An International Pilot Survey on Advanced Practice Nursing: Education, Practice and Regulatory Issues Joyce Pulcini, PhD, APRN, BC, PNP, FAAN (USA) Alice Yuen Loke, BSN, MN, PhD (Hong Kong) Alice Yuen Loke, BSN, MN, PhD (Hong Kong) Raisa Gul, RN, RM, MHA, PhD (Pakistan) Monika Jelic, BSN, MSN, CPNP, MPH (USA)

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 programs (Affara, 2006). Gathering data from different countries on regulatory issues is a critical challenge due to differing language for educational programs, degrees, regulatory titles and practice models.

Aims The study examines NPs/APNs efforts to develop their role, the barriers to role development, and areas where progress has been made. This is a report of the preliminary results of an international web-based pilot study by the International Council of Nurses International NP/APN Network.

Methodology International web-based pilot survey International web-based pilot survey Tool used: SurveyMonkey Tool used: SurveyMonkey Online Survey: open for 3 weeks in February and March, 2007 Online Survey: open for 3 weeks in February and March, minutes in length minutes in length Results: qualitative and quantitative descriptive analyses Results: qualitative and quantitative descriptive analyses

Survey Development Survey developed by the Education/Practice Subgroup of the INP/APNN. Survey developed by the Education/Practice Subgroup of the INP/APNN. Consultation with Core Steering Group and Research, and Policy/Standards/Regulation Subgroups Consultation with Core Steering Group and Research, and Policy/Standards/Regulation Subgroups Many drafts circulated in 2006 focusing on: Many drafts circulated in 2006 focusing on: Content and Outline for SurveyContent and Outline for Survey Language IssuesLanguage Issues Regulatory TerminologyRegulatory Terminology Nursing TitlesNursing Titles

Survey Categories General Information General Information NP/APN Education and Programs NP/APN Education and Programs NP/APN Student Profile NP/APN Student Profile NP/APN Regulatory Issues NP/APN Regulatory Issues NP/APN Practice/Role NP/APN Practice/Role General Questions General Questions Comments on the Survey Tool Comments on the Survey Tool

Sample Participants: identified from ICN INP/APNN contact lists, subgroups and word of mouth Participants: identified from ICN INP/APNN contact lists, subgroups and word of mouth ed to 70 participants plus INP/APNN Education/Practice Subgroup and Core Steering groups ed to 70 participants plus INP/APNN Education/Practice Subgroup and Core Steering groups 16 returned undeliverable 16 returned undeliverable 32 respondents from 18 countries 32 respondents from 18 countries

18 Countries Represented in the NP/APN Pilot Survey (n=32) Argentina Argentina Australia (n=5) Australia (n=5) Bahrain Bahrain Botswana (n=2) Botswana (n=2) Canada (n=3) Canada (n=3) Hong Kong, China (n=2) Hong Kong, China (n=2) Ethiopia Ethiopia Finland Finland France France Ireland (n=2) Ireland (n=2) Nepal (n=2) Nepal (n=2) Netherlands Netherlands Singapore Singapore South Africa (n=3) South Africa (n=3) Switzerland Switzerland Tanzania Tanzania United Kingdom United Kingdom USA (n=3) USA (n=3)

Findings Description of 32 respondents multiple roles Description of 32 respondents multiple roles 17 NPs/APNs17 NPs/APNs 5 registered/generalist nurses5 registered/generalist nurses 18 nurse educators18 nurse educators 22 clinicians22 clinicians 18 involved in research18 involved in research 9 administrators9 administrators NP/APN title NP/APN title 14 different titles for NP/APN identified14 different titles for NP/APN identified

Positions Held by NPs/APNs in Various Countries (23 Respondents)

NP/APN Education, Programs and Student Profile* 58% have formal NP/APN programs in their country 58% have formal NP/APN programs in their country All NP/APN students must be registered or generalist nurses All NP/APN students must be registered or generalist nurses 2-5 years registered or generalist nursing experience required before entering program 2-5 years registered or generalist nursing experience required before entering program *24 respondents

Specialties or Types of NP/APNs Educated in the NP/APN Programs (19 respondents)

Credential Granted at Completion of NP/APN Programs (19 respondents) Credential Granted at Completion of NP/APN Programs (19 respondents)

NP/APN Regulatory Issues 75% had formal recognition of the NP/APN role (22 respondents) 75% had formal recognition of the NP/APN role (22 respondents) 52% had NP/APN licensure maintenance requirements (21 respondents), such as: 52% had NP/APN licensure maintenance requirements (21 respondents), such as: Continuing education (92.3%)Continuing education (92.3%) Practice requirements (69.2%)Practice requirements (69.2%) Portfolio maintenance (53.8%) (13 respondents)Portfolio maintenance (53.8%) (13 respondents)

NP/APN Practice Requirements (22 Respondents) NP/APN Practice Requirements (22 Respondents)

NP/APN Description of Practice and Regulation (22 Respondents)

General Questions Development of NP/APN role (19 respondents) Development of NP/APN role (19 respondents) 68% identified strong support for nursing practice68% identified strong support for nursing practice 42.1% identified need for more health care providers for rural/underserved areas42.1% identified need for more health care providers for rural/underserved areas Health care planning (21 respondents) Health care planning (21 respondents) 84% stated that NPs/APNs participate at the local level84% stated that NPs/APNs participate at the local level 68% stated that NPs/APNs participate at the national level68% stated that NPs/APNs participate at the national level Professional organizations identified usually as the national nurses association rather than specific NP/APN organizations (21 respondents) Professional organizations identified usually as the national nurses association rather than specific NP/APN organizations (21 respondents)

Supporters and Advocates of the NP/APN Role (21 respondents)

Opposition to the NP/APN Role (14 Respondents)

Summary Confusion surrounding nomenclature for the NP/APN was found with14 different titles listed. Confusion surrounding nomenclature for the NP/APN was found with14 different titles listed. NPs/APNs practice represented a broad variety of health care settings and a varied scope of practice. NPs/APNs practice represented a broad variety of health care settings and a varied scope of practice. 58.3% stated that NP/APN education was available in their own country with most providing a Masters Degree upon completion. 58.3% stated that NP/APN education was available in their own country with most providing a Masters Degree upon completion. About 75% stated that formal recognition of the NP/APN exists in their country by the government, hospital/health care agency or professional nursing organization. About 75% stated that formal recognition of the NP/APN exists in their country by the government, hospital/health care agency or professional nursing organization. Support for the NP/APN role was found primarily in domestic nursing organizations and the government, while opposition came mostly from domestic physician organizations. Support for the NP/APN role was found primarily in domestic nursing organizations and the government, while opposition came mostly from domestic physician organizations.

Comments on the Survey Tool Feedback from participants was solicited in order to refine the tool for future use. Length of survey (20 respondents) Length of survey (20 respondents) 90% right length90% right length 10% too long10% too long Other comments: Other comments: More free text space neededMore free text space needed Explanations of answersExplanations of answers Suggestions for additional questionsSuggestions for additional questions Need to distinguish between nursing organizations, directors of nursing and nursesNeed to distinguish between nursing organizations, directors of nursing and nurses

Limitations Participants required to have /internet access Participants required to have /internet access Limited number of participants from each country (2-5) Limited number of participants from each country (2-5) Unable to go into detail about country specifics Unable to go into detail about country specifics Most participants are affiliated with the ICN and appreciate the international scope of development of the NP/APN role – may bias their answers. 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 Currently survey is available in English only

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

Future Plans Revise survey using comments from pilot Revise survey using comments from pilot Send to full complement of countries represented by ICN INP/APNN Send to full complement of countries represented by ICN INP/APNN Consider if survey should be translated into other languages Consider if survey should be translated into other languages Identify individual programs in countries and do survey on educational curriculum Identify individual programs in countries and do survey on educational curriculum