1. An International Survey on Advanced Practice Nursing: Education, Practice and Regulatory Issues: 2008 Joyce Pulcini, PhD, APRN, BC, PNP, FAAN (USA) Alice Yuen Loke, BSN, MN, PhD (Hong Kong) Raisa Gul, RN, RM, MHA, PhD (Pakistan) Monika Jelic, MPH, MSN, CPNP (USA) Katelyn Carroll (Research Asst)

2. 2 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 programmes (Schober & Affara, 2006). 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 programmes (Schober & Affara, 2006).

3. 3 Gathering data from different countries on regulatory issues is a critical challenge due to differing language for educational programmes, degrees, regulatory titles and practice models.

4. 4 Aims The study examines NPs/APNs efforts to develop their role internationally, examines educational programmes and regulation, the barriers and facilitators to role development, and areas where progress has been made. The study examines NPs/APNs efforts to develop their role internationally, examines educational programmes and regulation, the barriers and facilitators to role development, and areas where progress has been made. This is a report of the results of an international web-based study by the International Council of Nurses International NP/APN Network (INP/APNN). This is a report of the results of an international web-based study by the International Council of Nurses International NP/APN Network (INP/APNN). http://www.icn-apnetwork.org http://www.icn-apnetwork.org http://www.icn-apnetwork.org

5. 5 Methodology International web-based pilot survey International web-based pilot survey Tool used: SurveyMonkey Tool used: SurveyMonkey Online Survey: open for 6 weeks in February and March, 2008 Online Survey: open for 6 weeks in February and March, 2008 15-25 minutes in length 15-25 minutes in length Results: qualitative and quantitative descriptive analyses Results: qualitative and quantitative descriptive analyses

6. 6 Sections of the Survey Survey developed by the Education/Practice Subgroup of the INP/APN Network. Survey developed by the Education/Practice Subgroup of the INP/APN Network. Consultation with Core Steering Group and Research, and Policy/Standards/Regulation Subgroups Consultation with Core Steering Group and Research, and Policy/Standards/Regulation Subgroups Prior to pilot, many drafts circulated in 2006 focusing on: Prior to pilot, 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 Pilot survey completed in 2007 Pilot survey completed in 2007 Final survey completed in 2008 Final survey completed in 2008

7. 7 In spring of 2008, a web-based survey was sent to 174 key informants who were members of the International Nurse Practitioner/ Advanced Practice Nursing Network (INP/APNN) using survey monkey. In spring of 2008, a web-based survey was sent to 174 key informants who were members of the International Nurse Practitioner/ Advanced Practice Nursing Network (INP/APNN) using survey monkey. Participants were leaders and experts of ANP development in their respective countries. Participants were leaders and experts of ANP development in their respective countries. The survey was based on a 2007 pilot survey with network members and the final survey was refined to reflect cross national cultural, professional and linguistic differences. The survey was based on a 2007 pilot survey with network members and the final survey was refined to reflect cross national cultural, professional and linguistic differences. The survey was completed by 91 members of the INP/APNN from 33 of the 34 countries represented in the Network with a response rate of 52.2%. The survey was completed by 91 members of the INP/APNN from 33 of the 34 countries represented in the Network with a response rate of 52.2%.

8. 8 Survey Categories General Information General Information NP/APN Education and programmes NP/APN Education and programmes NP/APN Regulatory Issues NP/APN Regulatory Issues NP/APN Practice/Role NP/APN Practice/Role General Questions General Questions Indepth description of one programmes in country Indepth description of one programmes in country NP/APN Educational programmesNP/APN Educational programmes NP/APN Student ProfileNP/APN Student Profile

9. 9 Sample Participants: identified from ICN INP/APNN contact lists and subgroups Participants: identified from ICN INP/APNN contact lists and subgroups Emailed to 174 key informants who were members of the INP/APN Network Emailed to 174 key informants who were members of the INP/APN Network 91 respondents from 32 countries 91 respondents from 32 countries 33/34 (97%) countries in the Network (one of these removed due to lack of data on form) 33/34 (97%) countries in the Network (one of these removed due to lack of data on form) Response rate = 52.2% Response rate = 52.2%

10. 10 Participants (n=91) Multiple roles Multiple roles 83.5% were practicing nurses83.5% were practicing nurses 55% were educators55% were educators 20.8% were administrators20.8% were administrators 42.8% were involved in research42.8% were involved in research Of practicing nurses Of practicing nurses 67.1% (51) were NP/APNs67.1% (51) were NP/APNs 25% (19) were Registered/Generalist nurses25% (19) were Registered/Generalist nurses 21% (16) answered other21% (16) answered other Of educators: 16% taught NP/APN students Of educators: 16% taught NP/APN students

11. 11 Countries of Respondents in the NP/APN Survey (n=33) Argentina: 1 Argentina: 1 Australia: 25 Australia: 25 Botswana: 2 Botswana: 2 Canada: 5 Canada: 5 China/Peoples Republic of China: 2 China/Peoples Republic of China: 2 England/UK: 6 England/UK: 6 Ethiopia: 1 Ethiopia: 1 Fiji: 1 Fiji: 1 Finland: 1 Finland: 1 France: 1 France: 1 Grenada: 1 Grenada: 1 Hong Kong: 1 Hong Kong: 1 India: 2 India: 2 Ireland: 4 Ireland: 4 Italy: 1 Italy: 1 Jamaica: 1 Jamaica: 1 Japan: 2 Japan: 2 Netherlands: 1 Netherlands: 1 New Zealand: 1 New Zealand: 1 Nigeria: 2 Nigeria: 2 Oman: 1 Oman: 1 Pakistan: 1 Pakistan: 1 Portugal: 1 Portugal: 1 Saudi Arabia/KSA: 1 Saudi Arabia/KSA: 1 Singapore: 1 Singapore: 1 South Africa: 7 South Africa: 7 South Korea: 1 South Korea: 1 Spain: 2 Spain: 2 Switzerland: 2 Switzerland: 2 Taiwan: 2 Taiwan: 2 Tanzania: 1 Tanzania: 1 Thailand: 4 Thailand: 4 USA: 6 USA: 6

12. 12

13. 13 Findings Findings are presented in two ways: Findings are presented in two ways: Country Level Responses (n=32)Country Level Responses (n=32) NP/APN Education and programmes NP/APN Education and programmes NP/APN Regulatory Issues NP/APN Regulatory Issues Role as practicing nurse, educator, administrator Role as practicing nurse, educator, administrator Types of positions held Types of positions held Scope of practice Scope of practice Individual level responses (n=91)Individual level responses (n=91) NP/APN Practice/Role and Scope of practice NP/APN Practice/Role and Scope of practice Role questions Role questions Skills performed Skills performed Type of continuing education to stay current Type of continuing education to stay current Supporters and opponents to the role Supporters and opponents to the role

14. Country Level Responses

15. 15 NP/APN Education, Practice Questions Varying responses on number of NP/APN programmes in their country Varying responses on number of NP/APN programmes in their country Did not tend to know nurse-physician ratio in the country Did not tend to know nurse-physician ratio in the country > 17 titles for NP/APN found > 17 titles for NP/APN found

16. 16 TitleFrequencyPercent Nurse Practitioner3736.6% Advanced Practice Nurse1514.9% Advanced Nurse Practitioner98.9% Clinical Nurse Specialist76.9% Nurse Specialist44.0% Registered Nurse22.0% Professional Nurse22.0% Basic Nurses11.0% Expert Nurse11.0% Certified Registered Nurse Practitioner11.0% Chief Professional Nurse with post-basic training in Primary Health Care 11.0% Nurse Consultant11.0% Specialist Nurse Practitioner11.0% Out of Hours Nurse Practitioner11.0% Primary Healthcare Nurse11.0% Advanced nurse in a specialty11.0% Staff Nurse11.0%

17. 17 Country Level Responses Does your country have formal NP/APN programmes? (31 countries responding)Does your country have formal NP/APN programmes? (31 countries responding) Yes (71%) Yes (71%) No (29%) No (29%)

18. 18 Types of credentials granted to NP/APNs in your country (20 countries) MS degree: 56% MS degree: 56% BS degree: 28.1% BS degree: 28.1% Certificate: 25% Certificate: 25% Advanced Diploma: 21.9% Advanced Diploma: 21.9% No credential: 0 No credential: 0

19. 19 Most prevalent credential granted to NP/APNs in country (20 countries) MS degree: 50% MS degree: 50% BS degree: 15% BS degree: 15% Certificate: 15% Certificate: 15% Advanced Diploma: 20% Advanced Diploma: 20%

20. 20 SPECIALTIES OR TYPES OF NP/APNS EDUCATED IN THE NP/APN PROGRAMMES (22 COUNTRIES)

21. 21 Level of practice of majority of NP/APNs in country (28 Countries) RN/Generalist Nurse: 17.4 % RN/Generalist Nurse: 17.4 % Post RN/Generalist Nurse: 69.6 % Post RN/Generalist Nurse: 69.6 % Other: 9.4% Other: 9.4% Examples: APN, Post RN generalist plus midwifery cert., RN/Registered midwife with public health certificationExamples: APN, Post RN generalist plus midwifery cert., RN/Registered midwife with public health certification

22. 22 POSITIONS HELD BY NPS/APNS (25 COUNTRIES)

23. 23 Types of positions that exist in the Country Hospital: 75% Hospital: 75% Hospital-based clinic: 62.5% Hospital-based clinic: 62.5% Community-based Clinic: 62.5% Community-based Clinic: 62.5% Mental Health: 62.5% Mental Health: 62.5% Specialty practice (disease based): 59.4% Specialty practice (disease based): 59.4% Public Health or ministry of health agency: 56.3% Public Health or ministry of health agency: 56.3% Faculty Position: 53.1% Faculty Position: 53.1% Administration: 50% Administration: 50% Research: 40.6% Research: 40.6% Home health care facility: 40.6% Home health care facility: 40.6% Independent Nsg. Practice: 37.5% Independent Nsg. Practice: 37.5% Long term care facility: 34.4% Long term care facility: 34.4% School Health: 34.4% School Health: 34.4% Occupational Health: 31.3% Occupational Health: 31.3% Doctors office: 31% Doctors office: 31% Other: 6.3% Other: 6.3%

24. 24 NP/APN SCOPE OF PRACTICE (24 COUNTRIES) Results may vary at the provincial/state level Results may vary at the provincial/state level

25. 25 Formal Recognition of NP/APNs in your country (23 countries) Government: 53.1% Government: 53.1% Hospital or other health care agency: 53.1% Hospital or other health care agency: 53.1% Professional Org: 59.4% Professional Org: 59.4% Other: 15.6% Other: 15.6% Examples– Health professions counsel, National professional counsels, no recognitionExamples– Health professions counsel, National professional counsels, no recognition

26. 26 Requirement for NP/APN Practice (25 countries)

27. 27 NP/APNs without formal education (28 countries) 42% said that there are nurses undertaking/working in NP/APN role who have not been formally educated in the role at a Post RN or graduate level. Of these, 42% said that there are nurses undertaking/working in NP/APN role who have not been formally educated in the role at a Post RN or graduate level. Of these, 42.9% said all had at least post RN level education42.9% said all had at least post RN level education 21.4% said all or most had some education either formal or informal21.4% said all or most had some education either formal or informal One respondent said there is no additional educationOne respondent said there is no additional education

28. 28 Requirements for renewal (maintenance) of NP/APN licensure (27 countries) 48% said that there were specific requirements for renewal or maintenance of NP/APN license or registration 48% said that there were specific requirements for renewal or maintenance of NP/APN license or registration Annual: 21.4%Annual: 21.4% Every 5 years: 50%Every 5 years: 50% Other (i.e. 3-5 yrs): 28.6%Other (i.e. 3-5 yrs): 28.6%

29. 29 License or Registration Renewal Requirements (16 countries)

30. Individual Level Responses

31. 31 NP/APN Scope of Practice (73 Respondents)

32. 32 Performance of specific skills by NPs (70 Respondents) Minor surgery (38.6%) Minor surgery (38.6%) Suturing (85.7%) Suturing (85.7%) Treating fractures (50%) Treating fractures (50%) Midwifery (74.3%) Midwifery (74.3%)

33. 33 Performance of specific skills only by MDs (81 Respondents) Major surgery (100%) Major surgery (100%) Minor surgery (56.8%) Minor surgery (56.8%) Diagnosis (25.9%) Diagnosis (25.9%) Treatment (21%) Treatment (21%)

34. 34 Type of education which would help NP/APNs to stay current in their areas of practice (78 Respondents) CE online: 76.9% CE online: 76.9% Other CE: 80.8% Other CE: 80.8% Conferences: 91% Conferences: 91% Mentoring experiences for new techniques: 85.9% Mentoring experiences for new techniques: 85.9% Formal educational programmes: 79.5% Formal educational programmes: 79.5% Other: 5% examples Other: 5% examples

35. 35 General Questions Development of NP/APN role: Facilitators (78 Respondents) Development of NP/APN role: Facilitators (78 Respondents) 57.7% identified strong support for nursing practice57.7% identified strong support for nursing practice 79.5% identified need for more health care providers for rural/underserved areas79.5% identified need for more health care providers for rural/underserved areas 71.8% identified consumer demand for increased access to health care71.8% identified consumer demand for increased access to health care

36. 36 Supporters and Advocates of the NP/APN Role (77 Respondents)

37. 37 Opposition to the NP/APN Role (60 Respondents)

38. 38 Opposition to the NP/APN Role Other opponents Other opponents Nurse leadersNurse leaders Universities where nursing is taughtUniversities where nursing is taught Certain hospitalsCertain hospitals Government agenciesGovernment agencies Summary: Support for the NP/APN role was found primarily in domestic nursing organizations and the government, while opposition came mostly from domestic physician organizations and other nurses.

39. 39 NP/APN Involvement in Policy Policy or health care planning (79 Respondents) Policy or health care planning (79 Respondents) 76.9% stated that NPs/APNs participate at the local level76.9% stated that NPs/APNs participate at the local level 61.3% stated that NPs/APNs participate at the national level61.3% stated that NPs/APNs participate at the national level 85% said that NP/APNs are organized as a professional group in the country (80 Respondents) 85% said that NP/APNs are organized as a professional group in the country (80 Respondents) Professional organizations identified most frequently as the national nurses association rather than specific NP/APN organizationsProfessional organizations identified most frequently as the national nurses association rather than specific NP/APN organizations

40. 40Conclusion The survey provides information on a broad representation of countries on NP/APN education, practice and regulatory issues. The survey provides information on a broad representation of countries on NP/APN education, practice and regulatory issues. The findings advance knowledge on role development issues of NP/APNs internationally and highlight the challenges ahead. The findings advance knowledge on role development issues of NP/APNs internationally and highlight the challenges ahead. NP/APNs will increasingly be important health care providers globally. Tracking the progress of these roles will facilitate educational interventions and regulatory policy development worldwide. NP/APNs will increasingly be important health care providers globally. Tracking the progress of these roles will facilitate educational interventions and regulatory policy development worldwide.

41. 41 Summary Confusion surrounding nomenclature for the NP/APN was found with different titles listed. Confusion surrounding nomenclature for the NP/APN was found with 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. 71% stated that NP/APN education was available in their country with half reporting that the Masters Degree was the predominant credential for NP/APNs. 71% stated that NP/APN education was available in their country with half reporting that the Masters Degree was the predominant credential for NP/APNs.

42. 42 Limitations Participants required to have email or internet access Participants required to have email or internet access Number of participants from each country (1-25)- Sometimes answers differed. Leaders consulted when there were discrepancies. Number of participants from each country (1-25)- Sometimes answers differed. Leaders consulted when there were discrepancies. 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

43. 43 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

44. 44 Future Plans Consider if survey should be translated into other languages Consider if survey should be translated into other languages Further analyze individual educational programmes and student information provided in current survey Further analyze individual educational programmes and student information provided in current survey Consider survey of individual educational programmes who are identified in this survey Consider survey of individual educational programmes who are identified in this survey