International Development of Advanced Practice Nursing

Advanced practice nursing has evolved in the international arena over the last half-century. With an initial focus in the United States, advanced practice nurse (APN) roles are now becoming more visible as a response to improving health care for people in all parts of the world. Internationally, health care problems have rapidly evolved from a major focus on deadly diseases, high infant mortality, and maternal morbidity to a new focus on chronic or noncommunicable diseases, an aging population, and lifestyle choices that promote health (Skolnik, 2008). Many areas of the world, such as sub-Saharan Africa, continue to have dire health care problems with communicable diseases and mortality, but managing chronic diseases and promoting healthy lifestyles have eclipsed infectious diseases worldwide as infant and child mortality rates have begun to drop globally (Liu, Johnson, Cousens, et al., 2012; World Health Organization [WHO], 2011). Child mortality has decreased to a point that some of the poorest countries are projected to meet Millennium Development Goal 4 for reducing child mortality (Demombynes & Trommlerova, 2012). Many countries are realizing that their aging population will have very different needs in the future and are gearing up to meet the chronic health care problems that accompany aging. Maternal mortality which was a huge problem in parts of South America and Africa, has begun to resolve itself with a greater emphasis on population control and women’s health (Grady, 2010; Hogan, Foreman, Mohsen, et al., 2010). Nurses have played a key and relatively independent role in providing health care in rural areas, particularly in parts of Africa and Australia, where major physician shortages exist. Increasingly, these nurses are entering programs that educate them for role expansion. As the incidence of chronic diseases increases, nurses and APNs will have an even greater role to play in managing these problems and educating the public on lifestyle issues.

Other issues, such as the global health worker shortage and mass migration of health care workers to more developed countries, are important drivers of continued gaps in care. Along with these shortages are huge inequities of care across the globe, with some urban areas having an acute oversupply of providers and excellent health care facilities and others with desperate inequities and shortages of care. Economic disparities have increased over the last 30 years and this rate has accelerated with the recent worldwide recession, starting in 2008 (Leach-Kemmon, Chou, Schneider, et al., 2012). APN educational programs have also been developing in many areas of the world and, as these programs increase, the nursing workforce will be better prepared to function with advanced nursing knowledge. Recently, the World Health Organization (WHO) (2010) issued an important report underscoring the need to enhance the global nursing and midwifery workforce.

The purpose of this chapter is to provide an overview of international developments related to advanced practice nursing. A key premise is that APNs are part of the solution to global health care problems and, if used appropriately, can partner with other health care providers to improve global health.

Definitions

There are several definitions of advanced practice nursing. The definition used in this text (see Chapter 3) states that “Advanced practice nursing is the patient-focused application of an expanded range of competencies to improve health outcomes for patients and populations within a specialized clinical area of the larger discipline of nursing” (see p. 71). Key elements of the definition are required graduate education and APN certification and the identification of seven core competencies, which distinguish APN-level practice regardless of role. The four specific APN roles used in this book are those used in the United States—nurse practitioner (NP), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS). These different roles, as they are being developed in a global context, will be discussed later in the chapter.

The International Council of Nurses (ICN)–International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) definition states that “A nurse practitioner/advanced practice nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level” (ICN–INP/APNN, 2012). Although some notable similarities exist among definitions, particularly in acknowledging competencies, expanded practice, and recommending graduate education, the ICN definition is general and recognizes that the terms nurse practitioner and advanced practice nurse are used interchangeably in some parts of the world. This definition incorporates nurse practitioner and advanced practice nurse into one definition to reflect a broad interpretation of APN roles as they are applied in different countries. This definition advances educational expectations by recommending a master’s level education, an important milestone for achieving advanced-level practice.

International Evolution of the Advanced Practice Nurse

When looking at the four APN roles from an international perspective, it is apparent that each of the roles is evolving with country- or region-specific differences. More time is needed to move to the standardization of roles, titles, and responsibilities for the various APN roles internationally, but this work is clearly beginning with a focus on competencies and scope of practice rather than on specific titles (ICN, 2009; ICN–INP/APNN, 2012). All these roles are discussed in detail in other chapters; this section will emphasize the international evolution of APNs.

Nurse Practitioner

The NP had its origins in the United States and has had more than 45 years to develop as a primary care specialty, with additional foci on specialty care and acute care. In other countries, such as the United Kingdom, the NP role is at best 20 years old and is still developing, having evolved from routine well or primary care to the management of more complex specialty conditions in the context of an interdisciplinary team (Sibbald, Laurant, & Reeves, 2006).

The United States and United Kingdom often serve as models for the evolution of the NP role. In Canada, Australia, and New Zealand, the use of a specific nursing title is restricted to those who have met certain requirements to practice. Also, in these countries, national standards for the regulation of and education for the role are becoming well developed and NP prescribing is regulated (Canadian Nurses Association [CNA], 2008; Nursing and Midwifery Board of Australia, 2011; Nurse Practitioner Council of New Zealand, 2012). Although there are also NPs in England, both in primary care and specialty care, variability exists as to the level of education and prescribing abilities; nurses in general who have specific education can prescribe drugs from the British formulary (Kroezen, van Dijk, Groenewegen, & Francke, 2011). To add to the variability, some countries do not use the term nurse practitioner. In the Netherlands, the term nurse specialist has recently been adopted, replacing the NP title with five recognized specialties—intensive care, acute care, chronic care, mental health care, and preventive care (Frauenfelder, 2012; see Exemplar 6-1). In other countries such as in Singapore, the term advanced practice nurse is used instead of NP and is generally preferred. In Singapore, APNs initially function in hospital settings and some outpatient facilities or polyclinics in the community (Mei, 2012; Schober, 2012; see Exemplar 6-2).

Exemplar 6-1 Evolution of the Nurse Practitioner Role in the Netherlands *

Lillian Garcia Maas RN, MS

The first NP program was created in collaboration between the Hanze University of Applied Sciences and Groningen University Hospital in Groningen, the Netherlands. Petrie Roodbol, RN, PhD, developed the first program in 1997, with six students in the inaugural class. The NP role originated because of the lack of medical specialists in the hospitals; as a result, so-called supernurses, initially called NPs and now called nurse specialists, were trained to take over medical tasks. This need for medically oriented nurses led to the development of a master’s program for NPs, which was the first master’s degree for clinically focused nursing at a university of applied sciences. Prior to this graduate degree, a Master of Science degree was available for nursing researchers. Keeping nurses at the bedside is the focus of the master’s in advanced nursing practice programs at universities of applied sciences in the Netherlands. Since 1997, NP education has expanded to a total of nine universities of applied sciences across the Netherlands. The Dutch Minister of Health designates and subsidizes approximately 300 NP student placements per year; the trend is to increase the number of NP students in the near future. The full-time Master’s in Advanced Nursing Practice (MANP) program is a 2-year work study program. The students work 3 or 4 days in their clinical work setting while attending class one day per week. The students are paid as NPs in training during the program. The MANP faculty works closely with the medical and nursing preceptors to ensure that the competencies are being met within their clinical practice. The final project in the MANP is completion of a master’s thesis on a clinical topic. The focus of NP education is to bridge care and cure while providing holistic healthcare.

The roles of the Dutch NP are based on the CanMEDS model for medical specialist, which is based on a medical model developed by the Royal College of Physicians and Surgeons of Canada (2011). This is the current model for medical education in the Netherlands and has been translated to advanced nursing practice. The roles of the model are further adapted to meet the competencies of advanced nursing practice. The core role of advanced practice nurses is the clinical expert. The six complementary roles to support the clinical expert are as follows: (1) professional; (2) communicator; (3) collaborator; (4) manager; (5) health advocate; and (6) scholar. These roles have been adapted to advanced practice nursing competencies.

NP specialty practices include the following:

1. Preventive care (e.g., pediatric screening clinics, travel health, family care)

2. Acute care (e.g., prehospital, emergency room)

3. Intensive care (e.g., transplantation, cardiology)

4. Chronic care (e.g., nursing homes, rehabilitation facilities)

5. Mental health care (e.g., health care clinics, hospitals)

NP students must meet the competencies of their specific practice focus to graduate and legally practice in their role. Following successful completion of the required competencies from an accredited MANP program, the students can register to practice as a nurse specialist (Verpleegkundig Specialisten Register, 2012). The title of NP–nurse specialist is legally protected and recognized. To maintain their license, NPs–nurse specialists are required to become recertified every 5 years by meeting a set of requirements, such as the number of clinical hours at the bedside and certified continuing education courses. NPs–nurse specialists in the Netherlands are legally able to diagnose autonomously, perform a set of delegated medical procedures, and prescribe within their specialty domain.

As of January 2012, there were 1373 registered NPs–nurse specialists. The following are the totals of registered NPs in the five specialties (Verpleegkundig Specialisten Register, 2012): preventive care, 34; acute care, 80; intensive care, 691; chronic care, 271; and mental health care, 297.

Trends in Education: Internationalization of the Nurse Practitioner Curriculum

An international experience has become increasingly common for many MANP programs in the Netherlands. Because of the limited number of NP role models, many MANP programs have developed international experiences in the United States. The NP role originated in the United States, so many students are interested in spending time with their American counterparts. The international experience is used as an educational tool to develop the role further by benchmarking one’s own health care and nursing system and exchanging ideas with her or his international NP colleagues, an idea that can be a model for student experiences (Maas, 2011).

One unique example of organizing short-term international group immersion trips to the United States is the Rotterdam University (RU) of Applied Sciences. RU requires an international experience prior to graduation and is the first of its type in Europe. In addition, internationalization is emphasized in the curriculum to create borderless NPs who are open to other philosophies, cultures, and possibilities (Maas & ter Maten, 2009). The global village is at our doorstep, and RU wants to support its students in looking across borders for solutions and opportunities.

As of March 2012, 161 NP–nurse specialist students have been to the United States and participated in clinical observations. The international experience allows students to witness well-established NP environments. Seeing the NP role accepted has empowered Dutch NP–nurse specialist students to create a vision for themselves and lays the foundation for role development. The challenge of distinguishing advanced nursing practice as an autonomous level of practice becomes clearer (ter Maten & Maas, 2009). The international experience fosters a new sense of nursing pride for the students. For many years, RU has collaborated with the NP program at Texas Woman’s University. Eight weeks prior to the international experience, the NP–nurse specialist students work on collaborative keypal assignments with their U.S. counterparts. The keypal exchange is an effective acculturation tool for an international experience (Maas, 2009). The assignment consists of seven weekly topics of health care, nursing system, and professional issues. In addition, the students work on joint clinical case studies. When the Dutch and U.S. students meet, they are able to meet their keypal and discuss the differences and similarities of their clinical case studies and health care and nursing systems. Ultimately, an international experience can instill new vision and confidence to help support leadership skills for future Dutch NPs–nurse specialists.

^*The author thanks Lillian Garcia Maas, RN, MS, International Coordinator and Faculty Member, Institute of Healthcare, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands, for authoring this exemplar.

The survey by Pulcini and colleagues (2010) also identified the most common types of NP-APN specialties. This survey used the term NP-APN but was intended to survey NP roles, listed in Table 6-1. Table 6-2 indicates the most common types of positions held by NP-APNs from the survey.

TABLE 6-1

Specialties (Types) of NPs and APNs *

ANP, Adult nurse practitioner; FNP, family nurse practitioner; GNP, geriatric nurse practitioner; PNP, pediatric nurse practitioner.

^*Survey of NPs and APNs educated in 21 countries.

Adapted from Pulcini, J., Jelic, M., Gul, R., & Loke, A.Y. (2010). An international survey on advanced practice nursing education, practice and regulation. Journal of Nursing Scholarship, 42, 31–39.

TABLE 6-2

Most Common Types of Positions Held by NPs and APNs *

^*Survey of NPs and APNs in 25 countries.

Adapted from Pulcini, J., Jelic, M., Gul, R. & Loke, A.Y. (2010). An international survey on advanced practice nursing education, practice and regulation. Journal of Nursing Scholarship, 42, 31–39.

Exemplar 6-2 Advanced Practice Nursing Development in Singapore *

Madrean Schober RN, ANP, MN, FAANP

Formal and informal discussions among nursing leaders and key decision makers have provided the conceptual beginnings for advanced nursing roles in Singapore. In 1997, a national Nursing Task Force recommended implementation of a nurse clinician role to keep highly skilled nurses in clinical practice (Lim, 2005). A hybrid model based on the clinical nurse specialist and NP roles in the United States provides the foundation for the current Singaporean APN role (Kannusamy, 2006). The Singapore city-state of 5.5 million people has steadily established the APN role in Asia. The initial academic program was introduced at the National University of Singapore (NUS) in January 2003, under the auspices of the Yong Loo Lin School of Medicine. The program is now managed solely under the direction of the Head of Department for the Alice Lee Centre of Nursing Studies. The Head of Department confers with the Dean of School of the Medicine when there are major changes, such as the addition of a new specialty to the program.

The use of the title advanced practice nurse is protected under the Amendment to the Singapore Nurses’ and Midwives’ Act, passed in 2005 (Nurses and Midwives Act, amended by Act 15 of 2005). These regulations include a role definition, scope of practice, and competencies that delineate the role. From concept to current development, the Ministry of Health (MOH) has been pivotal to the feasibility and sustainability of the APN initiative. Unlike the United States, where candidates for education programs are often self-funded and potential students choose their university or program, all student fees are fully funded by the Singapore MOH and an employer (hospital, polyclinic, or other health care institution) selects the potential candidate from the current nursing staff. In addition, the employing institution pays the full salary during the period that the individual is a student and requires the nurse to agree to fulfill a bonding period for 2 to 3 years following graduation and successful completion of their internship. Upon successful completion of the Master of Nursing (MN) at the National University of Singapore, the aspiring APN must complete a minimum of a one-year internship in order to qualify for certification, registration and licensure as an APN.

Impetus for Role Development

Historically, Singapore had been losing highly skilled nurses to management and education career tracks for promotion and remuneration. Key decision makers envisioned that the creation of a clinical career path would retain nurses in clinical practice (Ang, 2002). The APN initiative is still in its infancy; therefore, it is too early to determine the success of this strategy. However, since the entrance of the first students into the Master’s in Nursing program in 2003, the number of APN students has grown from 15 in the initial cohort to annual intakes of 20 to 25. As of July 2012, 138 students have completed the APN program. The program began as an 18-month master’s program that has now expanded to a 24-month, 2-year master’s.

Impetus for the APN role in Singapore has been attributed to a plea by nursing and nurse leaders for clinical career advancement, along with a view that nurses with advanced skills and knowledge could fill gaps and add quality to the provision of health care services. The Singapore national health care agenda has developed an increased focus on chronic illness and mental health needs, especially as they relate to the aging population. In addition, the MOH has envisioned that more services should be accessible in the community. The anticipation of increased demands on health care systems in the country and a shortage of physicians in certain specialties has provided additional momentum for APNs in various settings. Presently, most APNs are hospital-based, in settings ranging from intensive care units, heart failure clinics, preoperative services, and mental health specialties. In 2012, a decision was made to include pediatrics in the academic curriculum.

As is often the case when launching a new idea, progress has been turbulent at times, with some graduates of the APN program choosing not to complete the compulsory internship. Further attrition is associated with the inability of APN interns to complete the certification process successfully. The path to successful role implementation has also been fraught with confusion over what the APN can do that is different from the generalist nurse or nurse clinicians who already hold positions of advanced responsibility in Singapore health care systems. Nurse clinicians are educated in 8-month advanced diploma programs and function in the capacity of care managers in health care settings throughout Singapore. Physicians and nurse managers continue to be puzzled over the inclusion of APNs in the health care workforce, even though the support for this new nursing role is positive.

Only gold members can continue reading. Log In or Register to continue