Kathy J. Wheeler, PhD, APRN, FNP-BC, FNAP, FAANP, 1 Minna Miller, DNP, MSN, NP(F), FNP-BC, FAANP, 2 Joyce Pulcini, PhD, PNP-BC, FAAN, FAANP, 3 Deborah Gray, DNP, ANP-BC, FNP-C, FAANP, 4 Elissa Ladd, PhD, RN, FNP-BC, FAAN, 5 and Mary Kay Rayens, PhD 1
1 University of Kentucky College of Nursing, US
Find articles by Kathy J. Wheeler2 British Columbia Children’s Hospital, CA
Find articles by Minna Miller3 George Washington University School of Nursing, US
Find articles by Joyce Pulcini4 Old Dominion University School of Nursing, US
Find articles by Deborah Gray5 MGH Institute of Health Professions, US
Find articles by Elissa Ladd1 University of Kentucky College of Nursing, US
Find articles by Mary Kay Rayens 1 University of Kentucky College of Nursing, US 2 British Columbia Children’s Hospital, CA 3 George Washington University School of Nursing, US 4 Old Dominion University School of Nursing, US 5 MGH Institute of Health Professions, US Kathy J. Wheeler: ude.yku@2eehwkCORRESPONDING AUTHOR: Kathy J. Wheeler, PhD, APRN, FNP-BC, FNAP, FAANP University of Kentucky College of Nursing, US ude.yku@2eehwk
Received 2022 Jan 10; Accepted 2022 May 9. Copyright : © 2022 The Author(s)This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.
Several subgroups of the International Council of Nurses Nurse Practitioner/Advanced Practice Nurse Network (ICN NP/APNN) have periodically analyzed APN (nurse practitioner and clinical nurse specialist) development around the world. The primary objective of this study was to describe the global status of APN practice regarding scope of practice, education, regulation, and practice climate. An additional objective was to look for gaps in these same areas of role development in order to recommend future initiatives.
An online survey was developed by the research team, and included questions on APN practice roles, education, regulation/credentialing, and practice climate. The study was launched in August 2018 at the 10 th Annual ICN NP/APNN Conference in Rotterdam, Netherlands. Links to the survey were provided there and via multiple platforms over the next year.
Survey results from 325 respondents, representing 26 countries, were analyzed through descriptive techniques. Although progress was reported, particularly in education, results indicated the APN profession around the world continues to struggle over titling, title protection, regulation development, credentialing, and barriers to practice.
APNs have the potential to help the world reach the Sustainable Development Goal of universal health coverage. Several recommendations are provided to help ensure APNs achieve these goals.
Keywords: advanced practice nurse, nurse practitioner, clinical nurse specialist, certified nurse midwife, nurse midwife, midwife, nurse in advanced practice
The advanced practice nurse (APN) is an established healthcare provider delivering care throughout much of the world. In 2020, the International Council of Nurses defined the APN as:
a generalist or specialized nurse who has acquired, through additional graduate education (minimum of a master’s degree), the expert knowledge base, complex decision-making skills and clinical competencies for Advanced Nursing Practice, the characteristics of which are shaped by the context in which they are credentialed to practice (adapted from ICN, 2008). The two most commonly identified APN roles are Clinical Nurse Specialist (CNS) and Nurse Practitioner (NP) [1 (p6)].
Broadly speaking, NPs assess, diagnose, order and interpret laboratory tests, and prescribe medications for individual patients within a framework of collaboration with other medical providers and systems [2]. Though still involved in the direct provision of care to patients, CNSs tend to work more in healthcare administration and provide consultation and guidance to nursing staff and systems who manage complex patient care [3]. It is estimated about 40 countries currently have well-established APN roles [4]. Some of these countries have hundreds of thousands of APNs and others have more modest numbers.
Looking to the future, APNs may help counter the shortage and maldistribution of healthcare providers around the world. The World Health Organization predicts there will be a global deficit of 12.9 million physicians, nurses, and midwives by 2035 [5]. Physician roles and functions are fairly consistent throughout the world [6,7]. However, for APNs there are variations in the roles, titles, tasks, and regulatory, education and practice structures under which APNs provide care, country to country, and even jurisdiction to jurisdiction. Since 1999 several studies have attempted to document the evolution, expansion, and variation of the APN around the world (see Tables 1 and and2) 2 ) [8,9,10,11,12]. These studies serve as snapshots in time of global role development and denote steady growth around the world and improving clarity of education, certification, and regulatory underpinnings.
APN Role and Regulation Studies.
– ICN International Conference 1999 (London, England) – ICN NP/APNN Conference 2000 – ICN Nursing Association Members (120) – 40 countries responded – education beyond that of a licensed or registered nurse in 33 countries, with education varied – only 26 countries reported education that led to a degree, diploma or certificate – education programs reported some kind of accreditation or approval process, though varied widely – some form of regulation reported in 13 of the countries – 3 rd ICN NP/APNN Conference (Gronigen, The Netherlands) – conference attendees – over 60 countries reported either presence or interest in APN roles – 174 key respondents and members of the ICN NP/APNN – 32 responding countries – 13 titles identified for the NP/APN role– NP/APN education in 71% of 31 countries, with 50% recognizing master’s degree as prevalent credential
– NP/APN role formally recognized in 23 countries, with 48% having licensure maintenance or renewal requirements
– greatest support from domestic nursing organizations, individual nurses, and the government – greatest opposition from domestic physician organizations and individual physicians – National Nursing Associations and global nursing health policy makers – 30 responding countries with 26 reporting evidence of APN role – questions on regulation, education, scope of practice, opposition/barriers– significant variation in educational requirements, regulation, and scope of practice from country to country
– country experts suggested by group of international experts– 39 responding countries with 27 reporting evidence of APN role via task shifting (England, Northern Ireland, Scotland, Wales all reporting separately)
– 11 countries demonstrated significant task shifting, 16 countries demonstrated limited task shifting, 12 countries demonstrated no task shifting
Country Responses Compared to Previous APN Studies.
Northern Ireland Northern Ireland* Unclear if participation in survey demonstrated presence of APN role.
** Role present in all countries, though significant variation in regulation and education.
*** Level of task shifting as follows: 1 = significant task shifting, 2 = limited task shifting, 3 = no task shifting.
Although titles, roles, and duties vary around the world, advanced practice nurse is a commonly accepted umbrella term representing four generally established advanced roles—the two described above, NP and CNS, as well as nurse anesthetist and nurse midwife. And while APN is a broadly accepted representative term, most countries and jurisdictions use other terms to refer to nurses who practice in an advanced role. For instance, the title adopted in the United States (US) is Advanced Practice Registered Nurse (APRN), specifically developed by the Consensus Model for APRN Regulation in 2008 [13]. Aside from codifying the titles of the four disciplines representing APRNs--Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS), Certified Nurse Midwife (CNM), and Certified Registered Nurse Anesthetist (CRNA)—the Consensus Model sought to ensure consistency in licensure, accreditation, certification, and education, facilitating regulation of APRNs throughout the US. The Consensus Model, which was adopted in the US in 2008, is a rather recent development relative to the observation that varied APN roles have existed in some form for over a hundred years [14,15]. The first global definition occurred in 2002, when the ICN defined an NP and APN, and the master’s degree was only a recommendation [16]. The more recent ICN definition of the APN, provided above, set the master’s degree as the minimal education requirement and emphasized an advanced level of decision-making and responsibility. However, it did not include definitions for APNs who deliver anesthesia or who participate in childbirth.
To describe the global status of APN practice regarding scope of practice, education, regulation, and practice, the Health Policy Subgroup of the International Council of Nurses Nurse Practitioner/Advanced Practice Nurse Network (ICN NP/APNN) recently completed this global study. An additional objective was to look for gaps in these same areas of role development in order to recommend future initiatives.
An online survey was developed by the research team, drawn largely from the 2010 Pulcini, Jelic, Gul, and Loke survey [10] as well as regulatory questions from the 2015 Heale and Buckley survey [11], once adaptation permission was granted. Questions were refined, with several areas added or developed, most notably the modification of questions on education, professional issues, clinical skills, credentialing, and certification. The survey categorized questions according to practice roles, education, regulation/certification, and practice climate. Because of the complexity of APN titling and practice issues, respondents were given the opportunity to answer multiple questions with open-ended responses in addition to multiple choice options. To clarify distinctions of education and credentialing, definitions for title protection, certificate, certification, and recertification were provided (see Table 3 ).
Education and Credentialing Definitions Provided in Survey for Items Needing Clarification.
| TERM | DEFINITION AS PROVIDED IN SURVEY |
|---|---|
| Title protection | Title protection, as adapted from the American Nurses Association definition, refers to the restricted use of the title to only those individuals who have fulfilled the requirements for the licensure/recognition in each jurisdiction’s legislation/regulations/rules so as to protect the public against unethical, unscrupulous, and incompetent practitioners. |
| Certificate/certification | To clarify the difference between the meaning of “certificate” and the meaning of “certification” the following definitions are provided by the American Accreditation Board for Nursing Specialties: Certificate program refers to “an educational program that awards a certificate after completing the program.” Certification refers to “an earned credential that demonstrates the holder’s knowledge, skills and experience. It is awarded by a third party.” Generally the third party is non-governmental but, in some situations, could be a governmental agency. |
| Certification/recertification | Certification, as defined by the American Accreditation Board of Nursing Specialties, refers to “an earned credential that demonstrates the holder’s knowledge, skills and experience. It is awarded by a third party…” Generally the third party is non-governmental but, in some situations, could be a governmental entity. Conditions for certification usually involve experience, education and an exam. Conditions for recertification usually involve experience and continuing education, but may involve another exam. Certification is a formal recognition of an individual’s education, skills and practice AS OPPOSED to licensure/registration/endorsements, which is an individual’s formal authorization to practice. |
Once the research team obtained institutional review board (IRB) approval from the Office of Research Integrity of the University of Kentucky and the survey was approved by the Core Steering Group of the ICN NP/APNN, the study was launched in August 2018 at the 10 th Annual ICN NP/APNN Conference in Rotterdam, Netherlands. Links to the survey were provided there and via ICN social media platforms. When initial data analysis showed response gaps from several continents due to institutional firewalls, the IRB approval was amended to allow document surveys to be anonymously submitted with deadline extended to September 2019.
A convenience sample approach was used because of the difficulty accessing all eligible participants or countries worldwide. Participants completed the survey once in this cross-sectional assessment. Study participants were required to be APNs, APN educators, APN administrators, and/or APN researchers; be fluent in reading/writing English; and have access to a computer with an Internet connection. Completion of the survey established participant consent. Survey responses from 325 respondents, representing 26 countries, were analyzed. However, the study data were summarized as being from 23 countries, with data from England, Northern Ireland, Scotland, and Wales, combined as a single location category (i.e., United Kingdom [UK]).
Each survey was analyzed for sufficiency of response. Participants from all represented countries answered both multiple choice and open-ended questions. We received 482 surveys in total, but 157 of them were not able to be retained due to widespread missing values; the effective sample size was 325, reflecting 67% of the total surveys received. Descriptive statistics, including frequencies and percentages, were used to analyze and describe the sample data. SAS, v. 9.4 was used for the quantitative analysis.
Responses came from countries in all the major regions of the world, specifically Africa (n = 4), Asia (n = 2), Europe (n = 10), North America (n = 3), South America (n = 2) and Oceania (n = 2), as presented in Table 4 .
Demographic totals and percentages are presented in Table 5 .
Demographics of Survey Respondents.
| PRACTICING NURSES | N | PERCENT* |
|---|---|---|
| Registered/Generalist Nurse | 71 | 21.82 |
| Hospitalist/Acute Care NP/APN | 48 | 14.77 |
| Specialty care specific to disease or illness NP/APN | 50 | 15.38 |
| Specialty care specific to an age group or population NP/APN | 32 | 9.85 |
| Family NP/APN | 121 | 37.23 |
| Geriatric/Gerontologic NP/APN | 18 | 5.54 |
| Paediatric NP/APN | 17 | 5.23 |
| Adult NP/APN | 45 | 13.85 |
| Adult Gerontologic NP/APN | 7 | 2.15 |
| Women’s Health NP/APN | 12 | 3.69 |
| Midwife | 2 | 0.62 |
| Community Health NP/APN | 21 | 6.46 |
| Mental Health NP/APN | 17 | 5.23 |
| CNS | 22 | 6.77 |
| Other | 47 | 14.46 |
| EDUCATORS | N | PERCENT |
| Registered/Generalist Nurse | 18 | 11.69 |
| NP/APN | 65 | 42.21 |
| Both of above | 59 | 38.31 |
| Other | 12 | 7.79 |
| ADMINISTRATORS | N | PERCENT |
| Nursing personnel | 22 | 48.89 |
| Non-nursing personnel | 0 | 0 |
| Both of above | 23 | 51.11 |
| RESEARCHERS | N | PERCENT |
| Nursing related | 56 | 52.83 |
| Non-nursing related | 6 | 5.66 |
| Both of above | 44 | 41.51 |
| OTHER ROLES | N | PERCENT |
| 73 |
* Percentages do not add to 100% because respondents could select more than one answer.
Eligible participants could identify themselves as practicing nurses, educators, administrators, and/or researchers. Because nurses (and those associated with nurses) function in many roles, respondents were asked to check all that applied in each category or provide additional roles if an option was not listed. For this reason, the cumulative percentage across all roles exceeds 100%.
Of respondents who reported practicing as nurses, 37% (n = 121) identified as a Family NP/APN, 22% (n = 71) as a registered/generalist nurse, 15% (n = 50) as a NP/APN specialist devoted to a specific disease, 15% (n = 48) as a Hospitalist/Acute Care NP/APN, 14% (n = 45) as an Adult NP, 10% (n = 32) as a NP/APN specialist devoted to a specific age or population, 7% (n = 22) as a Clinical Nurse Specialist, 6% (n = 18) as a Geriatric/Gerontologic NP/APN, 6% (n = 21) as a Community Health NP/APN, 5% (n = 17) as a Mental Health NP/APN, 5% (n = 17) as a Paediatric NP/APN, 4% (n = 12) as a Women’s Health NP/APN, 2% (n = 7) as an Adult/Gerontologic NP/APN, and 1% (n = 2) as a Midwife. The 14% (n = 47) of practicing nurses who reported roles outside those offered in the survey listed roles such as neonatal nurse practitioner or nurse anesthetist.
Of respondents who identified as educators, 12% (n = 18) reported they educated registered/generalist nurses only, 42% (n = 65) educated APNs only, and 38% (n = 59) reported they educated both. An additional 8% (n = 12) reported educating students other than registered/generalist nurses or APNs. Those who identified as administrators were almost equally split, with 49% (n = 22) reporting oversight of nursing personnel and 51% (n = 23) reporting oversight of both nursing and non-nursing personnel. Over half of the researchers reported they were involved exclusively in nursing research (53% (n = 56), 6% (n = 6) in non-nursing research, and 42% (n = 44) in both.
Practice questions centered on titling and types of APN roles, presence/absence of title protection, professional issues, and clinical skills (see Appendix A). Most countries with some sort of APN practice reported more than one advanced role. Though most used the titles NP, CNS, or midwife, other titles were listed, such as APN, nurse in advanced practice, expert nurse, nurse specialist, and others. In some countries the term CNS (or a similar title) referred to nurses who function more as NPs, or vice versa (i.e., providers titled NPs but who functioned more as CNSs). Some countries reported midwives were commonly educated at the registered/generalist level or as a non-nurse, while other countries reported educating midwives at a post registered/generalist nurse level. Title protection was reported in Australia, Botswana, Canada, France, Hungary, Israel, Jamaica, the Netherlands, New Zealand, Portugal, Republic of Ireland, Singapore, and the US. Title protection was not reported in Chile, Finland, Germany, Ghana, Italy, Kenya, Spain, Tanzania, or the UK.
Respondents chose from 15 APN work-place position options, such as doctor’s office, hospital-based clinic, hospital, faculty, and the like. Respondents could report all that applied as well and were able to list any unnamed workplace settings in an open-ended question. Australia, Botswana, Canada, Finland, the Netherlands, New Zealand, Spain, the UK, and the US responded affirmatively to all site options. Portugal reported all site options except occupational/workplace health, while the Republic of Ireland reported all site options except school health and occupational or workplace health. Singapore reported a little over half the work site options, while the remaining countries reported fewer than half of the work site options. Israel reported only specialty practice sites and Hungary reported that the role was too recently instituted to provide any details. Ecuador reported the role did not exist outside US government agencies, so will only be reported in the tables but not included in discussions or subsequent calculations. Other questions pertained to 21 clinical skills (from skin lesion removal to suturing to X-ray interpretation) and 12 professional issues (from carrying their own caseload of clients/patients to ability to prescribe to reimbursement (see Appendix A).
Education questions pertained to presence/absence of programs, number of programs, level of education, types of specialties or APNs, program details, and student requirement details (see Table 6 ).