DOES REGULATION OF
ADVANCED NURSING PRACTICE
ROLES ASSIST IN FUTURE GLOBAL
DEVELOPMENT
Rachel Bard
ICN 25th Quadrennial Congress
Melbourne, Australia, 18 to 23 May, 2013
© Canadian Nurses Association, 2013
Outline
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Introduction
Methodology
Demographics
Regulation of roles
Education
Requirements to practice
Scope of practice
Themes
Discussion
Introduction
• Background
• INP/APNN subgroups
• Pulcini et al 2010
• Regulatory Framework
Advanced Practice Nurse
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.
International Council of Nurses
Literature
• Development of APN roles is a global trend
(Bryant, 2005)
• Developed to meet specific needs such as
shortages in human health resources or to
address emerging health needs of the
population (ICN, 2008).
• There is wide variation of APN scope of
practice, education requirements, regulation
worldwide (ICN, 2009).
Background
– Little opportunity for INP/APNN to focus on
regulatory issues in past
– Particular student interest in international
APN work
– Challenges globally around the regulation of
APNs
Background
Regulation of professional practice is
important.
– legitimacy through credentialing
– defines scope of practice, authorizes clinical tasks
and entry requirements
– helps to ensure safe and competent practice
(Gummer, 1984; Morrison & Benton, 2010; Bryant, 2005).
Methodology
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International on-line survey
Ethics approval
Convenience sample (snowball)
Invitation to ICN member countries
Individual recruitment
Survey Development
• Coordination of information and resources:
– Literature
– 2007 survey by Pulcini et al
– Consultations:
• INP/APNN Core Steering Group
• INP/APNN Education/Practice Subgroup
• Health Policy Subgroup
• ICN Regulatory Consultant
• McMaster and Laurentian Universities, Ontario,
Canada
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Survey Categories
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General Information
Types of APNs
Regulation of roles
Education
Requirements to practice
Scope of practice
Countries Represented in
the APN Survey (n=36)
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Angola
Australia
Austria
Bahamas
Bolivia
Botswana
Bulgaria
Canada
Congo, Democratic Republic of
Finland
France
Gambia, The
Greece
Iran, Islamic Republic of
Ireland, Republic of
Italy
Japan
Lebanon
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Malaysia
Mongolia
Netherlands
New Zealand
Poland
Sierra Leone
Singapore
Spain
Sri Lanka
Suriname
Switzerland
Taiwan
Tanzania
Thailand
Togo
Trinidad and Tobago
United Kingdom
United States
APNs identified
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NP: 16 countries
APN: 12 countries
CNS: 18 countries
NS: 15 countries
Nurse midwives: 2 countries
Nurse anesthetist: 2 countries
Clinical nurse consultant: 1 country
No APN role: 4 countries
Regulation of Roles
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NPs with regulation = 8 (n=15)
APN = 5 (n=11)
CNS = 4 (n=14)
NS = 6 (n=10)
Nurse midwives = 2 (n=2)
Clinical Nurse Consultant = 1; not regulated
• APN roles with regulation (25)
– 16 are regulated by federal legislation
– 9 by individual jurisdiction
– (2/3 vs. 1/3)
Educational Requirements
• 42 (n=52) roles identified across all the countries
require a minimum level of education
• Educational requirements ranged from:
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post basic certificate (non-academic)
baccalaureate
masters
post masters certificate and
doctorate
• 25 (N=52) require masters preparation
Practice Requirements
• Title protection =19 (n=48)
• Licensing exam = 20 (n=49) yes
– 4 = varies by jurisdiction
• Of the credentialing mechanisms required, an
approved education program was the most
commonly cited
Scope of Practice
N=47
– Diagnosing = 30
– Prescribe = 18
– Order Diagnostic Tests = 20
– Admit to Hospital = 16
– Refer to other health care providers = 31
– Practice without physician supervision = 20
– Performs practice independently = 27
Two Open-Ended Questions
Has there been opposition to the regulation of
this type of APN role in your country?
– The majority responded “no”.
– When there was opposition, most identified
opposition from physicians and medical
organizations.
– A few mentioned opposition to APN roles in some
countries by pharmacists, government and
administrations.
Second Question
What barriers in your country prevent
those in this type of APN role from
functioning to full scope of practice?
Themes
Legislation limitations
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Patients are reimbursed less for prescriptions from an
NP than from a physician
Limited prescribing list
Federal and provincial legislative barriers
Lack of nursing representation in policy development
Lack of title protection
Lack of regulation
Themes
Education
– Limited accessibility to APN programs
– No accreditation of APN programs
Opposition
– Other health care providers
– Requirement of physician supervision
Themes
Lack of Leadership
– Government
– Nurse leaders
– No ‘strategic” leadership at different levels
– Lack of recognition of advanced roles
– Lack of standardization (of competencies)
– “Lack of political strength of nurses”
Themes
Health Human Resources
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Working conditions
Low remuneration
Lack of facilities
Expectations to work beyond scope of practice
Unable to work to full scope of practice
Disparities in APN roles between health care
settings
– Lack of understanding of the APN role
Themes
• Economy
• Health System is designed to a Medical
Model
• Societal Status of Women
• APN role development in infancy in
many countries
Limitations
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Timelines of survey
Language and nomenclature
Technology
Conflicting responses from one country
Determining the appropriate sample
Incomplete survey responses
Discussion
• Differences in nomenclature (as noted in
previous studies)
• Multiple APN roles in many countries,
often with quite different credentialing
criteria
• Wide variation in regulation globally
APNs and Health Policy
“It is important that nurses…take every
opportunity to influence events and contribute to
policy debates, which determine or affect the
context of their professional practice. In this way,
they can become agents of constructive change
for public benefit and professional growth, rather
than passive victims of potentially destructive
change proposed and promoted by others (ICN,
2009, p. 21).”
ICN & INPAPNN
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Global database
Continue APN regulation research
Country to country, peer-support
Access to skill-building for policy
development
References
• Bryant, R. (2005). Regulation, roles and competency development.
International Council of Nurses.
• Gaumer, G. (1984). Regulating health care professionals: A review of the
empirical literature. The Milbank Memorial Fund Quarterly. Health and
Society, 62(3), 380-416.
• International Council of Nurses. (2008). The scope of practice, standards
and competencies of the advanced practice nurse. ICN Regulation Series.
ICN: Geneva, Switzerland.
• International Council of Nurses. (2009). Regulation 2020: Exploration of
the present; Vision for the future. ICN Regulation Series. ICN: Geneva,
Switzerland.
• Morrison, A., & Benton, D. C. (2010). Analyzing nursing regulation
worldwide. Journal of Nursing Regulation. 1(1), 44- 48.
Thank you
Photo credits :
© Canadian Nurses Association, 2013