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



AimTo explore the regulation of advanced nurse practice internationally and to identify differences and commonalities.Background Regulation of advanced practice nursing does not occur in many countries. Ireland is currently in the minority in regulating advanced practice at a national level.Key issuesLack of regulation poses difficulties for national governments and for society due to uncertainty in advanced practice concept and role.MethodsA literature review of 510 scholarly nursing papers published in CINAHL, PubMed and MEDLINE between 2002 and 2013 and 30 websites was undertaken.ResultsThere is a lack of consistency in legislative systems internationally. Nursing organisations have recognised advanced nurse practice by regulation in some countries and by voluntary certification in others.Conclusions Research has demonstrated that care delivered by advanced nurse practitioners has enhanced patient outcomes yet regulation of advanced practice is not undertaken in most countries.Implications for nurse managerNurse managers need to know that criteria for the regulation of advanced practice are in place and reflect the minimum requirements for safe practice.
Regulation of advanced nurse practice: its existence and
regulatory dimensions from an international perspective
PhD, MBA, FFNMRCSI, FICHN, Dipl Nurse Teaching, RNT, RGM, RM
Associate Professor of Nursing, Dean, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland,
Dublin, Ireland
Marie Carney
Royal College of Surgeons in
123 St Stephen’s Green
Dublin 2
CARNEY M. (2014) Journal of Nursing Management
Regulation of advanced nurse practice: its existence and regulatory
dimensions from an international perspective
Aim To explore the regulation of advanced nurse practice internationally and to
identify differences and commonalities.
Background Regulation of advanced practice nursing does not occur in many
countries. Ireland is currently in the minority in regulating advanced practice at a
national level.
Key issues Lack of regulation poses difficulties for national governments and for
society due to uncertainty in advanced practice concept and role.
Methods A literature review of 510 scholarly nursing papers published in
CINAHL, PubMed and MEDLINE between 2002 and 2013 and 30 websites was
Results There is a lack of consistency in legislative systems internationally.
Nursing organisations have recognised advanced nurse practice by regulation in
some countries and by voluntary certification in others.
Conclusions Research has demonstrated that care delivered by advanced nurse
practitioners has enhanced patient outcomes yet regulation of advanced practice
is not undertaken in most countries.
Implications for nurse manager Nurse managers need to know that criteria for
the regulation of advanced practice are in place and reflect the minimum
requirements for safe practice.
Keywords:advanced nurse practice, certification, licensing, professional bodies,
regulation, regulatory systems
Accepted for publication: 10 November 2014
Legislative and regulatory practices vary between and
within countries (Delamaire & Lafortune 2010). Pro-
fessional nursing organisations have recognised
advanced nurse practice by regulation in some coun-
tries and by voluntary certification in others (Ameri-
can Nurses Association 2010). Senior nurses in the
United Kingdom (Report of the Prime Minister 2010)
and in Australia (Australian Nursing & Midwifery
Council 2009) have questioned if regulation or
registration of advanced practice is necessary or if it is
the natural extension to the role of the nurse and ask
if regulation has the potential unduly to limit the
practice of nurses who do not meet the specified
requirements (Royal College of Nursing 2012). The
United States has developed the ‘LACE (licensure,
accreditation, certification and education) consensus
model’ to clarify the roles of advanced practice nurses
and to standardise education, licensure and certifica-
tion – areas where confusion exists (American Nurses
Association 2010, APRN 2012). The goal of this
DOI: 10.1111/jonm.12278
ª2014 John Wiley & Sons Ltd 1
Journal of Nursing Management, 2014
paper is to explore the international literature
regarding the regulation of advanced nurse practice
and to identify current differences and commonalities.
Countries are at different stages in implementing more
advanced roles for nurses and midwives and some unof-
ficial practices may already exist that adversely affect
the role (Delamaire & Lafortune 2010). There are up to
13 different titles being used to denote advanced prac-
tice, leading to debate on the subject. Ireland uses the
title of ‘advanced nurse/midwife practice’ (ANP/MP) to
identify the advanced practice nurse. The title advanced
practice nurse (APN), first used in the United States in
1965 as an overarching concept to signify nurses prac-
tising at a higher level than that of traditional registered
nurses, is now used as an international concept that
incorporates a number of advanced practice roles such
as advanced practice nurse (APN), nurse practitioner
(NP), nurse consultant (NC) clinical nurse specialist
(CNS), nurse anaesthetist (NA) and certified nurse-mid-
wife (CN/M). Debate is also taking place regarding the
criteria required for advanced practice. Some regulatory
bodies and professional organisations have developed
criteria that include registration as a nurse, acquisition
of expert knowledge base, complex decision-making
skills and clinical competencies for extended practice,
the characteristics of which are shaped by the context
and/or country in which the nurse is credentialed to
practice, whilst others have not done so. For example,
education for advanced nurse practice ranges from
diploma to PhD level with a master’s degree in nursing
recommended or required in most countries where the
role has been introduced (Schober & Affara 2006, ICN
Literature search
Three electronic databases were searched for the key
words regulation of advanced practice nurse/advanced
nurse practice: Cumulative Index of Nursing and Allied
Health Literature (CINAHL), PubMed and MEDLINE.
Search parameters were research papers, policy docu-
ments and international material that dealt with regula-
tion of advanced practice, published between 2002 and
2013. International websites pertaining to regulation,
registration or licensure of advanced nurse practice
including national governments and professional organ-
isations were also chosen. Five hundred and 10
scholarly nursing papers published in international
journals and 30 websites were reviewed.
Analysis and critical appraisal of the literature
Content analysis was undertaken on the 510 papers
that were reviewed using a simple analytical frame-
work – Search, Appraisal, Synthesis and Analysis
(SALSA) (Grant & Booth 2009). The SALSA frame-
work was joined with NVIVO 9.0 software for docu-
ment analysis, which involves organising, linking,
categorising, questioning, shaping and synthesising rel-
evant qualitative data by exploring material, searching
text, analysing documents and linking document
themes and attributes. Full texts and abstracts, avail-
able in English, were critically appraised for material
that met the inclusion criteria: regulation by country
and alternative forms of registration of advanced prac-
tice nurses’ such as licensure, certification and accredi-
tation. Synthesis of the published material was
undertaken and comparisons made between types of
regulation, if any, occurring. Further analysis of sub-
ject matter to determine similarities and differences
between countries took place (NVivo 2014).
The process of documentary analysis focused on texts
by browsing for advanced practice concepts, which
included regulation. Themes relating to regulation,
licensure and certification were identified and compared
by type and purpose of regulation used across interna-
tional countries. The next step involved comparing and
contrasting the themes and creating document and data
links and finally identifying concepts such as knowl-
edge, scope and competencies needed for advanced
nurse practice, through linking the themes and attri-
butes extracted. Rigour was obtained through careful
scrutiny of the documents selected and adherence to
inclusion criteria. A senior college librarian identified
relevant documents and then discussed those documents
with the researcher while maintaining reference to the
inclusion criteria. Content analysis was reviewed with
an expert in advanced practice regulation.
The aims of this literature review were to:
1 To explore the regulation of advanced nurse prac-
tice in international literature.
2 To identify, compare and contrast differences and
The scholarly literature revealed a lack of clarity in
definitions and terminology relating to the regulation
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2Journal of Nursing Management
M. Carney
of advanced practice. The reviewed documents related
mainly to criteria for advanced nurse practice, knowl-
edge level required for practice, advanced clinical
competencies needed for extended practice and differ-
ences between the CNS and ANP. As a result, the
scope of the literature search was broadened to
include regulation and policy information derived
from material published in 30 websites including the
Organization of Economic Co-Operation and Devel-
opment (OECD) countries, professional organisation
publications, national and regulatory body reports.
Exploration of 510 scholarly articles indicated that
just 25 (5%) related to the ‘regulation of advanced
nurse practice/advanced practice nurse’. A further 30
websites that were available in English yielded relevant
material that met the ‘regulation’ criteria. Materials
were reviewed in relation to 19 countries: Australia,
Canada, Denmark, Finland, France, Germany, Hong
Kong, Ireland, Italy, Japan, Netherlands, New Zealand,
Norway, Singapore, Spain, Sweden, Switzerland, Uni-
ted Kingdom and United States. The findings indicated
that regulation occurred in nine countries. These coun-
tries are Australia, Canada, Hong Kong, Ireland, New
Zealand, Singapore, Spain, United Kingdom and United
States. Findings further indicated that six countries are
at a more advanced stage in the regulation of advanced
practice than others and have well defined regulation in
place or in process. These countries are Australia, Can-
ada, Ireland, New Zealand, UK and USA. The findings
are presented by individual country alphabetically
below with an overview by country, regulation, regula-
tory body or organisation and criteria for advanced
practice, including educational requirements, presented
in Appendix S1. A summary table of regulation across
countries, depicting differences and commonalities is
presented in Appendix S2.
The role of Advanced Nurse Practitioner (ANP) exists.
Definitions of advanced practice nursing and nurse
practitioner appear on the Nursing and Midwifery
Board of Australia (ANMC 2009) and there is a regis-
tration standard for endorsement as a nurse practi-
tioner. As of March 2011, nurses in Australia are
regulated by the Australian Health Practitioner Regu-
lation Agency, the key national governance body for
nursing. The Australian Nursing and Midwifery Coun-
cil Inc. (ANMC 2009) published competency stan-
dards that are the core competencies that all nurses
must possess and assist in indicating the scope of
nursing practice (ANMC 2009).
The role of ANP exists. Two broad categories of nurse
practitioner (NP) currently co-exist: Primary Care NPs
and Acute Care NPs. In the late 1990s, nurse practi-
tioner regulation was supported by doctors in order to
ensure guarantees of appropriate skills and the NP
role is now recognised in the legislation of all 10 prov-
inces and three territories via separate acts. Profes-
sional legislation governing nursing practice is a
provincial rather than a federal responsibility (Cana-
dian Nurses Association 2009, DiCenso & Bryant-Lu-
kosius 2009, Nurse Practitioners’ Association of
Ontario 2010).
The role of ANP does not exist and there is no regula-
tion for advanced nurse practice in Denmark. There is
no legally protected ‘specialist nurse’ title except that
of ‘home visiting nurse’. Registration is the responsi-
bility of the National Board for Health which autho-
rises the right to practise and which holds registers for
17 professional groups, including nurses and mid-
wives. The Bachelor degree in Nursing is regulated by
the Ministry of Education (OECD 2012a,b).
The role of ANP does not exist and advanced practice
nursing is not regulated in France. Nursing is in tran-
sition and the French Nursing Council in 2009 created
mandatory registration of all nurses representing a
shift from state regulation to self-regulation (OECD
2012a,b). The nursing profession is seeking to expand
advanced nurse practice with the development of
recent advanced practice programmes in some colleges
(ICN 2008a,b). Regulation of first level nurses is the
State certification as approved by the Ministry of
Health (OECD 2006).
The role of ANP exists. Advanced practice nursing is
not regulated in Finland. Specialist nurses’ are not
recognised through separate registration. The nurse is
regulated by law and working requires authorisation
from Valvira. The National Supervisory Authority for
Welfare and Health (Valvira) grants the right to prac-
tise as a licensed professional and authorises the use
of the occupational title of health-care professional
and added to the Central Register of Health Care
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Journal of Nursing Management 3
International regulation of advanced nurse practice
Professionals (Terhikki) for practice (Valvira 2014).
The first evaluation of the advanced practice ‘nurse
leader’ role in Finland was published by Fagerstr
and Glasberg in 2011.
The role of ANP does not exist. There is no national
system of registration or a regulatory nursing body
and responsibility for registration is devolved to the
regions. The National Nursing Act and Ordnance of
1985 regulates general nurse education at a national
level and defines the professional competence and
responsibilities of nurses (OECD 2006).
Hong Kong
The role of ANP exists. The Hong Kong Nursing
Board was established in 1931. With the introduction
of Nurses Registration (Amendment) Ordinance in
1997, it was re-named as the Nursing Council with
greater self-regulation and involvement of the nursing
profession. The Nursing Council of Hong Kong is the
statutory body for nurses in Hong Kong (NCHK
2014a,b). The recognition of the ‘nurse specialist’ role
during the health-care reform in 1990s lent itself to
the role of the Advanced Practice Nurse (NCHK
The role of ANP exists. The Nurses and Midwives
Act (2011) is the current statutory framework for the
regulation of nursing and midwifery in Ireland. These
professions are self-regulated: certain responsibilities
for regulation are granted by the state through legisla-
tion to An Bord Altranais (ABA 2010a,b) the profes-
sional regulatory body, re-named The Nursing and
Midwifery Board of Ireland. It is the legal definition
of nursing and midwifery practice (ABA 2010a,b,
2011) which is included in professional legislation,
that establishes the basis for the scope of practice in
which a registered nurse or midwife may engage while
fulfilling EU Directive 2005/36/EC (EU Directive
2005, NCNM 2008, ABA 2010a,b, 2011).
The role of ANP does not exist. Registers for nurses
are kept by colleges of nursing in each province and
allow practice throughout Italy. According to the law,
the aims of provincial colleges are to protect the
public and support and to guarantee the professional-
ism of nurses. There is no central control/validation of
degree courses (OECD 2006).
The role of ANP does not exist. Two levels of nurse
exist in Japan: registered and licensed practical nurse
and there is regulation of first and second level
nurses (Japanese Nursing Association 2006, OECD
The role of ANP does not exist. Specialist training
programmes are recognised by both nursing associa-
tions and employers. Midwifery is not a specialisation
of nursing and is regulated as a separate entity. The
Diploma Van Verpleegkundige has regulated nursing
practice since the 1921 Act (OECD 2006). The WET
BIG, regulates eight health-care professions and states
that only those registered as Verpleegkundige can use
the title and such registration only takes place once
the registrar is informed that the candidate has an
appropriate diploma (OECD 2006, Donato 2009).
New Zealand
The role of ANP exists. The Nursing Council of New
Zealand is the statutory authority governing the prac-
tice of nurses. In 2003, the Health Practitioners Com-
petence Assurance Act established a common and
consistent framework across health professions, while
retaining separate registering bodies, including a new
separate Midwifery Council (Nursing Council of New
Zealand 2012). In 2004, nursing registers were
replaced by four scopes of practice for registered
nurse, nurse practitioner, nurse assistant and enrolled
nurse (Nursing Council of New Zealand 2012).
The role of ANP exists. The Ministry of Education
and Research regulates advanced practice. Masters
and doctoral programmes are offered, including the
master’s in advanced nursing practice (ICN 2008a,b).
Regulation of first level nurses is provided by the Min-
istry of Education and Research that also regulates
nurse education. The Ministry of Health and Care Ser-
vices issues the licence for practice as a Registered
Nurse after an approved Bachelor Degree (EU Law/
Sweden 2006, OECD 2006).
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4Journal of Nursing Management
M. Carney
The role of ANP exists. Nursing and midwifery is
regulated through the Singapore Nursing Board
(SNB) through the Nurses and Midwives Act
(2012). The Board maintains the Advanced Practice
Nurses Register. The Act, with the approval of the
Minister, has powers to ensure that nurses are pre-
pared and competent to practise as defined in the
Standards for Advanced Practice Nurse Education
(SNB 2012).
The role of ANP exists. In 2001, registration of
advanced practice nursing became the responsibility of
the General Council of Nursing (OECD 2006). There
is one level: the first level ‘registered nurse’. Regula-
tion of first level nurses’ education is regulated by the
Ministry of Education. The midwifery qualification is
recognised in law. All nurses must be registered with
their local Provincial College of Nurses.
The role of ANP exists. Advanced nurse practice is
not regulated in Sweden. The Swedish nurse is regu-
lated and the title ‘nurse’ is protected as a person who
is a ‘general care nurse’. Regulation is as set out in
law in the Act (1998), which deals with authorisation
relating to professional activities within the health-
care system. All nurses in Sweden are ‘general care
nurses’ and must register with the National Board of
Health and Welfare (OECD 2006).
The role of ANP does not exist. There is one level –
the ‘registered nurse’. There is no national accrediting
body for specialist programmes and therefore
advanced practice is not regulated. University pro-
grammes in advanced practice are offered (OECD
2006). Regulation of first level nurses was through the
Red Cross, but is now at Federal level through various
United Kingdom
The role of ANP exists, but advanced nurse practice is
not specifically regulated by legislation. Nurses
became regulated via the Nurses Registration Act,
1919 and midwifery in the 1902 Act. In the UK,
Nurse Practitioners (NPs) have been part of the
National Health Service since the early 1970s (Duke
2012). Governance in the creation of advanced prac-
tice nurses dwells with the health-care system and
with individual health-care organisations rather than
with regulatory bodies. Nursing is regulated under the
United Kingdom Central Council for Nursing, Mid-
wifery and Health Visiting, UKCC (CREB 2008,
CHRE 2009, Royal College of Nursing 2012).
United States
The role of ANP exists. In 1938, New York State
passed the first mandatory Nurse Practice Act, which
established two levels of nursing: ‘licensed registered
nurse’ and ‘licensed practical nurse’. Other states fol-
lowed. States now recognise expanded nursing roles
(NCSBN 2012). The National Board is made up of
the boards in the 50 states, the District of Columbia,
and five United States territories. Plans are underway
and well advanced to revamp nursing regulation in
the USA, from the current single-state licensure
model to a mutual recognition model, as proposed
by the NCSBN Inc. (American Nurses Association
2010, NCSBN 2012). See Appendix S1 for further
Synthesis of regulation for advanced nurse
The findings indicate that countries have adopted dif-
ferent regulatory systems for nurses and some have
varying systems for regulating advanced nurse prac-
tice. All regulate nurses to some extent, some regulate
advanced practice but others such as Australia, Swe-
den and United Kingdom do not differentiate between
the regulation of nurses and midwives and the regula-
tion of advanced practice. Regulation of advanced
practice is difficult to establish as some countries,
Hong Kong, Ireland, New Zealand, Singapore and
Spain, have clearly defined laws regulating advanced
practice. Separate Regulation of Midwifery occurs in
Ireland, Netherlands, Spain, Sweden and United King-
dom. Of the 19 countries studied, 10 countries do not
regulate advanced practice. These countries are Den-
mark, Finland, France, Germany, Italy, Japan, Nether-
lands, Sweden, Switzerland and United Kingdom. The
remaining nine countries, Australia, Canada, Hong
Kong, Ireland, New Zealand, Norway, Singapore,
Spain and United States regulate advanced practice.
The different forms that regulation takes are
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Journal of Nursing Management 5
International regulation of advanced nurse practice
Different approaches
National legislation
Regulation of advanced nurse practice occurs in
Ireland through Legislation via the Nursing and Mid-
wifery Board of Ireland (ABA 2011); in Japan
through Legislation and Certification via the Japanese
Nurses Association (JNA 2006); in New Zealand
through Legislation via the Nursing Council of New
Zealand (NCNZ 2012); in Singapore through the Sin-
gapore Nursing Board (SNB 2012) and in Hong
Kong through The Nursing Council of Hong Kong
(NCHK 2014a,b): the statutory body for the regula-
tion of general nurses and for advanced practice
State regulation of advanced practice occurs in Aus-
tralia where each state has its own regulatory authority
and a similar regulation occurs in Canada: Provincial
Regulation of advanced practice, through separate acts
in each of the 10 provinces and two territories.
Legislation through Licensure for advanced practice
nurses occurs via the Boards of Nursing in the United
States (APRN 2012). The United States recently devel-
oped the ‘LACE Consensus Model’ which clarifies and
standardises the roles of APNs (APRN 2012).
Countries that do not regulate advanced practice
Legislation to regulate nurses and midwives in the Uni-
ted Kingdom is via the Nurses Act (1919) and the Mid-
wives UK (1902) through the UKCC. There is not a
separate regulation for advanced practice nurses (RCN
2012). Federal State Law regulation of nurses occurs in
Germany and Switzerland; regulation of nurses in Italy
occurs via the Colleges of Nursing; Ministry Regulation
of nurses occurs through the National Board of Health
and Welfare in Sweden; through the Ministry of Educa-
tion and General Council of Nursing in Spain; and
through the Ministry of Education and Research in
Norway. In Finland the nurse is regulated by law
through the National Supervisory Authority for Welfare
and Health (Valvira 2014) and is then added to the
Central Register of Health Care Professionals (Ter-
hikki). In the Netherlands distinct regulation of eight
health professions takes place through Legislation
termed WET BIG. Regulation Differences and
commonalities are presented in Appendix S2.
Researchers appear to by-pass the dimension of
regulation and the effects of non-regulation on
practice. The Council of the European Union pro-
duces directives from time to time, which have direct
implications for nursing and midwifery practice. Euro-
pean countries have legislation to determine the prac-
tice of health professions, yet regulation of advanced
nurse practice remains in its infancy. Research has
portrayed advanced nurse practice as being at varying
early stages of development in many European coun-
tries including Austria, Greece, Holland and Slovak
Republic (NCNM 2005, OECD 2012b). Greece is
reported as having more physicians than nurses in
practice and as a result there is little support for
advancing the nursing role (OECD 2012a,b) and the
Hellenic Nurses Association (2013) state that no certi-
fied nurse registration for advanced nurse practice
exists in Greece.
Professional nursing organisations have supported
the recognition of advanced nurse practice through
the mechanism of regulation in some countries and
voluntary certification in others. These systems have
evolved mainly due to the difficulty inherent in apply-
ing professional certification requirements to regula-
tory systems, including legal regulations, as these are
the responsibility of legislators and Boards of Nursing
(APRN 2012). There is a lack of consistency in regula-
tory systems, titles and professional awards resulting
in role confusion for the public, legislators, nurses and
health-care providers (Villegas & Allen 2012, Harris
& Ott 2013).
Research has demonstrated that outcomes from care
delivered by advanced nurse practitioners have
enhanced patient care in relation to level of satisfac-
tion, quality and access (Ritz et al. 2000, Green &
Davis 2005, Sheer & Wong 2008, Stanley et al.
2009, Gerrish et al. 2011). However, the regulation
of advanced practice has stalled or is not being con-
sidered in some countries for many reasons (Institute
of Medicine 2011, Duke 2012, Ellerbe & Regen
2012). The different titles and levels of education
being used to designate the advanced nurse practi-
tioner are contributing to the lack of official recogni-
tion of the role and to adversely impacting the
professional role.
Issues relating to role definitions and boundary blur-
ring are inhibiting the advancement of the nursing
profession globally as new roles are being taken on by
‘physician assistants’ who are carrying out a number
of clinical and administrative tasks, some of which
overlap with those of advanced practice nurses (Hor-
rocks et al. 2002, Laurent et al. 2005, Sidani et al.
2006). The main reasons put forward for the growth
of these assistant roles are related to cost containment
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6Journal of Nursing Management
M. Carney
by health-care managers in an effort to delegate tasks
away from more expensive doctors, thus developing
new physician assistant roles but also more advanced
roles for nurses, particularly in the United States, Uni-
ted Kingdom and Canada. A further cause is the real-
isation by managers that ANPs improve access to
care in the face of a limited or diminishing supply of
doctors, such as in Australia and Canada. Also, in
European countries, as a consequence of the Euro-
pean Union Working Time Directive, (HSE 2008)
advanced practice nurses (APNs) have taken responsi-
bility for routine patient care that was previously
undertaken by doctors, in an effort to reduce doctors’
workload and to provide continuity in health-care
Countries are reviewing the roles of health profes-
sionals including nurses in seeking to improve the
quality of health care delivered (Jones 2005, Gardner
et al. 2007, 2010) and consequently the expertise of
advanced practice nursing is being acknowledged
worldwide (Brooten et al. 2012), particularly in areas
such as chronic disease management (Sciamanna et al.
2006), primary care (Brown & Grimes 2005, Schober
2007), emergency nursing (Lloyd-Jones 2005, Meyer
& Miers 2005, Carter & Chochinov 2007) and cancer
care (Kleinpell 2005, 2013). This expertise is likely to
lead to the regulation of advanced nurse practice in
countries not currently regulating practice (Moore
2005, Hurlock-Chorostecki et al. 2008, Delamaire &
Lafortune 2010, Pulcini et al. 2010). Nurse practitio-
ners in Australia are being heavily invested in by the
Australian Government, through the Australian
Health Practitioner Regulation Agency 2013 (ANMC
Implications for nurse managers
Nurse managers need to know that regulation of
advanced practice nursing is in place, that criteria for
regulation have been developed and that these criteria
reflect the minimum requirements for safe and compe-
tent practice and are the least burdensome criteria
consistent with public protection (ANMC 2009). The
protection of the public is the key role in regulation.
Without regulation standards of care delivered by
advanced nurse practitioners are likely to differ. The
importance of an agreed definition and consistency in
the use of the term of advanced nursing practice will
assist nurse managers in making decisions regarding
the advanced practice role requirements of their or-
ganisations and in ensuring that the environments
advanced nurse practitioners work in are suitable for
delivering optimal outcomes for patients and clients
(Report of Prime Minister 2010, Royal College of
Nursing 2012). While regulators in the United King-
dom and Australia express the view that advanced
practice need not be regulated and that advanced
practice is the extension of the role of registered
nurses, the growth pattern and trajectory is difficult to
access because many of those new appointments and
roles are not based on a registerable qualification and
local differences often exist between job titles and
grades as well as varying levels of educational qualifi-
cation (ANMC 2009). Nurse managers will benefit
from the knowledge that advanced nurse practitioners
are continuing to take on new roles in acute and pri-
mary care settings (DiCenso & Bryant-Lukosius 2009,
Lindblad et al. 2010) with positive results (Meyer &
Miers 2005) and also that care delivered by advanced
practitioners continues to produce positive outcomes
for patients. Magnet hospitals report positive patient
outcomes, nurse autonomy and good working rela-
tionships between nurses and doctors (ACNP 2003,
American Nurses Association 2010).
Regulatory systems have been developed to authorise
advanced practice and professional certification for
licensing or registration. Regulation and regulatory
authority must work to protect public safety, yet most
European countries do not regulate advanced practice
or acknowledge the role. More discussion, debate and
research in the area would lead to a greater under-
standing of the role. Advanced nurse practitioners can
assist in the promotion of regulation for advanced
practice through articulation of the responsibilities to
the wider audience of health-care professionals, man-
agement and community, otherwise the confusion
around the role and its concepts, evident in many
countries, will lead to further splintering of the
advanced practitioner title, roles, functions and
The paper is part of a wider study. The author
acknowledges the support of senior executives in the
Nursing and Midwifery Board of Ireland (NMBI)
when discussing the content of the wider study. The
author also acknowledges the support of Dr Pidgeon,
CEO, NMBI; Dr Ryan, Chief Education Officer,
NMBI; Ms Neary, Education Officer, NMBI; Librari-
ans from NMBI and RCSI.
ª2014 John Wiley & Sons Ltd
Journal of Nursing Management 7
International regulation of advanced nurse practice
Source of Funding
The author also acknowledges the part funding
offered for the wider study by NMBI.
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International regulation of advanced nurse practice
Supporting information
Additional Supporting Information may be found in
the online version of this article:
Appendix S1. Regulation of advanced practice nurs-
ing in 19 countries.
Appendix S2. Summary of regulation across coun-
tries: differences and commonalities (1.1–1.12).
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... Regulatory frameworks for NPs include criteria for professional registration such as defining minimum standards of education and clinical practice standards (Carney, 2016). Internationally, there is a great diversity in implementing and regulating NP roles (Carney, 2016;Delamaire & Lafortune, 2010 International research by NPs reporting the outcomes of the services provided has been published (Begley, Murphy, Higgins, & Cooney, 2014;Donald et al., 2013;Jennings, Gardner, O'Reilly, & Mitra, 2015). ...
... Regulatory frameworks for NPs include criteria for professional registration such as defining minimum standards of education and clinical practice standards (Carney, 2016). Internationally, there is a great diversity in implementing and regulating NP roles (Carney, 2016;Delamaire & Lafortune, 2010 International research by NPs reporting the outcomes of the services provided has been published (Begley, Murphy, Higgins, & Cooney, 2014;Donald et al., 2013;Jennings, Gardner, O'Reilly, & Mitra, 2015). The literature, in relative terms, is scant in comparison with the number of NP positions internationally and the length of time the role has existed. ...
Full-text available
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.
... Prosjektet og den endelige evalueringen er ikke ferdig. Kunnskap fra prosjekt som er gjennomført i andre vestlige land, viser at også andre helsemyndigheter har arbeidet med rolleavklaring når det gjelder oppgave-og ansvarsfordelingen mellom helsepersonell og hvordan en best mulig kan utnytte kompetansen i primaerhelsetjenesten (Carney, 2016;Quallich et al., 2018). ...
Full-text available
Bakgrunn: Det er forventet at antall personer med komplekse helseproblem i primærhelsetjenesten vil øke i årene som kommer. Dette byr på vesentlige utfordringer når det gjelder å finne gode modeller for organiseringen i helsetjenestene. Hensikten med denne studien var derfor å undersøke hvilken rolle diabetessykepleiere i primærhelsetjenesten opplever at de har, og hvordan de erfarer at deres kompetanse blir brukt. Metode: Vi gjennomførte kvalitative intervju med åtte diabetessykepleiere i primærhelsetjenesten. Sykepleierne var invitert til å delta i telefonintervju i etterkant av en spørreskjemaundersøkelse blant medlemmer av Norsk Sykepleierforbunds Faggruppe for Diabetessykepleiere høsten 2017. Vi analyserte intervjuene ved bruk av tematisk analyse. Resultater: Vi identifiserte tre hovedtema som beskriver diabetessykepleiernes erfaringer: «Betydningen av en selvstendig og autonom rolle som diabetessykepleier», «Ulike roller og forskjellige forventninger» og «Varierende grad av samarbeid innad i kommunen og på tvers av tjenestenivå». Konklusjon: En nærmere avklaring av oppgave- og ansvarsfordeling mellom helsepersonell innad i kommunen og på tvers av tjenestenivå samt en mer hensiktsmessig bruk av ressursene vil kunne bidra til at avansert sykepleiekompetanse utnyttes bedre i primærhelsetjenesten.
... The role of the nurse practitioner has been defined by the International Council of Nurses (ICN) as an advanced practice nurse (APN) who integrates nursing and medical clinical skills, to assess, diagnose and manage patients in primary health care, acute care and chronic illness populations (ICN, 2020). The nurse practitioner role is identified as the most senior clinical nursing role across several countries and is supported with regulatory frameworks (Carney, 2016). ...
Background: Nurse practitioners are acknowledged as clinical leaders responsible for transforming healthcare delivery. It is important that Nurse Practitioners contribute to healthcare knowledge using scientific processes for the implementation of evidence-based practice and evaluation of outcomes of interventions for their patient groups. Evaluation: 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 healthcare 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.
... Emerging evidence has revealed that advanced nurse practitioners can provide comparable levels of care and achieve similar outcomes as physicians (both junior and senior clinicians / medical doctors) and, in some cases, attain superior outcomes with regards to patient satisfaction, waiting times, control of chronic disease, and cost-effectiveness. Although this position has been supported by the International Council of Nurses, Carney (2014) highlights that defining the distinctive nature of advanced nursing practice, recognizing the key competencies and capabilities of advanced nurse practitioners, and exploring facilitative strategies in maintaining, implementing. and supporting the role of advanced nurse practitioners worldwide, is still incrementally developing and on-going studies are needed to map and monitor ANP progression. ...
Aim To evaluate the effectiveness of the role of advanced nurse practitioners compared to physicians-led/ usual care (care managed by medical doctors or non-advanced nurse practitioners) Background Advanced nurse practitioners contribute to the improvement of quality patient care and have substantial potential to optimise the health of people globally. Since the formal recognition of advanced nurse practitioners by the International Council of Nurses, among others, the role has been adopted across most departments and clinical specialties, particularly in high-income countries. Design Systematic review of primary research evidence Data Source MEDLINE, EMBASE, CINAHL, Cochrane registry, Cochrane trials, and Cochrane EPOC (PDQ Evidence) were searched for randomised controlled trials (RCTs) of patient care and health resource utilisation outcomes associated with advanced nurse practitioners. Review Methods The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The chosen articles were restricted to full-text English language trials published in the last 20 years, incorporating comparators of usual care. Search terms were limited to variations of advanced nurse practitioner role and practice. The eligible studies were bias risk assessed and quality assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Clinical and service outcomes were analysed using narrative synthesis as the marked heterogeneity between studies precluded meta-analysis. Results Thirteen RCTs were reviewed. All of them were conducted across high-income countries within primary care and hospital settings involving paediatric and adult patients. Five trials were assessed as high quality, and eight were of low to moderate quality. Positive effects were demonstrated for the impact of advanced nurse practitioners on usual care; for indigestion, mean difference [MD] 2.3: 95% CI 1.4, 3.1]), perceptions of health status [ (MD –140.6; 95% CI –184.8, –96.5)], satisfaction levels [ (MD ranged from –8.79; 95% CI –13.59, –3.98 to 0.61; 95% CI –4.84, 6.05)], physical function (1.58 [SD 0.76] v. 1.81 [SD 0.90]), and blood pressure control (systolic [133 [SD 21] v. 135 [SD 19] mmHg p = 0.04] and diastolic [77 [SD 10] v. 80 [SD 11] mmHg p = 0.007]) were looked at. Positive effects related to service provision included improved patient satisfaction and reductions in waiting times and costs, which significantly favoured advanced nurse practitioners (all p < 0.05). Conclusion The evidence of this review supports the positive impact of advanced nurse practitioners on clinical and service-related outcomes: patient satisfaction, waiting times, control of chronic disease, and cost-effectiveness especially when directly compared to medical practitioner-led care and usual care practices - in primary, secondary and specialist care settings involving both adult and paediatric populations.
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. 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. 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. 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. 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. 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. 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.
This chapter is focused on an in-depth review of the influences and impact of the APN role worldwide and is the beginning of the process of understanding the APN role with an intent of providing insight into who the APN student will become as APN. This chapter will aid in the differentiation of the APN role from other nursing roles. The APN role has identified assumption, characteristics, responsibilities, scope of practice, and core functions. Each will be discussed and applied to the structured APN role transition process. The common universal influences on the development of the APN include the sociopolitical environment, health needs of the country, the supply and demand of available healthcare workers, status of collaboration within nursing and other healthcare providers, and the development of the APN workforce within the country. The intent of this chapter is to expand the student’s knowledge of the APN role and how the role works in their country and start the introspective work of a structured process for APN professional identity through role transition.
Health care organisations in many countries are developing advanced clinical practitioner roles to address workforce shortages and growing demand for services. Even in countries where advanced practice roles are more established there are low numbers, clustered in a limited range of professions, mostly nursing specialities. Successful implementation of national policies encouraging increased advanced practice roles and from a broader range of professions, requires attention to all levels of the health system. There is a lack of evidence as to the motivation to take-up these roles at the micro, individual actor level. This study explored the motivations important at the micro level in influencing a range of health professionals to undertake advanced practice roles. The study used an interpretive methodology with thematic analysis and was framed by theories of motivational domains in the work environment. Semi-structured interviews were undertaken with eighteen advanced clinical practitioners working in health care organisations in England. The motivators for role take-up were found to be predominantly intrinsic reflecting participants’ desires for advancement, both personal and for their profession, and improved efficiency of patient care. Participants described experiencing limited organisational support and sometimes discouragement from other professionals. There is potential for health organisations at the meso level of health care systems to support national growth of advanced practice roles by giving attention to the motivations of diverse health professionals. We propose a new theoretical framework of motivators for advanced clinical practice role uptake at the micro level.
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:
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.
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This article examines the nature of advanced nursing practice. It identifies confusion around the terms of advanced nurse practitioners (ANPs), nurse practitioners and specialist nurses, and identifies what advanced practice is. The history of how ANPs evolved is discussed from its haphazard development to a more organised approach. Current advanced practice is identified, along with NHS plans for nurse development. Law, ethics and professional accountability are examined in relation to the additional responsibility ANPs have. Finally, the author's role as an ANP is considered within the context of primary care and NHS reforms.
Just as boards of nursing (BONs) operationalize statutes specific to states' rules and regulations within their nurse practice act, Congress provides the U.S. Department of Veterans Affairs (VA) with the power and authority to regulate the professional activities of its health care practitioners under Title 38 of United States Code. Under this authority, the VA establishes qualifications for nurses and regulates their professional conduct. This article presents a demographic overview of VA registered nurses, nurse practitioners, and clinical nurse specialists; nursing practice standards and elements; the appointment, credentialing, and peer review of VA professional nurses; advanced practice registered nurse privileging; reporting and responding to BONs; and the related processes that ensure public safety.
Objective: To determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting. Design: Systematic review of randomised controlled trials and prospective observational studies. Data sources: Cochrane controlled trials register, specialist register of trials maintained by Cochrane Effective Practice and Organisation of Care Group, Medline, Embase, CINAHL, science citation index, database of abstracts of reviews of effectiveness, national research register, hand searches, and published bibliographies. Included studies: Randomised controlled trials and prospective observational studies comparing nurse practitioners and doctors providing care at first point of contact for patients with undifferentiated health problems in a primary care setting and providing data on one or more of the following outcomes: patient satisfaction, health status, costs, and process of care. Results: 11 trials and 23 observational studies met all the inclusion criteria. Patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). No differences in health status were found. Nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. No differences were found in prescriptions, return consultations, or referrals. Quality of care was in some ways better for nurse practitioner consultations. Conclusion: Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care. What is already known on this topic What is already known on this topic Nurse practitioners have existed in North America for many years An increasing number of such nurses are being employed in the United Kingdom in general practice, emergency departments, and other primary care settings Reviews suggest that nurse practitioners are equivalent to doctors on most variables studied, but the relevance of this in the context of the NHS is unclear
Changes occurring in the healthcare environment require healthcare delivery systems to provide high quality care services with increased efficiency and cost-effectiveness. Healthcare systems are encouraged to use less expensive care providers for medical management responsibilities while maintaining or increasing quality of patient care. Accompanying the changes in healthcare delivery modes is the parallel rise in patient acuity levels related to chronic illnesses of patients admitted for cardiac services such as cardiovascular surgeries. This retrospective, 2-group comparison study examined patient and economic outcomes between 2 groups of adult patients for whom postoperative cardiovascular care was directed by either cardiovascular surgeons alone or cardiovascular surgeons in collaboration with acute care nurse practitioners. Outcome measures included length of stay and cost for an episode of care. Findings revealed that when cardiovascular surgeons, in collaboration with acute care nurse practitioners, directed postoperative care, the length of stay decreased 1. 91 days and total cost decreased $5,038.91 per patient.
Organizations, health systems, and interested individuals globally are assessing and investigating issues related to community health care services, home health management, and advanced nursing practice. Scarcity of financial and human resources has motivated health care policy makers to rise to the challenge to explore skill mix in the health care workforce in the hope of improving multidisciplinary collaboration in the provision of care for the world's populations. Nurses with advanced knowledge and skills are at the forefront of providing health care in home-based and community settings. This article describes the extent of this global phenomenon as it relates to advanced nursing practice and identifies a variety of international strategies utilized to introduce advanced practice nurses into health care systems.
Advanced practice registered nurses (APRNs) have the unique potential to affect the changing needs of health care in the United States, but are restricted in care provision by varying state regulations and reimbursement policies. Although research shows APRN care to be safe, cost-effective, and of high quality, most medical professional organizations continue to oppose the removal of scope-of-practice barriers, citing patient safety concerns. Nursing organizations at the state and national levels have already begun to invest the time and resources needed for policy change. However, empirical evidence of APRN quality of care must be shared with policymakers, funding entities, and the public. Additionally, support must be garnered from the public and other health care disciplines. Scope-of-practice policy change will occur through the emergence of strong individuals within nursing professional organizations and the joining together of organizations to form one voice.
The current health care environment has heightened the importance of achieving positive patient outcomes and excellent customer satisfaction. To remain competitive, health care organizations must adapt quickly to changing regulatory requirements, quality improvement initiatives, and customer expectations. To ensure nursing practice at the Saint Clare's Health System in Northwest New Jersey is at the forefront of leading change, the nursing staff has embraced the Institute of Medicine report The Future of Nursing: Leading Change. The empowered nursing team has applied Benner's Novice to Expert model and McCauley's Careful Nursing Theory as the foundation for nursing practice. The ability to apply evidence-based nursing research and cultivate professional development at the bedside has resulted in retention of expert nurses at the bedside. Engaging the nursing team has resulted in increased patient satisfaction and improved clinical outcomes. Advanced practice nurses play an important role to mentor the nursing staff and promote an interdisciplinary, collaborative relationship between all health care disciplines and community support programs. Nurses are recognized for their accomplishments and encouraged to obtain specialty certification, advanced degrees, and earn state and national recognition through professional organizations. The professional nurses at the Saint Clare's Health System are prepared to work in whatever environment the new normal creates.