Survey Development

An online survey was developed by the research team, drawn largely from the 2010 Pulcini, Jelic, Gul, and Loke survey [10] as well as regulatory questions from the 2015 Heale and Buckley survey [11], once adaptation permission was granted. Questions were refined, with several areas added or developed, most notably the modification of questions on education, professional issues, clinical skills, credentialing, and certification. The survey categorized questions according to practice roles, education, regulation/certification, and practice climate. Because of the complexity of APN titling and practice issues, respondents were given the opportunity to answer multiple questions with open-ended responses in addition to multiple choice options. To clarify distinctions of education and credentialing, definitions for title protection, certificate, certification, and recertification were provided (see Table 3).

Procedure

Once the research team obtained institutional review board (IRB) approval from the Office of Research Integrity of the University of Kentucky and the survey was approved by the Core Steering Group of the ICN NP/APNN, the study was launched in August 2018 at the 10^th Annual ICN NP/APNN Conference in Rotterdam, Netherlands. Links to the survey were provided there and via ICN social media platforms. When initial data analysis showed response gaps from several continents due to institutional firewalls, the IRB approval was amended to allow document surveys to be anonymously submitted with deadline extended to September 2019.

Design and Sample

A convenience sample approach was used because of the difficulty accessing all eligible participants or countries worldwide. Participants completed the survey once in this cross-sectional assessment. Study participants were required to be APNs, APN educators, APN administrators, and/or APN researchers; be fluent in reading/writing English; and have access to a computer with an Internet connection. Completion of the survey established participant consent. Survey responses from 325 respondents, representing 26 countries, were analyzed. However, the study data were summarized as being from 23 countries, with data from England, Northern Ireland, Scotland, and Wales, combined as a single location category (i.e., United Kingdom [UK]).

Analysis

Each survey was analyzed for sufficiency of response. Participants from all represented countries answered both multiple choice and open-ended questions. We received 482 surveys in total, but 157 of them were not able to be retained due to widespread missing values; the effective sample size was 325, reflecting 67% of the total surveys received. Descriptive statistics, including frequencies and percentages, were used to analyze and describe the sample data. SAS, v. 9.4 was used for the quantitative analysis.

Demographics

Responses came from countries in all the major regions of the world, specifically Africa (n = 4), Asia (n = 2), Europe (n = 10), North America (n = 3), South America (n = 2) and Oceania (n = 2), as presented in Table 4.

Demographic totals and percentages are presented in Table 5.

Eligible participants could identify themselves as practicing nurses, educators, administrators, and/or researchers. Because nurses (and those associated with nurses) function in many roles, respondents were asked to check all that applied in each category or provide additional roles if an option was not listed. For this reason, the cumulative percentage across all roles exceeds 100%.

Of respondents who reported practicing as nurses, 37% (n = 121) identified as a Family NP/APN, 22% (n = 71) as a registered/generalist nurse, 15% (n = 50) as a NP/APN specialist devoted to a specific disease, 15% (n = 48) as a Hospitalist/Acute Care NP/APN, 14% (n = 45) as an Adult NP, 10% (n = 32) as a NP/APN specialist devoted to a specific age or population, 7% (n = 22) as a Clinical Nurse Specialist, 6% (n = 18) as a Geriatric/Gerontologic NP/APN, 6% (n = 21) as a Community Health NP/APN, 5% (n = 17) as a Mental Health NP/APN, 5% (n = 17) as a Paediatric NP/APN, 4% (n = 12) as a Women’s Health NP/APN, 2% (n = 7) as an Adult/Gerontologic NP/APN, and 1% (n = 2) as a Midwife. The 14% (n = 47) of practicing nurses who reported roles outside those offered in the survey listed roles such as neonatal nurse practitioner or nurse anesthetist.

Of respondents who identified as educators, 12% (n = 18) reported they educated registered/generalist nurses only, 42% (n = 65) educated APNs only, and 38% (n = 59) reported they educated both. An additional 8% (n = 12) reported educating students other than registered/generalist nurses or APNs. Those who identified as administrators were almost equally split, with 49% (n = 22) reporting oversight of nursing personnel and 51% (n = 23) reporting oversight of both nursing and non-nursing personnel. Over half of the researchers reported they were involved exclusively in nursing research (53% (n = 56), 6% (n = 6) in non-nursing research, and 42% (n = 44) in both.

Practice Role

Practice questions centered on titling and types of APN roles, presence/absence of title protection, professional issues, and clinical skills (see Appendix A). Most countries with some sort of APN practice reported more than one advanced role. Though most used the titles NP, CNS, or midwife, other titles were listed, such as APN, nurse in advanced practice, expert nurse, nurse specialist, and others. In some countries the term CNS (or a similar title) referred to nurses who function more as NPs, or vice versa (i.e., providers titled NPs but who functioned more as CNSs). Some countries reported midwives were commonly educated at the registered/generalist level or as a non-nurse, while other countries reported educating midwives at a post registered/generalist nurse level. Title protection was reported in Australia, Botswana, Canada, France, Hungary, Israel, Jamaica, the Netherlands, New Zealand, Portugal, Republic of Ireland, Singapore, and the US. Title protection was not reported in Chile, Finland, Germany, Ghana, Italy, Kenya, Spain, Tanzania, or the UK.

Respondents chose from 15 APN work-place position options, such as doctor’s office, hospital-based clinic, hospital, faculty, and the like. Respondents could report all that applied as well and were able to list any unnamed workplace settings in an open-ended question. Australia, Botswana, Canada, Finland, the Netherlands, New Zealand, Spain, the UK, and the US responded affirmatively to all site options. Portugal reported all site options except occupational/workplace health, while the Republic of Ireland reported all site options except school health and occupational or workplace health. Singapore reported a little over half the work site options, while the remaining countries reported fewer than half of the work site options. Israel reported only specialty practice sites and Hungary reported that the role was too recently instituted to provide any details. Ecuador reported the role did not exist outside US government agencies, so will only be reported in the tables but not included in discussions or subsequent calculations. Other questions pertained to 21 clinical skills (from skin lesion removal to suturing to X-ray interpretation) and 12 professional issues (from carrying their own caseload of clients/patients to ability to prescribe to reimbursement (see Appendix A).

Education

Education questions pertained to presence/absence of programs, number of programs, level of education, types of specialties or APNs, program details, and student requirement details (see Table 6).

All the countries reported having formal education programs for APNs. Only Australia, Canada, the Netherlands, the UK, and the US reported more than ten such programs in their country, with the remainder reporting fewer than this. Most of the countries offered multiple education paths for those wanting to practice as APNs. All the countries except Ghana and Israel listed the master’s degree as the education credential available to APN graduates, with Ghana offering the baccalaureate and advanced diploma, and Israel offering a certificate. Canada, New Zealand, and the US reported all five levels of education (doctorate, master’s, baccalaureate, certificate, advanced diploma), but Canada and the US specified those who earned the lower credentials had done so before the master’s had been required and had been grandfathered into practice. The UK reported all five levels of education but also reported some programs educated APNs but granted no credential. Germany reported offering doctorate, master’s, and baccalaureate degrees as well as programs of APN education where no credential was granted.

Australia, Canada, the Netherlands, the UK, and the US reported education for all advanced roles, though New Zealand participants specified midwifery was not considered an advanced role. Other than Israel, the remaining countries reported a variety of roles for which there were APN programs, including some listing disease-specific programs (e.g., an oncology APN track).

Reports of program length varied from 18 months to five years according to program type and degree, with most reporting programs that require two to three years of full-time schooling. Several programs reported a minimum of 500 clinical hours, though some required considerably more (e.g., 800; 1000; 1200; or 1490), additional internships (e.g., one year long; another as long as 5000 hours), and one specified clinical hours specifically devoted to pharmacology (in addition to other hours required).

All the countries with APN programs reported requiring students to be registered/generalist nurses with academic degrees before entering the program. With the exception of the US, nearly all the programs required registered/generalist nurses to have a minimum of two years of experience as a nurse, with some requiring as many as seven years.

Regulation and Credentialing

Regulation and credentialing questions pertained to presence/absence of recognition, regulation level, requirements to practice, requirements to renew, and certification (see Table 7).

Nearly half (45%, n = 10) reported formal recognition by the government, hospital/health care agency, and/or professional organizations in their countries and some (14%, n = 3) reported formal recognition by the government and professional organizations only. The remaining (40%, n = 9) reported the role was recognized though there were no formal regulations at any governmental level. We assumed that the APNs working in these countries were credentialed by the local agencies employing them.

For those who reported regulation by a governmental agency, most regulation was reported at the federal level. However, Australia, Canada, New Zealand, the Republic of Ireland, and the US reported jurisdictional level regulation as well. Only Ghana reported regulation solely at the jurisdictional level.

All the countries reported requiring an academic degree and/or approved education program in order to enter practice as an APN, though some reported grandfathering had occurred in the past for experienced APNs who would not be able to meet current education standards. Over half the countries (64%, n = 14) required registration, licensure, or endorsement at some governmental level to practice. Of the remaining countries (36%, n = 8), registration, licensure or endorsement to practice was listed at agency level authorization. Canada, Israel, and the US required passage of a certification exam in order to practice. Requirements to continue to practice mostly involved maintenance of practice, earning continuing education credits, or meeting portfolio requirements on some interval basis.

Practice Climate

Practice climate questions pertained to factors that facilitated or hindered APN role development and level of policy making and professional group organization (see Appendix B).

Nearly all respondents (73%, n = 16) reported the basis for development of the APN role was due to a need for providers in rural or underserved areas, with several (23%, n = 5) reporting very specific physician shortage issues in neonatal care or psychiatry, or policy changes that limited work hours of residents or junior doctors. Nearly all (77%, n = 17) reported consumer demand led to APN role development. One respondent reported that extensive dialogue had gone on about providing the right (high quality) care in the most (cost) efficient way, as well as patient needs moving from “illness and cure” to “health and behavior”.

Responses about who specifically advocated for or opposed the role were mixed. Advocacy options included the following: government; international organizations; individual nurses; individual physicians; consumers; insurance companies; universities; media; and/or in-country nursing, physician, nongovernmental/nonprofit institutions or private institutions. Two countries reporting affirmatively for all, but the remaining cited a mixture of responses. Over half of the countries (68%, n = 15) reported that government and nursing organizations within country were the prime advocates for the APN role. Over a third (37%, n = 8) reported physician organizations within country advocated for the role as well. However, regarding role opposition, physician organizations were reported the most (73%, n = 16), followed by individual physicians (68%, n = 15), individual nurses (55%, n = 12), and governments (45%, n = 10).

The majority of the countries (73%, n = 16) reported that policy making for APNs occurred at both a national and local level, though the respondent from Jamaica reported it occurred at the local level and the respondent from Italy reported it occurred at the national level. The development of APN organizations was reported mostly (73%, n = 16) at both the national and local level but the respondent from Chile reported it only at the national level, while France and Ghana reported it only at the local level. Hungary reported no evidence of either.

Distribution of APNs

Understanding the number, distribution, and types of providers present in the world is extremely complicated. It is even more complex for APNs, not only because of inherent problems of workforce data collection but also due to issues of categorization unique to nursing and APNs. The World Health Organization collects data on healthcare professionals throughout the world but admits the quality and completeness of the data is a concern [18]. Categories of collection include medical doctors, nursing and midwifery personnel, dentistry, and a few others. There is no separate category for APNs, their presence being counted among the nurses and midwives. This same limitation of data collection on APNs persists throughout many of the countries and jurisdictions of the world. Nonetheless, it is known NPs and CNSs are established in the Americas (US [19], Canada [19], Jamaica [20], Belize [20], Brazil [20], Chile [20], and Columbia [20], among others), much of Europe (Austria [21], Belgium [22], Czech Republic [22], Finland [22], France [22], Germany [23], Republic of Ireland [22], the Netherlands [19], Poland [22], Switzerland [23], the UK [22], among others), Australia [22], New Zealand [19], a few countries in Africa (Botswana [19], Ghana [24], Eswatini [25], Kenya [19], Namibia [19], and Zimbabwe [19], among others), and a few countries in Asia (Israel [23], Japan [22], Oman [19], Singapore [19], and Taiwan [26], among others). This aligns well with the responses obtained not only from this study but also those cited in Table 2, and may point to areas of the world that could potentially benefit from NP and CNS role introduction.

Titling, Role, and Practice

Inconsistencies in titling, role, and practice continue to affect the profession. If individuals do not need to work outside the country or jurisdiction, the variations are not inherently limiting. However, healthcare needs are not always geographically bound, nor are the needs of professionals who sometimes must move for personal or professional reasons. Numerous authorities indicate this lack of standardization limits the ability of APNs to meet unmet healthcare needs, collaborate across borders, partake in scholarly exchanges with a common language, or participate in dependable and consistent research on the profession or the outcomes of care [27, 28, 29].

Title protection is also a critical professional issue, regardless of geographic mobility. Since title protection is the limited use of a title unless the title holder meets regulatory requirements [30] the finding that nearly half of the countries reported no title protection causes concern. The American Nurses Association states title protection protects the public from “unethical, unscrupulous, and incompetent practitioners” [31 (para 1)]. It also protects the practitioner from unfair competition from someone who does not meet education or regulatory standards. Additionally, having a defined and protected title provides regulators and the public with a common and understood frame of reference from which to create sound regulations and measure, monitor, and discipline the profession.

Education

That nearly all the countries reported the master’s degree as the primary form of education for APNs is evidence the 2002 ICN recommendation of a master’s degree for advanced practice has had an impact. It is noteworthy these programs also required similar entry criteria, as well as similar clinical requirements and program length. The greatest variation was found in program and role offerings available by schools or within countries, a likely variation dictated by local need or knowledge of available roles. However, while this local determination might meet current local needs it could also limit geographic flexibility or the ability to attend to future, evolving needs. And local determination could be very restrictive to the nurse who wants to do something outside of what is locally available but has limited resources to seek education elsewhere. Unfortunately, this study did not look at educational curricula or program accreditation.

Regulation and Credentialing

The most difficult professional area to understand and describe for the status of APNs around the world is regulation and credentialing. In 1997, as a concept fundamental to regulation, the ICN defined credentialing as:

processes used to designate that an individual, programme, institution or product have met established standards set by an agent (governmental or non-governmental) recognised as qualified to carry out this task. The standards may be minimal and mandatory or above the minimum and voluntary. Licensure, registration, accreditation, approval, certification, recognition or endorsement may be used to describe different credentialing processes…Credentials may be periodically renewed as a means of assuring continued quality and they may be withdrawn when standards of competence or behavior are no longer met [32 (p44)].

Because this terminology is complicated, with terms used interchangeably, APNs may not be able to fully describe the level of credentialing involved in the ability to practice or teach, which was reflected in this study. Considerable cross referencing had to be done to understand the regulatory models of the countries represented. Clearly, many APNs work and practice without the benefit of regulation at any governmental level. What remains for these APNs is agency recognition, a level of credentialing that may cause concern and confusion for the public.

Certification is another term used in a variety of ways as a credential descriptor. For the purposes of this study, professional certification was defined as:

the voluntary process by which a(n)…entity grants a time-limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria. It is the vehicle that a profession or occupation uses to differentiate among its members, using standards sometimes developed through a consensus-driven process, based on existing legal and psychometric requirements [33 (p5)].

While certification can refer to a level of recognition based on curriculum, this study looked specifically for competency-based certification (exam-based) as well as portfolio- based competency. Though considered the best measure of competency, few countries relied on this level of certification for credentialing.

Table 8 provides a comparison of positive and negative factors related to level of regulation and certification.

Table 8

Regulatory Models: Advantages and Disadvantages.

		REGULATORY MODEL	POSITIVE FACTORS	NEGATIVE FACTORS
	Competency Based Credential	Centralized/decentralized regulation + Certification by Exam (including maintenance)	Favored by most authorities	Requires significant resources todevelop/deliver exams
		Centralized/decentralized regulation + Certification by Portfolio (including maintenance)	Favored by most authorities	Requires significant resources to reviewportfolios
	Curriculum Based Credential	National (centralized) regulation	Can advance role if kept up-to-date [34]	Can negatively impact role if not kept up-to-date [34]
		Jurisdictional (decentralized) regulation	Meets local needs	Leads to inconsistencies in practice and role clarity [34] Requiressignificant time and resources to change [34]
		Agency regulation	Meets agencyneeds	Leads to greater inconsistencies in practice and role clarity [34] Results in limited data for the profession [34]
	Limited Competency Credential	Agency regulation	May meet care needs at some level	Increasespotential for incompetent providers Leads to inconsistencies in practice androle clarity Requires coordinated effort to move to higher levelcredential Results in limited data for the profession

Clearly, regulatory models matter significantly to the practice of APNs and the potential for expansion of care they could provide. At the same time, recognition must be given to the effort that has already gone into developing the role and which will be required for future regulatory model expansion.

Practice Climate

Despite nearly universal reporting of a need for providers in rural or underserved areas, as well as consumer demand, practice climate continues to negatively impact the profession, even where the APN role has functioned for decades. A 2009 study by the Organization for Economic Cooperation and Development (OECD) looked at 12 countries (Australia, Belgium, Canada, Cyprus, Czech Republic, Finland, France, Ireland, Japan, Poland, the UK, and the US) and the factors that helped or hindered APN role development [35]. Similar to this study, the OECD found the following were affecting APN development: support and opposition from the medical and nursing community, issues related to regulation, and limitations of educational opportunities. It is noteworthy that the same practice climate issues still surround advanced practice a decade later.