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Worldview 2008: A global nursing perspective

Advanced nursing practice: The global experience

by Madrean Schober

The contribution of nursing to health care, specifically the added value of advanced practice nursing (APN) roles, is receiving renewed attention as the worldwide call for health care reform intensifies. Increasing demands on already overburdened health care systems are the focus of journal articles, conference themes and media hype. Although problems vary from country to country, none, it appears, escapes the negative effects of out-of-control costs combined with growing need for various health care services.

Madrean Schober

Escalating rates of chronic illness and infectious diseases, combined with aging populations and increased consumer awareness of health care options, are driving reassessment of how health care needs are best met. Challenges associated with poverty, natural disasters and conflict are coinciding with shortages of health care professionals and lack of access to health care service. Nurses with advanced knowledge and skills are increasingly viewed as an important part of the solution.

Knowledge of advancement of nursing roles internationally, and of nursing as a profession, has become part of the repertoire of the savvy health care professional, educator, administrator and key health-policy decision maker. The growing presence of nurse-managed clinics, advanced practice nurses as part of teams in hospitals, and nurse practitioners in rural and remote areas, as well as nurses in expanded roles providing services to vulnerable and at-risk populations, is catching the attention of health care planners globally. Understanding dimensions of change associated with the impact of globalization requires awareness of issues related to nursing and advanced nursing practice.

Beginnings
The United States is most often credited with introducing, at the beginning of the 20th century, the role of clinical nurse specialist (CNS) within hospital psychiatric settings and, in the 1960s, the nurse practitioner (NP) role in primary health care (Keeling & Bigbee, 2005). Although it is not absolutely clear that the United States is responsible for development of advanced nursing roles, acceptance of benchmark documents by institutions and countries considering implementation of these new roles appears to support that conclusion.

Various sources and surveys indicate that anywhere from 30 to more than 60 countries are currently investigating the concept of APN roles. Stakeholders representing new initiatives are attempting to assess and analyze what model or framework works best for country-specific projects and endeavors. Meanwhile, other countries are striving to refine fundamentals needed to sustain APN services that are already an active component of the health care workforce.

The International Council of Nurses’ (ICN) International NP/APN Network (INP/APNN) has been actively seeking to portray an accurate worldwide picture of APN presence. A pilot survey of 18 countries conducted in 2007 indicates there are 14 titles used to identify these roles. Poor role definition complicates accurate analysis of global APN adoption. Standards considered essential for advanced nursing practice are varied and fragmented. Educational requirements are diverse, ranging from certificate- or diploma-level programs to those at the master’s level (International Council of Nurses, n.d.).

Successes in Australia, Canada, New Zealand, the United Kingdom and the United States are held up as illustrations of progress in this field. It is exciting to see the heightened professionalism and autonomy associated with these new nursing roles. The history and stories behind these successes rest on the shoulders of pioneers and committed individuals with vision.

For example, in Botswana, during a severe shortage of physicians in the 1970s, nurses, out of necessity, were required to function at an advanced level and took on knowledge and skills usually associated with physician practice. When nurses demanded further education to better prepare for their expanded responsibilities, the family nurse practitioner (FNP) role emerged. On many islands of the Western Pacific, nurses regularly diagnose and treat patients and dispense medication, using titles of midlevel practitioner or nurse practitioner. Health care professionals in Jamaica have worked diligently for more than 30 years to protect the role of approximately 70 nurse practitioners.

In response to an urgent need for community health care services, Thailand identified short- and long-term goals to educate general NPs to work in the community as primary care providers. The first nurse practitioner program was started in the 1970s, but health care reform initiated in 2002 accelerated development of educational programs to respond to the call for more nurses in community settings.

Hong Kong nurse practitioner Chin Yee interacts with an elder from Tai O Village, Lantau Island. Hong Kong’s largest island, Lantau is the site of Hong Kong’s new international airport.

Hong Kong has been pursuing the concept of APN/NP education and roles for several years, while facing complicated governmental, clinical and academic challenges. A nurse practitioner initiative is expected to commence in 2008 in Tai O Village, Lantau Island, to provide coordinated services to its citizens. An APN education program was established in Singapore in 2003 in response to a request from the Ministry of Health. Key decision makers are working to adapt models and frameworks from the United States for a general APN curriculum, while attempting to develop APN roles within hospital settings.

France, the Nordic countries, and Switzerland are exploring integration of advanced nursing roles based on country demographics and needs. The Netherlands, after establishing NP roles in hospital settings, is now progressing to out-of-hospital care as the country responds to needs associated with chronic illness. The United Kingdom continues its effort to come to grips with issues of title protection, role definition and supportive regulation.

Advanced nursing practice: Not a trouble-free course
The road from inspiration to success in development of the APN role is not a smooth, progressive continuum. Evolution at times is fragmented and disjointed. Plans presented prematurely lead to disillusionment, and key decision makers search for a formula to emulate the success of those few countries that appear to have built the foundations necessary to support advanced nursing presence.

Trying to grasp what APN roles look like as they develop around the world is a bit like watching a whirling dervish. Title confusion prevails, scopes of practice are unclear or unstated, and even with the best intentions, national health care leaders struggle with making APN initiatives succeed. In some cases, schemes and plans simply collapse for lack of a comprehensive or championed approach to what, at first glance, appears to be a dynamic and beneficial nursing role.

Contradictions constantly tug at the essence of advanced nursing practice as countries and institutions strive to adapt role concepts to their own nursing culture and demographic needs. At times, it seems there is more heated debate over the appropriate title to use for this new category of nurses than there is discussion over its scope of practice and integration into the health care workforce.

Trends and potential
The strength and potential for new nursing roles around the world are not realized by filling gaps in existing health care arrangements that have been bruised and battered, but rather in the ability of competent and capable nurses to present a positive image and increased visibility for the profession. In countries where nursing is not yet seen as an honorable profession, every effort must be made to strengthen the foundations of nursing education and practice.

The author (third from right) and a social worker for Family Welfare Services in Tai O Village (fourth from right) with Hong Kong nurse practitioner students.

Opportunities for nurses to work differently and in new roles will continue to increase. For APNs to reach their full potential, critical challenges will need to be faced. All affected personnel and decision makers must be actively involved in integrating advanced practice nurses into workforce planning. International consensus building around definitions, scope of practice, core competencies and education will provide a unified point of reference.

In many countries, capacity building will be essential for bridging gaps between current and optimal education levels needed to support APN practice. Defining these gaps and finding evidence to support the value of advanced nursing practice are key and require research, research, research. Like it or not, current environments require APNs to provide evidence that their role is sustainable and that they are valued providers of health care.

Advanced nursing practice is as diverse in its interpretation as the countries attempting to introduce new nursing roles. What is commonplace in one setting may be considered shocking and unacceptable in another. Nurses functioning in strategic roles have opportunity to be at the forefront of a new era of care. As this new field of nursing evolves worldwide, it is inevitable that, in addition to the health care it provides, associated changes will influence the profession’s identity and values. RNL

Madrean Schober, MSN, APN, FAANP, is a visiting fellow at Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore.

References:

International Council of Nurses. Nurse practitioner/advanced practice network. Retrieved November 20, 2007, from http://www.icn-apnetwork.org/

Keeling, A.W., & Bigbee, J.L. (2005). The history of advanced practice nursing in the United States. In A.B. Hamric, J.A. Spross, & C. M. Hanson (Eds.), Advanced practice nursing: An integrative approach, (3rd ed.; pp. 3-43). St. Louis: Elsevier, Saunders.

Schober, M., & Affara, F. (2006). Advanced nursing practice. Oxford: Blackwell Publishing.