Chapter 5: Global Perspectives on Advanced Nursing Practice Flashcards
FACTORS CONTRIBUTING TO INTERNATIONAL GROWTH OF ADVANCED NURSING PRACTICE
Themes common throughout the world:
Escalating disease burden
Increased inpatient acuity and complexity of treatment
Impact of technological innovations and use of new therapeutic approaches
Increased emphasis on primary health care and community-based services
Growing request for and complexity of home care
General global shortage of health-care workers, including physicians, which is stimulating new consideration of skill-mix and task-shifting options
More demand for specialized services
Better-informed health-care consumers
Intensified call for options to increase access to health care and to address out-of-control health-care costs
The quest for quality
Nurses moving into the mainstream of higher education and demanding career choices
Call for professional advancement in nursing as a reason to remain in practice
THE INTERNATIONAL COUNCIL OF NURSES (ICN)
Transnational authority for advanced practice
ICN NETWORKS AND DOCUMENTS
International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) originated in 2000
The Scope of Practice, Standards and Competencies of the Advanced Practice Nurse (ICN, 2008a)
Nursing Care Continuum – Framework and Competencies (ICN, 2008b)
THE ICN DEFINITION APN
… 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. A master’s degree is recommended for entry level.
(ICN, 2002)
TRANSNATIONAL AMBIGUITIES AND ISSUES
Inability to define scope of practice nationally: poor role clarification
Proliferation of titles
Dominance of medicine in health care
Conflict of scope of practice with work of other health professionals
Mistrust between APRNs and other nurses
Variations in autonomy linked to differences in recognition, acceptance, and regulation
Disparate educational credentials
REGULATION, CREDENTIALING, AND STANDARD SETTING
The backbone to establishing advanced practice
Regulation often needs to catch up with innovation: be cautious and unrushed
Restrictive regulations may precede facilitative ones
Call for constant evaluation and revision of regulations, if needed
National nursing organizations are a major influence
Professional mobility will shape consensus for credentialing among countries
PRESCRIPTION OF MEDICINE AND THERAPEUTICS
Historically a common function outside a legal framework
In many areas, prescribing from a limited formulary is part of primary care practice
Less controversial than in the United States
AFRICA: BOTSWANA
Lack of specific regulations, qualifications, or routes for career advancement for the APRN
Focus on primary health-care services
Both a four-semester certificate program and a master’s FNP program exist
Discussion of articulating the certificate with master’s program at University of Botswana
Autonomy is commendable
AFRICA: REPUBLIC OF SOUTH AFRICA (RSA)
ANP titled Family Nurse Practitioner (FNP)
2005 Nursing Act calls for assured competencies, but education is illusive
Postbasic preparation for FNPs does not require specialized education
Separate license to dispense medications
Employment mainly in primary care
AFRICA: WESTERN AFRICA
Most nurses also prepared in midwifery
Recognized by a national certification exam and provide direct primary care services
All have post-entry education in a specialty
Advanced education not recognized for registration
Over 1,000 nurses hold the master’s degree
THE AMERICAS: CANADA
Nurses are regulated at the provincial or territorial level
CNS and NP roles are utilized in all of Canada’s thirteen provinces and territories
However, the only role with governmental regulation and title protection is the NP
THE AMERICAS: CAYMAN ISLANDS
NP-like roles evolved in response to the needs of the people, as well as within geographical circumstances
Since 1930, NP services progressed with the official employment of nurses experienced in midwifery and community health to provide PHC to Caymans, tourists, and refugees
THE AMERICAS: JAMAICA
Master’s education for NP
Nurse anesthetists (NAs) are classified as NPs, although they predated the NP and do not require master’s preparation
Neither NA nor NP are regulated, nor have prescriptive authority
Specialty areas are family, pediatrics, and MH; pediatrics preparation has been discontinued
Most function in primary care settings
EASTERN MEDITERRANEAN (EMR)
2001, WHO convened leadership group to give direction for ANP and prescribing in the area
Prescribing a range of essential drugs was determined to be within the scope of a general nurse
EMR: BAHRAIN
Environment supports APNs in primary care
Basic 1-year education, called advanced practice, is available post-entry
The BSN is considered entry-level for nursing practice
No master’s education is available
Candidates for study are sent to the United States
EMR: IRAN
14 master’s programs and 10 PhD programs in nursing, with 40 doctoral graduates reported
Advanced Specialists work autonomously in rural areas; in urban areas, they share responsibility with physicians
Physician supervision is not needed
Nurses, not only APNs, can open private practice
EMR: ISRAEL
2002, master’s degree in advanced practice
ANP blends the roles of NP and CNS
The APN role addresses the entire continuum of care from hospital to community practice, from individuals to groups
No regulatory recognition of APNs; no diagnosis or prescriptive authority possible
EMR: OMAN
Considering community nursing and community nurse practitioner roles
There is resistance from physicians who prefer specialty-trained nurses
A lack of educators for the role and limited understanding of the nature of services
Unqualified nurses in remote areas are performing ANP functions
EUROPE: THE EUROPEAN UNION
Consists of 27 culturally and linguistically different member states.
APNs are rarely licensed, independent, and practice autonomously.
First NPs in UK in 1991, and from there to the rest of Europe.
Many European universities have established APN programs at the master’s level.
EUROPE: FINLAND
Physician shortage prompted APN acceptance
APN known as a Clinic Expert Nurse
Education is a master’s program, which prepares chiefly for secondary prevention: acutely ill and follow-up on chronic disease
EUROPE: FRANCE
Progress on APN roles is emerging, but progress is slow
Nurses are not considered a point of entry into the health-care system
Neither educational programs nor legislative support exists for APNs
Private practice nurses depend on a medical order to deliver care
EUROPE: IRELAND
Regulatory recognition of ANP, including advanced midwife practitioner (AMP) role
Educational preparation at master’s level
Diagnosis and treatment, with physician collaboration
Title enabled by certification
Practice only possible within an approved and accredited post
EUROPE: NETHERLANDS
2,000 NPs working in Netherlands
Introduction of physician assistants (PAs) has not diminished numbers
Legislation provides prescriptive authority and title protection
Education is partially government subsidized, and mostly at the master’s level
Vast consumer acceptance
EUROPE: SWEDEN
Current need for community primary care and NPs
Prescriptive authority for nurses is in place for at least 10 years
Negotiated definition blends the APN with the district nurse role
EUROPE: SWITZERLAND
A drive to APNs fueled by physician shortage
Exploration of APN roles that resemble PAs
A master’s degree in advanced practice exists
Absence of a framework that addresses legal, policy, standards, and reimbursement issues
EUROPE: UNITED KINGDOM
RCN Accredits NP educational programs
7 accredited university program, and the Association of Advanced Nursing Practice Educators now has 43 higher education institutions in its membership
Practice includes diagnosis and prescription
More than 10,000 nurses are Independent Prescribers (IPs); but not all IPs are APNs
There is no government regulation of APNs
SOUTHEAST ASIA: THAILAND
First educational program, 4 months postentry
Intend to move education for APNs to the master’s level, but continue to acknowledge the 4-month certificate preparation
Certification offered by the Thailand Nurse and Midwifery Council
Many APNs are working beyond their defined scope of practice
WESTERN PACIFIC: AUSTRALIA
NP is a protected title
Most states/territories agree that the master’s degree is the basic requirement for practice
Role is compromised by state/federal differences in scope of practice
Competency standards exist between Australia and New Zealand
In 2011, more than 400 NPs in practice
WESTERN PACIFIC: BRUNEI
Proceeding forward in exploring advanced nursing practice
Recommendation made for task force to promulgate criteria, standards, and regulations for ANP (2011)
Debate focused on alignment of NP and specialist roles with nurse-midwives under the ANP umbrella
WESTERN PACIFIC: CHINA/HONG KONG
Hong Kong has still to find a champion for APN practice to catch a foothold in the health-care system
Although there is evidence of strong practice, there has been very little progress on advanced practice
No regulatory oversight exists, resulting in uneven educational and clinical development
ISLANDS OF THE WESTERN PACIFIC
A variety of midlevel practitioners have provided health-care services for the populations of the Pacific island countries for more than 20 years
WESTERN PACIFIC: FIJI
Fiji School of Nursing offers NP program with postgraduate 6-month internship
Established scope of practice
Published protocols, allowing prescriptive privileges
Immediacy of health-care needs prohibits education at the master’s level
Regional education well developed
WESTERN PACIFIC: SAMOA
Nurse specialists are considered to be APNs
Nurses prescribe in life-threatening situations, but broader prescriptive rights are being reviewed
Mental health specialist nurses function independently and fairly autonomously
WESTERN PACIFIC: NEW ZEALAND
Regulations include title protection, standards for educational programs, clinical competencies, and a description of role
Master’s preparation or equivalent is required, 4-years’ experience in specialty, and presentation of a practice portfolio
APNs are authorized to prescribe from an extensive formulary since 2005
As of May 2011, there were 96 NPs in NZ
WESTERN PACIFIC: PHILIPPINES
No public policy that defines or recognizes the APN or their practice
An emphasis on post-entry specialty education
Post-entry specialists are informally recognized by government with certification/program accreditation
Many entry-level and master’s programs, and at least three doctoral programs exist
WESTERN PACIFIC: SINGAPORE
A comprehensive master’s degree exists in advanced practice with no designated specialty; followed by an internship
A second APN preparation exists in critical care
APNs are placed on a government registry
WESTERN PACIFIC: SOUTH KOREA
NP-like nursing roles have been in place in Korea since the 15th century
Community health nurse practitioners are very prominent in rural areas
Scope of practice includes diagnosis, prescriptive authority, and referral
Qualifications include master’s-level education, certification, and experience in a chosen specialty
WESTERN PACIFIC: TAIWAN
ANP focus is chiefly acute care
Education is mostly in hospital training schools, but one master’s and one doctoral program do exist
A certification with both theoretical and hands-on evaluations is being offered
Official NP recognition and title protection accomplished in 2000
global apn summary
The APN role surfaces from the needs and geography of the country
These nursing roles are feasible, are sustainable, provide quality competent health care, and are growing
Legislation and regulations are critical and necessary to legitimize the role, but they often lag behind practice
Progression of the role is more an intricate maze or puzzle rather than a picture of coordinated forward motion
International momentum is increasing, but it is fraught with frustration and role ambiguity
APNs will be asked to provide evidence that they are cost-effective, valued, and sustainable
