Healthcare systems worldwide are evolving as they face reform and restructuring in order to meet the changing needs of population demographics and consumer expectations. As systems adapt and shift their emphasis on the diverse aspects for provision of care opportunities emerge for nurses, especially advanced practice nurses, to meet these demands. Spain is to be commended for joining the ranks of many other countries that have embraced the APN concept as an integral part of the healthcare workforce. This editorial provides commentary on this dynamic and emerging field of nursing from an international perspective.
BackgroundAn APN is a nurse who has acquired clinical competencies and advanced decision-making skills, through additional education, for expanded nursing clinical practice (ICN, 2008)1. Nurse practitioners and clinical nurse specialists are two common categories of APN practice that have emerged internationally, however, Pulcini et al.2 as demonstrated, there are multiple titles and descriptors utilized to identify nurses practicing in an advanced capacity. The diversity in categorizing APN clinical practice is shaped by the context or country in which the role develops and where the APN is credentialed to practice.
The expanded role of a nurse is not a recent phenomenon. The term specialist as it relates to nursing emerged in the United States in the early 20th Century as postgraduate courses in specific nursing practice became available.3-5 Psychiatric nurse specialists, nurse anesthetists and nurse midwives led the way. These nurses were considered to practice at a higher degree of specialization than that already associated with nursing. These early domains of nursing practice were usually associated with traditional hospital based care and as a result the concept advanced unopposed.3 In primary healthcare the role of the nurse practitioner (NP) began in 1968 in the United States based on a public health model intended to provide care to children in underserved areas of the country.6 The concept of the NP evolved to include all general populations and subsequently developed in emergency and acute care settings.
Advanced practice nurses are educated and credentialed to manage health conditions with a focus on disease prevention. The APN, when authorized, performs physical examinations, makes diagnoses, and may have prescriptive authority to order medicines and therapeutic procedures. Their scope of practice spans the wellness-illness continuum to at least one population focus as defined by national or regional recognized role and population-focused competencies. Evidence demonstrates that patients cared for by APNs experience higher satisfaction with care provided, have fewer unnecessary emergency room visits, undergo fewer hospital readmissions and have fewer preventable hospitalizations compared to patients receiving similar care by physicians.7-11
International presence of Advanced Practice NursesIt is not within the scope of this Editorial to describe all countries that have successfully initiated the APN role but to illustrate the extent and range of the international presence of APNs. The first advanced nursing role in Europe was noted in the United Kingdom (UK) in the 1990s when the Royal College of Nursing started a nurse practitioner program. As of 2018 all four countries (England, Scotland, Northern Ireland and Wales) have APNs in both specialized settings and primary health care with the largest numbers in England. Although there is no regulatory protection of the ‘Advanced Nurse Practitioner’ in the UK the Advanced Practice Toolkit developed in Scotland is intended to work across all sectors to enhance understanding of advanced nursing roles (www.advancedpractice.scot.nhs.uk).12
The Netherlands has nearly 20 years of developing the APN concept (in Dutch it is ‘nurse specialist’) based on a projected shortage of physicians. As of 2016, 2750 APNs have been educated and registered in the country and are viewed as streamlining and improving care by integrating medical and nursing clinical reasoning. Finland newly launched an advanced nursing practice initiative in 2016. The title of Specialist in Nursing has been legally protected since 2003 in Iceland with roles mainly originating in hospital based settings. However, an effort is in place in Iceland to expand designated specialization to other fields such as family health.13
In Asia the concept of APN is emerging in various dimensions in Japan, Hong Kong, South Korea, Republic of China, Taiwan and Singapore. Singapore provides an example of decision makers wanting to keep expert nurses in clinical practice while also improving the status of nursing in the city/state.14 An education program was launched in 2003 followed by definitive standards and regulations in 2006. Mental health and Intensive Care APNs led the way in the early developmental stages. Japan has a history of developing the concept of clinical nurse specialist and then enlarged the scope of practice in 2008 to gerontological care and use of the title ‘nurse practitioner’.13
In 2001, the Regional Director for Nursing in the Eastern Mediterranean Region of the World Health Organization convened a meeting of 14 countries to discuss the concepts of APN roles and nurse prescribing. As of 2016 Oman has been successful in initiating the role while also working to upgrade nursing skills in 16 health centers with an on the job training plan. However, numbers of APNs are small (6 as of May 2017) as it has taken time to convince key decision makers of the value of APNs. Lacking an education program in the country all Omani APNs are educated in the USA. Two universities in Pakistan have indicated interest in initiating the APN concept but efforts were diverted to educating nurse managers and teachers while the country also moves to establish the bachelor's degree for generalist nursing practice.13
Nurse Practitioners in New Zealand have demonstrated safe advanced practice since they were first regulated in 2001 with the first NP designating the specialty of neonatal care. The Nursing Council of New Zealand accredits clinical master's programs as the required qualification for nurse practitioners. Australia provides an illustration of healthcare reform impacting momentum for introducing APNs. The title used is nurse practitioner (NP) with a regulatory framework in place that guides NP practice. As of 2016 the majority of NPs in Australia are employed in the acute sector and tend to specialize in areas such as emergency. However, there is an interest in moving to a greater focus on primary healthcare.13
Country issues that shape development of advanced practice nursingThe fundamental level of nursing practice and adequate level of nursing education that exists in a country shapes the potential for introducing and developing APN roles. The professional status of nursing and its ability to introduce a new role influences the launching of a successful APN initiative. The prominence and maturity of nursing can be assessed by the presence of other nursing specialties, established levels of nursing education, policies specific to nurses and the extent of nursing research.13
Shaping and establishing a new nursing roleDeveloping a new nursing role based on the paradigm shift associated with APN roles requires debate and discussion of multiple issues. The following questions call for deliberation when exploring the possibility of launching an APN initiative13 (p. 5):
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What is the nurses’ perspective of advancement and advanced nursing practice?
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What does advancement or professional progression for nursing mean within the country?
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Is there a career structure for promotion that could support the integration of advanced practice nurses?
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Is there an official place for the APN within the healthcare system with well-defined job descriptions and a career pathway commensurate to their qualifications and capabilities?
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Are the key components of APN practice acknowledged and addressed?
The motivation for introducing the APN concept varies and is sensitive to the healthcare culture and socio-political environment of the country or region where role development takes place. Literature reveals the following themes that influence role development13–16:
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An identified population based healthcare need to enhance access to care
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An answer to skill mix and healthcare workforce planning
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Interest in innovative practice patterns and new models of care
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A desire to advance nursing roles and improve the status of nursing
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Cost containment of healthcare services
No single starting point is seen as pivotal and often there are multiple reasons for considering this option for provision of healthcare services. It is important to note that motivation alone does not speak to the complex issues worthy of consideration when launching a successful scheme. In an effort to provide strategical guidance17 developed a Conceptual Policy Framework for Advanced Practice Nursing to assist decision makers. The framework provides a comprehensive approach to considering policy and policy processes that impact the implementation of APN roles. In addition, Canadian researchers18 developed the PEPPA Framework to provide guidance in the development, implementation and evaluation of APN roles.
ChallengesThe process of incorporating APNs into the healthcare workforce is a dynamic process characterized by change, alterations in service delivery and advancement toward a new era in nursing practice. The nature of the shift in nursing practice is met with both enthusiasm and skepticism. Conflict between APNs and other nurses as well as nursing and medical colleagues present significant challenges to overcome. Medical colleagues and collaborating physicians may challenge the APN concept and question the ability of nurses to provide a credible presence in the healthcare system. Other nurses may suggest that the APN has forgotten the foundation of nursing principles in adopting a role that overlaps with nursing and medicine. The consumer might be confused by the addition of another healthcare professional and will need to understand what the APN can do for them. Evidence of success in other countries is helpful, but researchers in Spain will be asked to provide evidence of successful outcomes specific to nursing, medical and consumer cultures in Spain in order to ensure a sustainable transition.
The following topics will require attention:
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Meeting the hopes and aspirations of APNs in Spain
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Diplomatic inter professional negotiations impacting role implementation
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Identifying pivotal nursing leadership to accomplish solutions for anticipated and unanticipated problems
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Financial strategies to support education, clinical positions for APNs and ongoing research
International enthusiasm for advanced clinical nursing roles has increased as healthcare reform continues to gain momentum. Worldwide there are diverse opportunities for nurses in advanced clinical roles to meet the needs of disparate populations in varied healthcare settings. To welcome and adopt this concept it is essential to understand the assumptions and core characteristics that provide the foundation for advanced practice nursing. In addition, there is a need to offer clarity, guidelines and resources for key stakeholders, decision makers, healthcare planners and professionals as they explore the option of advanced practice nursing roles for provision of healthcare services.
