An International Survey on Advanced Practice Nursing Education

An International Survey on Advanced Practice Nursing: Education, Practice and Regulatory Issues: 2008 Joyce Pulcini, Ph. D, APRN, BC, PNP, FAAN (USA) Alice Yuen Loke, BSN, MN, Ph. D (Hong Kong) Raisa Gul, RN, RM, MHA, Ph. D (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). 2

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. 3

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 4

Methodology n n n International web-based pilot survey Tool used: Survey. Monkey Online Survey: open for 6 weeks in February and March, 2008 15 -25 minutes in length Results: qualitative and quantitative descriptive analyses 5

Sections of the Survey n n n 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 6

n n 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%. 7 7

Survey Categories n n n 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 8

Sample n n n 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% 9

Participants (n=91) n Multiple roles • • n n 83. 5% were practicing nurses 55% were educators 20. 8% were administrators 42. 8% were involved in research 67. 1% (51) were NP/APNs 25% (19) were Registered/Generalist nurses 21% (16) answered other Of practicing nurses Of educators: 16% taught NP/APN students 10

Countries of Respondents in the NP/APN Survey (n=33) n n n n 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 n n n n n 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 11

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Findings n Findings are presented in two ways: • Country Level Responses (n=32) n NP/APN Education and programmes n NP/APN Regulatory Issues n Role as practicing nurse, educator, administrator n Types of positions held n Scope of practice • Individual level responses (n=91) n NP/APN Practice/Role and Scope of practice n Role questions n Skills performed n Type of continuing education to stay current n Supporters and opponents to the role 13

Country Level Responses

NP/APN Education, Practice Questions < n n 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 15

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% 16

Country Level Responses • Does your country have formal NP/APN programmes? (31 countries responding) Yes (71%) n No (29%) n 17

Types of credentials granted to NP/APNs in your country (20 countries) n MS degree: 56% n BS degree: 28. 1% n Certificate: 25% n Advanced Diploma: 21. 9% n No credential: 0 18

Most prevalent credential granted to NP/APNs in country (20 countries) n MS degree: 50% n BS degree: 15% n Certificate: 15% n Advanced Diploma: 20% 19

SPECIALTIES OR TYPES OF NP/APNS EDUCATED IN THE NP/APN PROGRAMMES (22 COUNTRIES) 20

Level of practice of majority of NP/APNs in country (28 Countries) n RN/Generalist Nurse: 17. 4 % n Post RN/Generalist Nurse: 69. 6 % n Other: 9. 4% • Examples: APN, Post RN generalist plus midwifery cert. , RN/Registered midwife with public health certification 21

POSITIONS HELD BY NPS/APNS (25 COUNTRIES) 22

Types of positions that exist in the Country n n n n 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% 23

NP/APN SCOPE OF PRACTICE (24 COUNTRIES) n Results may vary at the provincial/state level 24

Formal Recognition of NP/APNs in your country (23 countries) n n 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 25

Requirement for NP/APN Practice (25 countries) 26

NP/APNs without formal education (28 countries) n 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 27

Requirements for renewal (maintenance) of NP/APN licensure (27 countries) n 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% 28

License or Registration Renewal Requirements (16 countries) 29

Individual Level Responses

NP/APN Scope of Practice (73 Respondents) 31

Performance of specific skills by NPs (70 Respondents) n Minor surgery (38. 6%) n Suturing (85. 7%) n Treating fractures (50%) n Midwifery (74. 3%) 32

Performance of specific skills only by MDs (81 Respondents) n Major surgery (100%) n Minor surgery (56. 8%) n Diagnosis (25. 9%) n Treatment (21%) 33

Type of education which would help NP/APNs to stay current in their areas of practice (78 Respondents) n n n 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 34

General Questions n 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 35

Supporters and Advocates of the NP/APN Role (77 Respondents) 36

Opposition to the NP/APN Role (60 Respondents) 37

Opposition to the NP/APN Role n “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. 38

NP/APN Involvement in 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 n 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 39

Conclusion n 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. 40

Summary n n n 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. 41

Limitations n n 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 42

Discussion n n Collaboration with other subgroups How to best promote NP/ANP education internationally Language issues in survey and in future surveys Dissemination of results 43

Future Plans n n n 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 44