An International Survey on Advanced Practice Nursing: Education, Practice and Regulatory Issues: 200

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An International Survey on Advanced Practice
NursingEducation, 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)

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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

• 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

• 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

• 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 of 52.2.

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Survey Categories

• 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

• 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 (n91)

• Multiple roles
• 84 were practicing nurses
• 55 were educators
• 21 were administrators
• 43 were involved in research
• Of practicing nurses
• 67 (51) were NP/APNs
• 25 (19) were Registered/Generalist nurses
• 21 (16) answered other
• Of educators 56 taught NP/APN students
• Identified 13 different titles for NP/APN

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Countries of Respondents in the NP/APN Survey
(n33)

• Argentina 1
• Australia 25
• Botswana 2
• Canada 5
• China/Peoples 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

• 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

• Findings are presented in two ways
• Country Level Responses (n32)
• NP/APN Education and programmes
• NP/APN Regulatory Issues
• Role as practicing nurse, educator, administrator
  
• Types of positions held
• Scope of practice
• Individual level responses (n91)
• 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 LevelResponses
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NP/APN Education, Practice Questions

• Varying responses on number of NP/APN programmes
  in their country
• Did not tend to know nurse-physician ratio in the
  country

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Country Level Responses

• Does your country have formal NP/APN programmes?
  (31 countries responding)
• Yes (71)
• No (29)

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

• MS degree 90
• BS degree 45
• Certificate 40
• Advanced Diploma 35
• No credential 0

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

• MS degree 50
• BS degree 15
• Certificate 15
• Advanced Diploma 20

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SPECIALTIES OR TYPES OF NP/APNSEDUCATED IN THE
NP/APN PROGRAMMES (21 COUNTRIES)
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Level of practice of majority of NP/APNs in
country (23 Countries)

• RN/Generalist Nurse 17
• Post RN/Generalist Nurse 74
• Other 9
• Post RN generalist plus midwifery cert.,
  RN/Registered midwife with public health
  certification

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POSITIONS HELD BY NPS/APNS (25 COUNTRIES)
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Types of positions held by NP/APNs by frequency
(25 countries)

• Hospital 96
• Hospital-based clinic 80
• Community-based Clinic 80
• Mental Health 80
• Specialty practice (disease based) 76
• Public Health or ministry of health agency 72
• Faculty Position 68
• Administration 64
• Research 52
• Home health care facility 52
• Independent Nursing Practice 44
• Long term care facility 44
• School Health 44
• Occupational Health 40
• Doctors office 40
• Other 12

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NP/APN SCOPE OF PRACTICE (24 COUNTRIES)

• Results may vary at the provincial/state level

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

• Government 87
• Hospital or other health care agency 78
• Professional Org 78
• Other 26
• Examples Health professions councils, National
  professional councils, no recognition

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Requirement for NP/APN Practice (25 countries)
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NP/APNs without formal education (28 countries)

• 43 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 said all had at least post RN level education
• 50 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)

• 48 said that there were specific requirements
  for renewal or maintenance of NP/APN license or
  registration
• Annual 15
• Every 5 years 54
• Other (i.e. 3-5 yrs) 31

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License or Registration Renewal Requirements (16
countries)
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Individual LevelResponses
31
Performance of specific skills by NPs (70
Respondents)

• Minor surgery (38.6)
• Suturing (85.7)
• Treating fractures (50)
• Midwifery (74.3)

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Performance of specific skills only by MDs (81
Respondents)

• Major surgery (100)
• Minor surgery (56.8)
• Diagnosis (25.9)
• Treatment (21)

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Type of education which would help NP/APNs to
stay current in their areas of practice (78
Respondents)

• CE online 76.9
• Other CE 80.8
• Conferences 91
• Mentoring experiences for new techniques 85.9
• Formal educational programmes 79.5
• Other 5

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General Questions

• Development of NP/APN role Facilitators (78
  Respondents)
• 58 identified strong support for nursing
  practice
• 80 identified need for more health care
  providers for rural/underserved areas
• 72 identified consumer demand for increased
  access to health care
• 14 indicated other factors

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Supporters and Advocates of the NP/APN Role (77
Respondents)
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Opposition to the NP/APN Role(60 Respondents)
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Opposition to the NP/APN Role

• 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

• Policy or health care planning
  (based on 79 Respondents)
• 77 stated that NPs/APNs participate at the local
  level
• 61 stated that NPs/APNs participate at the
  national level
• 85 stated that NP/APNs are organized as a
  professional group in the country (based on 80
  respondents)
• Professional organizations identified most
  frequently as the national nurses association
  rather than specific NP/APN organizations

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Conclusion

• 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

• 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
  Masters Degree was the predominant credential
  for NP/APNs.

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Limitations

• 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

• 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

• 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