchmarks, recommending national regulation and master's-level education incorporating advanced assessment, pharmacology, pathophysiology, clinical reasoning, leadership, and research [ 4 – 6 ]. In countries like the U.S. and Canada, APNs are educated through accredited graduate programs that include simulation, interprofessional training, and clinical preceptorships under national oversight [ 7 , 8 ]. Austria emphasizes outcome-based education [ 9 ], while Spain and Switzerland are piloting multidisciplinary programs integrating nursing science, clinical practice, and health policy [ 10 , 11 ]. Countries with mature APN models report better outcomes, higher patient satisfaction, and increased cost-effectiveness [ 12 ]. France, for example, has improved access and responsiveness following the legal adoption of APNs in 2018 [ 13 ]. Switzerland's APNs play key roles in meeting primary care demands, although challenges like role clarity persist [ 10 ]. Lithuania mirrors trends seen in other Central and Eastern European countries, where APN development is still in its infancy and inconsistent [ 14 ]. Although advanced nursing is offered at the bachelor's level, formal postgraduate APN pathways are only beginning to emerge [ 4 ]. A lack of structured, ICN-aligned curricula prevents nurses from acquiring the competencies and credentials needed for independent practice [ 5 ]. Additionally, program quality is constrained by limited placements and preceptors [ 8 ]. Despite these limitations, pilot initiatives in home-based care and integrated primary care are testing expanded roles for nurses, particularly in chronic care [ 15 , 16 ]. Universities and professional expert groups are collaborating to launch APN-focused educational offerings. Several barriers hinder APN integration in Lithuania. Key among these is the absence of a national regulatory framework. Unlike countries with mature APN systems that legally define and protect APN roles, Lithuania lacks formal definitions and title protection [ 8 , 17 , 18 ]. Consequently, nurses often perform advanced tasks without official recognition or consistent practice standards. Physician resistance also remains a significant obstacle, as doctors may view advanced nursing roles as encroachment, especially in hierarchical systems [ 14 , 19 – 21 ]. Some Lithuanian physicians express doubts about nurses' ability to practice autonomously, largely due to limited awareness of APN competencies and traditional team dynamics [ 22 , 23 ]. Conversely, countries like the UK, Canada, and Switzerland show that clear role definitions, trust-building, and institutional support can enable collaborative, team-based APN models [ 10 , 24 ]. Public and professional awareness is another major challenge. Without recognition of APN competencies, patients and colleagues may undervalue these roles [ 11 , 25 ]. However, international evidence suggests that once patients experience APN-led care, acceptance and support grow [ 10 , 11 , 26 ]. The Lithuanian Ministry of Health has recognized the need to expand nursing roles to alleviate physician shortages, particularly in underserved regions. The 2024 ‘Action Plan to Reduce the Shortage of Doctors’ (formally the Health Professional Attraction and Retention Action Plan 2024–2029) includes explicit provisions to enhance the training and retention of nurses, reflecting a strategic shift toward extending nursing competencies [ 27 ]. Still, legislative and institutional gaps limit implementation [ 28 – 30 ]. The State Accreditation Service monitors nursing qualifications but does not distinguish generalist from APN roles [ 31 ]. Pilot projects like Integrated Team-Based Home Care have demonstrated the feasibility and benefits of advanced roles despite lacking regulatory frameworks [ 32 ]. Comparatively, Nordic countries such as Finland, Sweden, and Norway have established clear APN regulations, protected titles, and ICN-aligned master's programs [ 4 , 14 , 33 , 34 ]. Finland's nurse practitioners function independently in both primary care and leadership positions, while Sweden implements national frameworks across care settings [ 35 , 36 ]. To advance APN integration, Lithuania must invest in education, regulation, faculty, and fair compensation [ 19 ]. Though APNs can improve chronic care and reduce hospital readmissions [ 37 ], initial investment is difficult to secure without robust pilot data or external funding [ 12 ]. Role recognition, institutional support, and public awareness are essential to prevent skilled nurses from feeling undervalued and underutilized [ 4 , 38 – 40 ]. Healthcare managers in Lithuania support APN implementation but stress the need for clear role definitions and structured postgraduate training. While nurses are eager to take on more responsibility, wider acceptance will depend on sustained awareness-raising and trust-building efforts. International collaboration, particularly with Nordic countries, could help accelerate development [ 41 , 42 ]. Lithuania's interest in APN roles aligns with global efforts to optimize nursing practice to meet workforce demands and improve care delivery. While the potential is evident, the absence of formal regulation, education, and recognition remains a barrier. With targeted investment and strategic alignment with ICN standards, Lithuania can harness the full potential of Advanced Practice Nursing to strengthen its healthcare system. Methods Aim and research questions The aim of the study was to examine the perspectives of selected nurses and healthcare managers on the integration of Advanced Practice Nurses into health system. To achieve this aim, the following research questions were formulated: What is the perceived need for advanced practice nurses in the Lithuanian health system from the perspectives of nurses and healthcare managers? What motivates advanced practice nurses within the Lithuanian health system according to nurses and healthcare managers? What problems and possible solutions do nurses and healthcare managers identify regarding the integration of advanced practice nurses into the Lithuanian health system? Study design and setting This study uses exploratory, qualitative interpretative design and adopts an interpretivist paradigm and a phenomenological approach to explore nurses’ perceptions, recognising that meaning is constructed through their lived experiences [43]. This design was chosen because it allows flexibility in data collection, provides rich and detailed qualitative data, and is particularly suitable for gaining comprehensive insights into participants' personal experiences, perceptions, and attitudes related to the topic [44]. Sampling and study participants This study was conducted in healthcare institutions providing emergency care, anaesthesia and intensive care, and primary healthcare services. Interviews were carried out between February - March, 2025. Participants were recruited using purposive sampling [45], based on their professional roles, experience, and relevance to the research objectives concerning the integration of APNs into healthcare settings. Initial contact with the potential participants was made through formal emails and institutional channels. Upon expressing interest, participants were provided detailed information about the research objectives, procedures, and ethical considerations. Written informed consent was obtained from each participant prior to conducting the interviews [46]. Efforts were made to accommodate participants' schedules, ensuring convenience, privacy, and comfort during data collection. Inclusion criteria of the APN: Having advance practice nursing degree in the field of emergency care, anaesthesia and intensive care, or primary healthcare settings. Having an active advance practice nursing licence. Willing and able to provide informed consent and participate in recorded interviews. Exclusion Criteria of the APN: Not actively involved in clinical work as an APN. Unable or unwilling to provide informed consent or to participate in recorded interviews. Inclusion criteria of the healthcare managers: Holding positions of director, head nurse, or other administrative roles directly involved in the decision-making related to nursing practice and integration of APNs. Willing and able to provide informed consent and participate in recorded semi-structured interviews. Exclusion criteria of the healthcare managers: Not directly involved in the administrative processes concerning APN integration. Unable or unwilling to provide informed consent or to participate in recorded interviews. Participants were specifically chosen due to their direct roles, experience, and insight into the integration and management of advanced practice nursing within their respective institutions. APNs were eligible if they held a relevant APN degree (in emergency care, anaesthesia and intensive care, or primary healthcare), an active APN license, and were willing to provide informed consent for recorded interviews. Healthcare managers qualified if they held roles such as director, head nurse, or similar positions involved in decision-making on APN integration, and consented to participate in interviews. The diversity of participants ensured comprehensive representation and rich qualitative data relevant to the study objectives. Data collection Data were collected using a semi-structured interview guide [47], which was specifically developed for this study, has not been previously published elsewhere, and was designed to explore the experiences, perceptions, and expectations regarding the integration of APNs into the Lithuanian healthcare system. An English-language version of the interview guide developed for this study has been added as a supplementary file. The guide was drafted by the first author based on an analysis of evidence-based literature to ensure alignment with the research objectives and academic rigor and was subsequently approved by the co-authors to ensure clarity, coherence, and relevance to the study’s aims. Two tailored versions of the guide were created for different participant groups. One for APNs focusing on their clinical practice, motivation, and vision for professional development. Other for healthcare managers, addressing institutional strategies, policy considerations, and organizational readiness for APN integration. The interview guide consisted of questions organized into key thematic areas, including: professional roles and related responsibilities. perceived healthcare needs and APN contributions. barriers and challenges to APN integration. motivation and professional career development. support at the organizational and systemic levels. anticipated developments in future healthcare delivery models. Participants were explained the purpose of the study, and the importance of their shared experience was emphasized. In addition, they were informed that the participation in the study is voluntary, and they can withdraw at any stage of research. Before the interviews, informed consent forms were signed, then digitised after the interviews and stored in a secure cloud server of the university, while the paper versions were destroyed using a paper shredder. All interviews were conducted by the first author, individually, face-to-face, in Lithuanian, recorded with informed consent using a secure research-designated mobile device. The duration of interviews was from 45-90 minutes. After transcribing the interviews, the participants were coded, and all potentially identifiable data was removed. After transcription, all recordings were deleted. The resulting database was stored on the university’s secure cloud server, with access restricted to the first author. Data analysis Data analysis was conducted using reflexive thematic analysis. Initially, all recorded interviews were manually transcribed by the researcher. Transcripts were carefully reviewed multiple times to ensure accuracy and familiarity with the data by all the authors. The thematic analysis process involved the following stages [48]: Familiarization: Repeated reading of transcripts to understand participants' perspectives thoroughly. Coding: Relevant segments of text were identified and assigned initial codes based on repeated ideas and concepts directly linked to the research questions. Categorization and Thematic Analysis: Codes were grouped into broader categories and subcategories, facilitating the identification of main themes and patterns. Interpretation and Description: Identified themes were interpreted and described, ensuring the participants’ perspectives regarding the integration of Advanced Practice Nurses into healthcare settings were accurately represented. Individual participant quotations will be included to illustrate key findings. Results The study included six APNs—two from each specialty working at the data collection in emergency care (n=2), anaesthesia and intensive care (n=2), and primary healthcare (n=2) were involved. As well as 6 healthcare managers who contributed as health institutions directors (n=2), head nurses (n=2), and health care institutions deputy directors (n=2). Overview of Study Participants Participants were purposefully selected for their experience and direct involvement in APN integration, ensuring diverse perspectives and rich qualitative data. The interviewed nurses reported between 5–12 years of experience as nurse practitioners and 1–3 years as advanced practice nurses. Among the healthcare managers, the directors had 2–3 years of experience in their current roles, whereas the deputy directors reported 5 and 7 years of experience, respectively. The head nurses had accumulated 4 and 8 years of experience in their positions. The interviews highlighted key themes and subthemes pertaining to nurses’ perceptions in Table 1. Table 1. Perceptions of APNs: the main themes and subthemes identified Theme Subtheme Current professional roles and responsibilities Formal role remains as General Practice Nurse despite advanced qualifications. Gradual shift in physician perception of nurse capabilities. Perceived healthcare needs and APN contributions Addressing diagnostic delays, limited test access, and chronic disease management. Reducing waiting times and enhancing patient access, especially in rural areas. Barriers and challenges to APN integration Lack of legal authority and restrictive policies. Resistance from older-generation healthcare professionals and lack of public awareness. Professional motivation and career development Desire for greater autonomy and recognition of clinical expertise. Decline in motivation due to limited system-level support. Organizational and system-level support Need for mentorship, educational programs, and consultation spaces. Importance of management and policy backing for APN roles. Expectations for future healthcare delivery models APNs as public health leaders and contributors to preventative care. Integration leading to more responsive, flexible, and sustainable health systems. Current Roles and Evolving Responsibilities The APNs described a wide array of responsibilities in their current practice, including delivering preventive care, administering immunizations, performing home visits, and coordinating care with other professionals. Despite their qualifications and experience, most participants stated that their formal roles remain confined to those of General Practice Nurses (GPNs). " After completing my master’s studies, my role has not changed... I still work as a General Practice Nurse, with the same responsibilities, but now with broader knowledge ." – Nurse 6. Other noted a slow but noticeable shift in their responsibilities, where physicians are gradually beginning to appreciate and rely on nurses’ knowledge and perspectives. This ongoing transition illustrates both the stagnation and the potential for growth in the professional scope of APNs, particularly in settings where systemic support is lacking. " In my daily practice, my main role is still primarily following physicians’ orders and assisting them. However, I have noticed that doctors’ attitudes are gradually changing ...". – Nurse 3. Anticipated Impact of APN Integration Participants were unanimous in their belief that APN integration would significantly enhance their roles, offering greater independence in clinical decision-making, patient assessment, and chronic disease management. There was a strong belief that such integration would not only benefit individual nurses but also the wider healthcare system. "With the integration of Advanced Practice Nurses into the healthcare system, my role will become more autonomous, with greater responsibility and influence in patient care decision-making." – Nurse 1. The APN role was envisioned as bridging gaps in accessibility, especially in rural and underserved regions, while supporting the redistribution of tasks traditionally handled by physicians. Such expanded responsibilities are seen as a way to increase efficiency, reduce waiting times, and ensure that more complex cases receive appropriate attention from physicians. " We could manage less difficult patients... APNs could take over home visits and even handle emergency patients with flu-like symptoms ." – Nurse 2. Challenges in Current Practice Addressable by APNs Participants reported several systemic and operational barriers that limit effective care delivery. Many challenges—such as delayed diagnostic decisions, the inability to prescribe or order routine tests, and long waiting times—were seen as solvable through expanded APN roles. " We can’t order certain tests... patients must be sent to the GP just to order harmless tests like ferritin or vitamin D ." – Nurse 2. " If a patient comes in for a blood transfusion, an APN could order it without waiting for a physician... saving valuable time ." – Nurse 3. Several nurses also stressed that APNs could act swiftly in acute situations, preventing unnecessary delays and hospitalizations. " There are cases where a nurse’s assessment would be sufficient to provide needed services, but due to lack of legal authority, we are limited ." – Nurse 6. Healthcare Needs Addressed by APNs The nurses identified major public health and systemic challenges that could be addressed through the inclusion of APNs. These included access to care in remote areas, increasing numbers of patients with chronic conditions, and insufficient patient education. " APNs could monitor patients with chronic diseases... and implement health promotion programs that reduce disparities and improve overall public health ." – Nurse 1. " In the future, APNs could even replace GPs in remote areas where there are staff shortages ." – Nurse 2. Other suggestions included structuring APN roles around chronic disease panels, where each APN would be responsible for the long-term management of a specific patient group. Motivations to Pursue the APN Role Motivations were both personal and professional. Participants were driven by a desire to provide holistic, patient-centred care and to apply their expanded clinical knowledge in a more autonomous setting. " It’s thrilling when your patients come back to you instead of registering with the GP—it shows trust and independence ." – Nurse 2. " I believe that advanced practice functions allow nurses to fully realize their potential—not just following doctors’ orders, but actively participating in decision-making, prevention, and education ." – Nurse 1. Some nurses described internal barriers to motivation, particularly in settings where their potential remains underutilized. " At the moment, I feel a significant drop in motivation because... I don’t see any real prospects for APNs in Lithuania due to lack of regulation and support ." – Nurse 6. Professional Development and Career Satisfaction Nurses emphasized that APN roles promote continuous learning and create opportunities for advancement into teaching, management, and research roles. They expressed a strong sense of purpose in being able to impact patient care directly. " The APN role opens new paths in clinical practice and leadership. It’s empowering to see how your knowledge can shape outcomes ." – Nurse 5. Nonetheless, they also stressed that without institutional recognition and proper job structures, the benefits of advanced education remain theoretical. " To enhance professional development, more APN positions need to be created, and management must trust in APN competencies ." – Nurse 3. Barriers to APN Integration Numerous challenges were identified that hinder the integration of APNs, including unclear legal frameworks, scepticism from colleagues, and lack of awareness among the public. " There’s still a lack of legal frameworks, mistrust from doctors, and unclear role definitions. " – Nurse 1. " I see a negative attitude from older-generation nurses and doctors... and scepticism from patients ." – Nurse 6. Structural barriers like restrictive laws and inadequate compensation models were also noted. " Laws in some cases are very restrictive... they should change to give more freedom to APNs ." – Nurse 2. Systemic Changes Needed for APN Integration Participants proposed clear and actionable changes necessary for successful integration. These included: Establishing legal and regulatory clarity. Developing APN job descriptions across all levels of care. Creating financial incentives and reimbursement systems. Launching public education campaigns about APN roles. " First, a clear legal framework must be established to define APN competencies... this would avoid confusion and ensure safe, high-quality service delivery ." – Nurse 1. " There needs to be clear regulations... and a defined set of job requirements for APN positions ." – Nurse 4. Support and Resources Required Support systems were seen as vital, especially during the early implementation phase. Nurses stressed the need for mentorship, access to continuous education, administrative support, and physical infrastructure like consultation rooms. The role of healthcare institutions in mentoring and promoting APNs was emphasized as a critical factor in successful transition. " Support from administration is very important, and collaboration with GPs is also essential ." – Nurse 2. " Educational institutions should provide practical training and ensure programs meet real-world demands ." – Nurse 5. Expected Impact on the Healthcare System All participants agreed that APNs would play a crucial role in improving the healthcare system's responsiveness, especially amid physician shortages and increasing chronic disease prevalence. " APNs could significantly improve patient health outcomes... they can dedicate more time to education and consultations ." – Nurse 5. " They would improve system flexibility, accessibility, and sustainability ." – Nurse 1. They envisioned APNs not only as care providers but also as educators, policy influencers, and leaders in public health. " APNs can become not just care providers, but also leaders in public health... their potential is still underutilized in Lithuania ." – Nurse 1. The interviews revealed the following themes and subthemes related to healthcare managers’ perceptions presented in Table 2. Table 2. Perceptions of healthcare managers: the main themes and subthemes identified Theme Sub-theme Current professional roles and responsibilities APNs understood as independent decision-makers and care providers. Capability to prescribe, refer, and manage chronic conditions. Perceived healthcare needs and APN contributions Relieving physician workload and improving care access. Enhancing patient care continuity, especially in underserved areas. Barriers and challenges to APN integration Legal ambiguity, unclear scope, and interprofessional resistance. Public misunderstanding and cultural resistance in rural areas. Professional motivation and career development Support for APNs as a modern evolution of skilled nursing practice Organizational and system-level support Clear job roles, institutional support, fair compensation. Need for national legislation, education campaigns, and structural planning. Expectations for future healthcare delivery models Improving system efficiency and expanding care access. Phased integration, increased public trust, and interdisciplinary cooperation. Defined success as clarity, autonomy, and measurable health outcomes. Understanding of the APN Role Healthcare managers (HM)showed clear support for the APN role, highlighting their broad clinical skills, independent decision-making, and ability to connect physicians and nurses. One saw APNs as autonomous healthcare professionals, not just assistants. “ The APN role is important... a specialist with broader competencies, having sufficient knowledge and skills to examine patients, make decisions, and act independently .” – HM 1. “ They work independently, in separate offices from doctors, consulting physicians only in emergency situations .” – HM 4. “ I would say advance practice nurse is a highly trained nurse with advanced clinical skills and the ability to work independently in certain areas, such as diagnosis, prescribing, and chronic disease management .” – HM 6. One HM reinforced this vision by highlighting that APNs could take over various tasks traditionally performed by physicians, such as issuing prescriptions, ordering and interpreting tests, and referring patients to specialists. “ APNs could support the doctor, prescribe medications, order tests, interpret results, and write referrals .” – HM 3. Perceived Contribution of APNs to Patient Care HMs uniformly agreed that APNs could make substantial contributions to patient care, particularly by relieving physician workload and improving access to healthcare services. They envisioned APNs as key contributors to both acute and chronic patient management. These reflections underscore the potential for APNs to expand healthcare system capacity without compromising care quality. “ They would relieve the burden on doctors, take over part of their functions, and ensure faster access to care .” – HM 1. “ In our institution... APNs would reduce the workload of both doctors and nurses and should be able to provide many services independently .” – HM 3. Some highlighted their role in addressing care gaps when doctors are unavailable, especially in rural or underserved regions. “ In outpatient clinics, it's nearly impossible to get doctors to work. This is another niche for APNs—to manage routine cases and refer difficult ones .” – HM 4. Areas of Significant Impact When asked about specific areas or departments where APNs could have the greatest influence, HMs pointed to primary healthcare, chronic disease management, outpatient services, emergency rooms and even anaesthesiology. “ At the primary care level... APNs could independently take over a large share of work, especially in chronic disease management .” – HM 5. “ I think APNs would be especially effective in family medicine departments .” – HM 3. “ Especially in primary care, emergency departments, and home-based care programs APN’s can have significant impact in improved and timely care .” – HM 6. This broad applicability suggests APNs could help optimize patient flow and improve outcomes across care levels, provided the system enables their full integration. Healthcare Needs Addressed by APNs The healthcare system in Lithuania faces multiple pressures, including prevalence of chronic diseases, physician shortages, and regional disparities. HMs believed APNs are uniquely positioned to help alleviate these challenges. “ Independent consultations, prescription renewals, monitoring of patients with multiple chronic conditions—APNs could cover all of these needs .” – HM 1. “ The most urgent needs are related to physician shortages, particularly in regional hospitals, and the growing burden of chronic diseases. APNs could help address all these issues .” – HM 6. HMs also emphasized the importance of preventive health initiatives and patient education, both of which fall naturally within the scope of advanced nursing practice. However, there was concern over the current ambiguity in legal definitions of the APN role. “ Currently, the law defines the role very broadly but without clarity. That’s just my opinion .” – HM 3. Impact on Organizational Efficiency and Outcomes HMs highlighted APNs’ potential to increase healthcare delivery efficiency by handling routine cases independently and allowing physicians to focus on complex cases. “ If APNs handle straightforward consultations independently, it will speed up access to specialists for urgent or complex cases .” – HM 5. Some cautioned that the effect on patient wait times would depend on how extensively APNs are implemented. “ If there were at least four APNs in a large facility, yes—it would make a difference. But one APN might not change much .” – HM3. Nonetheless, the overall sentiment was that APNs would improve service coordination and responsiveness. Resources, Funding, and Integration Support Successful integration requires systemic and institutional support. HMs emphasized the need for clear legal definitions, proper workplace setup, access to modern tools, and appropriate salary structures. “ First, clearly define duties, rights, and responsibilities, and update the legal framework .” – HM 5. “ Support from hospital management is essential, along with ministerial orders and clear job roles .” – HM 3. Financial sustainability was a recurrent concern. While APN roles are seen as cost-effective in the long run, initial implementation and funding strategies remain unresolved. “ Maintaining an APN position would cost less than a family doctor or specialist... funds could be used for more diagnostics and tools .” – HM 2. Anticipated Challenges Key challenges included lack of trust from existing medical staff, unclear regulations, and public perception. Resistance could arise from both physicians and general nurses if roles and responsibilities are not clearly communicated. “ Doctors may resist if they’re held accountable for APN errors. Nurses may resist due to wage gaps .” – HM 1. “ The biggest challenge will be role clarity—differentiating APNs from general nurses and physicians .” – HM 6. The need for public education was repeatedly stressed, particularly in rural areas. “In rural areas, it will be different. Patients still want to see 'the doctor.' That belief will take time to change. ” – HM 4. Participants suggested that trust would grow once patients experience the competence of APNs firsthand. Collaboration and Interdisciplinary Teamwork APNs were envisioned as collaborative partners in care, working with physicians, lifestyle specialists, and other healthcare professionals. “ The APN can create a care plan with the family doctor, monitor the patient’s indicators, and coordinate with the team .” – HM 2. Interdisciplinary trust and communication were viewed as essential for successful integration. Some healthcare managers proposed structured collaboration strategies, including joint training and informal team building. “ Unite everyone into one team to work cooperatively... training or after-work events could improve relationships .” – HM 3. Others suggested a phased approach—beginning with shared tasks and transitioning toward independent APN-led care. Long-Term Vision and Impact on the Healthcare System Most HMs expressed optimism that APNs would contribute meaningfully to the future of Lithuanian healthcare. Their introduction was seen as inevitable and essential for improving service delivery, especially in response to aging populations and rising multymorbidity. “ APNs will be employed according to need and will take over tasks from family doctors and GPNs... access to services should improve markedly .” – HM 2. “ APNs are practically like doctors... with time, the population will accept and even prefer them for certain cases .” – HM 4. HMs highlighted the importance of professional respect, visibility, and long-term policy support to sustain these roles. Defining Successful APN Integration Success was defined by clarity, trust, and autonomy. HMs felt that legal certainty, fair compensation, public education, and institutional support were key pillars of sustainable APN integration. “ Success means allowing each specialist to work fully within their competencies and have autonomy .” – HM 2. “ Public education about the new service is key .” – HM 1. “ It would mean having a defined and recognized APN role, supported by national legislation, funded training programs, and measurable outcomes .” – HM 6. Some referenced the historical role of feldshers and nurses with extended responsibilities as a precedent, suggesting that APNs represent a formal and modern evolution of this concept. “ Compared to other countries, we’re far behind... APNs are a modern version of feldshers—independent, community-focused, and practical .” – HM 3. These expanded findings illustrate a cautious yet hopeful stance from healthcare managers. They largely align with the aspirations of APNs themselves and provide clear strategic directions for successful integration—emphasizing collaboration, regulation, education, and structural investment. Comparative Perceptions of APN Integration Understanding of APN Role: Nurses see themselves as still working within general nursing roles but expect to gain more autonomy and clinical responsibility as APNs are integrated. Healthcare managers describe APNs as independent clinicians who have the potential to manage patients and make decisions on their own. Contribution to Healthcare: Nurses believe that APNs will strengthen chronic care management, reduce wait times, and improve healthcare accessibility, particularly in rural areas. In comparison, healthcare managers see APNs as a way to alleviate doctors’ workloads and broaden patient access, especially in underserved communities. Barriers to Integration: Nurses highlight the absence of clear legal frameworks, resistance from colleagues, and poorly defined roles as the main barriers to APN integration. In comparison, healthcare managers emphasize regulatory uncertainty, interprofessional skepticism, and insufficient funding as the primary challenges to successful implementation. Support and Resources Needed: Nurses stress the importance of mentorship, dedicated APN training programs, and strong policy-level backing to ensure successful integration. In contrast, healthcare managers emphasize the need for well-defined job descriptions, sufficient funding, appropriate infrastructure, and robust administrative support to facilitate the effective implementation of the APN role. Future Vision and System Impact: Nurses envision APNs as leaders in public health, patient educators, and autonomous care providers delivering advanced clinical services. Meanwhile, healthcare managers anticipate a transformation in care models, greater system efficiency, and APNs filling diverse roles across departments such as primary care, chronic disease management, and emergency care. Definition of Successful Integration: Nurses stress the importance of legal recognition, increased public awareness, and the creation of structured APN positions that align with their specialized training. In comparison, healthcare managers emphasize the need for clearly defined competencies, greater clinical autonomy, measurable outcomes, and strengthened professional respect to ensure successful APN integration. Discussion The findings indicate readiness, motivation, and role clarity among Lithuanian APNs in relation to transforming healthcare delivery; however, these results should not be interpreted as representative of all advanced practice nurses in Lithuania. While challenges remain, there is a clear consensus on the need for institutional, legal, and cultural change to unlock the full potential of APNs in the Lithuanian health system. This study offers new insights into how APNs and healthcare managers perceive APN integration in Lithuania’s healthcare system. The findings echo international literature while highlighting local barriers and opportunities. APNs shared that they still perform mainly general nursing tasks despite readiness for greater autonomy, a pattern seen elsewhere. Hill et al., 2023 found that unclear roles limit UK APNs in community care [24]. Beil-Hildebrand & Smith, 2022 reported similar constraints in German-speaking countries due to hierarchical cultures [49]. In Lithuania, healthcare managers noted APNs’ potential but stressed the lack of clear legal frameworks, echoing the International Council of Nurses’ view that absent legislation hinders APN practice [50]. Both groups cited physician shortages, chronic disease burdens, and poor rural access—issues matching the Lithuanian Ministry of Health’s “Action Plan to Reduce the Shortage of Doctors” [27]. Internationally, APNs help fill such gaps: in France [13] and Spain [19], APNs improved care in underserved areas [13, 19]. The focus on chronic disease management also aligns with recent Spanish studies showing APNs’ role in patient education and monitoring [11]. Healthcare managers emphasized the need for clear job descriptions, legal frameworks, and fair pay—conditions echoed in the literature. For example, Toniolo et al., 2024 found that policy alignment, readiness, and collaboration were key for APN roles in France [50]. Unsworth et al., 2024 also stressed structured pathways, funding, and leadership as vital enablers [51]. Effective teamwork with physicians remains a challenge due to trust and unclear roles. Lee et al., 2023 showed that defining interprofessional roles early supports smoother implementation [34]. Torrens et al., 2020 noted physician resistance and poor team integration as barriers across Europe, highlighting the need for cultural as well as policy change [18]. Both groups agreed public understanding of APN roles in Lithuania is low. Darginavičienė et al., 2022 found patients often don’t know when to see an APN [23]. By contrast, the UK and Scandinavia have raised awareness through public campaigns and structured roles [4, 52]. Lithuanian APNs showed strong motivation to expand their roles, similar to Finnish APNs driven by professional identity [21]. But sustained motivation depends on systemic support—without it, APNs risk frustration and burnout, as seen by Colson et al., 2021 in France [53]. The discussion shows that Lithuania shares common APN integration challenges but can learn from international success stories. Key recommendations include: Clarify APN roles through legislation and local protocols [5, 13]. Raise public and professional awareness to build acceptance [23]. Create collaborative frameworks and supervision models for interprofessional practice [34]. Offer financial incentives and clear career paths to retain APNs [51]. Monitor pilot projects to inform national rollout, as seen in France and Spain [19, 50]. Strengths and limitations This study has several notable strengths and some limitations that should be considered when interpreting its findings. Firstly, this study provides a good overview, which enables Lithuania to learn from successful APN integration models in other EU countries and adapt them to local needs. Secondly, this study demonstrated an increasing demand for advanced practice nurses due to physician shortages, an ageing population, and the rising burden of chronic diseases. Due to the limited availability of evidence-based information, the comparison of results is restricted. Therefore, this study rather maps the current situation. There is limited data on pilot program outcomes, weak insight into public and professional views, and little evidence on cost-effectiveness, especially for rural areas. Lack of local pilot projects or well-defined APN roles makes implementation and scaling more difficult. The results of this study cannot be generalized to the whole of Lithuania, mainly due to the relatively small sample size. However, the findings highlight the need for further research and mark the first study of its kind in Lithuania. Conclusions This study shows that both APNs and healthcare managers in Lithuania view APN integration as essential for healthcare evolution. There is a strong need for APNs to support primary care, ease physician workload, manage chronic diseases, and improve access in underserved areas. APNs are motivated to expand their roles but face risks from unclear institutional support and role definitions. Integration barriers are mainly structural and cultural—unclear laws, funding gaps, low public awareness, and staff resistance—which can be addressed through policy changes, education, and investment in collaboration. Lithuania has an opportunity to formalize APN roles and join Europe’s shift toward more flexible, patient-centred care. Achieving this will require coordinated action in education, regulation, and policy, guided by regional and global best practices. Despite rising awareness of APNs’ contributions, multiple barriers hinder their broader adoption, notably regulatory gaps, professional resistance, limited education pathways, and systemic or cultural factors. These are especially challenging for Lithuania at its early stage of APN development. Change management is a long-term and challenging process, and the same applies to APN integration, which requires steady progress and responsiveness to the needs of the population and the health sector by adopting the best global practices. In conclusion, while nurses and healthcare managers share the vision of APNs as valuable contributors to the health system, their perspectives highlight the need for clear legal frameworks, defined roles, and strong organizational support to achieve successful integration in Lithuania. Abbreviations APN- Advance practice nurse ICN- International Council of Nurses HM – Healtcare manager NP- Nurse Practitioner RN- Registered nurses Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the the Ethics Committee for Scientific Research of the Faculty of Medicine of Vilnius University (Protocol Nr. (1.7 E) 150000-KT-21) and written informed consents were obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable Availability of data and materials All data generated or analysed during this study are included in this published article. The data supporting the findings of this study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions Study design: IQ, JS, NI. Data acquisition: IQ. Data analysis and interpretation: IQ, JS. Manuscript preparation: IQ, JS, NI. Critical revision of the manuscript for intellectual content: JS, NI. Manuscript review: IQ, JS, NI. Obtaining financing: None. Acknowledgements The authors thank all participants, whose valuable contributions support the integration of APN into the healthcare system Authors' information IQ is an Advanced Practice Nurse, MSc, and was a master’s student during the data collection phase at the Faculty of Medicine of Vilnius University, Lithuania. JS holds her PhD in Health Sciences and serves as an docent at Vilnius University, Lithuania. NI holds her PhD in Health Sciences and contributes as a Professor and Senior Researcher at the Vilnius University, Lithuania. References Zhang Y. What is nursing in advanced nursing practice? Applying theories and models to advanced nursing practice-A discursive review. 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Advanced Practice Nurses (APNs)\u0026mdash;including Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives, and Nurse Anesthetists\u0026mdash;are increasingly acknowledged for their expert knowledge, clinical autonomy, and decision-making capabilities, usually supported by a master's degree or higher [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the concept of APNs is broadly accepted, implementation differs due to variations in legislation, system readiness, and professional recognition. The International Council of Nurses (ICN) provides global benchmarks, recommending national regulation and master's-level education incorporating advanced assessment, pharmacology, pathophysiology, clinical reasoning, leadership, and research [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In countries like the U.S. and Canada, APNs are educated through accredited graduate programs that include simulation, interprofessional training, and clinical preceptorships under national oversight [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Austria emphasizes outcome-based education [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], while Spain and Switzerland are piloting multidisciplinary programs integrating nursing science, clinical practice, and health policy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCountries with mature APN models report better outcomes, higher patient satisfaction, and increased cost-effectiveness [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. France, for example, has improved access and responsiveness following the legal adoption of APNs in 2018 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Switzerland's APNs play key roles in meeting primary care demands, although challenges like role clarity persist [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLithuania mirrors trends seen in other Central and Eastern European countries, where APN development is still in its infancy and inconsistent [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although advanced nursing is offered at the bachelor's level, formal postgraduate APN pathways are only beginning to emerge [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A lack of structured, ICN-aligned curricula prevents nurses from acquiring the competencies and credentials needed for independent practice [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, program quality is constrained by limited placements and preceptors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these limitations, pilot initiatives in home-based care and integrated primary care are testing expanded roles for nurses, particularly in chronic care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Universities and professional expert groups are collaborating to launch APN-focused educational offerings.\u003c/p\u003e\u003cp\u003eSeveral barriers hinder APN integration in Lithuania. Key among these is the absence of a national regulatory framework. Unlike countries with mature APN systems that legally define and protect APN roles, Lithuania lacks formal definitions and title protection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Consequently, nurses often perform advanced tasks without official recognition or consistent practice standards.\u003c/p\u003e\u003cp\u003ePhysician resistance also remains a significant obstacle, as doctors may view advanced nursing roles as encroachment, especially in hierarchical systems [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Some Lithuanian physicians express doubts about nurses' ability to practice autonomously, largely due to limited awareness of APN competencies and traditional team dynamics [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Conversely, countries like the UK, Canada, and Switzerland show that clear role definitions, trust-building, and institutional support can enable collaborative, team-based APN models [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePublic and professional awareness is another major challenge. Without recognition of APN competencies, patients and colleagues may undervalue these roles [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, international evidence suggests that once patients experience APN-led care, acceptance and support grow [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Lithuanian Ministry of Health has recognized the need to expand nursing roles to alleviate physician shortages, particularly in underserved regions. The 2024 \u0026lsquo;Action Plan to Reduce the Shortage of Doctors\u0026rsquo; (formally the Health Professional Attraction and Retention Action Plan 2024\u0026ndash;2029) includes explicit provisions to enhance the training and retention of nurses, reflecting a strategic shift toward extending nursing competencies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Still, legislative and institutional gaps limit implementation [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The State Accreditation Service monitors nursing qualifications but does not distinguish generalist from APN roles [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePilot projects like Integrated Team-Based Home Care have demonstrated the feasibility and benefits of advanced roles despite lacking regulatory frameworks [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Comparatively, Nordic countries such as Finland, Sweden, and Norway have established clear APN regulations, protected titles, and ICN-aligned master's programs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Finland's nurse practitioners function independently in both primary care and leadership positions, while Sweden implements national frameworks across care settings [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo advance APN integration, Lithuania must invest in education, regulation, faculty, and fair compensation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Though APNs can improve chronic care and reduce hospital readmissions [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], initial investment is difficult to secure without robust pilot data or external funding [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Role recognition, institutional support, and public awareness are essential to prevent skilled nurses from feeling undervalued and underutilized [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHealthcare managers in Lithuania support APN implementation but stress the need for clear role definitions and structured postgraduate training. While nurses are eager to take on more responsibility, wider acceptance will depend on sustained awareness-raising and trust-building efforts. International collaboration, particularly with Nordic countries, could help accelerate development [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLithuania's interest in APN roles aligns with global efforts to optimize nursing practice to meet workforce demands and improve care delivery. While the potential is evident, the absence of formal regulation, education, and recognition remains a barrier. With targeted investment and strategic alignment with ICN standards, Lithuania can harness the full potential of Advanced Practice Nursing to strengthen its healthcare system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eAim and research questions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of the study was to examine the perspectives of selected nurses and healthcare managers on the integration of Advanced Practice Nurses into health system.\u003c/p\u003e\n\u003cp\u003eTo achieve this aim, the following research questions were formulated:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWhat is the perceived need for advanced practice nurses in the Lithuanian health system from the perspectives of nurses and healthcare managers?\u003c/li\u003e\n \u003cli\u003eWhat motivates advanced practice nurses within the Lithuanian health system according to nurses and healthcare managers?\u003c/li\u003e\n \u003cli\u003eWhat problems and possible solutions do nurses and healthcare managers identify regarding the integration of advanced practice nurses into the Lithuanian health system?\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study\u0026nbsp;uses\u0026nbsp;exploratory, qualitative interpretative design and\u0026nbsp;adopts an interpretivist paradigm and a phenomenological approach to explore nurses\u0026rsquo; perceptions, recognising that meaning is constructed through their lived experiences\u0026nbsp;[43].\u0026nbsp;This design was chosen because it allows flexibility in data collection, provides rich and detailed qualitative data, and is\u0026nbsp;particularly suitable for gaining comprehensive insights into participants\u0026apos; personal experiences, perceptions, and attitudes related to the topic\u0026nbsp;[44].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and study participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in healthcare institutions providing emergency care, anaesthesia and intensive care, and primary healthcare services. Interviews were carried out between February - March, 2025.\u0026nbsp;Participants were recruited using purposive sampling [45], based on their professional roles, experience, and relevance to the research objectives concerning the integration of APNs into healthcare settings. Initial contact with the potential participants was made through formal emails and institutional channels. Upon expressing interest, participants were provided detailed information about the research objectives, procedures, and ethical considerations. Written informed consent was obtained from each participant prior to conducting the interviews [46]. Efforts were made to accommodate participants\u0026apos; schedules, ensuring convenience, privacy, and comfort during data collection.\u003c/p\u003e\n\u003cp\u003eInclusion criteria of the APN:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eHaving advance practice nursing degree in the field of emergency care, anaesthesia and intensive care, or primary healthcare settings.\u003c/li\u003e\n \u003cli\u003eHaving an active advance practice nursing licence.\u003c/li\u003e\n \u003cli\u003eWilling and able to provide informed consent and participate in recorded interviews.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExclusion Criteria of the APN:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eNot actively involved in clinical work as an APN.\u003c/li\u003e\n \u003cli\u003eUnable or unwilling to provide informed consent or to participate in recorded interviews.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eInclusion criteria of the healthcare managers:\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eHolding positions of director, head nurse, or other administrative roles directly involved in the decision-making related to nursing practice and integration of APNs.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWilling and able to provide informed consent and participate in recorded semi-structured interviews.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExclusion criteria of the healthcare managers:\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eNot directly involved in the administrative processes concerning APN integration.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003eUnable or unwilling to provide informed consent or to participate in recorded interviews.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eParticipants were specifically chosen due to their direct roles, experience, and insight into the integration and management of advanced practice nursing within their respective institutions. APNs were eligible if they held a relevant APN degree (in emergency care, anaesthesia and intensive care, or primary healthcare), an active APN license, and were willing to provide informed consent for recorded interviews. Healthcare managers qualified if they held roles such as director, head nurse, or similar positions involved in decision-making on APN integration, and consented to participate in interviews. The diversity of participants ensured comprehensive representation and rich qualitative data relevant to the study objectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using a semi-structured interview guide [47], which was specifically developed for this study, has not been previously published elsewhere, and was designed to explore the experiences, perceptions, and expectations regarding the integration of APNs into the Lithuanian healthcare system. An English-language version of the interview guide developed for this study has been added as a supplementary file.\u003c/p\u003e\n\u003cp\u003eThe guide was drafted by the first author based on an analysis of evidence-based literature to ensure alignment with the research objectives and academic rigor and was subsequently approved by the co-authors to ensure clarity, coherence, and relevance to the study\u0026rsquo;s aims.\u003c/p\u003e\n\u003cp\u003eTwo tailored versions of the guide were created for different participant groups. One for APNs focusing on their clinical practice, motivation, and vision for professional development. Other for healthcare managers, addressing institutional strategies, policy considerations, and organizational readiness for APN integration. The interview guide consisted of questions organized into key thematic areas, including:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eprofessional roles and related responsibilities.\u003c/li\u003e\n \u003cli\u003eperceived healthcare needs and APN contributions.\u003c/li\u003e\n \u003cli\u003ebarriers and challenges to APN integration.\u003c/li\u003e\n \u003cli\u003emotivation and professional career development.\u003c/li\u003e\n \u003cli\u003esupport at the organizational and systemic levels.\u003c/li\u003e\n \u003cli\u003eanticipated developments in future healthcare delivery models.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eParticipants were explained the purpose of the study, and the importance of their shared experience was emphasized. In addition, they were informed that the participation in the study is voluntary, and they can withdraw at any stage of research. Before the interviews, informed consent forms were signed, then digitised after the interviews and stored in a secure cloud server of the university, while the paper versions were destroyed using a paper shredder.\u003c/p\u003e\n\u003cp\u003eAll interviews were conducted by the first author,\u0026nbsp;individually, face-to-face, in Lithuanian, recorded with informed consent using a secure\u0026nbsp;research-designated mobile device. The duration of interviews was from 45-90 minutes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter transcribing the interviews, the participants were coded, and all potentially identifiable data was removed. After transcription, all recordings were deleted.\u0026nbsp;The resulting database was stored on the university\u0026rsquo;s secure cloud server, with access restricted to the first author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was conducted using reflexive thematic analysis. Initially, all recorded interviews were manually transcribed by the researcher. Transcripts were carefully reviewed multiple times to ensure accuracy and familiarity with the data by all the authors. The thematic analysis process involved the following stages\u0026nbsp;[48]:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFamiliarization:\u003c/strong\u003e Repeated reading of transcripts to understand participants\u0026apos; perspectives thoroughly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCoding:\u003c/strong\u003e Relevant segments of text were identified and assigned initial codes based on repeated ideas and concepts directly linked to the research questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategorization and Thematic Analysis:\u003c/strong\u003e Codes were grouped into broader categories and subcategories, facilitating the identification of main themes and patterns.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterpretation and Description:\u003c/strong\u003e Identified themes were interpreted and described, ensuring the participants\u0026rsquo; perspectives regarding the integration of Advanced Practice Nurses into healthcare settings were accurately represented. Individual participant quotations will be included to illustrate key findings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included six APNs\u0026mdash;two from each specialty working at the data collection in emergency care (n=2), anaesthesia and intensive care (n=2), and primary healthcare (n=2) were involved. As well as 6 healthcare managers who contributed as health institutions directors (n=2), head nurses (n=2), and health care institutions deputy directors (n=2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverview of Study Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were purposefully selected for their experience and direct involvement in APN integration, ensuring diverse perspectives and rich qualitative data. The interviewed nurses reported between 5\u0026ndash;12 years of experience as nurse practitioners and 1\u0026ndash;3 years as advanced practice nurses. Among the healthcare managers, the directors had 2\u0026ndash;3 years of experience in their current roles, whereas the deputy directors reported 5 and 7 years of experience, respectively. The head nurses had accumulated 4 and 8 years of experience in their positions.\u003c/p\u003e\n\u003cp\u003eThe interviews highlighted key themes and subthemes pertaining to nurses\u0026rsquo; perceptions in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1. Perceptions of APNs: the main themes and subthemes identified\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eSubtheme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eCurrent professional roles and responsibilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFormal role remains as General Practice Nurse despite advanced qualifications.\u003c/li\u003e\n \u003cli\u003eGradual shift in physician perception of nurse capabilities.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003ePerceived healthcare needs and APN contributions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAddressing diagnostic delays, limited test access, and chronic disease management.\u003c/li\u003e\n \u003cli\u003eReducing waiting times and enhancing patient access, especially in rural areas.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eBarriers and challenges to APN integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLack of legal authority and restrictive policies.\u003c/li\u003e\n \u003cli\u003eResistance from older-generation healthcare professionals and lack of public awareness.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eProfessional motivation and career development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDesire for greater autonomy and recognition of clinical expertise.\u003c/li\u003e\n \u003cli\u003eDecline in motivation due to limited system-level support.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eOrganizational and system-level support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNeed for mentorship, educational programs, and consultation spaces.\u003c/li\u003e\n \u003cli\u003eImportance of management and policy backing for APN roles.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eExpectations for future healthcare delivery models\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAPNs as public health leaders and contributors to preventative care.\u003c/li\u003e\n \u003cli\u003eIntegration leading to more responsive, flexible, and sustainable health systems.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3 id=\"_Toc198587067\"\u003e\u003cstrong\u003eCurrent Roles and Evolving Responsibilities\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe APNs described a wide array of responsibilities in their current practice, including delivering preventive care, administering immunizations, performing home visits, and coordinating care with other professionals. Despite their qualifications and experience, most participants stated that their formal roles remain confined to those of General Practice Nurses (GPNs).\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eAfter completing my master\u0026rsquo;s studies, my role has not changed... I still work as a General Practice Nurse, with the same responsibilities, but now with broader knowledge\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 6.\u003c/p\u003e\n\u003cp\u003eOther noted a slow but noticeable shift in their responsibilities, where physicians are gradually beginning to appreciate and rely on nurses\u0026rsquo; knowledge and perspectives. This ongoing transition illustrates both the stagnation and the potential for growth in the professional scope of APNs, particularly in settings where systemic support is lacking.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIn my daily practice, my main role is still primarily following physicians\u0026rsquo; orders and assisting them. However, I have noticed that doctors\u0026rsquo; attitudes are gradually changing\u003c/em\u003e...\u0026quot;. \u0026ndash;\u0026nbsp;Nurse 3.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAnticipated Impact of APN Integration\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eParticipants were unanimous in their belief that APN integration would significantly enhance their roles, offering greater independence in clinical decision-making, patient assessment, and chronic disease management. There was a strong belief that such integration would not only benefit individual nurses but also the wider healthcare system.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;With the integration of Advanced Practice Nurses into the healthcare system, my role will become more autonomous, with greater responsibility and influence in patient care decision-making.\u0026quot;\u003c/em\u003e \u0026ndash;\u0026nbsp;Nurse 1.\u003c/p\u003e\n\u003cp\u003eThe APN role was envisioned as bridging gaps in accessibility, especially in rural and underserved regions, while supporting the redistribution of tasks traditionally handled by physicians. Such expanded responsibilities are seen as a way to increase efficiency, reduce waiting times, and ensure that more complex cases receive appropriate attention from physicians.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eWe could manage less difficult patients... APNs could take over home visits and even handle emergency patients with flu-like symptoms\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 2.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587069\"\u003e\u003cstrong\u003eChallenges in Current Practice Addressable by APNs\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eParticipants reported several systemic and operational barriers that limit effective care delivery. Many challenges\u0026mdash;such as delayed diagnostic decisions, the inability to prescribe or order routine tests, and long waiting times\u0026mdash;were seen as solvable through expanded APN roles.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eWe can\u0026rsquo;t order certain tests... patients must be sent to the GP just to order harmless tests like ferritin or vitamin D\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 2.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIf a patient comes in for a blood transfusion, an APN could order it without waiting for a physician... saving valuable time\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 3.\u003c/p\u003e\n\u003cp\u003eSeveral nurses also stressed that APNs could act swiftly in acute situations, preventing unnecessary delays and hospitalizations.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThere are cases where a nurse\u0026rsquo;s assessment would be sufficient to provide needed services, but due to lack of legal authority, we are limited\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 6.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587070\"\u003e\u003cstrong\u003eHealthcare Needs Addressed by APNs\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe nurses identified major public health and systemic challenges that could be addressed through the inclusion of APNs. These included access to care in remote areas, increasing numbers of patients with\u0026nbsp;chronic conditions, and insufficient patient education.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eAPNs could monitor patients with chronic diseases... and implement health promotion programs that reduce disparities and improve overall public health\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 1.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIn the future, APNs could even replace GPs in remote areas where there are staff shortages\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 2.\u003c/p\u003e\n\u003cp\u003eOther suggestions included structuring APN roles around chronic disease panels, where each APN would be responsible for the long-term management of a specific patient group.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587071\"\u003e\u003cstrong\u003eMotivations to Pursue the APN Role\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMotivations were both personal and professional. Participants were driven by a desire to provide holistic, patient-centred care and to apply their expanded clinical knowledge in a more autonomous setting.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIt\u0026rsquo;s thrilling when your patients come back to you instead of registering with the GP\u0026mdash;it shows trust and independence\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 2.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eI believe that advanced practice functions allow nurses to fully realize their potential\u0026mdash;not just following doctors\u0026rsquo; orders, but actively participating in decision-making, prevention, and education\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 1.\u003c/p\u003e\n\u003cp\u003eSome nurses described internal barriers to motivation, particularly in settings where their potential remains underutilized.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eAt the moment, I feel a significant drop in motivation because... I don\u0026rsquo;t see any real prospects for APNs in Lithuania due to lack of regulation and support\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 6.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587072\"\u003e\u003cstrong\u003eProfessional Development and Career Satisfaction\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNurses emphasized that APN roles promote continuous\u0026nbsp;learning and create opportunities for advancement into teaching, management, and research roles. They expressed a strong sense of purpose in being able to impact patient care directly.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThe APN role opens new paths in clinical practice and leadership. It\u0026rsquo;s empowering to see how your knowledge can shape outcomes\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 5.\u003c/p\u003e\n\u003cp\u003eNonetheless, they also stressed that without institutional recognition and proper job structures, the benefits of advanced education remain theoretical.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eTo enhance professional development, more APN positions need to be created, and management must trust in APN competencies\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 3.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587073\"\u003e\u003cstrong\u003eBarriers to APN Integration\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNumerous challenges were identified that hinder the integration of APNs, including unclear legal frameworks, scepticism from colleagues, and lack of awareness among the public.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThere\u0026rsquo;s still a lack of legal frameworks, mistrust from doctors, and unclear role definitions.\u003c/em\u003e\u0026quot; \u0026ndash; Nurse 1.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eI see a negative attitude from older-generation nurses and doctors... and scepticism from patients\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 6.\u003c/p\u003e\n\u003cp\u003eStructural barriers like restrictive laws and inadequate compensation models were also noted.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eLaws in some cases are very restrictive... they should change to give more freedom to APNs\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 2.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587074\"\u003e\u003cstrong\u003eSystemic Changes Needed for APN Integration\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eParticipants proposed clear and actionable changes necessary for successful integration. These included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eEstablishing legal and regulatory clarity.\u003c/li\u003e\n \u003cli\u003eDeveloping APN job descriptions across all levels of care.\u003c/li\u003e\n \u003cli\u003eCreating financial incentives and reimbursement systems.\u003c/li\u003e\n \u003cli\u003eLaunching public education campaigns about APN roles.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eFirst, a clear legal framework must be established to define APN competencies... this would avoid confusion and ensure safe, high-quality service delivery\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 1.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThere needs to be clear regulations... and a defined set of job requirements for APN positions\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 4.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587075\"\u003e\u003cstrong\u003eSupport and Resources Required\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eSupport systems were seen as vital, especially during the early implementation phase. Nurses stressed the need for mentorship, access to continuous education, administrative support, and physical infrastructure like consultation rooms. The role of healthcare institutions in mentoring and promoting APNs was emphasized as a critical factor in successful transition.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eSupport from administration is very important, and collaboration with GPs is also essential\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 2.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eEducational institutions should provide practical training and ensure programs meet real-world demands\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 5.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587076\"\u003e\u003cstrong\u003eExpected Impact on the Healthcare System\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAll participants agreed that APNs would play a crucial role in improving the healthcare system\u0026apos;s responsiveness, especially amid physician shortages and increasing chronic disease prevalence.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eAPNs could significantly improve patient health outcomes... they can dedicate more time to education and consultations\u003c/em\u003e.\u0026quot; \u0026ndash; Nurse 5.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThey would improve system flexibility, accessibility, and sustainability\u003c/em\u003e.\u0026quot; \u0026ndash;\u0026nbsp;Nurse 1.\u003c/p\u003e\n\u003cp\u003eThey envisioned APNs not only as care providers but also as educators, policy influencers, and leaders in public health.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eAPNs can become not just care providers, but also leaders in public health... their potential is still underutilized in Lithuania\u003c/em\u003e.\u0026quot; \u0026nbsp;\u0026ndash; Nurse 1.\u003c/p\u003e\n\u003cp\u003eThe interviews revealed the following themes and subthemes related to healthcare managers\u0026rsquo; perceptions\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003epresented in Table 2.\u003c/p\u003e\n\u003cp\u003eTable 2. Perceptions of healthcare managers: the main themes and subthemes identified\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eSub-theme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eCurrent professional roles and responsibilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAPNs understood as independent decision-makers and care providers.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCapability to prescribe, refer, and manage chronic conditions.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003ePerceived healthcare needs and APN contributions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eRelieving physician workload and improving care access.\u003c/li\u003e\n \u003cli\u003eEnhancing patient care continuity, especially in underserved areas.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eBarriers and challenges to APN integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLegal ambiguity, unclear scope, and interprofessional resistance.\u003c/li\u003e\n \u003cli\u003ePublic misunderstanding and cultural resistance in rural areas.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eProfessional motivation and career development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSupport for APNs as a modern evolution of skilled nursing practice\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eOrganizational and system-level support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eClear job roles, institutional support, fair compensation.\u003c/li\u003e\n \u003cli\u003eNeed for national legislation, education campaigns, and structural planning.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eExpectations for future healthcare delivery models\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eImproving system efficiency and expanding care access.\u003c/li\u003e\n \u003cli\u003ePhased integration, increased public trust, and interdisciplinary cooperation.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDefined success as clarity, autonomy, and measurable health outcomes.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3 id=\"_Toc198587078\"\u003e\u003cstrong\u003eUnderstanding of the APN Role\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eHealthcare managers (HM)showed clear support for the APN role, highlighting their broad clinical skills, independent decision-making, and ability to connect physicians and nurses. One saw APNs as autonomous healthcare professionals, not just assistants.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe APN role is important... a specialist with broader competencies, having sufficient knowledge and skills to examine patients, make decisions, and act independently\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 1.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThey work independently, in separate offices from doctors, consulting physicians only in emergency situations\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 4.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI would say advance practice nurse is a highly trained nurse with advanced clinical skills and the ability to work independently in certain areas, such as diagnosis, prescribing, and chronic disease management\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 6.\u003c/p\u003e\n\u003cp\u003eOne HM reinforced this vision by highlighting that APNs could take over various tasks traditionally performed by physicians, such as issuing prescriptions, ordering and interpreting tests, and referring patients to specialists.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eAPNs could support the doctor, prescribe medications, order tests, interpret results, and write referrals\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 3.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587079\"\u003e\u003cstrong\u003ePerceived Contribution of APNs to Patient Care\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eHMs uniformly agreed that APNs could make substantial contributions to patient care, particularly by relieving physician workload and improving access to healthcare services. They envisioned APNs as key contributors to both acute and chronic patient management. These reflections underscore the potential for APNs to expand healthcare system capacity without compromising care quality.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThey would relieve the burden on doctors, take over part of their functions, and ensure faster access to care\u003c/em\u003e.\u0026rdquo;\u0026nbsp;\u0026ndash; HM 1.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIn our institution... APNs would reduce the workload of both doctors and nurses and should be able to provide many services independently\u003c/em\u003e.\u0026rdquo;\u0026nbsp;\u0026ndash; HM 3.\u003c/p\u003e\n\u003cp\u003eSome highlighted their role in addressing care gaps when doctors are unavailable, especially in rural or underserved regions.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIn outpatient clinics, it\u0026apos;s nearly impossible to get doctors to work. This is another niche for APNs\u0026mdash;to manage routine cases and refer difficult ones\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 4.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAreas of Significant Impact\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWhen asked about specific areas or departments where APNs could have the greatest influence, HMs pointed to primary healthcare, chronic disease management, outpatient services, emergency rooms and even anaesthesiology.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eAt the primary care level... APNs could independently take over a large share of work, especially in chronic disease management\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 5.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI think APNs would be especially effective in family medicine departments\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 3.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eEspecially in primary care, emergency departments, and home-based care programs APN\u0026rsquo;s can have significant impact in improved and timely care\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 6.\u003c/p\u003e\n\u003cp\u003eThis broad applicability suggests APNs could help optimize patient flow and improve outcomes across care levels, provided the system enables their full integration.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587081\"\u003e\u003cstrong\u003eHealthcare Needs Addressed by APNs\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe healthcare system in Lithuania faces multiple pressures, including prevalence of chronic diseases, physician shortages, and regional disparities. HMs believed APNs are uniquely positioned to help alleviate these challenges.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIndependent consultations, prescription renewals, monitoring of patients with multiple chronic conditions\u0026mdash;APNs could cover all of these needs\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe most urgent needs are related to physician shortages, particularly in regional hospitals, and the growing burden of chronic diseases.\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAPNs could help address all these issues\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 6.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHMs also emphasized the importance of preventive health initiatives and patient education, both of which fall naturally within the scope of advanced nursing practice. However, there was concern over the current ambiguity in legal definitions of the APN role.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eCurrently, the law defines the role very broadly but without clarity. That\u0026rsquo;s just my opinion\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 3.\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc198587082\"\u003e\u003cstrong\u003eImpact on Organizational Efficiency and Outcomes\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eHMs highlighted APNs\u0026rsquo; potential to increase healthcare delivery efficiency by handling routine cases independently and allowing physicians to focus on complex cases.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIf APNs handle straightforward consultations independently, it will speed up access to specialists for urgent or complex cases\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 5.\u003c/p\u003e\n\u003cp\u003eSome cautioned that the effect on patient wait times would depend on how extensively APNs are implemented.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIf there were at least four APNs in a large facility, yes\u0026mdash;it would make a difference. But one APN might not change much\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM3.\u003c/p\u003e\n\u003cp\u003eNonetheless, the overall sentiment was that APNs would improve service coordination and responsiveness.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587083\"\u003e\u003cstrong\u003eResources, Funding, and Integration Support\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eSuccessful integration requires systemic and institutional support. HMs emphasized the need for clear legal definitions, proper workplace setup, access to modern tools, and appropriate salary structures.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eFirst, clearly define duties, rights, and responsibilities, and update the legal framework\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 5.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eSupport from hospital management is essential, along with ministerial orders and clear job roles\u003c/em\u003e.\u0026rdquo;\u0026nbsp;\u0026ndash; HM 3.\u003c/p\u003e\n\u003cp\u003eFinancial sustainability was a recurrent concern. While APN roles are seen as cost-effective in the long run, initial implementation and funding strategies remain unresolved.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eMaintaining an APN position would cost less than a family doctor or specialist... funds could be used for more diagnostics and tools\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 2.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587084\"\u003e\u003cstrong\u003eAnticipated Challenges\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eKey challenges included lack of trust from existing medical staff, unclear regulations, and public perception. Resistance could arise from both physicians and general nurses if roles and responsibilities are not clearly communicated.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eDoctors may resist if they\u0026rsquo;re held accountable for APN errors. Nurses may resist due to wage gaps\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 1.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe biggest challenge will be role clarity\u0026mdash;differentiating APNs from general nurses and physicians\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 6.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe need for public education was repeatedly stressed, particularly in rural areas.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In rural areas, it will be different. Patients still want to see \u0026apos;the doctor.\u0026apos; That belief will take time to change.\u003c/em\u003e\u0026rdquo; \u0026ndash; HM 4.\u003c/p\u003e\n\u003cp\u003eParticipants suggested that trust would grow once patients experience the competence of APNs firsthand.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587085\"\u003e\u003cstrong\u003eCollaboration and Interdisciplinary Teamwork\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAPNs were envisioned as collaborative partners in care, working with physicians, lifestyle specialists, and other healthcare professionals.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe APN can create a care plan with the family doctor, monitor the patient\u0026rsquo;s indicators, and coordinate with the team\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 2.\u003c/p\u003e\n\u003cp\u003eInterdisciplinary trust and communication were viewed as essential for successful integration. Some\u0026nbsp;healthcare managers\u0026nbsp;proposed structured collaboration strategies, including joint training and informal team building.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eUnite everyone into one team to work cooperatively... training or after-work events could improve relationships\u003c/em\u003e.\u0026rdquo;\u0026nbsp;\u0026ndash; HM 3.\u003c/p\u003e\n\u003cp\u003eOthers suggested a phased approach\u0026mdash;beginning with shared tasks and transitioning toward independent APN-led care.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587086\"\u003e\u003cstrong\u003eLong-Term Vision and Impact on the Healthcare System\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMost HMs expressed optimism that APNs would contribute meaningfully to the future of Lithuanian healthcare. Their introduction was seen as inevitable and essential for improving service delivery, especially in response to aging populations and rising multymorbidity.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eAPNs will be employed according to need and will take over tasks from family doctors and GPNs... access to services should improve markedly\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 2.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eAPNs are practically like doctors... with time, the population will accept and even prefer them for certain cases\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 4.\u003c/p\u003e\n\u003cp\u003eHMs highlighted the importance of professional respect, visibility, and long-term policy support to sustain these roles.\u003c/p\u003e\n\u003ch3 id=\"_Toc198587087\"\u003e\u003cstrong\u003eDefining Successful APN Integration\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eSuccess was defined by clarity, trust, and autonomy. HMs felt that legal certainty, fair compensation, public education, and institutional support were key pillars of sustainable APN integration.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eSuccess means allowing each specialist to work fully within their competencies and have autonomy\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 2.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003ePublic education about the new service is key\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 1.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIt would mean having a defined and recognized APN role, supported by national legislation, funded training programs, and measurable outcomes\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 6.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome referenced the historical role of feldshers and nurses with extended responsibilities as a precedent, suggesting that APNs represent a formal and modern evolution of this concept.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eCompared to other countries, we\u0026rsquo;re far behind... APNs are a modern version of feldshers\u0026mdash;independent, community-focused, and practical\u003c/em\u003e.\u0026rdquo; \u0026ndash; HM 3.\u003c/p\u003e\n\u003cp\u003eThese expanded findings illustrate a cautious yet hopeful stance from healthcare managers. They largely align with the aspirations of APNs themselves and provide clear strategic directions for successful integration\u0026mdash;emphasizing collaboration, regulation, education, and structural investment.\u003c/p\u003e\n\u003cp id=\"_Toc198583753\"\u003e\u003cstrong\u003eComparative Perceptions of APN Integration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnderstanding of APN Role: Nurses see themselves as still working within general nursing roles but expect to gain more autonomy and clinical responsibility as APNs are integrated. Healthcare managers describe APNs as independent clinicians who have the potential to manage patients and make decisions on their own.\u003c/p\u003e\n\u003cp\u003eContribution to Healthcare:\u0026nbsp;Nurses believe that APNs will strengthen chronic care management, reduce wait times, and improve healthcare accessibility, particularly in rural areas. In comparison, healthcare managers see APNs as a way to alleviate doctors\u0026rsquo; workloads and broaden patient access, especially in underserved communities.\u003c/p\u003e\n\u003cp\u003eBarriers to Integration: Nurses highlight the absence of clear legal frameworks, resistance from colleagues, and poorly defined roles as the main barriers to APN integration. In comparison, healthcare managers emphasize regulatory uncertainty, interprofessional skepticism, and insufficient funding as the primary challenges to successful implementation.\u003c/p\u003e\n\u003cp\u003eSupport and Resources Needed: Nurses stress the importance of mentorship, dedicated APN training programs, and strong policy-level backing to ensure successful integration. In contrast, healthcare managers emphasize the need for well-defined job descriptions, sufficient funding, appropriate infrastructure, and robust administrative support to facilitate the effective implementation of the APN role.\u003c/p\u003e\n\u003cp\u003eFuture Vision and System Impact: Nurses envision APNs as leaders in public health, patient educators, and autonomous care providers delivering advanced clinical services. Meanwhile, healthcare managers anticipate a transformation in care models, greater system efficiency, and APNs filling diverse roles across departments such as primary care, chronic disease management, and emergency care.\u003c/p\u003e\n\u003cp\u003eDefinition of Successful Integration: Nurses stress the importance of legal recognition, increased public awareness, and the creation of structured APN positions that align with their specialized training. In comparison, healthcare managers emphasize the need for clearly defined competencies, greater clinical autonomy, measurable outcomes, and strengthened professional respect to ensure successful APN integration.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings indicate readiness, motivation, and role clarity among Lithuanian APNs in relation to transforming healthcare delivery; however, these results should not be interpreted as representative of all advanced practice nurses in Lithuania. While challenges remain, there is a clear consensus on the need for institutional, legal, and cultural change to unlock the full potential of APNs in the Lithuanian health system. This study offers new insights into how APNs and healthcare managers perceive APN integration in Lithuania\u0026rsquo;s healthcare system. The findings echo international literature while highlighting local barriers and opportunities.\u003c/p\u003e\n\u003cp\u003eAPNs shared that they still perform mainly general nursing tasks despite readiness for greater autonomy, a pattern seen elsewhere. Hill et al., 2023 found that unclear roles limit UK APNs in community care [24].\u0026nbsp;Beil-Hildebrand \u0026amp; Smith, 2022 reported similar constraints in German-speaking countries due to hierarchical cultures [49].\u0026nbsp;In Lithuania, healthcare managers noted APNs\u0026rsquo; potential but stressed the lack of clear legal frameworks, echoing the International Council of Nurses\u0026rsquo; view that absent legislation hinders APN practice [50].\u003c/p\u003e\n\u003cp\u003eBoth groups cited physician shortages, chronic disease burdens, and poor rural access\u0026mdash;issues matching the Lithuanian Ministry of Health\u0026rsquo;s \u0026ldquo;Action Plan to Reduce the Shortage of Doctors\u0026rdquo; [27].\u0026nbsp;Internationally, APNs help fill such gaps: in France [13]\u0026nbsp;and Spain [19], APNs improved care in underserved areas [13, 19].\u0026nbsp;The focus on chronic disease management also aligns with recent Spanish studies showing APNs\u0026rsquo; role in patient education and monitoring [11].\u003c/p\u003e\n\u003cp\u003eHealthcare managers emphasized the need for clear job descriptions, legal frameworks, and fair pay\u0026mdash;conditions echoed in the literature. For example, Toniolo et al., 2024 found that policy alignment, readiness, and collaboration were key for APN roles in France [50].\u0026nbsp;Unsworth et al., 2024 also stressed structured pathways, funding, and leadership as vital enablers [51].\u003c/p\u003e\n\u003cp\u003eEffective teamwork with physicians remains a challenge due to trust and unclear roles. Lee et al., 2023 showed that defining interprofessional roles early supports smoother implementation [34].\u0026nbsp;Torrens et al., 2020 noted physician resistance and poor team integration as barriers across Europe, highlighting the need for cultural as well as policy change [18].\u003c/p\u003e\n\u003cp\u003eBoth groups agreed public understanding of APN roles in Lithuania is low. Darginavičienė et al., 2022 found patients often don\u0026rsquo;t know when to see an APN [23].\u0026nbsp;By contrast, the UK and Scandinavia have raised awareness through public campaigns and structured roles [4, 52].\u0026nbsp;Lithuanian APNs showed strong motivation to expand their roles, similar to Finnish APNs driven by professional identity [21].\u0026nbsp;But sustained motivation depends on systemic support\u0026mdash;without it, APNs risk frustration and burnout, as seen by Colson et al., 2021 in France [53].\u003c/p\u003e\n\u003cp\u003eThe discussion shows that Lithuania shares common APN integration challenges but can learn from international success stories. Key recommendations include:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eClarify APN roles through legislation and local protocols [5, 13].\u003c/li\u003e\n \u003cli\u003eRaise public and professional awareness to build acceptance [23].\u003c/li\u003e\n \u003cli\u003eCreate collaborative frameworks and supervision models for interprofessional practice [34].\u003c/li\u003e\n \u003cli\u003eOffer financial incentives and clear career paths to retain APNs [51].\u003c/li\u003e\n \u003cli\u003eMonitor pilot projects to inform national rollout, as seen in France and Spain [19, 50].\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several notable strengths and some limitations that should be considered when interpreting its findings. Firstly, this study provides a good overview, which enables Lithuania to learn from successful APN integration models in other EU countries and adapt them to local needs. Secondly, this study demonstrated an increasing demand for advanced practice nurses due to physician shortages, an ageing population, and the rising burden of chronic diseases.\u003c/p\u003e\n\u003cp\u003eDue to the limited availability of evidence-based information, the comparison of results is restricted. Therefore, this study rather maps the current situation. There is limited data on pilot program outcomes, weak insight into public and professional views, and little evidence on cost-effectiveness, especially for rural areas. Lack of local pilot projects or well-defined APN roles makes implementation and scaling more difficult. The results of this study cannot be generalized to the whole of Lithuania, mainly due to the relatively small sample size. However, the findings highlight the need for further research and mark the first study of its kind in Lithuania.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study shows that both APNs and healthcare managers in Lithuania view APN integration as essential for healthcare evolution. There is a strong need for APNs to support primary care, ease physician workload, manage chronic diseases, and improve access in underserved areas. APNs are motivated to expand their roles but face risks from unclear institutional support and role definitions. Integration barriers are mainly structural and cultural\u0026mdash;unclear laws, funding gaps, low public awareness, and staff resistance\u0026mdash;which can be addressed through policy changes, education, and investment in collaboration.\u003c/p\u003e\u003cp\u003eLithuania has an opportunity to formalize APN roles and join Europe\u0026rsquo;s shift toward more flexible, patient-centred care. Achieving this will require coordinated action in education, regulation, and policy, guided by regional and global best practices. Despite rising awareness of APNs\u0026rsquo; contributions, multiple barriers hinder their broader adoption, notably regulatory gaps, professional resistance, limited education pathways, and systemic or cultural factors. These are especially challenging for Lithuania at its early stage of APN development.\u003c/p\u003e\u003cp\u003eChange management is a long-term and challenging process, and the same applies to APN integration, which requires steady progress and responsiveness to the needs of the population and the health sector by adopting the best global practices. In conclusion, while nurses and healthcare managers share the vision of APNs as valuable contributors to the health system, their perspectives highlight the need for clear legal frameworks, defined roles, and strong organizational support to achieve successful integration in Lithuania.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAPN-\u003c/strong\u003e Advance practice nurse\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICN-\u003c/strong\u003e International Council of Nurses\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHM \u0026ndash;\u003c/strong\u003e Healtcare manager\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNP-\u003c/strong\u003e Nurse Practitioner\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRN-\u003c/strong\u003e Registered nurses\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the the Ethics Committee for Scientific Research of the Faculty of Medicine of Vilnius University (Protocol Nr. (1.7 E) 150000-KT-21) and written informed consents were obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article. The data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy design: IQ, JS, NI. Data acquisition: IQ. Data analysis and interpretation: IQ, JS. Manuscript preparation: IQ, JS, NI. Critical revision of the manuscript for intellectual content: JS, NI. Manuscript review: IQ, JS, NI. Obtaining financing: None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participants, whose valuable contributions support the integration of APN into the healthcare system\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIQ\u003c/strong\u003e is an Advanced Practice Nurse, MSc, and was a master\u0026rsquo;s student during the data collection phase\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eat the Faculty of Medicine of Vilnius University, Lithuania.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJS\u0026nbsp;\u003c/strong\u003eholds her PhD in Health Sciences and serves as an docent at\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eVilnius University, Lithuania.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNI\u003c/strong\u003e holds her PhD in Health Sciences and contributes as a Professor and Senior Researcher at the Vilnius University, Lithuania.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eZhang Y. 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Accessed 9 Sep 2025.\u003c/li\u003e\n \u003cli\u003eMinistry of Health of the Republic of Lithuania. Action plan to reduce the shortage of doctors. https://sam.lrv.lt/en/during-the-visit-to-japan-the-focus-was-on-patient-safety/action-plan-to-reduce-the-shortage-of-doctors/. (2024). Accessed 9 Sep 2025.\u003c/li\u003e\n \u003cli\u003eVanckavičienė A, Blaževičienė A, Zagurskienė D, Sta\u0026scaron;aitis K. Health workforce forecast in the university hospital: evidence from Lithuania. BMC Nurs. 2024; doi: 10.1186/s12912-024-02326-9.\u003c/li\u003e\n \u003cli\u003eE-seimas. Dėl lietuvos respublikos sveikatos apsaugos ministro 2017 m. liepos 7 d. įsakymo nr. v-852 \u0026bdquo;dėl lietuvos medicinos normos mn 160:2017\u0026bdquo; i\u0026scaron;plėstinės praktikos slaugytojas. teisės, pareigos, kompetencija ir atsakomybė\u0026ldquo; patvirtinimo\u0026ldquo; pakeitimo. 2023.https://eseimas.lrs.lt/portal/legalAct/lt/TAP/3d8cf6e1937111eea70ce7cabd08f150?positionInSearchResults=4\u0026amp;searchModelUUID=506a7322-ef0b-42a0-8b2f-6107b221dc3f. Accessed 9 Sep 2025.\u003c/li\u003e\n \u003cli\u003eMinistry of Health of the Republic of Lithuania. Nurses and midwives will be able to provide consultations. https://sam.lrv.lt/en/during-the-visit-to-japan-the-focus-was-on-patient-safety/nurses-and-midwives-will-be-able-to-provide-consultations/. (2023) Accessed 9 Sep 2025.\u003c/li\u003e\n \u003cli\u003eValstybinė akreditavimo sveikatos priežiūros veiklai tarnyba prie Sveikatos apsaugos ministerijos. 2024. https://licencijavimas.vaspvt.gov.lt/License/PublicSpecialistIndex. Accessed 9 Sep 2025.\u003c/li\u003e\n \u003cli\u003eDanusevičienė L, Jurkuvienė R, Butkevičienė R, Gajdosikienė I. The Changing Role of a Nurse in Lithuania Related to Integrated Team-Based Home Care Pilot Projects. Nurs Educ Res Pract. 2014; 4(1):2-10\u003c/li\u003e\n \u003cli\u003eGoryakin Y, Thi\u0026eacute;baut SP, Cortaredona S, Lerouge MA, Cecchini M, Feigl AB, Ventelou B. Assessing the future medical cost burden for the European health systems under alternative exposure-to-risks scenarios. PLoS One. 2020; doi: 10.1371/journal.pone.0238565.\u003c/li\u003e\n \u003cli\u003eLee GA, Baker EE, Stewart C, Raleigh M. Advanced practice and clinical supervision: An exploration of perceived facilitators and barriers in practice. J Clin Nurs. 2023; doi: 10.1111/jocn.16341.\u003c/li\u003e\n \u003cli\u003eHan R, Rogers M, Asplund S, Fagerstr\u0026ouml;m L. Nurse Practitioners\u0026apos; Practice Patterns in Primary Care in Finland: A Descriptive Qualitative Study. Glob Qual Nurs Res. 2025; doi: 10.1177/23333936251365612.\u003c/li\u003e\n \u003cli\u003eLjungbeck B, Carlson E, Forss KS. Swedish stakeholders\u0026apos; views of the preparatory work needed before introducing the nurse practitioner role in municipal healthcare-A focus group study. Scand J Caring Sci. 2024; doi: 10.1111/scs.13224.\u003c/li\u003e\n \u003cli\u003eAbraham CM, Norful AA, Stone PW, Poghosyan L. Cost-Effectiveness of Advanced Practice Nurses Compared to Physician-Led Care for Chronic Diseases: A Systematic Review. Nurs Econ. 2019; 37(6):293-305.\u003c/li\u003e\n \u003cli\u003eLewis R. The evolution of advanced nursing practice: Gender, identity, power and patriarchy. Nurs Inq. 2022; doi: 10.1111/nin.12489.\u003c/li\u003e\n \u003cli\u003eCasey M, O\u0026apos;Connor L, Cashin A, Fealy G, Smith R, O\u0026apos;Brien D, Stokes D, McNamara M, O\u0026apos;Leary D, Glasgow ME. Enablers and challenges to advanced nursing and midwifery practice roles. J Nurs Manag. 2019; doi: 10.1111/jonm.12697.\u003c/li\u003e\n \u003cli\u003eFealy GM, Casey M, O\u0026apos;Leary DF, McNamara MS, O\u0026apos;Brien D, O\u0026apos;Connor L, Smith R, Stokes D. Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers. J Clin Nurs. 2018; doi: 10.1111/jocn.14550.\u003c/li\u003e\n \u003cli\u003eYlit\u0026ouml;rm\u0026auml;nen T, Kvist T, Turunen H. Perceptions on nurse-nurse collaboration among registered nurses in Finland and Norway. Scand J Caring Sci. 2019; doi: 10.1111/scs.12669.\u003c/li\u003e\n \u003cli\u003eAlstveit M, Lahti S, J\u0026oacute;nsd\u0026oacute;ttir SS, Egeland N, S\u0026oslash;rensen SK, Eklund AJ. Public health nurse education in the Nordic countries. Public Health Nurs. 2022; doi: 10.1111/phn.13029.\u003c/li\u003e\n \u003cli\u003eRodriguez A, Smith J. Phenomenology as a healthcare research method. Evid Based Nurs. 2018; doi: 10.1136/eb-2018-102990.\u003c/li\u003e\n \u003cli\u003eDoyle L, McCabe C, Keogh B, Brady A, McCann M. An overview of the qualitative descriptive design within nursing research. J Res Nurs. 2020; doi: 10.1177/1744987119880234.\u003c/li\u003e\n \u003cli\u003eAhmad M, Wilkins S. Purposive sampling in qualitative research: a framework for the entire journey. Qual. Quant. 2024; doi: 10.1007/s11135-024-02022-5.\u003c/li\u003e\n \u003cli\u003eManti S, Licari A. How to obtain informed consent for research. Breathe. 2018; doi: 10.1183/20734735.001918.\u003c/li\u003e\n \u003cli\u003eKallio H, Pietil\u0026auml; AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016; doi: 10.1111/jan.13031.\u003c/li\u003e\n \u003cli\u003eByrne, D. A worked example of Braun and Clarke\u0026rsquo;s approach to reflexive thematic analysis. Qual Quant. 2022; doi.org/10.1007/s11135-021-01182-y.\u003c/li\u003e\n \u003cli\u003eBeil-Hildebrand MB, Smith HB. Comparative Analysis of Advanced Practice Nursing: Contextual and Historical Influences in North American and German-Speaking European Countries. Policy Polit Nurs Pract. 2022; doi: 10.1177/15271544221105032.\u003c/li\u003e\n \u003cli\u003eToniolo J, Berger V, Deplanque A, Langlois M, Pelletier I, Ngoungou EB, Preux PM, Beloni P. Advanced practice nursing implementation in France: A mixed-method study. J Adv Nurs. 2024; doi: 10.1111/jan.16303.\u003c/li\u003e\n \u003cli\u003eUnsworth J, Greene K, Ali P, Lilleb\u0026oslash; G, Mazilu DC. Advanced practice nurse roles in Europe: Implementation challenges, progress and lessons learnt. Int Nurs Rev. 2024; doi: 10.1111/inr.12800.\u003c/li\u003e\n \u003cli\u003eWood E, King R, Senek M, Robertson S, Taylor B, Tod A, Ryan A. UK advanced practice nurses\u0026apos; experiences of the COVID-19 pandemic: a mixed-methods cross-sectional study. BMJ Open. 2021; doi: 10.1136/bmjopen-2020-044139.\u003c/li\u003e\n \u003cli\u003eColson S, Schwingrouber J, Evans C, Roman C, Bourriquen M, Lucas G, Mellinas M, Brunet P, Cermolacce M, Chinot O, Mayen S, Berbis P. The creation and implementation of advanced practice nursing in France: Experiences from the field. Int Nurs Rev. 2021; doi: 10.1111/inr.12684.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Advanced Practice Nurses, Healthcare Managers, Quality of Care, Lithuanian Health System, Qualitative Study","lastPublishedDoi":"10.21203/rs.3.rs-7639650/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7639650/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Amid the growing complexity of healthcare, Advanced Practice Nurses are increasingly recognized worldwide for enhancing access to care, improving patient outcomes, and boosting system efficiency. Despite the pivotal role that nurses occupy within the Lithuanian healthcare system, the potential of Advanced Practice Nurses remains largely unrealized, due to the absence of clearly defined formal roles and structured pathways that would enable Advanced Practice Nurses to practise autonomously and apply their advanced competencies to their full extent. This study aimed to examine the perspectives of selected nurses and healthcare managers on the integration of Advanced Practice Nurses into health system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e A qualitative descriptive design employing semi-structured interviews was utilised in Lithuania with Advanced Practice Nurses (n=6) and healthcare managers (n=6). Participants were recruited based on inclusion criteria. The interviews covered six main topics. The average duration of the interviews was 67.5 minutes. Data were analyzed using thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThe analysis yielded twelve themes each for the nurses and healthcare managers. The results indicated that Advanced Practice Nurses and healthcare managers have differing perspectives on how Advanced Practice Nurses should be integrated, yet both regard it as a necessary evolution of the health system. Motivations were both personal and professional, driven by a commitment to holistic, patient-centred care and the desire to apply advanced clinical knowledge autonomously. Managers perceived successful integration as dependent on role clarity, mutual trust, and professional autonomy. Integration barriers are chiefly structural and cultural—unclear legislation, insufficient funding, low public awareness, and professional resistance—but can be addressed through policy reform, education, public engagement, and investment in collaborative models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e There is a clear and increasing need for Advanced Practice Nurses to strengthen healthcare, alleviate physician workload, manage chronic conditions, and expand access in underserved regions. Advanced Practice Nurses demonstrate strong motivation to apply their competencies and assume broader roles, yet this is constrained by limited institutional pathways, recognition, and role definition. Further national-level research is needed in Lithuania to assess the effectiveness, safety, patient satisfaction, health outcomes, service utilization, and economic impact of Advanced Practice Nurse-led care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Integrating Advanced Practice Nurses into the Health System: Views from Nurses and Healthcare Managers – A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-14 16:55:30","doi":"10.21203/rs.3.rs-7639650/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-06T04:14:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-05T10:54:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-21T20:46:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187521331933824229468580724601184410854","date":"2025-12-09T16:38:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328010039123473373323540786957300479870","date":"2025-12-09T12:07:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-09T05:38:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-01T04:49:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-24T19:05:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-23T15:46:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-09-23T13:34:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e9ce231c-f216-4c92-a632-c0a72a01da2d","owner":[],"postedDate":"December 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:12:09+00:00","versionOfRecord":{"articleIdentity":"rs-7639650","link":"https://doi.org/10.1186/s12912-026-04427-z","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-02-20 15:57:26","publishedOnDateReadable":"February 20th, 2026"},"versionCreatedAt":"2025-12-14 16:55:30","video":"","vorDoi":"10.1186/s12912-026-04427-z","vorDoiUrl":"https://doi.org/10.1186/s12912-026-04427-z","workflowStages":[]},"version":"v1","identity":"rs-7639650","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7639650","identity":"rs-7639650","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}