Transcript An International Survey on Advanced Practice Nursing: Education, Practice and Regulatory Issues:Joyce Pulcini, PhD, APRN, BC, PNP, FAAN (USA) Alice Yuen Loke, BSN, MN,

An International Survey on
Advanced Practice Nursing:
Education, Practice and
Regulatory Issues:
2008
Joyce Pulcini, PhD, APRN, BC, PNP, FAAN (USA)
Alice Yuen Loke, BSN, MN, PhD (Hong Kong)
Raisa Gul, RN, RM, MHA, PhD (Pakistan)
Monika Jelic, MPH, MSN, CPNP (USA)
Katelyn Carroll (Research Asst)
Background
Many challenges and opportunities exist
in regards to the increasing numbers of
APNs globally. These include poor role
clarification, proliferation of APN titles,
differing educational requirements and
degrees, scope of practice conflicts,
fragmentation/ variability in standards
and quality of educational programmes
(Schober & Affara, 2006).
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Gathering data from different countries
on regulatory issues is a critical
challenge due to differing language
for educational programmes,
degrees, regulatory titles and
practice models.
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Aims
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The study examines NPs/APNs’ efforts to
develop their role internationally,
examines educational programmes and
regulation, the barriers and facilitators to
role development, and areas where
progress has been made.
This is a report of the results of an
international web-based study by the
International Council of Nurses
International NP/APN Network
(INP/APNN).
http://www.icn-apnetwork.org
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Methodology
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International web-based pilot survey
Tool used: SurveyMonkey
Online Survey: open for 6 weeks in
February and March, 2008
15-25 minutes in length
Results: qualitative and quantitative
descriptive analyses
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Sections of the Survey
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Survey developed by the Education/Practice
Subgroup of the INP/APN Network.
Consultation with Core Steering Group and
Research, and Policy/Standards/Regulation
Subgroups
Prior to pilot, many drafts circulated in 2006
focusing on:
• Content and Outline for Survey
• Language Issues
• Regulatory Terminology
• Nursing Titles
Pilot survey completed in 2007
Final survey completed in 2008
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In spring of 2008, a web-based survey was sent
to 174 key informants who were members of the
International Nurse Practitioner/ Advanced
Practice Nursing Network (INP/APNN) using
survey monkey.
Participants were leaders and experts of ANP
development in their respective countries.
The survey was based on a 2007 pilot survey with
network members and the final survey was
refined to reflect cross national cultural,
professional and linguistic differences.
The survey was completed by 91 members of the
INP/APNN from 33 of the 34 countries
represented in the Network with a response rate
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of 52.2%.
Survey Categories
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General Information
NP/APN Education and programmes
NP/APN Regulatory Issues
NP/APN Practice/Role
General Questions
Indepth description of one
programmes in country
• NP/APN Educational programmes
• NP/APN Student Profile
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Sample
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Participants: identified from ICN
INP/APNN contact lists and subgroups
Emailed to 174 key informants who
were members of the INP/APN
Network
91 respondents from 32 countries
33/34 (97%) countries in the
Network (one of these removed due
to lack of data on form)
Response rate = 52.2%
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Participants (n=91)
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Multiple roles
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83.5% were practicing nurses
55% were educators
20.8% were administrators
42.8% were involved in research
Of practicing nurses
• 67.1% (51) were NP/APNs
• 25% (19) were Registered/Generalist nurses
• 21% (16) answered other
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Of educators: 16% taught NP/APN
students
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Countries of Respondents in
the NP/APN Survey (n=33)
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Argentina: 1
Australia: 25
Botswana: 2
Canada: 5
China/People’s Republic of
China: 2
England/UK: 6
Ethiopia: 1
Fiji: 1
Finland: 1
France: 1
Grenada: 1
Hong Kong: 1
India: 2
Ireland: 4
Italy: 1
Jamaica: 1
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Japan: 2
Netherlands: 1
New Zealand: 1
Nigeria: 2
Oman: 1
Pakistan: 1
Portugal: 1
Saudi Arabia/KSA: 1
Singapore: 1
South Africa: 7
South Korea: 1
Spain: 2
Switzerland: 2
Taiwan: 2
Tanzania: 1
Thailand: 4
USA: 6
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Findings
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Findings are presented in two ways:
• Country Level Responses (n=32)
 NP/APN Education and programmes
 NP/APN Regulatory Issues
 Role as practicing nurse, educator,
administrator
 Types of positions held
• Individual level responses (n=91)
 NP/APN Practice/Role
 Role questions
 Skills performed
 Type of continuing education to stay current
 Supporters and opponents to the role
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Country Level
Responses
NP/APN Education, Practice
Questions
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Varying responses on number of
NP/APN programmes in their country
Did not tend to know nurse-physician
ratio in the country
> 17 titles for NP/APN found
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Title
Frequency
Percent
Nurse Practitioner
37
36.6%
Advanced Practice Nurse
15
14.9%
Advanced Nurse Practitioner
9
8.9%
Clinical Nurse Specialist
7
6.9%
Nurse Specialist
4
4.0%
Registered Nurse
2
2.0%
Professional Nurse
2
2.0%
Basic Nurses
1
1.0%
Expert Nurse
1
1.0%
Certified Registered Nurse Practitioner
1
1.0%
Chief Professional Nurse with post-basic training
in Primary Health Care
1
1.0%
Nurse Consultant
1
1.0%
Specialist Nurse Practitioner
1
1.0%
Out of Hours Nurse Practitioner
1
1.0%
Primary Healthcare Nurse
1
1.0%
Advanced nurse in a specialty
1
1.0%
Staff Nurse
1
1.0%
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Country Level Responses
• Does your country have formal NP/APN
programmes? (31 countries responding)
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Yes (71%)
No (29%)
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Types of credentials granted to NP/APNs
in your country (20 countries)
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MS degree: 56%
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BS degree: 28.1%
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Certificate: 25%
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Advanced Diploma: 21.9%
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No credential: 0
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Most prevalent credential granted
to NP/APNs in country (20
countries)
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MS degree: 50%
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BS degree: 15%
AD, 20%
Certificate,
15%
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Certificate: 15%
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Advanced Diploma: 20%
MS, 50%
BS, 15%
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Specialties or Types of NP/APNs Educated in
the NP/APN programmes (22 countries)
60%
50%
40%
30%
20%
10%
0%
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Level of practice of majority of
NP/APNs in country (28 Countries)
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RN/Generalist Nurse: 17.4 %
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Post RN/Generalist Nurse: 69.6 %
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Other: 9.4%
• Examples: APN, Post RN generalist plus
midwifery cert., RN/Registered midwife
with public health certification
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80%
70%
60%
50%
40%
30%
20%
10%
0%
Other
Research
Administration
Faculty
Occupational
Health
School Health
Mental Health
Specialty
Practice
Longterm
Care
Home Health
Care
Hospital
Public
Health/MOH
Communitybased Clinic
Hospital based Clinic
Independent
Nrsg Practice
Doctor's office
Positions Held by NPs/APNs
(25 countries)
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Types of positions that exist in the
Country
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Hospital: 75%
Hospital-based clinic: 62.5%
Community-based Clinic: 62.5%
Mental Health: 62.5%
Specialty practice (disease based): 59.4%
Public Health or ministry of health agency: 56.3%
Faculty Position: 53.1%
Administration: 50%
Research: 40.6%
Home health care facility: 40.6%
Independent Nsg. Practice: 37.5%
Long term care facility: 34.4%
School Health: 34.4%
Occupational Health: 31.3%
Doctor’s office: 31%
Other: 6.3%
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Formal Recognition of NP/APNs
in your country (23 countries)
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Government: 53.1%
Hospital or other health care agency:
53.1%
Professional Org: 59.4%
Other: 15.6%
• Examples– Health professions counsel,
National professional counsels, no
recognition
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Requirement for NP/APN Practice
(25 countries)
Other
19%
Sponsorship by clin
agency
19%
Registration/licensure
59%
Programme completion
72%
50%
Academic degree
0%
10%
20%
30%
40%
50%
60%
70%
80%
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NP/APNs without formal education
(28 countries)
42% said that there are nurses
undertaking/working in NP/APN role
who have not been formally educated
in the role at a Post RN or graduate
level. Of these,
• 42.9% said all had at least post RN level
education
• 21.4% said all or most had some
education either formal or informal
• One respondent said there is no
additional education
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Requirements for renewal
(maintenance) of NP/APN licensure
(27 countries)
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48% said that there were specific
requirements for renewal or
maintenance of NP/APN license or
registration
• Annual: 21.4%
• Every 5 years: 50%
• Other (i.e. 3-5 yrs): 28.6%
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License or Registration Renewal
Requirements (16 countries)
Other
13%
Exams
13%
Practice Requirements
47%
Portfolio
25%
Continuing Education
41%
0%
10%
20%
30%
40%
50%
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Individual Level
Responses
NP/APN Scope of Practice
(73 Respondents)
Are consulted in their practice by other
health care professionals
82%
Practice independently without
physician supervision
59%
Receive payment for services from
other sources (NHS, insurance cos)
26%
Receive direct payment for services
from clients
16%
Refer to other health care
professionals
86%
Have the authority to dispense
medications
55%
Have the authority to prescribe
medications
71%
Carry their own case load of clients
77%
Maintain malpractice insurance
45%
30
0%
20%
40%
60%
80% 100%
Performance of specific skills by
NPs (70 Respondents)
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Minor surgery (38.6%)
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Suturing (85.7%)
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Treating fractures (50%)
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Midwifery (74.3%)
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Performance of specific skills only
by MDs (81 Respondents)
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Major surgery (100%)
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Minor surgery (56.8%)
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Diagnosis (25.9%)
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Treatment (21%)
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Type of education which would help
NP/APNs to stay current in their areas
of practice (78 Respondents)
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CE online: 76.9%
Other CE: 80.8%
Conferences: 91%
Mentoring experiences for new
techniques: 85.9%
Formal educational programmes: 79.5%
Other: 5% examples
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General Questions
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Development of NP/APN role:
Facilitators (78 Respondents)
• 57.7% identified strong support for
nursing practice
• 79.5% identified need for more health care
providers for rural/underserved areas
• 71.8% identified consumer demand for
increased access to health care
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Supporters and Advocates
of the NP/APN Role (77 Respondents)
10%
Other
4%
Insurance Companies
Consumers
30%
Individual physicians
34%
Individual nurses
70%
International organization
16%
10%
Private Institution within your country
14%
NGO/Nonprofit within your country
Physician Org within your country
5%
Nursing Org within your country
92%
Government
68%
0%
20%
40%
60%
80%
100%
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Opposition to the NP/APN Role
(60 Respondents)
Other
5%
Insurance Companies
7%
Consumers
7%
Individual physicians
67%
Individual nurses
International organization
20%
0%
Private Institution within your country
NGO/Nonprofit within your country
7%
2%
Physician Org within your country
83%
Nursing Org within your country
12%
Government
23%
0%
20%
40%
60%
80%
100%
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Opposition to the NP/APN Role
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“Other” opponents
• Nurse leaders
• Universities where nursing is taught
• Certain hospitals
• Government agencies
Summary: Support for the NP/APN
role was found primarily in domestic
nursing organizations and the
government, while opposition came
mostly from domestic physician
organizations and other nurses.
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NP/APN Involvement in Policy
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Policy or health care planning
(79 Respondents)
• 76.9% stated that NPs/APNs participate at the
local level
• 61.3% stated that NPs/APNs participate at the
national level
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85% said that NP/APNs are organized as a
professional group in the country
(80 Respondents)
• Professional organizations identified most
frequently as the national nurses’ association
rather than specific NP/APN organizations
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Conclusion
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The survey provides information on a
broad representation of countries on
NP/APN education, practice and regulatory
issues.
The findings advance knowledge on role
development issues of NP/APNs
internationally and highlight the
challenges ahead.
NP/APNs will increasingly be important
health care providers globally. Tracking
the progress of these roles will facilitate
educational interventions and regulatory
policy development worldwide.
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Summary
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Confusion surrounding nomenclature
for the NP/APN was found with
different titles listed.
NPs/APNs’ practice represented a
broad variety of health care settings
and a varied scope of practice.
71% stated that NP/APN education
was available in their country with
half reporting that the Master’s
Degree was the predominant
credential for NP/APNs.
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Limitations
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Participants required to have email or
internet access
Number of participants from each country
(1-25)- Sometimes answers differed.
Leaders consulted when there were
discrepancies.
Most participants are affiliated with the
ICN and appreciate the international scope
of development of the NP/APN role – may
bias their answers.
Currently survey is available in English
only
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Discussion
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Collaboration with other subgroups
How to best promote NP/ANP
education internationally
Language issues in survey and in
future surveys
Dissemination of results
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Future Plans
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Consider if survey should be
translated into other languages
Further analyze individual educational
programmes and student information
provided in current survey
Consider survey of individual
educational programmes who are
identified in this survey
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