An International Survey on An International Survey on Advanced Practice Nursing:Advanced Practice Nursing:

Education, Practice and Education, Practice and Regulatory Issues: Regulatory Issues:

20082008

Joyce Pulcini, PhD, APRN, BC, PNP, FAAN Joyce Pulcini, PhD, APRN, BC, PNP, FAAN (USA)(USA)Alice Yuen Loke, BSN, MN, PhD Alice Yuen Loke, BSN, MN, PhD (Hong Kong)(Hong Kong)

Raisa Gul, RN, RM, MHA, PhD Raisa Gul, RN, RM, MHA, PhD (Pakistan)(Pakistan)Monika Jelic, MPH, MSN, CPNP Monika Jelic, MPH, MSN, CPNP (USA)(USA)

Katelyn CarrollKatelyn Carroll (Research Asst) (Research Asst)

22

BackgroundBackground

Many challenges and opportunities exist Many challenges and opportunities exist in regards to the increasing numbers of in regards to the increasing numbers of APNs globally. These include poor role APNs globally. These include poor role clarification, proliferation of APN titles, clarification, proliferation of APN titles, differing educational requirements and differing educational requirements and degrees, scope of practice conflicts, degrees, scope of practice conflicts, fragmentation/ variability in standards fragmentation/ variability in standards and quality of educational programmes and quality of educational programmes (Schober & Affara, 2006). (Schober & Affara, 2006).

33

Gathering data from different countries Gathering data from different countries on regulatory issues is a critical on regulatory issues is a critical challenge due to differing language challenge due to differing language for educational programmes, for educational programmes, degrees, regulatory titles and degrees, regulatory titles and practice models.practice models.

44

AimsAims The study examines NPs/APNs’ efforts to The study examines NPs/APNs’ efforts to

develop their role internationally, develop their role internationally, examines educational programmes and examines educational programmes and regulation, the barriers and facilitators to regulation, the barriers and facilitators to role development, and areas where role development, and areas where progress has been made. progress has been made.

This is a report of the results of an This is a report of the results of an international web-based study by the international web-based study by the International Council of Nurses International Council of Nurses International NP/APN Network (INP/APNN). International NP/APN Network (INP/APNN).

http://www.icn-apnetwork.org

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MethodologyMethodology

International web-based pilot surveyInternational web-based pilot survey Tool used: SurveyMonkeyTool used: SurveyMonkey Online Survey: open for 6 weeks in Online Survey: open for 6 weeks in

February and March, 2008February and March, 2008 15-25 minutes in length15-25 minutes in length Results: qualitative and quantitative Results: qualitative and quantitative

descriptive analyses descriptive analyses

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Sections of the Survey Sections of the Survey Survey developed by the Education/Practice Survey developed by the Education/Practice

Subgroup of the INP/APN Network. Subgroup of the INP/APN Network. Consultation with Core Steering Group and Consultation with Core Steering Group and

Research, and Policy/Standards/Regulation Research, and Policy/Standards/Regulation SubgroupsSubgroups

Prior to pilot, many drafts circulated in 2006 Prior to pilot, many drafts circulated in 2006 focusing on: focusing on: • Content and Outline for SurveyContent and Outline for Survey• Language IssuesLanguage Issues• Regulatory TerminologyRegulatory Terminology• Nursing TitlesNursing Titles

Pilot survey completed in 2007Pilot survey completed in 2007 Final survey completed in 2008Final survey completed in 2008

77

In spring of 2008, a web-based survey was sent to In spring of 2008, a web-based survey was sent to 174 key informants who were members of the 174 key informants who were members of the International Nurse Practitioner/ Advanced International Nurse Practitioner/ Advanced Practice Nursing Network (INP/APNN) using survey Practice Nursing Network (INP/APNN) using survey monkey. monkey.

Participants were leaders and experts of ANP Participants were leaders and experts of ANP development in their respective countries. development in their respective countries.

The survey was based on a 2007 pilot survey with The survey was based on a 2007 pilot survey with network members and the final survey was network members and the final survey was refined to reflect cross national cultural, refined to reflect cross national cultural, professional and linguistic differences. professional and linguistic differences.

The survey was completed by 91 members of the The survey was completed by 91 members of the INP/APNN from 33 of the 34 countries represented INP/APNN from 33 of the 34 countries represented in the Network with a response rate of 52.2%. in the Network with a response rate of 52.2%.

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Survey CategoriesSurvey Categories General InformationGeneral Information NP/APN Education and programmesNP/APN Education and programmes NP/APN Regulatory IssuesNP/APN Regulatory Issues NP/APN Practice/RoleNP/APN Practice/Role General QuestionsGeneral Questions Indepth description of one Indepth description of one

programmes in countryprogrammes in country• NP/APN Educational programmesNP/APN Educational programmes• NP/APN Student ProfileNP/APN Student Profile

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SampleSample

Participants: identified from ICN Participants: identified from ICN INP/APNN contact lists and subgroupsINP/APNN contact lists and subgroups

Emailed to 174 key informants who Emailed to 174 key informants who were members of the INP/APN were members of the INP/APN Network Network

91 respondents from 32 countries91 respondents from 32 countries 33/34 (97%) countries in the Network 33/34 (97%) countries in the Network

(one of these removed due to lack of (one of these removed due to lack of data on form)data on form)

Response rate = 52.2%Response rate = 52.2%

1010

Participants (n=91)Participants (n=91) Multiple roles Multiple roles

• 83.5% were practicing nurses 83.5% were practicing nurses • 55% were educators 55% were educators • 20.8% were administrators20.8% were administrators• 42.8% were involved in research 42.8% were involved in research

Of practicing nursesOf practicing nurses• 67.1% (51) were NP/APNs67.1% (51) were NP/APNs• 25% (19) were Registered/Generalist nurses25% (19) were Registered/Generalist nurses• 21% (16) answered other21% (16) answered other

Of educators: 16% taught NP/APN studentsOf educators: 16% taught NP/APN students

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Countries of Respondents in Countries of Respondents in the NP/APN Survey (n=33)the NP/APN Survey (n=33)

Argentina: 1Argentina: 1 Australia: 25Australia: 25 Botswana: 2Botswana: 2 Canada: 5Canada: 5 China/People’s Republic of China: China/People’s Republic of China:

22 England/UK: 6England/UK: 6 Ethiopia: 1Ethiopia: 1 Fiji: 1Fiji: 1 Finland: 1Finland: 1 France: 1France: 1 Grenada: 1Grenada: 1 Hong Kong: 1Hong Kong: 1 India: 2India: 2 Ireland: 4Ireland: 4 Italy: 1Italy: 1 Jamaica: 1Jamaica: 1

Japan: 2Japan: 2 Netherlands: 1Netherlands: 1 New Zealand: 1New Zealand: 1 Nigeria: 2Nigeria: 2 Oman: 1Oman: 1 Pakistan: 1Pakistan: 1 Portugal: 1Portugal: 1 Saudi Arabia/KSA: 1Saudi Arabia/KSA: 1 Singapore: 1Singapore: 1 South Africa: 7South Africa: 7 South Korea: 1South Korea: 1 Spain: 2Spain: 2 Switzerland: 2Switzerland: 2 Taiwan: 2Taiwan: 2 Tanzania: 1Tanzania: 1 Thailand: 4Thailand: 4 USA: 6USA: 6

1212

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FindingsFindings Findings are presented in two ways:Findings are presented in two ways:

• Country Level Responses (n=32)Country Level Responses (n=32) NP/APN Education and programmesNP/APN Education and programmes NP/APN Regulatory Issues NP/APN Regulatory Issues Role as practicing nurse, educator, administrator Role as practicing nurse, educator, administrator Types of positions heldTypes of positions held Scope of practiceScope of practice

• Individual level responses (n=91)Individual level responses (n=91) NP/APN Practice/Role and Scope of practiceNP/APN Practice/Role and Scope of practice Role questionsRole questions Skills performedSkills performed Type of continuing education to stay currentType of continuing education to stay current Supporters and opponents to the roleSupporters and opponents to the role

Country LevelCountry Level

ResponsesResponses

1515

NP/APN Education, Practice NP/APN Education, Practice QuestionsQuestions

Varying responses on number of Varying responses on number of NP/APN programmes in their countryNP/APN programmes in their country

Did not tend to know nurse-physician Did not tend to know nurse-physician ratio in the countryratio in the country

> 17 titles for NP/APN found> 17 titles for NP/APN found

1616

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 ResponsesCountry Level Responses

• Does your country have formal NP/APN Does your country have formal NP/APN programmes? (31 countries responding)programmes? (31 countries responding)

Yes (71%)Yes (71%) No (29%)No (29%)

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Types of credentials granted to NP/APNsTypes of credentials granted to NP/APNsin your country (20 countries)in your country (20 countries)

MS degree: 56% MS degree: 56%

BS degree: 28.1%BS degree: 28.1%

Certificate: 25%Certificate: 25%

Advanced Diploma: 21.9% Advanced Diploma: 21.9%

No credential: 0No credential: 0

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Most prevalent credential granted Most prevalent credential granted to NP/APNs in country (20 to NP/APNs in country (20

countries)countries)

MS degree: 50% MS degree: 50%

BS degree: 15%BS degree: 15%

Certificate: 15%Certificate: 15%

Advanced Diploma: 20%Advanced Diploma: 20%

MS, 50%

BS, 15%

Certificate, 15%

AD, 20%

2020

SPECIALTIES OR TYPES OF NP/APNSSPECIALTIES OR TYPES OF NP/APNSEDUCATED IN THE NP/APN PROGRAMMES EDUCATED IN THE NP/APN PROGRAMMES

(22 COUNTRIES)(22 COUNTRIES)

47%44%

38%34%

41%47%

41%47% 47% 50%

25%

0%

10%

20%

30%

40%

50%

60%

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Level of practice of majority of Level of practice of majority of NP/APNs in country (28 Countries)NP/APNs in country (28 Countries)

RN/Generalist Nurse: 17.4 %RN/Generalist Nurse: 17.4 %

Post RN/Generalist Nurse: 69.6 %Post RN/Generalist Nurse: 69.6 %

Other: 9.4%Other: 9.4%• Examples: APN, Post RN generalist plus Examples: APN, Post RN generalist plus

midwifery cert., RN/Registered midwife midwifery cert., RN/Registered midwife with public health certificationwith public health certification

2222

POSITIONS HELD BY NPS/APNS POSITIONS HELD BY NPS/APNS (25 COUNTRIES)(25 COUNTRIES)

31%38%

63% 63%56%

75%

41%34%

59% 63%

34% 31%

53%47%

41%

6%

0%10%20%30%40%50%60%70%80%

Docto

r's o

ffice

Inde

pend

ent

Nrsg

Pra

ctice

Hosp

ital -

base

d Cl

inic

Com

mun

ity-

base

d Cl

inic

Publ

icHe

alth

/MOH

Hosp

ital

Hom

e He

alth

Care

Long

term

Care

Spec

ialty

Prac

tice

Men

tal H

ealth

Scho

ol H

ealth

Occu

patio

nal

Heal

th

Facu

lty

Adm

inist

ratio

n

Rese

arch Othe

r

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Types of positions that exist in the Types of positions that exist in the CountryCountry

Hospital: 75%Hospital: 75% Hospital-based clinic: 62.5%Hospital-based clinic: 62.5% Community-based Clinic: 62.5%Community-based Clinic: 62.5% Mental Health: 62.5%Mental Health: 62.5% Specialty practice (disease based): 59.4%Specialty practice (disease based): 59.4% Public Health or ministry of health agency: 56.3%Public Health or ministry of health agency: 56.3% Faculty Position: 53.1%Faculty Position: 53.1% Administration: 50%Administration: 50% Research: 40.6%Research: 40.6% Home health care facility: 40.6%Home health care facility: 40.6% Independent Nsg. Practice: 37.5%Independent Nsg. Practice: 37.5% Long term care facility: 34.4%Long term care facility: 34.4% School Health: 34.4%School Health: 34.4% Occupational Health: 31.3%Occupational Health: 31.3% Doctor’s office: 31%Doctor’s office: 31% Other: 6.3%Other: 6.3%

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NP/APN SCOPE OF PRACTICE (24 COUNTRIES)NP/APN SCOPE OF PRACTICE (24 COUNTRIES)

Results may vary at the provincial/state levelResults may vary at the provincial/state level

33%

79%

63%

46%

79%

13%

29%

54%

83%

0% 20% 40% 60% 80% 100%

Maintain malpractice insurance

Carry their own case load of clients

Have the authority to prescribemedications

Have the authority to dispensemedications

Refer to other health care professionals

Receive direct payment for services fromclients

Receive payment for services from othersources (NHS, insurance cos)

Practice independently without physiciansupervision

Are consulted in their practice by otherhealth care professionals

2525

Formal Recognition of NP/APNs Formal Recognition of NP/APNs in your countryin your country (23 countries)(23 countries)

Government: 53.1%Government: 53.1% Hospital or other health care agency: Hospital or other health care agency:

53.1%53.1% Professional Org: 59.4%Professional Org: 59.4% Other: 15.6%Other: 15.6%

• Examples– Health professions counsel, Examples– Health professions counsel, National professional counsels, no National professional counsels, no recognitionrecognition

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Requirement for NP/APN Practice Requirement for NP/APN Practice (25 countries)(25 countries)

50%

72%

59%

19%

19%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Academic degree

Programme completion

Registration/licensure

Sponsorship by clinagency

Other

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NP/APNs without formal education NP/APNs without formal education (28 countries)(28 countries)

42% said that there are nurses 42% said that there are nurses undertaking/working in NP/APN role undertaking/working in NP/APN role who have not been formally educated who have not been formally educated in the role at a Post RN or graduate in the role at a Post RN or graduate level. Of these, level. Of these, • 42.9% said all had at least post RN level 42.9% said all had at least post RN level

educationeducation• 21.4% said all or most had some 21.4% said all or most had some

education either formal or informaleducation either formal or informal• One respondent said there is no One respondent said there is no

additional educationadditional education

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Requirements for renewal Requirements for renewal (maintenance) of NP/APN licensure(maintenance) of NP/APN licensure

(27 countries)(27 countries) 48% said that there were specific 48% said that there were specific

requirements for renewal or requirements for renewal or maintenance of NP/APN license or maintenance of NP/APN license or registrationregistration• Annual: 21.4%Annual: 21.4%• Every 5 years: 50%Every 5 years: 50%• Other (i.e. 3-5 yrs): 28.6%Other (i.e. 3-5 yrs): 28.6%

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License or Registration Renewal License or Registration Renewal Requirements (16 countries)Requirements (16 countries)

41%

25%

47%

13%

13%

0% 10% 20% 30% 40% 50%

Continuing Education

Portfolio

Practice Requirements

Exams

Other

Individual LevelIndividual Level

ResponsesResponses

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NP/APN Scope of Practice NP/APN Scope of Practice (73 Respondents)(73 Respondents)

45%

77%

71%

55%

86%

16%

26%

59%

82%

0% 20% 40% 60% 80% 100%

Maintain malpractice insurance

Carry their own case load of clients

Have the authority to prescribemedications

Have the authority to dispensemedications

Refer to other health careprofessionals

Receive direct payment for servicesfrom clients

Receive payment for services fromother sources (NHS, insurance cos)

Practice independently withoutphysician supervision

Are consulted in their practice by otherhealth care professionals

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Performance of specific skills by Performance of specific skills by NPs (70 Respondents)NPs (70 Respondents)

Minor surgery (38.6%)Minor surgery (38.6%)

Suturing (85.7%)Suturing (85.7%)

Treating fractures (50%)Treating fractures (50%)

Midwifery (74.3%)Midwifery (74.3%)

3333

Performance of specific skills only Performance of specific skills only by MDs (81 Respondents)by MDs (81 Respondents)

Major surgery (100%)Major surgery (100%)

Minor surgery (56.8%)Minor surgery (56.8%)

Diagnosis (25.9%)Diagnosis (25.9%)

Treatment (21%)Treatment (21%)

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Type of education which would help Type of education which would help NP/APNs to stay current in their areas NP/APNs to stay current in their areas

of practice (78 Respondents)of practice (78 Respondents) CE online: 76.9%CE online: 76.9% Other CE: 80.8%Other CE: 80.8% Conferences: 91%Conferences: 91% Mentoring experiences for new Mentoring experiences for new

techniques: 85.9%techniques: 85.9% Formal educational programmes: 79.5%Formal educational programmes: 79.5% Other: 5% examplesOther: 5% examples

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General QuestionsGeneral Questions Development of NP/APN role: Development of NP/APN role:

Facilitators (78 Respondents)Facilitators (78 Respondents)

• 57.7% identified strong support for nursing 57.7% identified strong support for nursing practice practice

• 79.5% identified need for more health care 79.5% identified need for more health care providers for rural/underserved areasproviders for rural/underserved areas

• 71.8% identified consumer demand for 71.8% identified consumer demand for increased access to health careincreased access to health care

3636

Supporters and Advocates Supporters and Advocates of the NP/APN Role (77 Respondents)of the NP/APN Role (77 Respondents)

68%

92%

5%

14%

10%

16%

70%

34%

30%

4%

10%

0% 20% 40% 60% 80% 100%

Government

Nursing Org within your country

Physician Org within your country

NGO/Nonprofit within your country

Private Institution within your country

International organization

Individual nurses

Individual physicians

Consumers

Insurance Companies

Other

3737

Opposition to the NP/APN RoleOpposition to the NP/APN Role(60 Respondents)(60 Respondents)

23%

12%

83%

2%

7%

0%

20%

67%

7%

7%

5%

0% 20% 40% 60% 80% 100%

Government

Nursing Org within your country

Physician Org within your country

NGO/Nonprofit within your country

Private Institution within your country

International organization

Individual nurses

Individual physicians

Consumers

Insurance Companies

Other

3838

Opposition to the NP/APN Role Opposition to the NP/APN Role

““Other” opponentsOther” opponents• Nurse leadersNurse leaders• Universities where nursing is taughtUniversities where nursing is taught• Certain hospitalsCertain hospitals• Government agenciesGovernment agencies

Summary: Support for the NP/APN role Summary: Support for the NP/APN role was found primarily in domestic was found primarily in domestic nursing organizations and the nursing organizations and the government, while opposition came government, while opposition came mostly from domestic physician mostly from domestic physician organizations and other nurses.organizations and other nurses.

3939

NP/APN Involvement in PolicyNP/APN Involvement in Policy

Policy or health care planning (79 Policy or health care planning (79 Respondents) Respondents) • 76.9% stated that NPs/APNs participate at the 76.9% stated that NPs/APNs participate at the

local levellocal level• 61.3% stated that NPs/APNs participate at the 61.3% stated that NPs/APNs participate at the

national levelnational level 85% said that NP/APNs are organized as a 85% said that NP/APNs are organized as a

professional group in the country (80 professional group in the country (80 Respondents)Respondents)• Professional organizations identified most Professional organizations identified most

frequently as the national nurses’ association frequently as the national nurses’ association rather than specific NP/APN organizationsrather than specific NP/APN organizations

4040

ConclusionConclusion The survey provides information on a The survey provides information on a

broad representation of countries on broad representation of countries on NP/APN education, practice and regulatory NP/APN education, practice and regulatory issues. issues.

The findings advance knowledge on role The findings advance knowledge on role development issues of NP/APNs development issues of NP/APNs internationally and highlight the internationally and highlight the challenges ahead. challenges ahead.

NP/APNs will increasingly be important NP/APNs will increasingly be important health care providers globally. Tracking health care providers globally. Tracking the progress of these roles will facilitate the progress of these roles will facilitate educational interventions and regulatory educational interventions and regulatory policy development worldwide.policy development worldwide.

4141

SummarySummary

Confusion surrounding nomenclature Confusion surrounding nomenclature for the NP/APN was found with for the NP/APN was found with different titles listed.different titles listed.

NPs/APNs’ practice represented a NPs/APNs’ practice represented a broad variety of health care settings broad variety of health care settings and a varied scope of practice. and a varied scope of practice.

71% stated that NP/APN education 71% stated that NP/APN education was available in their country with was available in their country with half reporting that the Master’s half reporting that the Master’s Degree was the predominant Degree was the predominant credential for NP/APNs. credential for NP/APNs.

4242

LimitationsLimitations Participants required to have email or Participants required to have email or

internet accessinternet access Number of participants from each country Number of participants from each country

(1-25)- Sometimes answers differed. (1-25)- Sometimes answers differed. Leaders consulted when there were Leaders consulted when there were discrepancies.discrepancies.

Most participants are affiliated with the Most participants are affiliated with the ICN and appreciate the international scope ICN and appreciate the international scope of development of the NP/APN role – may of development of the NP/APN role – may bias their answers.bias their answers.

Currently survey is available in English Currently survey is available in English onlyonly

4343

DiscussionDiscussion

Collaboration with other subgroupsCollaboration with other subgroups

How to best promote NP/ANP How to best promote NP/ANP education internationallyeducation internationally

Language issues in survey and in Language issues in survey and in future surveysfuture surveys

Dissemination of resultsDissemination of results

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Future PlansFuture Plans

Consider if survey should be Consider if survey should be translated into other languagestranslated into other languages

Further analyze individual Further analyze individual educational programmes and educational programmes and student information provided in student information provided in current surveycurrent survey

Consider survey of individual Consider survey of individual educational programmes who are educational programmes who are identified in this surveyidentified in this survey