Regulation of advanced nurse practice: its existence and regulatory dimensions from an international perspective

Factors influencing the development, recruitment, integration, retention and career development of advanced practice providers in hospital health care teams: a scoping review

BACKGROUND

Advanced practice providers (APPs), including physician assistants/associates (PAs), nurse practitioners (NPs) and other non-physician roles, have been developed largely to meet changing healthcare demand and increasing workforce shortages. First introduced in primary care in the US, APPs are prevalent in secondary care across different specialty areas in different countries around the world. In this scoping review, we aimed to summarise the factors influencing the development, recruitment, integration, retention and career development of APP roles in hospital health care teams.

METHODS

We conducted a scoping review and searched Ovid MEDLINE, Ovid Embase, Ovid Global Health, Ovid PsycINFO and EBSCOhost CINAHL to obtain relevant articles published between Jan 2000 and Apr 2023 that focused on workforce management of APP roles in secondary care. Articles were screened by two reviewers independently. Data from included articles were charted and coded iteratively to summarise factors influencing APP development, recruitment, integration, retention and career development across different health system structural levels (macro-, meso- and micro-level).

RESULTS

We identified and analysed 273 articles that originated mostly from high-income countries, e.g. the US (n = 115) and the UK (n = 52), and primarily focused on NP (n = 183) and PA (n = 41). At the macro-level, broader workforce supply, national/regional workforce policies such as work-hour restrictions on physicians, APP scope of practice regulations, and views of external collaborators, stakeholders and public representation of APPs influenced organisations' decisions on developing and managing APP roles. At the meso-level, organisational and departmental characteristics, organisational planning, strategy and policy, availability of resources, local experiences and evidence as well as views and perceptions of local organisational leaders, champions and other departments influenced all stages of APP role management. Lastly at the micro-level, individual APPs' backgrounds and characteristics, clinical team members' perceptions, understanding and relationship with APP roles, and patient perceptions and preferences also influenced how APPs are developed, integrated and retained.

CONCLUSIONS

We summarised a wide range of factors influencing APP role development and management in secondary care teams. We highlighted the importance for organisations to develop context-specific workforce solutions and strategies with long-term investment, significant resource input and transparent processes to tackle evolving healthcare challenges.

Scopes of practice for advanced practice nursing and advanced practice midwifery in Kenya: A gap analysis

BACKGROUND

There is increasing global evidence on the impact of advanced nursing and midwifery practitioners, and Kenya's healthcare system has an excellent opportunity to develop scopes of practice and other regulatory frameworks for the integration of these roles.

OBJECTIVE

The primary purpose of this gap analysis was to explore the existing evidence on opportunities and threats toward the integration of the advanced practice nursing (APN) and advanced practice midwifery (APM) roles in Kenya's healthcare system.

METHODS

The study team conducted a structured electronic database search of PubMed, CINAHL, Scopus, EBSCOhost Academic Search Complete, and PsycINFO to retrieve articles and credible websites for reports highlighting the opportunities and threats toward the integration of the APN and APM roles in Kenya's healthcare systems. The retrieved articles were screened for relevance and synthesized for reporting using the traditional literature review approach.

RESULTS

The Kenya Health Policy Framework 2014-2030, growing population needs, and implementation of universal health coverage provide an opportunity to harness and leverage advanced practice roles in nursing and midwifery. There is also momentum to develop advanced practice because of strategic alliances and global evidence showing the contributions and quality of services offered by advanced practice nurses and advanced practice midwives. However, lack of financial support, structural challenges, and lack of national policies, regulations, and legislation continue to obstruct progress.

CONCLUSION AND IMPLICATIONS FOR NURSING POLICY

Developing scopes of practice for APN and APM in Kenya will benefit the professions, the country's healthcare delivery system, and the population. Achieving universal health coverage depends on a health workforce trained and practicing at optimal levels in tandem with education and training to deliver quality care.

Advanced practice nurse roles in Europe: Implementation challenges, progress and lessons learnt

BACKGROUND

Advanced practice nursing (APN) roles offer improved access to care and increased quality and more timely care. Despite the advantages of APN roles, there is a disparity between European countries when it comes to implementing APN roles.

AIM

To explore the implementation of APN roles in a range of European countries and to explore what factors facilitate or hinder the implementation of these roles.

METHODS

A case study evaluation of the process of implementing APN roles. The sample included four countries where APN roles were well developed (Ireland, Spain, Norway and the United Kingdom) and four where APN roles were implemented (Estonia, Slovenia, Cyprus and Romania). Interviews were conducted with key informants (n = 28) from government departments, regulatory bodies, nursing associations and universities. The consolidated criteria for reporting qualitative research (CPREQ) has been used throughout.

LIMITATIONS

The small number of countries when considering the size of the region and key informants representing the view of only three to four people in each country.

RESULTS

Four themes were identified, including the rationale for the development of the roles, influence, the evolutionary nature of role development and evidence. The data also revealed a mismatch between the perceptions of how the roles develop among the different countries in the early stages of implementation.

CONCLUSION

Successful role implementation is dependent upon a tripartite approach between managers, practitioners and educators. An evolutionary approach to role development was used. Regulation and policy come later on in the process of implementation.

IMPLICATIONS FOR NURSING POLICY

APN policy should be based on patient needs rather than on the workforce or professional imperatives. The process of implementation can take 15-20 years in total. Recognising the importance of the relationships between service managers and educators is key to the early development of these roles.

Assessing the benefits of advanced clinical practice for key stakeholders

BACKGROUND

Advanced clinical practice roles, usually filled by nurses, have had positive effects on clinical effectiveness, including in patient satisfaction, but their benefits for other stakeholders (such as employers, health professionals, education providers and commissioners and professional/regulatory bodies) are less clear.

AIM

This study aimed to identify UK research on the potential benefits of advanced clinical practice and evaluate the evidence base for key stakeholders in this field.

METHOD

A mixed-methods systematic literature review was carried out to inform a narrative interpretive synthesis.

FINDINGS

44 articles of mixed quality were identified. Consensus was found regarding the definition of and barriers and facilitators to advanced clinical practice. This role is split into substitution (eg, of doctors) and supplementation (eg, adding value) aspects, and the clinical practice element dominates. Training for the role varies, as do scope of practice and regulation.

CONCLUSION

There are several barriers to the implementation of advanced clinical practice and therefore the realisation of its benefits for key stakeholders. Areas requiring attention include training, support from others for role expansion and organisational issues.

Alignment of the International Council of Nurses Advanced Practice Nursing Guideline Characteristics With Conceptual Frameworks: A Scoping Review

Background: During the past 50 years, numerous conceptual frameworks have been used to describe and evaluate advanced practice nursing (APN) roles and outcomes. The International Council of Nurses (ICN) released an updated description of APN characteristics intersecting with currently utilized frameworks allows for assessing relevance to practice. Purpose: The review aimed to examine the alignment of established and commonly used conceptual frameworks related to advanced practice roles with the ICN APN guidelines characteristics. This will help identify a globally relevant framework for APN roles. Method: PubMed, Cumulative Index in Nursing and Allied Health Literature, and ProQuest Central databases were searched using terms that characterize APN and conceptual frameworks. To address currency and relevance of frameworks was applied to discovered frameworks identifying and reviewing in detail those which were cited more than 15 times during the last five years. Results: This search found over 1107 publications. Of these, nine conceptual frameworks met all inclusion criteria. The frameworks captured some of the characteristics described by the ICN. Eight addressed all categories but in a limited fashion. Implications for Practice: Reviewing recently and frequently cited frameworks can inform the applicability in the interested readers, own nursing practice. This review not only does this but also examines the global uptake and the relationship to international standards of APN to provide additional information on the frameworks' reach and worldwide transferability. However, further research examining the relevance of these frameworks in low- and lower-middle-income countries is needed to understand their importance.

Nurses' Perceptions of the Clinical Nurse Specialist Role Implemented in a Highly Specialized University Hospital in Spain: A Qualitative Study

PURPOSE/AIMS

To explore nurses' perceptions of clinical nurse specialist practice as implemented in a highly specialized university hospital in Spain.

DESIGN

A descriptive qualitative study was carried out in 3 inpatient wards, with a clinical nurse specialist within the team, at a high specialized university hospital in Spain.

METHOD

Semistructured interviews were conducted by purposive sampling with 17 selected nurses with at least 2 years of professional experience who voluntarily agreed to participate and signed the informed consent form. Analysis of the qualitative data was conducted according to Burnard's method of content analysis. The Consolidated Criteria for Reporting Qualitative Research checklist was used.

RESULTS

Four main categories emerged from the analysis of the data: "qualities of the role-holder," "role competencies in practice," "integration with the team," and "impact of the role" on nursing, the patient, and the organization.

CONCLUSIONS

The findings of this study have interesting implications for the development and implementation of clinical nurse specialist practice in healthcare organizations. They also provide evidence of the benefit of implementing clinical nurse specialist practice for improving the quality of care, patient outcomes, and healthcare efficiency.

Delphi survey on the application of advanced practice nursing competencies: Strong points and unfinished business in cancer care

AIM

This study assessed the application of advanced practice nursing competencies in cancer care to identify obstacles to their full implementation.

BACKGROUND

Internationally, the implementation of advanced practice nursing roles depends on the context and environment, which shape the definition, scope and competencies associated with these roles.

METHODS

Nurses participated in two rounds of an online Delphi survey about the competencies of advanced practice oncology nurses. The threshold for expert consensus was set at 75%.

RESULTS

Eleven competency domains were proposed; all yielded consensus of over 75%. However, for 57.8% of the specific competencies proposed in round 1 and for 62.2% in round 2, there was no consensus on which were applied in practice. There was more agreement on the competencies applied in the domains of direct clinical practice, consultation and collaboration and interprofessional relations than in dimensions such as health care promotion, quality improvement, evidence-based practice and research. Barriers related to unimplemented competencies were identified.

CONCLUSIONS

The competencies applied in advanced practice nursing reflect incomplete development of these roles. Domains related to direct clinical practice, consultation and collaboration and interprofessional relations are relatively well developed, whereas those related to leadership, research, evidence-based practice and quality improvement are not. The identified barriers hindering implementation of some competencies can inform strategies to develop this role in cancer care.

IMPLICATIONS FOR NURSING MANAGEMENT

Hospital administrators and nurse managers should reflect and be mindful of the development of advanced practice nurse (APN) competencies along with the challenges associated with implementing advanced practice roles.

Advanced practice nursing roles in Arab countries in the Eastern Mediterranean region: a scoping review

OBJECTIVE

The objectives of this review were to map and summarize evidence regarding advanced practice nursing roles in Arab countries located in the Eastern Mediterranean region.

INTRODUCTION

Many countries have reported an increase in the number and types of advanced practice nursing roles as research demonstrating their positive impact on patient and health system outcomes continues to accumulate. There is international evidence that the achievement of these outcomes depends on the effective implementation of advanced practice nursing roles at the organizational and country levels. A comprehensive review of the status of advanced practice nursing role implementation in Arab countries in the Eastern Mediterranean region has not been conducted.

INCLUSION CRITERIA

Eligible studies included advanced practice nursing roles (including, but not limited to, nurse practitioners and clinical nurse specialists) in Arab countries in the Eastern Mediterranean region. Studies were considered if they focused on role development, titles, entry-level education, regulation and scope of practice, and facilitators and barriers to role implementation.

METHODS

A comprehensive systematic search was completed for both published and non-published literature. The databases searched included CINAHL, PubMed, PsycINFO, Embase, Nursing and Allied Health Database, and Scopus. Gray literature was searched using websites such as Google Scholar, ProQuest Dissertations and Theses, International Council of Nurses, World Health Organization regional office for the Eastern Mediterranean region, and websites of nursing associations and Ministries of Health in Arab countries. The search included literature published in Arabic and English from the inception of the databases to August 2020.

RESULTS

A total of 35 articles were included, the majority (n = 24) of which were published from 2010 onward. Ten of the included studies were empirical research papers that used qualitative and quantitative research designs. Advanced practice nursing role development is still in its infancy in most of the Arab countries in the Eastern Mediterranean region and can be described as slowly and steadily evolving. The main driving forces for the implementation of the roles in this region included a shortage of physicians both in number and specialties, the emergence of chronic diseases due to lifestyle changes, the desire to have more cost-effective primary care, and to advance nursing as a profession. Clinical nurse specialists and nurse practitioners are the most common titles for the advanced nursing roles practiced in the region. Some advanced practice nursing roles stipulated a master's degree as a minimum requirement, while others required a 12-month in-house training program. Oman is the only Arab country that authorizes nurse practitioners to prescribe pre-set medications. The common barriers to advanced practice nursing role implementation included a lack of recognition of roles at national levels, role ambiguity, lack of clear scope of practice, resistance from male physicians, low involvement of nurses in policy-making, and low status of nursing as a profession.

CONCLUSION

The successful implementation and sustainment of advanced practice nursing roles in Arab countries in the Eastern Mediterranean region requires foundational work, including development of definitions, educational standards, regulations, and a clear scope of practice.

SCOPING REVIEW REGISTRATION NUMBER

Open Science Framework: https://osf.io/wyj8a.

A translational research framework for nurse practitioners

AIMS

This study aims to explore a proposed translational research continuum for nurse practitioners.

BACKGROUND

Nurse practitioners are acknowledged as clinical leaders responsible for transforming health care delivery. It is important that nurse practitioners contribute to health care knowledge using scientific processes for the implementation of evidence-based practice and evaluation of outcomes of interventions for their patient groups.

EVALUATION

This paper provides a review of translational research literature including implementation science to align nurse practitioner activities to a modified translational research framework.

KEY ISSUES

A translational research framework has the potential to strengthen nursing research in the nurse practitioner role. Adapting an accepted translational research continuum for nurse practitioners places the clinical nursing leaders in an equitable research position with all health care professionals.

IMPLICATIONS FOR NURSING MANAGEMENT

The translational research continuum provides nursing management with a structure to benchmark nursing research. The continuum applies a modern research framework to support research engagement for the nurse practitioner role.

Perceptions and beliefs about the regulation of advanced nurse practitioners

BACKGROUND

The role of the advanced nurse practitioner (ANP) is not regulated in the UK, which has led to wide variation in the skills, competencies and academic qualifications of nurses using this title. Urgent treatment centres (UTCs) require a broad and experienced knowledge base to meet the demand of patients presenting with undifferentiated illnesses and injuries, which can be stressful and challenging.

AIM

To examine the perceptions and beliefs about ANP regulation, and to explore and discuss any ideas about proposed regulation.

METHOD

The author used interpretative phenomenological analysis to uncover valuable insights into the experiences of two ANPs working in an UTC, and their beliefs around regulation of the ANP role.

RESULTS

Both ANPs had different backgrounds and qualifications yet still had similar perceptions and beliefs regarding the regulation of ANPs. Five main themes were developed from the interview transcripts.

CONCLUSION

This study identified the need to consider the importance of ANPs' identity and the complex regulatory process required to standardise the role.

An integrative review to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes

AIMS

This study aimed to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes.

BACKGROUND

Changing health-care delivery is synonymous with the nurse practitioner role. The literature is critical of the lack of research by nurse practitioners, reporting the effects of a change to health-care delivery.

DESIGN

This study used a systematic integrative review by using Torraco's approach.

DATA SOURCES

Databases Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Web of Science and SCOPUS were searched for peer-reviewed publications from 2000 to 2019.

REVIEW METHODS

A systematic approach was used to screen and analyse the literature. Inclusion/exclusion criteria were applied, and quality appraisal was undertaken by two reviewers.

RESULTS

Eighteen articles were selected. The research projects were across the community and acute care settings. Research methodologies varied including preintervention and postintervention studies, evaluation of quality improvement projects, randomized controlled trial and descriptive studies. Multiple data collection tools were used. Two major themes were identified including evidence-based practice champions and improved patient outcomes.

CONCLUSION

The nurse practitioner role is pertinent toward improving evidence-based practice in clinical settings. Positive patient outcomes and praise for clinical leadership are evident in the literature. Research by nurse practitioners to date has focused on individual services.

A survey identifying leadership and research activities among Nurse Practitioners

Background: Nurse Practitioners are identified as the ideal conduit to transform healthcare delivery internationally. Healthcare transformation requires the application of leadership and research skills. Current literature has limited information on NPs as leaders or researchers in the nursing profession.Objectives: Determine if Nurse Practitioners identify themselves as leaders in nursing. Identify the leadership and research activities and influencing characteristics of Nurse Practitioners in Ireland and Australia. Establish similarities in leadership and research activities between Nurse Practitioners in Ireland and Australia. To identify if there is a relationship between leadership and research activities.Design: A quantitative electronic survey.Methods: A survey instrument was developed by combining two previously validated instruments. Nurse Practitioners in Ireland or Australia that had practiced within the last five years, and members of the respective professional association were included. Descriptive statistics were used to describe the findings and explore relationships in the data.Results: 14% (n = 96) of Nurse Practitioners responded to the survey. Nurse Practitioners in Ireland and Australia identified themselves as leaders of the nursing profession. Nurse Practitioners work practices, leadership and research activities are similar in Ireland and Australia. The majority (n = 55, 57%), of participants reported being research active. There was an association between perceived leadership and research activities among participants.Conclusion: Nurse Practitioners in both Ireland and Australia identify themselves as leaders of the nursing profession. There is no difference in reported work practices, leadership or research activities of Nurse Practitioners in both Ireland and Australia. There is an association between perceived leadership and research activity.Impact Statement: Nurse Practitioners in Ireland and Australia percieved themselves as leaders in nursing and this perception increases with research activity.

Professional boundary struggles in the context of healthcare change: the relational and symbolic constitution of nursing ethos in the space of possible professionalisation

The paper draws on Bourdieu's conceptualisation of the symbolic order and his little used concept of ethos in order to gain novel understandings of boundary struggles between nursing and medicine as well as internally in nursing. The constituents of boundary struggles are analysed in the context of healthcare transformation, focusing on organisational, institutional and political boundary undertakings. Changing conditions for boundary demarcations and professionalisation include a preference for evidence-based knowledge and practice, seen as a remedy against common problems in health care. The paper shows how nurses use the changes in 'the space of possible professionalisation' in their struggle for professionalisation when they expand their scope of practice and embark on what is conceptualised as a curing ethos, where nursing is understood as a discipline performing practices that lead to cure. However, this is repudiated by the medical profession at all levels. Moreover, curing stands opposed to the caring ethos in nursing and boundary struggles surface as 'ethos confrontation' between caring- and curing-oriented nurses in practice. The boundary struggles analysed in this paper raise important questions about healthcare manageability and the development of sustainable professional environments.

Team Functioning And Beliefs About Team Effectiveness In Inter-Professional Teams: Questionnaire Development And Validation

Purpose

Few validated instruments are available to measure team functioning in acute and primary care teams. To address this, we developed a questionnaire measuring healthcare provider perceptions of team effectiveness (Provider-PTE) and assessed its psychometric properties.

Patients and methods

Empirical evidence and a conceptual model were used for item generation. The 41-item self-completed questionnaire was developed. A cross-sectional survey of healthcare providers (n=283) across a range of settings was performed. Psychometric properties were assessed for French and English language questionnaires using Cronbach alpha (α) for reliability, the feedback form for face validity, expert opinion for content validity, and the known-group technique for construct validity. Responsiveness was examined by comparing scores in high and low functioning teams.

Results

The mean time needed to complete the questionnaire was less than 9 mins. Respondents were typically female (84%), and employed full time (80%) in urban settings (82%). Cronbach α values were as follows: Team Processes = 0.88; PTE-Overall = 0.91; Outcomes = 0.72. Significant differences were found by professional group (p = 0.017), length of time in the team (p = 0.025), and presence of nurse practitioners. Responses to Outcomes varied by employment status (p = 0.017). Differences were identified in high and low functioning teams (p<0.001). Feedback indicated that two questions related to team meetings needed to be added.

Conclusion

The study produced evidence of validity for English and French language Provider-PTE questionnaires. The revised 43-item instrument represents an important contribution by providing a validated questionnaire to measure team functioning across a range of settings that is consistent with a conceptual framework.

Low- and lower middle-income countries advanced practice nurses: an integrative review

AIM

To review published literature descriptions of advanced practice nurses' roles in low- and lower middle-income countries.

BACKGROUND

Advanced practice nurse roles have the potential to address insufficient healthcare resources in low- and lower middle-income countries.

INTRODUCTION

This integrative review highlights advanced practice nurses' roles in the delivery of healthcare services in low- and lower middle-income countries.

METHODS

Three electronic databases PubMed, CINAHL complete and ProQuest Health & Medicine were searched. No limits by year or language were set. The names for low- and lower middle-income countries and combinations 'related to advanced practice nurses' titles were used to identify papers. In addition, a review of publication type was performed. Themes found within the publications were assessed against the advanced practice nurses' International Council of Nurses' characteristics. An integrative review facilitated an appraisal of the papers identified.

RESULTS

The initial search identified 5778 publications in 16 languages. This number was reduced to 23, from 18 low- and lower middle-income once exclusion criteria were applied. Six publications were from 1977 to 1999, and six between 2000 and 2010, with the remaining 11 from 2011 to 2018. Zambia had the most publications. Notably, 63 countries were not represented. Of those meeting inclusion criteria, the majority addressed education with a lesser extent focusing on practice and regulation of advanced practice nurse's roles. The majority were published during the last decade.

DISCUSSION

This review of the published literature identified advanced practice nurses' roles and function within some healthcare systems. However, not all components were reported. Examination of the grey literature could provide additional information about the actual and potential benefits of advanced practice nurses' in low- and lower middle-income countries.

CONCLUSION

The published literature that referred to advanced practice nurses' identified their contribution to positive impacts on health care over the last 40 years. However, with only 11 publications identified in the last 7 years, further review is required to understand the advanced practice nurses' roles in these countries.

IMPLICATIONS FOR NURSING AND/OR HEALTH POLICY

Further development of advanced practice nurses' in low- and lower middle-income countries is supported by the lack of published literature.

The integration of new nurse practitioners into care of older adults: A survey study

AIMS AND OBJECTIVES

To assess Norwegian advanced geriatric nurses' (AGNs) use of their knowledge and skills, and factors that may influence AGNs' opportunities to use their knowledge and skills to reach their full potential.

BACKGROUND

Despite the need for nurses with advanced knowledge and skill in the care of older adults, the introduction of new advanced nursing roles has been challenging. Countries in the process of establishing advanced roles need to monitor and identify possible implementation issues.

DESIGN

A cross-sectional descriptive survey.

METHODS

We invited the total population of AGNs in Norway (n = 26) and some of their colleagues (n = 465) to answer an online questionnaire. Twenty-three (88.5%) of the AGNs and 195 (42.0%) of the invited colleagues completed and submitted the questionnaires. The data were analysed with descriptive statistics. STROBE guidelines were used in reporting this study.

RESULTS

Of the AGNs, 16 (69.6%) used their knowledge and skills to their full potential when providing direct care. However, a minority used their knowledge and skills to their full potential when proving indirect care (n = 11, 47.8%), teaching/supervision (n = 11, 47.8%) and coordination (n = 5, 21.8%). A total of 47 (24.1%) colleagues experienced the AGNs' scope of practice as completely clear, and 52 (26.6%) collaborated with the AGNs several times a week. Of the colleagues, 131 (67.2%) considered the AGNs' role and scope of practice contributed positively to a high degree to health service for older adults.

CONCLUSION

The results indicate the need for greater focus on organisational adjustment for the AGNs to utilise their knowledge and skills to their full potential.

RELEVANCE TO CLINICAL PRACTICE

There is a need for greater focus on organisational adjustment to integrate AGNs at the workplace, as complete integration may improve the AGNs' use of their knowledge and skills.

Enablers and challenges to advanced nursing and midwifery practice roles

AIM

To describe the enablers and challenges to the development and implementation of advanced nursing and midwifery practice roles in Ireland.

BACKGROUND

Leadership strategies need to be put in place to enhance the development and implementation of advanced nursing and midwifery practice roles.

METHOD

A descriptive qualitative approach using semi-structured interviews with key stakeholders (n = 15) was undertaken with nurses and midwives working in specialist and advanced practice roles and participants from other areas such as legislative, regulatory, policy, pharmacy, medicine and education.

RESULTS

Participant's perspectives on the enablers and challenges to enacting specialist and advanced practice roles resulted in the generation of three themes: organisational factors; collegial, interprofessional and interpersonal support; and role clarity, economic and regulatory contexts.

CONCLUSION

Addressing organisational factors, encouraging collegial and interprofessional support and establishing role clarity contribute to the effective development and implementation of the role of advanced practitioners.

IMPLICATIONS FOR NURSING AND MIDWIFERY MANAGEMENT

Managers of nursing services need to provide leadership in developing strategies to enhance the enablers and overcome the challenges to advanced practice role development in their own organisation.

Nurse Prescribing From the Global Vantage Point: The Intersection Between Role and Policy

Nurses around the world are increasingly prescribing and managing pharmaceutical agents. Prescribing by nurses is currently based on varying nursing roles, depending on national and regional norms and practices. Prescribing occurs within the advance practice, advanced level, and task-sharing roles, depending on the country. It is evolving both within and outside of traditional regulatory frameworks. Therefore, the purpose of this article is to describe the nurse prescribing globally among various nursing roles that support and facilitate the practice. We gathered practice, statutory, and regulatory information from gray and peer-reviewed literature, Google search and Google scholar, government websites, PubMed, and CINAHL electronic databases. In contrast to previous global policy reviews that focus primarily on high-income nations, our findings suggest that nurse prescribing occurs extensively in all six continents. Nurse prescribing within the context of advanced practice nursing occurs mostly in high-income countries. However, the predominant model of nurse prescribing from the global context occurs within the advanced level role by postbasic or postprofessional nurses. Additional nurse prescribing occurs through less formal task-sharing arrangements, primarily in low- to middle-income countries. In general, nurse prescribing is evolving rapidly around the world but within highly variable roles and regulatory frameworks. Codifying these roles by strengthening of educational and regulatory standards may serve to enhance the health system capacity, especially in low- to middle-income countries.

Irish Respiratory Clinical Nurse Specialists' Experiences of Their Role: A Qualitative Exploration

AIM AND OBJECTIVES

The aim of this study was to explore respiratory clinical nurse specialists' (CNSs') experiences of their role.

BACKGROUND

Respiratory illnesses are currently 1 of the top 3 causes of mortality resulting in 1 in 5 deaths and are associated with significant human burden. Respiratory CNSs play a vital role in the management of respiratory disease through supporting improvements in quality of life, reduction of exacerbations, and subsequent hospital admission. While published literature exists regarding the CNS role, there is a dearth of published literature on the respiratory CNS role.

DESIGN

A qualitative descriptive design allowed the researcher to elicit respiratory CNSs' experiences of their role.

METHODS

Ethical approval was obtained, CNSs were purposively sampled (n = 10), and data were collected by semistructured interviews, transcribed, and analyzed using content thematic analysis.

RESULTS

Three themes were identified within the findings: "multidimensional role," "interacting and collaborating," and "advancing the role."

CONCLUSIONS

Overall the study highlights that respiratory CNSs are active in the role as clinical experts, advocators, educators, collaborators, consultants, and health promoters. These findings recognize the importance of evaluating and building on the current CNS workforce in respiratory care and evaluating future development of the CNS role in specialized aspects of respiratory care in line with population and service needs.

Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers

AIMS AND OBJECTIVES

To collate, synthesise and discuss published evidence and expert professional opinion on enablers and barriers to the development and sustainability of specialist and advanced practice roles in nursing and midwifery.

BACKGROUND

Expanded practice is a response to population health needs, healthcare costs and practitioners' willingness to expand their scope of practice through enhanced responsibility, accountability and professional autonomy.

DESIGN

This discursive paper is based on a rapid review of literature on enablers and barriers to the development and sustainability of specialist and advanced practice roles and is part of a wider policy analysis.

METHODS

We analysed and synthesised of 36 research articles, reviews and discussion papers on enablers and barriers in the development and sustainability of expanded practice roles.

RESULTS

Several factors enable role expansion, including: role clarity; credentialing and endorsement; availability of education for expanded roles; individual practitioners' dispositions towards role expansion; support from peers, other professionals and the work organisation; and costs. Where limited or absent, these same factors can constrain role expansion.

CONCLUSIONS

Enabling nurses and midwives to practice to their full scope of education and expertise is a global challenge for disciplinary leadership, a national challenge for professional regulation and a local challenge for employers and individual clinicians. These challenges need to be addressed through multistakeholder coordinated efforts at these four levels.

RELEVANCE TO CLINICAL PRACTICE

This discursive paper synthesises empirical evidence and expert professional opinion on the factors that enable or hinder the development and sustainability of specialist and advanced practice roles. Providing a critical appraisal of current knowledge, it provides a reference source for disciplinary debate and policy development regarding the nursing and midwifery resource and informs clinicians of the myriad issues that can impact on their capacity to expand their scope of practice.

Shaping nursing profession regulation through history - a systematic review

AIM

The aim of this systematic review was to provide a critical synthesis of the factors that historically shaped the advancements of nursing regulators worldwide.

BACKGROUND

An in-depth examination of the different factors that moulded regulatory changes over time is pivotal to comprehend current issues in nursing.

INTRODUCTION

In the light of global health scenarios, the researchers explored the factors that historically influenced the socio-contextual circumstances upon which governments made regulatory changes.

METHODS

A systematic search was performed on the following databases: PubMed, CINAHL, Scopus, OpenGrey and ScienceDirect. The review included papers from January 2000 to October 2016 published in English. The authors used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and an inductive thematic approach for synthesis.

RESULTS

Two main themes were identified: factors underpinning current challenges and historical and contextual triggers of regulation. The first theme was composed of three aspects: education, migration and internationalization, and policy and regulation; the second theme consisted of four attributes: demographics, economics, history of registration and wars, and historical changes in nursing practice.

DISCUSSION

Factors that shaped nursing regulation were linked to changing demographics and economics, education, history of nursing registration, shifting patterns of migration and internationalization, nursing practice, policy and regulation and significant societal turns often prompted by wars.

CONCLUSION

A deeper understanding of the developments of the nursing regulatory institutions provides the foundation for portable standards that can be applied across an array of jurisdictions to guarantee a better public safety.

IMPLICATION FOR NURSING AND HEALTH POLICY

Understanding factors that socially, legislatively and politically have influenced the development of regulatory bodies over time helps to mould local, national and international policies that have a stronger impact on health worldwide. To achieve this, there must be effective cooperation among systems of nursing regulations globally.

The role of advanced geriatric nurses in Norway: A descriptive exploratory study

BACKGROUND

Care of older adults in the community is becoming increasingly complex. However, nursing staff often has insufficient knowledge and skills to adequately address the needs of frail older adults. There is therefore a need for nurses with advanced qualifications. To meet this need, advanced geriatric nursing has been introduced in Norway.

AIMS AND OBJECTIVES

This study aimed to describe the experiences of nurses with their new role as advanced geriatric nurses in care of older adults and to determine what strategies the nurses considered important in the development of their new role.

DESIGN

This study applied a descriptive, exploratory design.

METHODS

In-depth interviews were conducted with 21 nurses who had undergone an educational programme to become advanced geriatric nurses in Norway in 2016. Content analysis was used to analyse the data.

FINDINGS

The participants described a complex and extensive nursing role, which they related to a new understanding of the patients, relatives and the system in which they worked. This new gaze had developed based on a combination of their new knowledge, their skills, experiences and professional interests. The opportunities to use their role depended on their workplace conditions. They related to contextual challenges at their workplace in different ways to optimise the use of their new gaze.

CONCLUSIONS

Common for all participants was a broader and deeper understanding of the patient's health and life situation, which guided participants' actions. The key issue in developing the new role was developing effective strategies to foster role integration.

IMPLICATIONS FOR PRACTICE

Advanced geriatric nurses should collaborate with their managers to create a role that takes advantage of their knowledge and skills, as well as collaborate with colleagues to enhance understanding of utilisation of their role.

Development and regulation of advanced nurse practitioners in the UK and internationally

The NHS in the UK is under increasing pressure as a result of financial and recruitment issues, as well as an ageing population. Nursing has continued to adapt to this challenging time. Over the past few years, the advanced nurse practitioner (ANP) role has been implemented widely in primary and secondary care. However, the ANP role has lacked consistency in scope of practice, training and regulation. This article summarises the development of the ANP role in the UK and internationally, and issues relating to regulation. Globally, ANPs are regulated by one of three different bodies: nationally by central government or a professional body, or locally by employers. In the UK, the role is regulated by local procedures, relying on employers to make decisions about the scope and preparation for practice. Some of the challenges in the UK in relation to ANP regulation are discussed, including variations in scope, organisational constraints and lack of support. These challenges are exacerbated by a lack of role clarity, thereby indicating there is a need to improve regulation of ANPs. The Royal College of Nursing has responded to these challenges by introducing 'credentialing', a system for recording qualifications, skills and experience, but the uptake of this process is yet to be evaluated. Therefore, employers and ANPs should be aware of their collective responsibility for ensuring appropriate role regulation.

Advanced Practice Nursing Competency Assessment Instrument (APNCAI): clinimetric validation

OBJECTIVE

To describe the development and clinimetric validation of the Advanced Practice Nursing Competency Assessment Instrument (APNCAI) through several evidence sources about reliability and validity in the Spanish context.

DESIGN AND SETTING

APNCAI development was based on a multisequential and systematic process: literature review, instrument content consensus through qualitative Delphi method approach (a panel of 51 Advanced Practice in Nursing -APN- experts was selected) and the clinimetric validation process based on a sample of 600 nurses from the Balearic Islands public healthcare setting.

METHODS

An initial step for tool's content development process based on Delphi method approach of expert consensus was implemented. A subsequent phase of tool validation started from the analysis of APN core competencies latent measurement model, including exploratory and confirmatory techniques. Reliability evidence for each latent factor was also obtained. Items' scores were submitted to descriptive analysis, plus univariate and multivariate normality tests.

RESULTS

An eight-factor competency assessment latent model obtained adequate fit, and it was composed by 'Research and Evidence-Based Practice', 'Clinical and Professional Leadership', 'Interprofessional Relationship and Mentoring', 'Professional Autonomy', 'Quality Management', 'Care Management', 'Professional Teaching and Education' and 'Health Promotion'.

CONCLUSIONS

Adequate empirical evidence of reliability and validity for APNCAI makes it useful for application in healthcare policy programmes for APN competency assessment in Spain.

Descriptive, cross-country analysis of the nurse practitioner workforce in six countries: size, growth, physician substitution potential

OBJECTIVES

Many countries are facing provider shortages and imbalances in primary care or are projecting shortfalls for the future, triggered by the rise in chronic diseases and multimorbidity. In order to assess the potential of nurse practitioners (NPs) in expanding access, we analysed the size, annual growth (2005-2015) and the extent of advanced practice of NPs in 6 Organisation for Economic Cooperation and Development (OECD) countries.

DESIGN

Cross-country data analysis of national nursing registries, regulatory bodies, statistical offices data as well as OECD health workforce and population data, plus literature scoping review.

SETTING/PARTICIPANTS

NP and physician workforces in 6 OECD countries (Australia, Canada, Ireland, the Netherlands, New Zealand and USA).

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcomes were the absolute and relative number of NPs per 100 000 population compared with the nursing and physician workforces, the compound annual growth rates, annual and median percentage changes from 2005 to 2015 and a synthesis of the literature on the extent of advanced clinical practice measured by physician substitution effect.

RESULTS

The USA showed the highest absolute number of NPs and rate per population (40.5 per 100 000 population), followed by the Netherlands (12.6), Canada (9.8), Australia (4.4), and Ireland and New Zealand (3.1, respectively). Annual growth rates were high in all countries, ranging from annual compound rates of 6.1% in the USA to 27.8% in the Netherlands. Growth rates were between three and nine times higher compared with physicians. Finally, the empirical studies emanating from the literature scoping review suggested that NPs are able to provide 67-93% of all primary care services, yet, based on limited evidence.

CONCLUSIONS

NPs are a rapidly growing workforce with high levels of advanced practice potential in primary care. Workforce monitoring based on accurate data is critical to inform educational capacity and workforce planning.

Competency Development to Support Safe Nurse Practitioner Prescribing of Controlled Drugs and Substances in British Columbia

In 2012, Canada passed legislation giving nurse practitioners (NPs) authority to prescribe controlled drugs and substances. Steps toward safe implementation by the nursing regulatory body in British Columbia included development of controlled drugs and substances prescribing competencies for use in educating and authorizing NPs for this new scope. In this article, we discuss the development and refinement of the competencies, specifically their application to nursing regulation in British Columbia. Methods include incorporation of the Competency Outcome Performance Assessment Model as a guiding theoretical framework. Over two meetings in 2014, a small representative panel of health professionals completed face and content validation of 17 initial competencies using a visual Likert-type scale ranking process (1-5, unnecessary to essential) with Google Docs for real-time comparative refinement. The resulting 10 competency statements provide the foundation for outcome indicator development which will be used in NP education and the regulatory body's regulation and remediation processes. Finally, we describe the policy process applied to implement competencies for NP controlled drugs and substances prescribing and the subsequent challenges of implementation of controlled drugs and substances authority in British Columbia. The article concludes with an overview of lessons learned that may be beneficial to health professions regulatory bodies introducing or expanding prescribing scope for NPs.

Activities undertaken by Intensive Care Unit Liaison Nurses in Argentina

BACKGROUND

The Intensive Care Unit Liaison Nurse (ICULN), also known as an outreach nurse, is an advanced practice nursing role that emerged in the late 1990s in Australia and the United Kingdom (UK). Little is known about this role in less developed economies.

OBJECTIVE

To describe the activities undertaken by ICULNs in Argentina.

METHODS

Prospective, descriptive, observational, single site study in an Argentinean metropolitan tertiary referral hospital. Adult patients under ICULN follow up were included in the sample. Data on ICULN activities and patients were collected using an established tool developed by The Australian Intensive Care Unit Liaison Nurse Forum. Descriptive statistics were used to summarise the findings.

RESULTS

Two hundred patients were visited by the ICULNs during the study period. The mean age of patients was 52.5 years (SD 17.7). Cardiovascular disease (n=104, 52%), respiratory disease (n=90, 45%) and diabetes (n=40, 20%) were the most common comorbidities. 110 (55%) patients had surgical procedures. The primary reasons for ICULN visit were follow up post ICU discharge (n=138, 69%) and ward referral (n=46, 23%). 136 (68%) patients received up to 3 visits; the remaining 64 (32%) patients received ≥4 visits. In those patients in need of ≥4 visits ICULNs initiated more non-medical treatments (100%), referred to escalate treatment (35%) and to a higher level of care (13.8%) than in those who were visited up to 3 times.

CONCLUSIONS

This study is the first to document ICULN activity in Argentina using an international framework and data set. These findings can assist with understanding an advanced practice nursing role in Argentina. It may facilitate future comparisons with other contexts and could help managers implementing the role in similar settings. Further investigation will help develop this practice and document its influence on patient outcomes.