Introduction

Healthcare systems worldwide face persistent nursing shortages and challenges in retaining experienced nurses. Traditional nursing career advancement has often emphasized promotion into management roles, although not all experienced nurses wish to pursue administrative leadership. Internationally, advanced practice nursing (APN) roles have emerged as alternative career pathways that allow nurses to advance professionally while maintaining strong clinical involvement. The experiences of the United States, Canada, Japan, the United Kingdom, and Singapore suggest that diversified nursing career structures may support professional growth, workforce sustainability, and nurse retention. These international developments provide important lessons for Taiwan, where nursing career advancement remains largely oriented toward managerial roles.

Advanced Practice Nursing Roles: Creating Clinical Leadership Beyond Management

The International Council of Nurses recognizes Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs) as the two most common advanced practice nursing roles worldwide. APNs are expected to demonstrate advanced clinical expertise, leadership, consultation, education, and research competencies. In the United States and Canada, APN development has evolved into clearly differentiated professional roles. While NPs focus primarily on diagnosing, prescribing, and managing patient care, CNSs function as expert clinicians who also provide consultation, staff education, quality improvement, and system-level leadership. Rather than serving as administrative managers, CNSs bridge bedside practice and organizational improvement, promoting evidence-based care and nursing excellence. This multidimensional role allows experienced nurses to pursue career advancement without leaving clinical practice. Japan offers another example of differentiated nursing roles. Although the NP role has not been fully established, Japan has developed CNS and Certified Nurse systems. CNSs are expected to provide expert clinical care while contributing to consultation, education, and research activities. These roles recognize advanced nursing expertise and provide professional development opportunities beyond traditional managerial positions. UK increasingly conceptualizes advanced practice as a level of practice and recognizes that leadership can occur through clinical expertise and professional influence rather than solely through administrative authority. These international examples demonstrate that nursing leadership does not have to be synonymous with management. Clinical leadership, consultation, education, quality improvement, and research can all represent meaningful pathways for professional advancement.

Career Pathways: Lessons from Singapore

While APN roles provide role differentiation, Singapore has broadened this approach by developing a comprehensive nursing career pathway system. This system acknowledges that nurses possess diverse interests, strengths, and professional development goals. Nursing careers are therefore not limited to bedside care or management positions. Nurses may pursue pathways in advanced clinical practice, education, research, innovation, community health, leadership, and healthcare administration. Educational opportunities at the master's and doctoral levels further support career progression and specialization. Importantly, Singapore's approach acknowledges that professional development should not force all experienced nurses into managerial roles. Instead, multiple career tracks allow nurses to advance while contributing according to their expertise and interests. Clinical experts can remain close to patient care, educators can focus on workforce development, and researchers can contribute to knowledge generation and innovation. This model reflects a broader understanding of nursing talent. Not every highly skilled clinician wishes to become a manager, and not every effective manager necessarily emerges from the strongest clinical experts. By recognizing different forms of expertise, Singapore creates opportunities for career advancement while retaining experienced nurses within the profession.

Healthy Work Environments and Nurse Retention

The value of diversified nursing career pathways extends beyond professional development. They are also closely linked to healthy work environments and workforce retention. An integrative review of healthy work environments identified four essential elements: effective nursing leadership, effective communication, teamwork, and professional autonomy. These components create organizational conditions that support nurse well-being and professional satisfaction. Professional autonomy is particularly relevant to career pathway development. Nurses who are able to exercise advanced knowledge, participate in decision-making, and contribute through specialized expertise are more likely to experience professional fulfillment. Similarly, leadership opportunities do not necessarily require managerial authority. Advanced clinical roles such as CNSs allow nurses to influence patient care, mentor colleagues, and lead quality improvement initiatives while remaining embedded in clinical practice. Research has consistently demonstrated that healthy work environments are associated with improved nurse retention. Nurses are more likely to remain in organizations where they experience professional growth, support, recognition, and opportunities to contribute meaningfully. Conversely, limited advancement opportunities may contribute to dissatisfaction and workforce turnover. Therefore, career pathway development should not be viewed solely as a professional advancement strategy. It should also be considered a workforce retention strategy that supports both individual nurses and healthcare organizations.

Reflections for Taiwan

Taiwan has successfully established the NP system; however, the development of advanced practice nursing beyond the NP role remains in transition. In 2024, Taiwan completed the framework for the CNS system, representing an important milestone in advancing clinical nursing practice. Nevertheless, implementation remains at an early stage, and key elements, including standardized competency-based education, certification mechanisms, clearly defined scopes of practice, career pathways, reimbursement, and institutional support, continue to evolve. Currently, career advancement for experienced nurses in Taiwan is still largely directed toward managerial positions. Although nurse managers play essential roles in workforce management, budgeting, accreditation, quality improvement, and administrative leadership, many expert clinicians have limited opportunities for advancement while remaining in direct clinical practice. Consequently, advanced clinical expertise in consultation, specialty care, evidence-based practice, education, and quality improvement is not always fully utilized within existing career structures. The development of the CNS system provides an opportunity to establish complementary pathways for administrative and clinical leadership. Rather than creating another professional title, the CNS system aims to build a competency-based framework that supports clinical excellence, interdisciplinary collaboration, staff development, research translation, and quality improvement. A well-defined CNS career pathway would strengthen advanced nursing practice, improve retention of experienced nurses, and contribute to a healthier nursing work environment and sustainable healthcare system.

Conclusion

International experiences from the United States, Canada, Japan, the United Kingdom, and Singapore demonstrate that nursing career advancement can extend far beyond administrative management. Advanced practice and specialist nursing roles provide alternative pathways that recognize clinical expertise, education, research, consultation, and leadership. For Taiwan, continued development of advanced practice nursing through clear role delineation, well-defined clinical career pathways, and supportive organizational policies may strengthen healthy work environments and improve nurse retention. By recognizing multiple forms of professional excellence, healthcare organizations can better utilize nursing talent, enhance professional autonomy, support clinical leadership, and retain experienced nurses within the workforce. Ultimately, establishing a diversified and sustainable advanced nursing career framework will not only support nurses' professional growth but also enhance healthcare quality, organizational performance, and the long-term sustainability of Taiwan's healthcare system.

References

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全球醫療體系正持續面臨護理人力短缺及資深護理人員留任困難等挑戰。人口老化、慢性疾病增加、病人病情複雜度提升，以及醫療科技快速發展，使護理工作所需的專業判斷、跨團隊協調及照護整合能力日益增加。醫療體系需要的不只是更多護理人員，也需要保留具有豐富臨床經驗、能處理複雜照護問題並帶領專業發展的資深護理人才。然而，傳統護理職涯發展往往將晉升管理職視為主要，甚至是唯一的專業成就途徑。護理人員累積一定年資與經驗後，若希望獲得職位、薪資或專業地位上的提升，通常需轉任護理長、督導或其他行政管理職務。這樣的制度隱含一項假設，即優秀的臨床護理師最終應成為管理者；但事實上，並非所有具有豐富臨床經驗的護理人員都希望或適合從事行政管理。有些護理人員的專長在於複雜病人照護、專科諮詢、臨床教育、實證護理或品質改善，而非人力管理、預算控制與行政協調。當專業晉升只能透過離開第一線臨床來實現，醫療機構可能同時失去一位優秀的臨床護理師，卻未必得到一位真正投入管理工作的領導者。近年來，進階護理師（Advanced Practice Nurse, APN）及多元護理職涯制度逐漸成為國際護理專業發展的重要方向。這些制度使護理人員不必離開臨床，即可透過專科化、研究所教育與進階能力認證，獲得專業成長及職涯晉升的機會。美國、加拿大、日本、英國及新加坡等國家的經驗顯示，護理領導並不等同於行政管理；臨床領導、教育、研究、品質改善與專業諮詢，同樣可以成為正式且受到肯定的職涯發展方向。這些國際經驗對於目前護理職涯仍高度集中於管理職的台灣，具有重要的借鏡價值。

進階護理師角色：建立臨床領導，而非僅止於行政管理

國際護理協會（International Council of Nurses, ICN）將專科護理師（Nurse Practitioner, NP）及臨床護理專家（Clinical Nurse Specialist, CNS）視為目前國際上最主要的兩種進階護理角色。進階護理師除具備進階臨床能力外，亦應展現領導、諮詢、教育及研究等核心能力。美國的進階護理制度包含NP、CNS、麻醉護理師及助產護理師等不同角色，呈現高度角色分化。就NP與CNS而言，NP多以病人及疾病管理為核心，CNS則以特定病人族群、照護場域或臨床問題為專業領域，並同時介入病人、護理團隊及組織系統三個層級。CNS可以直接照護複雜病人，也可以協助第一線護理師進行臨床判斷、推動照護標準、分析品質指標、改善工作流程及處理跨專業照護問題。因此，CNS並非傳統意義下的行政管理者，而是以臨床專業產生影響力的領導者。加拿大亦正式認定NP與CNS兩種進階護理角色。加拿大的APN的核心能力不只包括直接且完整的臨床照護，也包括醫療系統優化、教育、研究、領導、諮詢與合作。加拿大CNS的發展，源自病人照護日益複雜後，醫療機構對臨床諮詢、專業指導及實證照護的需求，其角色重點在於協助護理人員處理複雜個案、促進照護品質及推動以證據為基礎的臨床實務，使進階護理專業可以同時改善病人結果與組織系統。日本則提供另一種不同的模式。雖然日本尚未全面建立NP制度，但已發展出CNS及認證護理師（Certified Nurse, CN）制度。CNS除了提供高階臨床照護外，也負責教育、諮詢及研究等工作，提供護理人員除了行政管理之外的另一條專業發展道路。英國則採取不同的概念。近年來，英國逐漸將Advanced Practice視為一種「執業層級（level of practice）」，而非單一職稱。進階實務工作者需同時具備臨床照護、領導、教育及研究四大核心能力。此模式強調，護理領導力不一定來自行政職位，而是可以透過臨床專業、專業影響力及跨團隊合作展現。綜觀上述各國制度，可以發現護理領導並不等同於行政管理；臨床領導、教育、研究、品質改善及專業諮詢，同樣都是護理專業發展的重要方向。

職涯發展：借鏡新加坡多元護理職涯制度

除了建立不同的進階護理角色，新加坡更進一步發展出完整的護理職涯發展制度（Nursing Career Pathway）。新加坡認為，每位護理人員皆具有不同的興趣、能力及職涯目標，因此護理職涯不應侷限於臨床照護或管理職。護理人員可依個人專長選擇進階臨床照護、教育、研究、創新、社區照護、領導或行政管理等不同發展方向，並透過碩、博士教育持續提升專業能力。更重要的是，新加坡的制度並未將管理職視為唯一的晉升途徑，而是建立多元的職涯軌道，使護理人員能依自身專長與興趣持續發展。例如，臨床專家可以持續投入病人照護，教育者可以培育下一代護理人才，研究者則可推動護理知識與創新。此制度反映了一個重要理念：並非每位優秀的臨床護理師都適合或希望成為管理者，而優秀的管理者也未必來自最優秀的臨床專家。透過建立多元職涯發展制度，不僅能尊重不同護理人才的專業特色，也能提升護理人員的職涯滿意度及留任意願。

友善職場與護理人員留任

多元的護理職涯制度，不僅有助於專業發展，更與友善職場及護理人員留任密切相關。研究指出，健康友善的護理工作環境包括四項核心要素：有效的護理領導（leadership）、良好的溝通（effective communication）、團隊合作（teamwork）以及專業自主（professional autonomy）。這些要素共同營造支持護理人員發展、提升工作滿意度及促進組織效能的工作環境。其中，專業自主與職涯發展密不可分。當護理人員能充分運用自身專業知識、參與決策並透過專業能力發揮影響力時，更容易獲得工作成就感。同樣地，領導力並不一定需要透過行政管理職來展現，像CNS這類進階臨床角色，即可透過臨床專業、教育、品質改善及指導同儕，發揮重要的領導功能。此外，多項研究亦指出，健康友善的工作環境與護理人員留任具有顯著相關性。當護理人員感受到專業成長、支持、肯定及發展機會時，更願意留任於組織；相反地，若職涯發展受限，則可能增加工作倦怠及離職意願。因此，建立多元職涯發展制度，不應僅被視為護理專業發展策略，更應視為改善護理人力留任的重要措施。

對臺灣的啟示

臺灣已建立專科護理師制度然而，專科護理師以外的進階護理實務（Advanced Practice Nursing, APN）發展仍處於持續建構階段。2024年，臺灣完成臨床護理專家（Clinical Nurse Specialist, CNS）制度架構的建立，為推動進階臨床護理發展的重要里程碑。然而，目前制度仍處於初步推動階段，包括能力導向的教育培育、認證機制、明確的執業範圍、職涯發展路徑、薪資給付制度，以及機構支持等關鍵要素，仍有待持續完善。目前，臺灣資深護理人員的職涯發展仍多以行政管理職為主要晉升方向。護理管理者雖肩負人力管理、預算規劃、醫院評鑑、品質改善及行政領導等重要職責，但許多具備豐富臨床經驗與專業能力的護理人員，若希望持續投入直接臨床照護，則缺乏相對應的職涯發展機會。因此，在臨床諮詢、專科照護、實證照護、教育培育及品質改善等領域所累積的專業能力，未能在現行職涯制度中獲得充分發揮。CNS制度的發展，提供了建立行政領導與臨床領導雙軌職涯發展的重要契機。CNS制度並非僅是新增一項專業職稱，而是建立以能力為導向的制度架構，支持卓越臨床實務、跨專業合作、人員培育、研究成果轉譯及品質改善。完善的CNS職涯發展制度，將有助於強化進階護理實務、提升資深護理人員留任率，並促進更健康的護理工作環境與醫療體系的永續發展。

結論

美國、加拿大、日本、英國及新加坡的經驗顯示，護理職涯發展不應侷限於行政管理，而應建立多元的進階護理及專科護理制度，讓臨床照護、教育、研究、品質改善、專業諮詢及領導皆成為護理專業發展的重要方向。對臺灣而言，透過明確的角色定位、完善的臨床職涯發展制度，以及支持性的組織政策，持續推動進階護理實務制度的發展，將有助於營造健康的工作環境並提升護理人員留任率。藉由肯定多元專業能力，醫療機構能更有效發揮護理人力價值，提升護理專業自主性，支持臨床領導的發展，並留任具有豐富經驗的護理人才。最終建立多元且永續的進階護理職涯制度，不僅能促進護理人員的專業成長，更能提升醫療照護品質、增進醫療機構整體效能，並促進臺灣醫療照護體系的長期永續發展。