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Addressing Issues Impacting Advanced Nursing Practice Worldwide

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Ruth Kleinpell, PhD, RN, ACNP, FAANP, FAAN
Andrew Scanlon, DNP, MN (Nurse Practitioner), MNS, RN, NP, FACN, FACNP
Denise Hibbert, RGN, MSc, BSc, DipHE, ONC, ST
Freda DeKeyser Ganz, PhD, RN
Linda East, PhD, RN
Debbie Fraser, MN, RNC-NIC
Frances Kam Yuet Wong, PhD, RN, FAAN, FHKAN
Michelle Beauchesne, DNSc, RN, CPNP, FAAN, FAANP, FNAP

Abstract

Advanced practice nursing roles are developing globally, and opportunities for advanced practice nursing are expanding worldwide due to the need for expert nursing care at an advanced level of practice. Yet it is well recognized that barriers exist with respect to APRNs being able to practice to the full extent of their education and training. Addressing barriers to APRN practice worldwide and ensuring that APRNs are able to practice to the full extent of their education and training can help to promote optimal role fulfillment as well as assessment of the impact of the APRN role.

Citation: Kleinpell, R., Scanlon, A., Hibbert, D., Ganz, F., East, L., Fraser, D., Wong, F., Beauchesne, M., (May 31, 2014) "Addressing Issues Impacting Advanced Nursing Practice Worldwide" OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 5.

DOI: 10.3912/OJIN.Vol19No02Man05

Key words: Advanced practice; Advanced practice nursing; Advanced practice registered nurse; Advanced nursing practice; international advanced practice nursing

Advanced practice nursing roles are developing globally, and opportunities for advanced practice nursing (APRN) are expanding worldwide due to the need for expert nursing care... Advanced practice nursing roles are developing globally, and opportunities for advanced practice nursing (APRN) are expanding worldwide due to the need for expert nursing care at an advanced level of practice. APRN is a term used to encompass certified nurse midwife, certified registered nurse anesthetist, clinical nurse specialist, and nurse practitioner. The International Council of Nursing defines an advanced practice nurse as a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice (International Council of Nursing 2013). A master's degree is recommended for entry level, yet in some countries such as the United States, a clinical practice doctorate is being recommended for APRN practice (National Council of State Board of Nursing, 2008).

International APRN Role Development

Regulatory mechanisms and country specific practice regulations underpin APRN practice, yet it is well acknowledged globally that APRN practice encompasses several components including the ability to diagnose, prescribe medication, prescribe treatments, and perform and interpret diagnostic testing, among aspects of advanced practice as outlined in Table 1.

The Institute of Medicine (IOM) report on the future of nursing has highlighted the importance of promoting the ability of APRNs to practice to the full extent of their education... The Institute of Medicine (IOM) report on the future of nursing has highlighted the importance of promoting the ability of APRNs to practice to the full extent of their education and training and to identify further nurses’ contributions to delivering high-quality care (IOM, 2010). Yet it is well recognized that barriers exist with respect to APRNs being able to practice to the full extent of their capabilities. A number of challenges exist in regards to the increasing numbers of APRNs globally. These include poor role clarification, proliferation of APRN titles, differing educational requirements and degrees, scope of practice conflicts, fragmentation/variability in standards and quality of educational programs (Schober & Affara, 2008; Hanson, 2013).

Table 1: Global Characteristics of the APRN Role

Right to diagnose
Authority to prescribe medication
Authority to prescribe treatment
Authority to refer clients to other professionals
Authority to admit patients to hospital
Legislation to confer and protect the title "Nurse Practitioner/Advanced Practice Nurse"
Legislation or some other form of regulatory mechanism specific to advanced practice nurses
Officially recognized titles for nurses working in advanced practice roles

Adapted from the International Council of Nursing, 2013

In a survey assessing international trends of nurse practitioners- advanced practice nurses (NP-APNs)(Pulcini et. al, 2010), respondents from 31 countries identified a number of barriers related to NP-APN practice including access to educational programs globally, lack of understanding of the NP-APN role, and lack of respect of the nursing profession, among others as outlined in Table 2. Variation in scope of practice, prescriptive authority and licensure requirements were also reported.

...specific country regulations can impose restrictions on various aspects of APRN care including legal/regulatory barriers, institutional barriers and cultural barriers. A new report from IOM identifies that specific country regulations can impose restrictions on various aspects of APRN care including legal/regulatory barriers, institutional barriers and cultural barriers. Specific examples include whether APRNs can admit patients, serve as primary care providers, sign orders for long-term care services, be reimbursed for services, or be recognized by health insurance companies as providers or reimburse them directly (Robert Wood Johnson Foundation, 2013).

Institutional and cultural barriers exist which can also impose barriers to APRN practice. Specific examples include healthcare institution’s medical staff bylaws which restrict who can admit patients or perform certain procedures, even if a qualified APRN is available. In many healthcare institutions, implementation of team-based, interprofessional collaboration is defeated by dated models of authoritarian leadership (Robert Wood Johnson Foundation, 2013). While the degree to which regulatory/legal, institutional and cultural barriers can vary, common themes emerge when reviewing the status of APRN practice in various countries.

Table 2: Global Challenges to the APRN Role

Limited access to educational programs
Insufficient nursing education
Focus on the medical model
Lack of understanding of the APRN role
Lack of respect toward the nursing profession
Dominance of the medical profession
Issues related to credentialing

Adapted from Pulcini et al, 2010

Selected Country Profiles

United States

Barriers to APRN practice in the United States (U.S.) include variation among the 50 states with respect to scope of practice, prescriptive authority, and collaborative practice requirements. Efforts to standardize the APRN role have been underway since the Barriers to APRN practice in the United States (U.S.) include variation among the 50 states with respect to scope of practice, prescriptive authority, and collaborative practice requirements. endorsement of the APRN Consensus Model which proposes uniformity in licensure, accreditation, certification and education in all 50 states by the year 2015 (National Council of State Boards of Nursing, 2008). In addition, the doctorate of nurse practice (DNP) has been identified as the recommended educational preparation for APRN practice. While not required, the DNP is being proposed as the optimal education for APRNs. Several ongoing initiatives to addressing barriers to APRN practice include active campaigns to bring public awareness and impact policy to remove restrictions to practice (Brassard & Smolenski, 2011). Federal and state laws and regulations as well as individual hospital and practice site bylaws and policies can impact APRN practice requirements. Addressing those that impose restrictions to practice is essential in order to promote uniformity in APRN practice among the U.S. 50 states. National organizations have acknowledged the importance of removing barriers to APRN practice, citing that removing barriers to care reduces costs of care, increases patient’s choice, and improves healthcare quality (American Association of Nurse Practitioners, 2012).

Australia

With the enactment of the 2009 Health Practitioner Regulation National Law Act in July 2010, Australia’s six states and two territory boards of nursing became one unified national board and with it a national nurse practitioner endorsement process. This move to a national board with national standards was not without difficulty or controversy (Scanlon, Cashin, Watson, & Byrce, 2012), but these initial implementation barriers have been somewhat overcome. Currently the requirements for nurse practitioner endorsement within Australia include: compliance with the Nurse Practitioner standards for practice (Nursing and Midwifery Board of Australia, 2014); an unrestricted registration as a registered nurse; 5000 hours experience at an advanced nursing practice level within the previous six years (Nursing and Midwifery Board of Australia, 2013); completion of an approved nurse practitioner program of study at Master’s level or equivalent; as well as compliance with national standards for recency of practice and additional continuing professional development (Nursing and Midwifery Board of Australia, 2011; 2012).

NP practice must be performed with knowledge of current Australian healthcare delivery mechanisms as well as Federal, State and local requirements for practice. However, having a national process for NP endorsement does not mean there is a singular legislative or regulatory process that governs all NP practice throughout Australia. On the contrary, there are additional layers of Federal, State and Territory legislative and regulatory requirements related to healthcare provider reimbursement or medication prescription subsidy from the Australian government’s universal healthcare system. Additionally, there are governance processes and authorization practices and protocols of individual healthcare organizations or networks all of which must comply with the National Framework for the Development of Decision-Making Tools for Nursing and Midwifery Practice (Australian Nursing and Midwifery Council, 2007). These additional requirements to practice appear to be at times contradictory to federal legislation, NPs training, experience, competency, authorization, or public need and have no clear rationale or uniformity from jurisdiction to jurisdiction or for other healthcare professionals practicing at similar levels and/or similar populations. As such, NP practice must be performed with knowledge of current Australian healthcare delivery mechanisms as well as Federal, State and local requirements for practice.

Israel

The Nursing Division of the Ministry of Health is the governing body that is responsible for credentialing all levels of nursing in Israel. In 2009, an executive order was published allowing for the first legalized advanced practice role in Israel, the Nurse Specialist in Palliative Care (Israel Ministry of Health, 2009). Only those nurses who had a master’s degree in nursing, completed a post-basic certification course in Geriatrics or Oncology, had a minimum of 3 years of palliative care clinical experience, completed a year-long course in palliative care, and who passed a practical and theoretical exam were considered as Nurse Specialists. However since that time, only one such course was conducted and no exam has been given. As part of this executive order, 35 nurses who were known to practice for a minimum of 5 years in palliative care, had either a bachelor’s or master’s degree in nursing and completed post-basic certification courses in Geriatrics or Oncology were grandfathered in as Nurse Specialists. This executive order did not specifically define the scope of practice, however these nurses are able to provide pain and symptom management and be consultants to caregivers, patients, and family members related to palliative care (Nursing Division, 2013). Most of these nurses are currently working within healthcare organizations, and so their scope of practice is varied and is determined by their current work environment. However, a significant number of these Nurse Specialists work in in-patient environments where they do not officially diagnose and treat, prescribe medications, refer to other professionals, or admit patients.

Although progress is being made with respect to giving advanced practice nurses the authority to diagnose and treat, prescribe medications, and refer to other professionals, there is a very limited scope of practice currently established for the role. In 2011, a new Nurse Specialist role was added, the Geriatric Nurse specialist (Nursing Division, 2013). Twenty nurses with post-basic certification in Geriatrics were admitted to a pilot program where they completed a one year course, and a practical and theoretical exam. Their scope of practice includes treating common illnesses and providing primary care in the case of an emergency situation. These nurses were given the authority to diagnose and treat, prescribe medications and refer to other professionals within a very limited scope of practice related to common illnesses (Nursing Division, 2013). More recently a new executive order was given that allowed for the introduction of other Nurse Specialist roles to be approved by the national head nurse. This order provided a legal basis and process through which other advanced practice roles could be approved however no new roles have gone through the process as of this publication. It should be noted that several groups of Israeli nurses have practiced parts or all of the aspects of advanced practice roles previous to these executive orders. For example, wound care nurses can diagnose and treat most aspects related to wound care without direct medical supervision. Kibbutz nurses often function as nurse practitioners, as they provide primary medical care in very rural areas where there is a lack of physicians. Although progress is being made with respect to giving advanced practice nurses the authority to diagnose and treat, prescribe medications, and refer to other professionals, there is a very limited scope of practice currently established for the role. In addition, barriers to advanced practice nursing role development include lack of knowledge of the role, limited opportunities for advanced practice, and slow development of new roles.

Saudi Arabia

Nursing in Saudi Arabia is still in its infancy, with Saudi Nationals making up approximately 29% of the nursing workforce. Nursing in Saudi Arabia is still in its infancy, with Saudi Nationals making up approximately 29% of the nursing workforce (Ministry of Health Saudi Arabia. Statistics Year Book, 2008). While nurse training programs have been provided for around 40 years, with movement away from hospital based education to university baccalaureate and masters’ level programs, there is as yet no postgraduate university education aimed at developing Advanced Practice Nurses, for example Clinical Nurse Specialist or Nurse Practitioner programs (Tumulty, 2001).

Saudi Nurses are hopeful for their future. The work of the Nursing Scientific Committee of the Saudi Commission for Health Specialties (SCFHS) has made great inroads over the last decade into professionalizing nursing, and has been responsible for ensuring that all nurses working within the Kingdom are registered. The World Health Organization has recognized the need for Advanced Practice Nurses within the Middle East, including Saudi Arabia. The SCFHS has recently accredited a twelve month, full time, hospital based Enterostomal Therapy Education Program (wound, ostomy, continence) aimed at developing nursing expertise to an advanced level within this specialist field. Additionally, Saudi Nurses are encouraged to avail themselves of scholarship opportunities in order to gain advanced practice qualifications in countries such as the United Kingdom and United States of America. Despite this, there are, to date, very few Advanced Practice Nurses within the Kingdom. This may be attributed to the poor image of clinical nursing, the lack of recognition by hospital administrators and physicians of the benefit of advancing the practice of nurses, and the absence of a clear clinical career structure (Hibbert, Al-Sanea, Balensm, 2012).

United Kingdom

Currently, no regulation or national requirements for advanced practice nursing currently exist within the United Kingdom (UK) Currently, no regulation or national requirements for advanced practice nursing currently exist within the United Kingdom (UK) other than a regulatory framework for nurse prescribing. other than a regulatory framework for nurse prescribing. Despite considerable lobbying by the Nursing and Midwifery Council, an influential 2009 report on professional regulation in the UK concluded that advanced practice can be embraced within the scope of initial registration and additional regulation is not required (CHRE, 2009). There is some justification for this position, in that there is no evidence of widespread public protection issues arising from the lack of regulatory legislation.

It has been argued that a permissive approach to the scope of nursing practice within the UK facilitates innovation and the development of expanded roles responsive to service needs (McGee, 2009). However, with no national oversight or required standards guiding the development of advanced practice nursing within the UK, roles are often developed in an unplanned manner and there is considerable variability in advanced practice nursing activities, preparation and remuneration.

In response to a call for more national guidance, the health departments of Scotland, Wales and England have all released publications intended to guide the development and management of advanced practice nursing (DoH, 2010; NLIAH, 2010; Scottish Government, 2008). All three publications propose broad and flexible definitions of advanced practice nursing, describing it as a higher level of nursing rather than any specific role or extended skills set. Notwithstanding, the governance of advanced practice nursing is at the discretion of local employers and national guidance is not enforced.

Essentially, the diverse, unregulated and flexible nature of advanced practice nursing within the UK varies somewhat from the state of advanced practice nursing in other western countries. On the one hand, there is evidence that advanced practice nurses are leading innovative services and improving patient care, with no barriers to limit their scope of practice. On the other hand, there is still no systematic understanding of exactly what advanced practice nurses are doing in practice, what they do/should earn, or what their development and training needs are. For a staff nurse aspiring to become an advance practice nurse, there is a bewildering array of courses available and a lack of a clearly defined career pathway.

Canada

Initially introduced in the 1970’s, there has been a renewed interest in nurse practitioner roles in Canada over the past 10-15 years. All provincial Colleges of Registered Nurses have developed standards of practice for nurse practitioners. Many, but not all, provinces have protected the title of Nurse Practitioner and work has been done in many provinces to approve or accredit nurse practitioner education programs (DiCenso et. al, 2007). The Canadian Nurse Practitioner Initiative (CNPI), spearheaded by the Canadian Nurses Association and funded by Health Canada in 2005, resulted in the development of a national Core Competency Framework (CNA, 2010) and a national exam based on those core competencies (CNPI, 2006a) as well as a Practice Framework (CNPI, 2006b) and a framework for education (CNPI, 2006c). Despite the development of this national framework, both education and health are regulated at a provincial level in Canada, therefore significant differences in legislation and educational programs exist across the country. These differences have led to role confusion and barriers to interprovincial practice.

A systematic review conducted by Sangster-Gormley, Martin-Misener, Downe-Wamboldt, and DiCenso (2011) identified a number of additional barriers which influence the ability of NPs to practice to their full scope in Canada. These factors include physician resistance, lack of funding for advanced practice roles, fee-for-service remuneration models, overlapping role functions between registered nurses and nurse practitioners, and restrictive legislation.

The NP role in Canada is at a critical juncture... To address a growing shortage of primary healthcare providers, many provinces are increasing seats in medical school programs and the role of physician assistant has been introduced in several provinces (Canadian Medical Association, 2010). These initiatives have resulted in increased competition for clinical practice opportunities for NP students and also in the creation of fewer employment opportunities for graduating NPs. The NP role in Canada is at a critical juncture and attention to these issues is critical in ensuring ongoing development of advanced practice nursing roles.

China (Hong Kong and Mainland China)

Mainland China refers to the area under the direct jurisdiction of the People’s Republic of China. Hong Kong is now a part of China designated as a special administrative region, but before 1997 it was a British colony. With the execution of two systems in one country, the advanced practice nurse development in Hong Kong and Mainland China is quite different so there will be two separate sections reporting role development in these two places.

The advanced practice nurses run independent nurse clinics to serve different client groups with specific health problems and now there are over 100 nurse clinics in Hong Kong. Hong Kong. Hong Kong has a total of 34,589 registered nurses (The Nursing Council of Hong Kong, 2014). In the Hospital Authority of Hong Kong, there is a clear clinical career pathway for registered nurses, developing as a specialty nurse to an Advanced Practicing Nurse, ultimately reaching the position of a Nurse Consultant (NC). There are now over 2700 APRNs in the system (Hospital Authority Annual Report 2011-2013) with over 70 granted the title of NC. The first APRN role was introduced in 1993 as Clinical Nurse Specialists (Sheer & Wong, 2008). Then an umbrella title of APRN was introduced in 2003 and the position of NC was established in 2008. The advanced practice nurses run independent nurse clinics to serve different client groups with specific health problems (Wong & Chung, 2006) and now there are over 100 nurse clinics in Hong Kong.

Education for APRNs in Hong Kong is at the postgraduate level. The first clinical nursing master’s degree was introduced in 1995 at the Hong Kong Polytechnic University, and now the Chinese University of Hong Kong and the University of Hong Kong are also offering postgraduate nursing programs at master and doctorate level. There are medical faculties that provide interdisciplinary programs that also support the preparation of APRNs.

The nurses in Hong Kong are striving hard to lobby the government to establish a statutory body to regulate advanced nursing practice in Hong Kong. The Provisional Hong Kong Academy of Nursing (PHKAN) was set up in 2011 for this dedicated purpose. The PHKAN has now conferred 2289 Fellows from 14 accredited Colleges in the specialty areas of cardiac, community and public health, critical care, education and research, emergency, gerontology, medical, mental health, midwives, nursing and healthcare management, orthopaedic, paediatric, perioperative and surgical nursing. Each College has specified competence, curriculum framework, and structured examinations to assess and certify Members/Fellows who practice at the advanced level in the related specialty area.

...nursing in China has faced some difficult times in the early days and is now working to recover. Mainland China. China has gone through much change socially and economically in the last few decades. Western nursing education in China was first introduced in the year of 1887. In 1951, all nursing programs were standardized to junior high level. Unfortunately there was the Cultural Revolution (1966-1975) that suspended all types of education. The university diploma nursing and baccalaureate programs were resumed in 1979 and 1983 respectively (Wong, 2010; Wong & Zhao, 2012). This brief history highlights that nursing in China has faced some difficult times in the early days and is now working to recover. The central government plays a key role in the process of development. In the Outline of Development Plan for Nursing in China (2011-2015) issued by Ministry of Health of the People’s Republic of China (2011), it was explicitly stated that the number of nurses and the level of education in China need to be enhanced. There is a section specifically outlining the plan of development of nursing in various specialties. The main development directives are to establish nurse specialist posts based on service needs, and the standardization of curriculum and educational standards. The Ministry of Health will issue the standards for the education program and requirements for the establishment of training sites. The provincial offices are expected to translate the policy directives into practice, governing the processes of implementation and operation. It is specified in the central document that by the year 2015, there should be 10 sites each in ICU and emergency nursing specialty and 5 sites each in blood purification, oncology, operative and psychiatric nursing. The target number of nurse specialists is 250,000 by year 2015. To date, there are 2.05 million nurses in Mainland China. In reference to the central development plan, many provinces and cities are spearheading programs for educating and accrediting advanced practicing nurses. In fact, the concept of APRN is not new as it was introduced in China more than 5 years ago through a book titled, “Introduction to Advanced Nursing Practice” (Wong, 2012). The first edition was published in 2008 is now designated as a recommended textbook by the Higher Education Curriculum Construction Committee, Ministry of Health of The People’s Republic of China & People’s Press. The province of Guangdong has taken the advantage of her proximity with Hong Kong and has begun the preparation of advanced practicing nurses in 2005 (Wong et al., 2010).

Nursing in China has many exciting developments in the 21st century. The discipline of nursing used to be subsumed under Clinical Medicine as a Second-Class subject. In 2011, the Academic Degrees Committee of the State Council has granted the status of First-Class subject to nursing. There are now quite a number of postgraduate nursing programs that have a clinical focus aiming to prepare APRNs (Wong & Zhao, 2012).   In 2008, a new Nurse Act was introduced to regulate and protect rights and responsibilities for registered nurses (Wong et al., 2010). Although there is no particular regulation for advanced practice, the standardization and certification of APRN programs is an important step to enforce standards of advanced nursing practice in the protection of the public. With the induction of China as a country member of ICN in 2013, China will set standards for nurses that are aligned with the international expectations and will work closely with the global counterparts to advance nursing for the health of the people.

International APRN Practice Roles

International concerns about the current state of healthcare delivery, safety and quality patient care led to a key examination of advanced practice nursing in 12 different countries (Australia, Belgium, Canada, Cyprus, Czech Republic, Finland, France, Ireland, Japan, Poland, United Kingdom and United States) by the Organization for Economic Cooperation and Development (OECD) in 2009 (Delamaire & Lafortune, 2010).

The aims of this comprehensive study were: to review the main factors motivating the development of advanced practice nursing roles and describe the state of development of these roles; review the results from evaluations on the impact on patient care and cost; and finally, examine the main factors that have either hindered or facilitated the development of these roles in the 12 different participating countries and how identified barriers have been overcome. Interestingly, the report found four factors may serve as either barriers or facilitators to implementing advanced nursing practice. Those factors identified were 1) professional interests of doctors and nurses, most often opposition from medical profession; 2) the organization of care and funding mechanisms, specifically types of primary care delivery and methods of payment for healthcare providers; 3) the impact of legislation and regulation on scope of practice; and 4) the capacity of education and training opportunities to prepare nurses for these roles. Various ways that government has facilitated and overcome potential and existing barriers in these countries include working with nursing and medical associations and other stakeholders to foster collaboration and reduce opposition; supporting new modes of care delivery and creating financial incentives that promote interprofessional cooperation; encouraging government review of regulation and legislation that promotes nurses to function at full scope of practice, specifically allowing prescriptive privileges; and providing increased funding for advanced nursing education and training programs. The report concludes with a recommendation for increased movement toward teamwork and a call for more sophisticated evaluation studies focusing on overall quality of care verses comparative studies of individual providers (Delamaire & Lafortune, 2010). This report led to a follow up survey of advanced nursing in Portugal (Buchan, Temido, Fronteira, Lapao & Dussault, 2013). This study found that although limited evidence exists for advance practice nursing in Portugal, much support was expressed for future development of innovative roles. The authors conclude that there is a need for further research in this area to inform policy development and encourage continued dialogue.

Implications

Variation in APRN practice exists with respect to scope of practice, requirements for prescribing privileges, oversight, certification, physician supervision and collaborative agreements (Fairman, Rowe, Hassmiller, & Shalala, 2011). This applies to international APRN practice, especially in the areas of role identity, role implementation, oversight, and regulations (Schober and Affara, 2006). It becomes evident that a number of challenges to APRN practice exist which need to be addressed on a global level (Table 3).

Table 3: Challenges to the APRN Role

Uniform scope of practice
Country specific regulations
Prescriptive authority recognition
Standardized educational requirements
Supervision requirements
Role recognition
Independent practice authority
Certification requirements

Adapted from Brassard & Smolenski, 2011.

Identifying the outcomes of APRN care is essential in outlining the benefit of the APRN role. Additionally, while a number of studies have been conducted which demonstrate the impact of APRN care (Newhouse et. al, 2011; O’Grady, 2010); a lack of research focused on international APRN practice exists. Identifying the outcomes of APRN care is essential in outlining the benefit of the APRN role (Kleinpell, 2013).

Several strategies can be implemented to remove barriers to APRN practice. As outlined in Table 4, communication about the APRN role and the value of APRN care in promoting patient access to healthcare, media campaigns to outline the role of APRN care in improving quality and safety of patient care, proactive lobbying to change restrictive APRN regulations and highlighting and demonstrating the impact of APRN care can assist in promoting APRN care that is consistent with education, training and scope of practice. Demonstrating the value of APRN care by implementing innovative models that leverage APRN skills, knowledge and experience can also be used as a strategy for promoting expansion of the APRN role (Robert Wood Johnson Foundation, 2013; O’Grady, 2010).

Table 4. Strategies for Removing Barriers to APRN Practice

  • Communicate about the APRN role and the value of APRN care to stakeholders including patients
  • Institute media campaigns on the role of APRN care in patient care
  • Conduct proactive lobbying to change restrictive APRN regulations
  • Highlight and demonstrate the impact of APRN care at institutional and national level
  • Demonstrate the value of APRN care by implementing innovative models that leverage APRN skills, knowledge and experience
  • Make APRN role visible by identifying contributions of APRN
  • Educate health ministries, administrative entities, credentialing committees, and medical staff about the practice of APRNs to assist in updating hospital bylaws
  • Encourage patients/consumers cared for by APRNs to advocate for them as competent providers
  • Disseminate/publish/present on exemplars in collaborative models that have demonstrated quality and safety improvements

Adapted from Robert Wood Johnson Foundation, 2013; Brassard & Smolenski, 2011.

Summary

Globally, the APRN role is expanding and further developing based on international needs for an expert practitioner to manage patient care as well as meet workforce needs. While specific country regulations impact APRN role components, international reports of APRN role issues continue to identify that a number of barriers to APRN practice exist. Addressing barriers to APRN practice and ensuring that APRNs are able to practice to the full extent of their education and training can help to promote optimal role fulfillment as well as establish the impact of the APRN role.

Authors

Ruth Kleinpell, PhD RN ACNP FAANP FAAN
Email: Ruth_M_Kleinpell@Rush.Edu

Dr. Kleinpell is Director, Center for Clinical Research & Scholarship at Rush University Medical Center and Professor, Rush University College of Nursing, in Chicago, Illinois. She maintains active practice as a nurse practitioner and serves as Chair of the Educational Subgroup, International Council of Nursing, Advanced Practice Nursing Network

Andrew Scanlon. DNP, MN (Nurse Practitioner), MNS, RN, NP, FACN, FACNP
Email: A.Scanlon@latrobe.edu.au

Dr. Scanlon is a Senior lecturer and coordinator of the Nurse Practitioner program at La Trobe University School of Nursing and Midwifery Bundoora in Victoria, Australia. He maintains an active practice as a nurse practitioner at Austin Health in the Department of Neurosurgery and as is currently a Doctor of Philosophy candidate at the University of Sydney School of Nursing and Midwifery. He is a member of the Educational Subgroup, International Council of Nursing, Advanced Practice Nursing Network

Denise Hibbert, RGN, MSc, BSc, DipHE, ONC, ST
Email: hibbert@kfshrc.edu.sa

Ms. Hibbert is Clinical Specialist Director and Director of the Saudi Enterostomal Therapy Diploma Program at the King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. Her role involves active practice in APRN within the field of colorectal nursing. She is a member of the Educational Subgroup, International Council of Nursing, Advanced Practice Nursing Network

Freda DeKeyser Ganz, PhD, RN
Email: freda@hadassah.org.il

Dr. Ganz is Coordinator, Research and Development and Associate Professor, Henrietta Szold School of Nursing, Hebrew University Faculty of Medicine, Kiryat Hadassah in Jerusalem, Israel. She is a member of the Educational Subgroup, International Council of Nursing, Advanced Practice Nursing Network.

Linda East, PhD, RN
Email: linda.east@nottingham.ac.uk

Dr. East is a lecturer and co-ordinator of the MSc Advanced Nursing program at the University of Nottingham, UK. She is a board member of the UK Association of Advanced Nursing Practice Educators, and a member of the Educational Subgroup, International Council of Nursing, Advanced Practice Nursing Network.

Debbie Fraser, MN, RNC-NIC
Email: dfraser@athabaca.ca

Ms. Fraser is an Associate Professor and Director of the Nurse Practitioner Program at Athabasca University and practices as an APRN in the NICU at St Boniface Hospital in Winnipeg. She is a member of the Canadian Association of Advanced Practice Nurses and a member of the Educational Subgroup, International Council of Nursing, Advanced Practice Nursing Network.

Frances Kam Yuet Wong, RN, PhD, FAAN, FHKAN (Education & Research)
Email: frances.wong@polyu.edu.hk

Dr. Wong is a Professor, School of Nursing at The Hong Kong Polytechnic University in Hong Kong. She is a member of the Core Steering Group and the Educational Subgroup, International Council of Nursing, Advanced Practice Nursing Network.

Michelle Beauchesne, DNSc, RN, CPNP, FAAN, FAANP, FNAP
Email: mbeauchesne@neu.edu

Ms. Beuchesne is Director, Doctor of Nursing Practice at Northeastern University in Boston Massachusetts. She maintains an active practice as a Pediatric Nurse Practitioner. She is a member of the Educational Subgroup, International Council of Nursing, Advanced Practice Nursing Network.

References

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Health Practitioner Regulation National Law Act 2009 (Qld) (Austl.).

Brassard, A., & Smolenski, M. (2011) Removing barriers to advanced practice registered nurse care. Insight on the Issue, 55. Washington, DC: AARP Public Policy Institute. Retrieved from http://campaignforaction.org/sites/default/files/RemovingBarriers-HospitalPrivileges.pdf

Buchan, J., Temido, M., Fronteira, I., Lapao, L., & Dussault, G. (2013). Nurses in advanced roles: a review of acceptability in Portugal. Rev. Latino-Am. Enfermagem, Jan-Feb: 21(Spec):38-46. Available at www.eerp.usp.br/rlae

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Canadian Nurses Association. (2010). Canadian nurse practitioner: Core competency framework. Ottawa, ON: CNA. Retrieved from www.cno.org/Global/for/rnec/pdf/CompetencyFramework_en.pdf?epslanguage=fr

Canadian Nurse Practitioner Initiative. (2006a). Nurse practitioners: The time is now. A solution to improving access and reducing wait times in Canada. Ottawa, ON: CNPI. Retrieved from www.npnow.ca/docs/tech-report/section1/01_Integrated_Report.pdf

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© 2014 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2014


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