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Advanced Practice in Nursing
Under the Auspices of the International Council of Nurses (ICN)
Series Editor: Christophe Debout
SophiaL.Thomas
JackieS. Rowles Editors
Nurse Practitioners
and Nurse
Anesthetists:
TheEvolution
oftheGlobal Roles
Advanced Practice in Nursing
Under the Auspices of the International
Council of Nurses (ICN)
Series Editor
ChristopheDebout
GIP-IFITS
Health Chair Sciences- Po Paris/IDS UMR Inserm 1145
Paris,France
This Series of concise monographs, endorsed by the International Council of
Nurses, explores various aspects of advanced practice nursing at the international level.
The ICN denition provided in the Guidelines on Advanced Practice Nursing
2020 (ICN, 2020) has been adopted for this series to dene advanced practice
nursing: “A Nurse Practitioner/Advanced Practice Nurse is a registered nurse who
has acquired the expert knowledge base, complex decision-making skills and
clinical competencies for expanded practice, the characteristics of which are shaped
by the context and/or country in which they are credentialed to practice.” (ICN,
2020, p. 6). A Master’s degree is required for entry level.
At the international level, the three most common levels of advanced practice
nursing include three levels of clinical practice:
Nurse practitioners (NPs) are advanced practice nurses who have integrated clinical
skills associated with nursing and medicine in order to assess, diagnose and manage
patients usually in primary healthcare (PHC) settings and acute care populations as well
as ongoing care for populations with chronic illness (ICN, 2020). NPs usually have
prescriptive authority and can make referrals to other healthcare professionals. Clinical
nurse specialists (CNSs) provide expert clinical advice and care based on established
diagnoses in specialized clinical elds of practice along with a systems approach in
practicing as a member of the healthcare team (ICN, 2020). Nurse Anesthetists (NAs)
who are dened by the 2021 ICN Guidelines: A Nurse Anesthetist is an Advanced
Practice Nurse who has the knowledge, skills and competencies to provide individualised
care in anesthesia, pain management, and related anesthesia services to patients across
the lifespan, whose health status may range from healthy through all levels of acuity,
including immediate, severe, or life-threatening illnesses or injury (ICN, 2021).
The scope of practice and responsibilities that dene these three categories of
advanced practice nurses includes ve interrelated components:
– Clinical practice
– Consultation
– Education
– Leadership
– Research
The monograph Series addresses four topics associated with advanced practice
nursing:
– APNs in clinical practice (NPs, CNSs, NAs)
– Education and continuous professional development for advanced prac-
tice nurses
– Coordination and implementation issues related to advanced practice nursing
– Policy and regulation for advanced practice nursing
The contributing authors represent international experts in their eld along with
representation from the ICN Nurse Practitioner/Advanced Practice Nurse Network.
They include clinicians, educators, policymakers and researchers.
Each book within the series reects the fundamentals of nursing which provides
the foundation for advanced practice nursing. The aim is to promote evidence-
informed advanced practice nursing.
Sophia L. Thomas • Jackie S. Rowles
Editors
Nurse Practitioners and
Nurse Anesthetists: The
Evolution of the Global
Roles
Editors
Sophia L. Thomas
DePaul Community Health Center
New Orleans, LA, USA
Jackie S. Rowles
School of Nurse Anesthesia
Texas Christian University
Fort Worth, TX, USA
ISSN 2511-3917 ISSN 2511-3925 (electronic)
Advanced Practice in Nursing
ISBN 978-3-031-20761-7 ISBN 978-3-031-20762-4 (eBook)
https://doi.org/10.1007/978-3-031-20762-4
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
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the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of
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mission or information storage and retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specic statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
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claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
v
Preface
Through the generations, nurses have provided compassionate care through calami-
ties including wars, famine, natural disasters as well as tending to the needs of those
individuals who would otherwise go without care and succumb to illness and
injuries.
The history of the global evolution of nursing begins at the dawn of time. To the
modern observer, it is unfathomable to recognize the times in which nurses were not
allowed to use a stethoscope, give an injection, or draw blood. Those tasks, and
countless more, were historically deemed as part of the role of physicians. In the
twenty-rst century, the role of the nurse has grown and expanded to meet the
healthcare needs of communities around the world. Advanced practice nursing
(APN) has increasingly allowed nurses to practice to the full scope of their educa-
tion and competencies. This includes the ability to assess, diagnose, treat, prescribe,
provide anesthesia, anesthesia-related care and pain management for patients of all
ages across the healthcare spectrum. The education and recognition of APNs whose
competencies include complex decision-making with advanced skills and care man-
agement has resulted in nursing-led transformative care which has improved health-
care access and outcomes globally. Nurses are the largest segment of the healthcare
workforce. Numerous research studies have proven that utilization of APNs allows
for increased access to quality care. No prior texts have successfully chronicled the
multiple aspects of these two APN roles while providing detailed illustrations of the
roles’ infancy and growth in countries throughout the world.
In 1877, the rst nurse to specialize in anesthesia care paved the way for advanced
practice nursing, and in 1965, the rst nurse practitioner educational program was
founded. Throughout early history, many brave pioneers made contributions which
spearheaded nursing to be an essential and foundational role in healthcare. In Nurse
Practitioners and Nurse Anesthetists: The Evolution of the Global Roles, the reader
will gain insight into the history of these two transformative and impactful APN
roles through the contributions of international authors who represent every World
Health Organization Region of the world. Topics of discussion include licensure,
practice, education, research, challenges, and impacts of these advanced prac-
tice roles.
Analysis of global role development illustrates the inuence on healthcare from
disasters to battleelds; clinical practice in urban and remote environments; the
evolution of academic education growth and opportunities, as well as Nurse
vi
Practitioner and Nurse Anesthetist roles as educators, researchers, and leaders. Role
development varies between countries and geographical areas based on economic
resources, available education, and governmental regulation and recognition.
Admittedly, countries have varied levels of acceptance and incorporation into the
healthcare system ber. Throughout history, nurses have faced many challenges to
their ability to practice to the full scope of their education, training, and competen-
cies. These challenges continue today and hinder the advancement of nursing to its
full potential in nearly all countries and all practice settings. It is our hope that this
book will not only provide the reader with a detailed view of the contributions of
Nurse Practitioners and Nurse Anesthetists to global health, but will also result in
progression of the roles through removal of unnecessary burdens and barriers to
practice, allowing patients access to essential healthcare services including increased
access to anesthesia and surgical services.
New Orleans, LA SophiaL.Thomas
Fort Worth, TX JackieS.Rowles
Preface
vii
Part I The Role of the Nurse Practitioner
Evolution in Healthcare: The Journey from a US Demonstration
Project to an International Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Barbara Sheer
The Global Emergence of the Nurse Practitioner Role . . . . . . . . . . . . . . . . . 41
Madrean Schober
Differentiation of International Advanced Practice
Nursing Roles: NP and CNS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Madrean Schober
Nurse Practitioner Education and Curriculum: A US Focus . . . . . . . . . . . . 69
Elizabeth Miller Walters, Tracy Vernon-Platt, Ashley Kellish,
Manisha Mittal, and Sean DeGarmo
NP Practice Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Mary Beth Bigley, Elizabeth Miller Walters, Joshua Evans,
and Sean DeGarmo
The Nurse Practitioner as a Leader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Joyce Pulcini, Nancy Street, and Steven Purcell
The NP and Research: A Global Perspective . . . . . . . . . . . . . . . . . . . . . . . . . 103
Patricia F. Flannery Pearce
Nurse Practitioner Outcomes Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Ruth Kleinpell, April N. Kapu, Brigitte Woo,
and Zhou Wentao
Part II NP Country Exemplars
The Nurse Practitioner in the USA: Role Exemplars . . . . . . . . . . . . . . . . . . 131
Mary Ellen Roberts and Joyce Knestrick
The NP Role and Practice in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Minna Miller, Natasha Prodan-Bhalla, and Stan Marchuk
Contents
viii
The Nurse Practitioner Role and Practice in Jamaica . . . . . . . . . . . . . . . . . 157
Heather McGrath
The Evolution of the Nurse Practitioner Role and Practice
in the United Kingdom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Melanie Rogers and Annabella Gloster
The NP Role and Practice in Finland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Anna Suutarla, Virpi Sulosaari, and Johanna Heikkilä
The Nurse Practitioner Role in Ireland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Daniela Lehwaldt and Emily B. Lockwood
Nurse Practitioner Development in German-speaking Countries:
Germany, Austria, and Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Elke Keinath, Andreas Dirksen, Daniela Lehwaldt,
Manela Glarcher, Roland Essl-Maurer, Christoph von Dach,
Christian Eissler, and Maya Zumstein-Shaha
The Nurse Practitioner Role and Practice in Botswana . . . . . . . . . . . . . . . . 225
Deborah C. Gray, Mabedi Kgositau, and Gaonyadiwe Lubinda-Sinombe
Nurse Practitioner Role in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Rachel Wangari Kimani and Eunice Ndirangu-Mugo
The Nurse Practitioner Role in Tanzania . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Joseph Kilasara Trinitas and Jane Blood-Siegfried
The Evolution and Future of Nurse Practitioners in New Zealand . . . . . . . 255
Sue Adams and Jenny Carryer
Transforming Healthcare: The Australian Nurse
Practitioner Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Christopher Helms and Leanne Boase
The Nurse Practitioner (NP) Role in Sri Lanka . . . . . . . . . . . . . . . . . . . . . . . 279
Sujeewa Dilhani Maithreepala
and Sriyani Padmalatha Konara Mudiyanselage
Advanced Nursing Practice in the Kingdom of Saudi Arabia . . . . . . . . . . . 287
Siobhan Rothwell
Why Pakistan Needs Advanced Nurse and Advanced Midwife
Practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Rafat Jan, Arusa Lakhani, Abeer Musaddique,
and Yasmin Nadeem Parpio
The Future for International NP Role Development . . . . . . . . . . . . . . . . . . . 303
Madrean Schober
Contents
ix
Part III The Role of the Nurse Anesthetist
Challenges to Global Access to Anesthesia and Surgical Care . . . . . . . . . . . 313
Richard Henker and Mai Taki
The International Federation of Nurse Anesthetists: Past,
Present, and Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Pascal Rod
Global Development of Nurse Anesthesia Education from
Mid- Nineteenth Century into Today’s Advanced
Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Marianne Riesen, Jaap Hoekman, and Karin Björkelund
Nurse Anesthesia Recognition: Practice Challenges,
Credentialing, and Title Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Sandra Maree Ouellette and Susan Smith Caulk
Universal Health Coverage and Nurse Anesthetists . . . . . . . . . . . . . . . . . . . 383
Janet A. Dewan and Aaron K. Sonah
Nurse Anesthetists in Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Jackie S. Rowles and Christophe Debout
Nurse Anesthetists: Sharing Our Caring . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Vera Meeusen, Sari Pyhälä, David Gaskin, Richard Henker,
Mohamed Abdi Abdilaahi, Thorunn Scheving Eliasdottir,
Lera Borg Ásmundsdóttir, Semia Bouzid, Christophe Debout,
Syah Insyah, Mohammed El Mouhajir, and Dorte Söderberg
Contents
Part I
The Role of the Nurse Practitioner
3
Evolution inHealthcare: TheJourney
fromaUS Demonstration Project
toanInternational Concept
BarbaraSheer
Introduction
The roots of the nurse practitioner (NP) movement are in public health nursing. This
chapter will briey review the history of public health nursing and the forces that
led to the creation of the nurse practitioner role, the concept of the expanded role,
and the geopolitical climate that made the nurse practitioner movement possible. It
will discuss the challenges of the expanded role in terms of acceptance from nursing
and medicine and explore the issues related to education, titling, scope of practice,
reimbursement, and prescribing. It will also describe how the evolution of the role
in the United States impacted the international movement and how networking fos-
tered a global phenomenon.
History ofNurses inPublic Health
Nursing has a long rich history. Florence Nightingale is known as the founder of
modern nursing. She revolutionized care during the Crimean War in the mid-
nineteenth century by establishing principles of cleanliness, light, rest, and nutri-
tion. Nightingale, an early epidemiologist, utilized statistics and was able to quantify
A small body of determined spirits red by an unquenchable
faith in their mission can alter the course of history.
—Mohandas Gandhi
B. Sheer (*)
Emeritus University of Delaware, Newark, DE, USA
e-mail: sheer@udel.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_1
4
the differences that “trained nurses” made in decreasing morbidity and mortality
during the war. After her experience in the Crimea, she established schools of nurs-
ing in the United Kingdom. Her model of training was followed in the United States
when early schools of nursing were established [1].
Throughout history other notable gures have provided models of healthcare that
had a signicant impact on populations in need. In 1893 Lillian Wald took on social
issues related to health with the development of the Henry Street Settlement. She
hired a small group of nurses to visit the tenements and improve living conditions to
make life better for the poor immigrants of NewYork City, living in deplorable
conditions. The nurses provided basic care, nourishment, and education. Convinced
that disease is caused by social issues such poverty, overcrowding, and poor sanita-
tion, the nurses took on social issues as the root cause of disease. This was the
beginning of population health which Wald described as public health nursing. Care
not only focused on disease but also on prevention of disease [1].
In rural Appalachia, access to healthcare was difcult if not impossible. Limited
access resulted in a high morbidity and mortality rate for women and children. Mary
Breckenridge recruited a group of midwives who went on horseback to care for women
and children in their homes and in the community. Nurses carried supplies in their sad-
dlebags, assisted in deliveries, and offered primary care services. This was the beginning
of the Frontier Nursing Service founded 1925. The midwifery service later expanded to
include primary care in the home, clinics, and later the hospital. This small group had a
profound effect on morbidity and mortality of the population in a rural community [2].
Others had an impact on local, state, and even national levels usually caring for
underserved populations, but the most profound impact has been the evolution of
the nurse practitioner movement attributed to Dr. Loretta Ford and Dr. Henry Silver,
which began as a demonstration project at the University of Colorado in 1965.
In the United States and elsewhere, it has long been recognized that all citizens do
not have equal healthcare access, and many do not receive basic services such as pre-
vention, screening, education, and other aspects of public health. Many times, this lack
of services affects vulnerable members of the population, such as pregnant women and
children. The national model of healthcare within the United States following the
Second World War developed an increasing focus on hospital-based care. Physicians in
the United States lobbied for the legal privilege to lead care teams and became increas-
ingly elevated in their social and economic status. Physician-driven models of care
based on pathology and procedures became ingrained in reimbursement designs.
During the 1960s, national social movements such as Vietnam War resistance and the
women’s rights movement caused more people to question prevailing models in many
areas of life, not the least of which was access to basic healthcare services.
Early Development ofExpanded Role
Although Loretta Ford RN, PhD, and Henry Silver MD are credited as the
founders of the nurse practitioner movement, a forerunner of this project was
established in 1958, at Duke University [3]. Thelma Ingles RN and Eugene
B. Sheer
5
Stead MD, Chair of the Department of Medicine, developed the rst masters
clinical nurse specialist program in primary care. The program ended a few
years later when it failed to gain National League for Nursing (NLN)
Accreditation after several attempts. At the time the NLN leadership believed
the program was medically oriented and that medical tasks performed by nurses
were dangerous [4].
This was also a time when navy corpsman and medics were exploring ways to
utilize their skills in a civilian capacity. Since nursing offered no avenue to build
on previous experience, the Ingles/Stead Program was revised and became the
rst physician assistant program in the nation. The program was designed to
expand the scope of practice and build on the skills of the corpsmen, to work
under the direct supervision of a physician. The program was expanded to the
northwest in 1968, as the Medex program sponsored by the University of
Washington School of Medicine and the Washington State Medical Association.
The program only admitted corpsman until 1974, when they began admitting
nurses. Physician assistants working under the direct supervision of physicians
became a new professional category of healthcare provider recognized nationally
and internationally [5].
A Demonstration Project
Loretta Ford PhD and Henry Silver MD developed a demonstration project in
1965 at the University of Colorado. This was in response to a manpower shortage,
maldistribution of healthcare resources, escalating costs, and a desire for nurses to
expand their practices. The intent of the program was to provide nurses additional
skills to provide quality healthcare to children who lacked access or affordable
healthcare. The demonstration program was rst offered as continuing education
and was viewed as an extension of the role of the public health nurse. Dr. Ford had
been a public health nurse in rural Boulder County where she found unmet needs
in primary healthcare particularly for children. In many cases she was the sole
provider. She realized that with advanced skill an expanded role for nurses was
possible [6]. The program had modest beginnings and as a continuing education
program did not need NLN accreditation. By 1967 Ford and Silver published
articles in both nursing and medical journals [6]. They documented outcomes and
were transparent in talking about the program to everyone that would listen and
offered visits to anyone interested. The visits became so popular that they turned
into conferences.
The concept met with resistance from nurse educators and physicians. The nurses
and nurse educators believed that nursing education would be controlled by physi-
cians and nurses would become “mini doctors.” Physicians initially feared lack of
patient acceptance and later were more concerned about the competition. The initial
outcome data indicated patient acceptance and that nurse practitioners could deliver
quality primary care to infants and children.
Evolution in Healthcare: The Journey from a US Demonstration Project…
6
Geopolitical Factors Facilitating Healthcare Revolution
There were many factors facilitating the success of the expanded role for nurses.
The healthcare system was undergoing signicant changes. The Hill Burton Act
of 1946 nanced the building of new hospitals. Hospitals were becoming more spe-
cialized as new technology and treatments were available. Medicare and Medicaid
passed in 1965 ensured the ow of money into hospitals. Nurses were becoming
more specialized as critical care units evolved [7].
New technology required expanded skills and decision-making authority for the
nurses in these specialized units. Hospital care became more specialized as new
technology and treatments were developed. The Social Security Act Amendments
of 1965 created the Medicare and Medicaid programs, two taxpayer-subsidized
national health insurance entitlement programs, that supported and advanced the
nancial viability of the hospital-based model of care. At the same time, nurses
were becoming more specialized as critical care units evolved [6]. New technology
required expanded skills and decision-making authority for the nurses in these spe-
cialized units.
Medical schools were focusing on the need for high-tech specialty care. Fewer
physicians were electing to go into primary care or general practice. Residencies for
physicians were expanding to the benet of hospitals, and the specialty practices
ensured a more lucrative income for physicians. Between 1950 and 1970, the medi-
cal workforce increased from 1.2 to 3.9 million, and the national healthcare expen-
ditures rose from 4.5 to 7.3% of the GNP [8].
The Kennedy administration took up the cause of community care, followed by
President Johnson’s Great Society and the war on poverty. Nationalized healthcare
programs such as Medicare and Medicaid greatly increased the demand for health-
care services, leading to spiraling healthcare costs and provider shortages. The
shortages were particularly acute in underserved populations. The concept of com-
munity healthcare in low-income areas as one-stop shopping became popular, but
stafng these centers was problematic [8].
Society was undergoing social upheaval. The Vietnam War was very unpopular.
As more young men were being drafted, there was growing discontent throughout
the nation particularly on college campuses. A counterculture evolved protesting
conventional values. It was a time of individual liberation and a ght for civil rights.
Women’s rights advocates like Betty Friedan and Gloria Steinem questioned the
traditional roles of women. The chaos was a time of opportunity. Nurses became
more empowered, and the time was right for change [8].
Expansion ofNurse Practitioner Programs
The initial success of the nurse practitioner program in Colorado led to the expan-
sion of programs in the northeast. The Bunker Hill—Massachusetts General NP
program began a short-term certicate, and around the same time, the Boston
College-Harvard Macy program began offering masters-level graduate nurse practi-
tioner programs [8]. With the expansion of the nurse practitioner role from
B. Sheer
7
pediatrics to family, programs also expanded to ll that need with the rst Family
Nurse Practitioner program initiated at the University of Washington in 1971.
Another demonstration project funded by the University of California Davis
trained nurse practitioners and family physicians together to practice in rural areas
in California. Simultaneously, the Tuskegee Institute prepared a nurse practitioner
and a technician to go to rural counties in a van to provide primary care to rural
areas in the south. These projects demonstrated the value of the nurse practitioner in
rural areas [9].
Programs and specialties continued to expand and become more specialized. The
rst adult nurse practitioner program to care for adults with chronic disease was
developed at the University of Kansas [10]. Women’s health programs were initi-
ated at multiple levels from short-term certicate programs to master’s degrees.
Most of the initial nurse practitioners were educated at the certicate level. Many
have basic nursing at the diploma or associate degree level. The differences in basic
education would later create some challenges.
In another demonstration project, physicians and nurses at Hartford Hospital in
Connecticut developed a 16-week program for nurse practitioners in obstetrics and
gynecology [11]. The program was so successful they decided to additionally pre-
pare family planning nurse practitioners.
The Planned Parenthood Federation of America also created in-house programs.
The Planned Parenthood programs did not include prenatal content and were not
recognized by many states. The graduates from the Planned Parenthood programs
were employed in Planned Parenthood centers and functioned under specic proto-
cols. Governmental funding in the form of Title X assisted the programs to become
standardized, offering 16weeks of intensive education [10].
When certication was established, Planned Parenthood programs were the last
to require a master’s degree. Many of the nurse practitioner providers were educated
at the diploma and associated degree levels. Often, they were from the community
and culturally competent. Salaries were lower and the nurse practitioners functioned
under protocols. Requiring a master’s degree presented an additional burden to nd
nurse practitioner providers for the programs, providing a needed service often in
underserved areas and populations.
There were additional challenges to role expansion. Healthcare was changing in
the hospital setting and primary care was being left behind. The roles of physicians
and nurses and their relationship were also changing, challenging the status quo.
Challenges toRole Expansion
The paradigm of healthcare was changing. Hospital care was increasing in com-
plexity, and physicians were gravitating to specialty practice and utilizing newer
technology. Medical education focused on the diagnosis and treatment of disease.
This focus on pathology was referred to as the curing part of healthcare. Nurses, by
contrast, focused on care which included biopsychosocial issues. They took a more
holistic approach to caring for individuals, families, and communities. Considering
these trends, adding advanced assessment skills to a nursing curriculum seemed a
Evolution in Healthcare: The Journey from a US Demonstration Project…
8
logical solution to expanding nursing practice and delivering primary care particu-
larly to underserved populations. In that context, it was surprising that initially the
major challenges came from other nurses and physicians. The public was accepting
the new role and outcome studies were very positive. Becoming accepted was only
the rst hurdle for new practitioners, yet to come were issues of education, titling,
scope of practice, reimbursement, and prescribing.
Nursing Opposition
Lack of support from nursing faculty at the University of Colorado came as a sur-
prise to Dr. Ford. The initial nurse practitioner program was a demonstration project
that enabled nurses with additional skills to expand their practice to provide care for
underserved children. The program was practice oriented in the clinical area.
Tenured faculty were threatened by the change in status quo. Traditional research
valued by universities for promotion did not involve being in the clinical area. The
new role created a need for clinical and applied research being incorporated into the
curriculum as another educational tool [12]. This change in the traditional paradigm
created an uncomfortable situation for tenured faculty.
The nurse practitioner program was evaluated by a social scientist specialist in
the theory of change and resistance. According to Dr. Ford, they utilized the theory
of change to understand and develop strategies, logistics, and tactics to seek valida-
tion in what they were doing [12]. In response, Drs. Ford and Silver decided trans-
parency was the best strategy. Rather than asking permission, they went to the Board
of Nursing and the Board of Medicine to explain the program. At that time Dr. Ford
was in fact on the Board of Nursing. Communication was key. They published,
hosted events, and invited others to see what they were doing. According to Dr.
Ford, they even had a dentist from New Zealand visit to explore the model for appli-
cability to dentistry in New Zealand. Dr. Esther Lucille Brown, author of “Nursing
for the Future,” visited and proclaimed, “I have witnessed nursing in the nest.” Dr.
Ford said this only made things worse [12].
The reluctance of nurses to accept the expanded role may be seen from nursing’s
historical roots [13]. Since the Victorian era nursing has been predominantly a
women’s profession. Even Florence Nightingale whose contributions accomplished
signicant social and political changes frequently acted from the shadows of seclu-
sion, as the sociopolitical environment was not ready for advanced advocacy from a
woman. Instead of voicing her arguments directly, she became adept at convincing
her inuential male counterparts to help present her ideas to Parliament. In this way
she was able to maintain the ladylike image of the Victorian woman as her proposals
for healthcare reform in the United Kingdom were approved, and her school at St
Thomas Hospital was funded.
Similarly, initial schools of nursing were based on an apprenticeship model and
attracted lower-income women, while physicians were being educated in universi-
ties and claimed a higher status. These distinctions were apparent in both practice
and social constructs. For example, in the hospital setting, the physician wrote
orders, and orders were followed by nurses without question. Nurses were taught to
B. Sheer
9
stand when a doctor entered the room or give up their seat [13]. These practices
continued in some areas until the 1990s. As nursing moved from the apprenticeship
model to the university level, nurses were better prepared with a scientic back-
ground, and the social divide was less apparent.
These patterns of behavior are described in detail by Stein who coined the phrase
“the doctor-nurse game,” which is a concept that has persisted and been revisited
many times over the years [13–15]. In this “game” the physician makes the decision,
but the nurse who has direct contact with the patient has additional knowledge. The
nurse therefore makes indirect suggestions for the care, in a way that the physician can
explore additional information. The physician then makes the desired decision. This
social dynamic allows the physician to remain in power, and the nurse does not have
the responsibility for the action. The nurse is ultimately able to achieve the desired
outcome without challenging authority. The patriarchal hierarchy was maintained.
The advent of the women’s movement in the 1960s was accompanied by a call
for action to stand up and challenge inequality. While women across the nation were
becoming more empowered and were ghting for equal rights, many in the tradi-
tional roles of teaching and nursing felt left behind in this revolution. While the
leaders of the movement sought to balance the inequalities, they experienced resis-
tance from the ingrained attitudes of the traditional nurses in leadership positions,
which created conict and cognitive dissonance. Nursing leaders who embraced the
traditional role were comfortable and did not see a need for an expanded role that
required additional responsibility and increased autonomy. They were not activists;
they were comfortable with the status quo and did not want to become what some
were calling “mini doctors.” Many viewed expanded practice with physical assess-
ment as an abandonment of the nursing role in favor of a medical role. Nurse educa-
tors often echoed this belief since initial programs were taught and precepted by a
combination of nurses and physicians. From the traditional perspective, nurse prac-
titioners were moving into the medical domain and trying to be “mini doctors”
without the benet of medical school [11].
Resistance could also be seen in other ways that were not subtle. In some of the
pediatric clinical areas where nurse practitioners and physicians were employed,
nurses refused to work in collaboration with nurse practitioners [12]. Nurses
weighed, measured, set up patients in an examination room, and gave immuniza-
tions and medications for the physicians. However, nurse practitioners were
expected to complete the entire visit without any assistance. Practicing in the dual
role of nurse and nurse practitioner, they were expected to do everything needed for
the visit. Lack of support from staff nurses created a less nurturing environment for
the pioneers who believed the new role was in fact an expansion of nursing [12].
Nurses who embraced the role saw the nurse practitioner role as an expansion of
the role of the public health nurse and within the scope of nursing [15–17]. A deni-
tion of the role of the nurse practitioner was published by the American Nurses
Association (ANA) in 1974 [18]. The role was dened as a registered nurse with
advanced skill who provides direct care utilizing the nursing process, working in a
collegial and collaborative relationship with other healthcare professionals. In this
denition the nurse practitioner is rst and foremost a nurse, practicing within their
scope of practice.
Evolution in Healthcare: The Journey from a US Demonstration Project…
10
Physician Opposition
The initial concept of the Ford-Silver program was to have masters-prepared nurses
functioning in collaborative roles with physicians. The nurse practitioners would
provide comprehensive well child care and manage common illnesses of childhood
affording the physician time to care for more complex sick children [14]. They were
to work in multiple settings including underserved areas. The nurse-doctor relation-
ship was to remain the same with the physician in control.
The success of the program became a problem for the doctor-nurse relationship.
Nurse practitioners moved into other specialty areas such as women’s health and
adult in-patient care, which physicians were previously seen as the only possible
healthcare provider. Multiple studies were done on patient acceptance and quality of
care [18]. The initial quality of care studies compared physicians and nurse practi-
tioners on various components. Although many of the early studies were awed,
they overwhelmingly supported the quality of care was at least equal and, in some
cases, better than the quality of care received by physicians. This opened the door
for perceived competition.
A landmark study was conducted by the US Government Ofce of Technology
Assessment (OTA) in 1986 [19]. The OTA study concluded that nurse practitioners,
physician assistants, and certied nurse midwives provided cost-effective, quality
care, improving access to care in rural areas. In this study the care provided by these
groups was compared to that of physicians.
The balance of power was being altered [20]. Healthcare had a hierarchy, and
that hierarchy was threatened by other providers. Physicians generally were more
accepting of physician assistants. Most physician assistants were former corpsmen
and functioned under the direct supervision of the physician. By contrast, nurse
practitioners were viewed as separate licensed professionals, and this was perceived
as a threat and infringement into medical practice [20].
Throughout the evolution of the nurse practitioner role, the American Medical
Association (AMA) has allocated signicant time and resources to inhibit expan-
sion. Their tactics range from professional lobbying to vitriolic smear campaigns.
One of the most egregious was the quack-quack media campaign suggesting that
nurse practitioners were nothing more than quacks practicing medicine without a
license. The Mattel toy company marketed a Nurse Quacktitioner doll in 2006, and
despite outrage from nurses, they refused to recall it stating they had positive com-
ments about the doll [21].
In 1985, the AMA voted to discontinue support of any federal funding to nurse
practitioner programs to restrict proliferation of the programs. If they had suc-
ceeded, there would have been a signicant impact on services in underserved pop-
ulations [18]. The campaigns against nurse practitioners continued at the national,
state, and local levels resulting in restricting nurse practitioners from practicing to
their full scope of practice. These issues and the continuing struggle will be dis-
cussed later. One of the AMA’s concerns was the lack of education of the new nurse
practitioners (Fig.1).
B. Sheer
11
Fig. 1 Brief Historical Timeline
Evolution in Healthcare: The Journey from a US Demonstration Project…
12
Education
The proliferation of educational programs and the lack of uniformity created signi-
cant issues. Most of the initial programs were at the certicate level, and the quali-
cation for admission was to be a registered nurse (RN). Graduates of diploma,
associate, baccalaureate, masters, and doctoral programs were admitted. Despite the
broad range of educational background and varied skill levels at which these stu-
dents entered the program, at the end of the nurse practitioner program, they all had
the same qualication. They were nurse practitioners [8].
Lack of curricular standardization presented another issue. The programs that
emerged at this time ranged from 4months to 2years with most being 4–12months.
By 1973, Pulcini reported that there were 65 programs in pediatrics, adult, and fam-
ily specialties with only a few at the masters level [8].
In 1965, the American Nurses Association (ANA) issued its rst position state-
ment on the education of nurses, differentiating between technical and professional
nurses. The minimum requirement for the professional nurse was at the baccalaure-
ate level [10]. This statement, although controversial and debated for years, implied
that nurse practitioner applicants needed a minimum of a baccalaureate degree for
admission to any program [22].
The American Academy of Pediatrics (AAP) recognized that physicians could
delegate portions of healthcare to properly trained individuals. In 1969, the AAP
developed training and certicate guidelines for pediatric nurse practitioners
(PNPs). The document was not well received by PNPs since it had no nursing input
and suggested that the role was a delegated role rather than a professional nursing
role [23].
In 1971, ANA and AAP jointly published guidelines on short-term continuing
education programs for the Pediatric Nurse Practitioner/Associate (PNP/A). This
was a collaborative effort to move toward a standardized curriculum. Having the
ANA and AAP develop a curriculum provided an incentive for PNPs to begin to
network. This was the beginning of a specialty group formalizing their commitment
to pediatric healthcare [23].
To identify the PNP programs, the American Academy of Pediatrics published a
list of programs which included the number of graduates, minimum prerequisites,
length of training, and certicate or degree granted. In 1965, of the 64 programs
listed, only 8 offered a higher-degree option [24].
In 1980, a National Task Force on Nurse Practitioner Curriculum funded by
Robert Wood Johnson published “Guidelines for Family Nurse Practitioner
Curricular Planning” [8]. This task force formed the groundwork for subsequent
guidelines and the formation of the National Organization of Nurse Practitioner
Faculties (NONPF) [9]. Formalized guidelines assisted in the move from short-
term programs to the masters and post-masters level within university nursing
programs.
The short-term programs housed in schools of medicine, hospitals, and univer-
sity continuing education programs were gradually being replaced with university-
based masters and post-masters programs. In 1984, the education committee of
B. Sheer
13
NONPF created a position paper supporting nurse practitioner education at the
masters level, and the committee laid the groundwork for competencies for
NPs [25].
Later, the National Organization of Nurse Practitioner Faculties (NONPF)
published the rst edition of the National Directory of Nurse Practitioner
Programs. The NONPF directory was utilized by prospective students and fac-
ulty and documented the rapid expansion of programs. By 1994 they published
the sixth Edition, and most of the programs listed were at the masters or post-
masters level [25].
NONPF published additional documents that continued the work of standardiz-
ing education: “Advanced nursing practice: Nurse Practitioner Curriculum
Guidelines” (1990, 1995), “Domains and Core Competencies” (1990), “Curriculum
Guidelines and Program Standards for Nurse Practitioner Education,” and “Criteria
for Evaluation of Nurse Practitioner Programs” (1997). In addition, they continued
to update the directory of nurse practitioner programs.
From the primary care outpatient beginnings to the acute care hospital settings,
programs continued to expand. There were many discussions related to required
clinical practice hours versus competencies. By 2000, preceptors were a mix of
nurse practitioners and physicians. Care was increasing in complexity and pro-
grams accommodated by adding additional content. The master’s degree became
the standard for entry into practice and a requirement for certication examina-
tions [26]. At that time some states were requiring national certication for licen-
sure. In 2004, the American Association of Colleges of Nursing (AACN) called
for the transition to the Doctor of Nursing Practice as the entry level by 2015 [26].
In 2006, AACN published “Essentials of Doctoral Education for Advanced
Practice Nurses,” and NONPF published the “Practice Doctorate Nurse Practitioner
Entry-level Competencies.” The American Academy of Nurse Practitioners
invited major stakeholders to a roundtable in 2008, to consider the issues of doc-
toral education [26].
Gradually masters programs were replaced with Doctor of Nursing Practice
(DNP) programs. Although the DNP programs were expanding, the goal was not
reached in 2015. A new goal for the doctorate as entry level is set for 2025. As the
educational level was increasing, the National Council of State Boards of Nursing
developed a consensus model for Advanced Practice Nurse regulation that com-
bined the elements of licensure, accreditation, certication, and education (LACE)
[25]. Doctoral education puts nursing on par with other healthcare professions. The
American Association of Colleges of Nursing (AACN) reported in 2022 that 357
programs were enrolling students and programs were available in all 50 states [26].
Education moved from short-term certicate programs with variable curriculum
content to the master’s degree and nally to the proposed required doctorate in
50years. Specialty groups and organizations developed standards for their spe-
cialty. Faculty groups identied programs, published criteria, curriculum guide-
lines, and competencies with measurable outcomes. This was a long process, but
nally through persistence educational programs shared consistency [27]. Another
step was to assure individual credibility through certication.
Evolution in Healthcare: The Journey from a US Demonstration Project…
14
Certification
Certication enhances credibility and validates knowledge by demonstrating clini-
cal competence. The evolution of certication began with the National Association
of Pediatric Nurse Practitioners (NAPNAP) in 1975. Certication was an option,
and many PNPs were conicted about this exam because it was initially prepared by
physicians [28].
The next certifying exam was offered by the American Nurses Credentialing
Center (ANCC) beginning with the family nurse practitioner examination in 1976
and expanding to adult, family, pediatric, school, and gerontologic nurse practitio-
ner examinations by 1989. The Nurses Association of American College of
Obstetricians and Gynecologists (NAACOG) Certication Corporation now
National Certication Corporation (NCC) developed examinations in obstetrics and
women health [11, 29]. The initial exams were designed to measure excellence in
practice rather than entry-level prociency.
The American Academy of Nurse Practitioners Certication Board (AANPCB)
began in 1993 with the family nurse practitioner exam and expanded to include
adult and acute care NPs. Certication was evolving, and many states were begin-
ning to require national certication for advanced practice licensure.
Requiring a master’s degree for the women’s health examination was debated for
many years by NCC.Women’s health content was expanding beyond family plan-
ning and prenatal care, and states were requiring a higher degree for licensure [11].
Reimbursement was often only available to masters-prepared nurses. By 2007 all
certication examinations required a master’s degree. Individual states were begin-
ning to require national certication for licensure [9]. The National Council of State
Boards of Nursing (NCSBN) concerned about the variation in the requirements for
the certifying exams in the 1990s, required that all advanced practice nurse certica-
tion organizations develop examinations that were legally defensible and psycho-
metrically sound [11].
Today most nurse practitioners are certied by AANP, ANCC, PNCB, or NCC
and add a certication designation to their title [4]. While this represented a great
advancement in the demonstration of clinical competence, the next challenge was a
lack of uniformity in the titling, leading to confusion for consumers and nurses.
Titling
Titling has been confusing and inconsistent throughout the years. Titling for nurses
utilizes educational level, specialty, certication, legislative denition, and honor-
ary titles. There are many educational levels, specialties, certications, and legal
denitions leading to a plethora of inconsistent initials.
The University of Colorado demonstration project originally used the term pub-
lic health pediatric nurse practitioner (PHPNP) which was shorten to pediatric nurse
practitioner (PNP). As other specialties emerged, other titles emerged such as wom-
en’s health nurse practitioner (WHNP) and acute care nurse practitioner (ACNP).
B. Sheer
15
Legislation on the state and national levels dened nurse practitioners and physi-
cian assistants as mid-level providers, physician extenders, nonphysician providers,
and allied health providers [13]. These terms also indicate a hierarchy rather than
professional accountability. The terms were used in the literature and legislation but
not in titling.
In 1996, ANA dened advanced practice registered nurses (APRNs) as nurse
practitioners, nurse midwives, nurse anesthetist, and clinical nurse specialist to clar-
ify credentials. Combining all advanced practice nurses into one category was not
embraced by nurse practitioners who had been marketing the title “nurse practitio-
ner” to the public for years. The public and legislators were beginning to understand
the concept of nurse practitioner practice. At the same time, states were using
advanced practice nurse (APN) as a designation; APN and APRN were being used
simultaneously with the same meaning [28].
The National Council of State Boards of Nursing (NCSBN) in 2008 recom-
mended the use of APRN in state legislative language combining the roles of the
nurse practitioner, nurse midwives, nurse anesthetists, and clinical nurse specialist.
This was in response to the lack of standardization of programs and the proliferation
of specialties and subspecialties using different titles. In addition, certifying bodies
did not have a standardized title to denote board certication [28].
Understanding credentials can be difcult for consumers. There are four sets of
credentials that can be used: the educational level, BSN, MSN, DNP, and PhD; the
licensure, RN, APN, APRN, CRNP, or other state designation; national certication
which again varies with the certifying body such as BC for board certied from
ANCC or C certied the designation from AANPCB; and honorary awards such as
Fellow of the American Academy of Nursing (FAAN) or Fellow of the American
Association of Nurse Practitioners (FAANP).
Recommendations on displaying credentials were posted by both AANPCB and
ANCC [30]. Both AANPCB and ANCC agree that the highest degree be listed rst
(PhD, DNP) then licensure (APRN, ARNP, NP), national certication (BC, C) and
honorary awards (FAAN, FAANP).If licensed in two states with different designa-
tions, there can be two sets of credentials, for instance, if Jane Doe was licensed in
PA and DE, she would be Jane Doe DNP, CRNP, FNP-BC, FAANP in Pennsylvania,
since the licensure is certied registered nurse practitioner, and Jane Doe, APN,
FNP-BC, FAANP in Delaware, since Delaware licensure is advanced practice
nurse. The profession is moving toward using APRN in all legislation but as of 2022
this has not occurred. Advanced practice nurses utilize more letters than any other
profession.
The credentialing is confusing to both nurses and the public. Perhaps there is a
lesson to be learned from other professions: physicians with the designation of MD,
pharmacists using PharmD, and osteopaths with DO.These single designations are
clear and make it easier for the public to identify the specialty. Now there is a new
debate with the designation of the title “doctor.”
The use of the term “doctor” has ignited signicant debate and has caused addi-
tional animosity between medicine and nursing. Nurse practitioners with a doctor-
ate are doctors in their discipline which is nursing. Physicians rmly believe the
Evolution in Healthcare: The Journey from a US Demonstration Project…
16
term doctor refers to a doctor of medicine and no other discipline. In 2006 the AMA
published Resolution 211(A-06) titled “Need to Expose and Counter Nurse Doctoral
Programs Misrepresentation” [31, 32]. The resolution contends that when nurse
practitioners identify themselves as doctors, it creates confusion, jeopardizes patient
care, and erodes trust in the patient-physician relationship.
Although this can be seen as another example of restraint of trade, the AMA is
continuing to support legislation restricting the use of doctor to physicians. Six
states have made it a felony restricting nurse practitioners from addressing them-
selves as doctor in a clinical area [32]. Nine states require the introduction to be
followed with “I am a nurse practitioner.” The fact that this legislation exists dem-
onstrates the power that medicine has in state boards and national legislation. This
debate will continue as the number of advanced practice nurses are prepared at the
doctoral level and their scope of practice continues to expand.
Scope ofPractice
Nurse practitioners have expanded the boundaries of the essence of nursing. This
has occurred at the state and national levels in a piecemeal fashion. An early state-
ment on the scope of nursing practice from the ANA set the stage for struggles
to come.
In 1955, the ANA described nursing as “care and council of the ill, the mainte-
nance of health and prevention of illness, and the administration of medication pre-
scribed by a physician.” In this statement they concluded that this did not include acts
of diagnosis or prescription of therapeutic measures. This restrictive denition was
problematic when it was published. The Indian Health Service nurses and the frontier
nurses were already making decisions and providing care without the oversight of a
physician [2]. The restrictive denition did not match the practice of the time.
By the 1960s healthcare in the United States was evolving. With the introduction
of the nurse practitioner role, the ANA denition was outdated and did not allow for
the changes occurring in practice. Under the direction of Health, Education, and
Welfare Secretary Elliott Richardson, a committee to study extended roles for
nurses was initiated. The committee concluded that the extended scope of practice
was essential to providing equal access to care and recommended (1) a national
certication and (2) development of a model practice law that could be applied to all
states [2].
In response to the recommendations, the ANA added an addendum to the 1955
denition: “A professional nurse may also perform such additional acts, under
emergency or other special conditions which may include special training, as are
recognized by the medical and nursing professions as proper to be performed by a
professional nurse under such condition, even though such acts might otherwise be
considered diagnoses and prescription” [2]. This addendum recognized that in spe-
cial circumstances, nurses with “special training” could diagnose and prescribe.
Rather than clarifying the situation, this continued to blur the scope of practice for
nurse practitioners and presented challenges over the years.
B. Sheer
17
A scope of practice for pediatric nurse practitioners published by NAPNAP in
1983 identied assessment, diagnosis, and treatment of common acute conditions of
children [33]. This denition of scope clearly indicated that the pediatric nurse prac-
titioners were in fact diagnosing and treating children within their scope of practice.
NAPNAP published standards of practice soon afterward which listed educational
preparation and role parameters. NAPNAP later declined to participate in the ANA
Task Force to develop a singular scope of practice believing NAPNAP standards
were specic for the pediatric population.
The ANA Council of Primary Health Care Nurse Practitioners published their
scope of practice in 1985, which acknowledged the evolution of knowledge and
practice in primary care. This denition included assessment, diagnosis, planning,
and intervention to include prescription of medication and consultation when appro-
priate. They concluded that the boundary of the scope of practice for nurse practi-
tioners would expand with increasing education, experience, and social demand [34].
The major issues of the time were scope and standards of practice, quality of
care, and cost-effectiveness. In response to the need for information, the American
Academy of Nurse Practitioners developed one-page summaries to educate physi-
cians, nurses, legislators, and the public. The documents published between 1989
and 1993 included “Scope of Practice for Primary Health Care for Nurse
Practitioners,” “Standards of Practice,” “Documentation of Quality of Service,” and
“Documentation of Cost Effectiveness” [35].
Ironically those who opposed the expanded scope of practice also continued to
cite quality of care, access to care, and the impact on increased costs. The following
studies are a sampling of studies addressing scope of practice, quality of care, and
cost-effectiveness. The conclusions called for regulation to allow nurse practitioners
to function to their full scope of practice.
A systematic review published in 2016 supported removing restrictive barriers
for nurse practitioners at the state level as a viable strategy to increase primary care
capacity [36]. Another study reviewing state nurse practitioner practice related to
regulation and outcomes found full practice authority increased access without
compromising quality of care [37]. Comparing the impact of access to care in rural
populations, Neff [38] found nurse practitioners lling the gap. Access was increased
when rural populations were required to travel less than 30miles. The rural clinics
were most often staffed by independent nurse practitioners.
In 2017, the Centers for Medicare and Medicaid Service Provider Utilization
reported nurse practitioners were the largest providers of home visits making 4.4
million visits to 1.6 beneciaries [39]. States with restrictive NP practice regulation
had decreased utilization. In 1979, a review of 21 studies published in the Annals of
Internal Medicine from the years 1967 to 1978 demonstrated nurse practitioners
delivered equivalent care to that of physicians with no differences in outcomes [40].
This study was repeated by Brown and Grimes in 1995 with similar results [41].
Nurse practitioners were studied more than any other professional group. There
were a few landmark studies that had a signicant impact on the future of nurse
practitioners. Of the four studies mentioned, one was authored by a nurse in the
Journal of the American Medical Association, two were Institute of Medicine
Evolution in Healthcare: The Journey from a US Demonstration Project…
18
Reports, and the fourth a regulatory review completed by the Dean of Yale
Law School.
Landmark Studies
Several landmark studies are consistently cited in the literature. The Ofce of
Technology Study in 1986 was an earlier study concluding that nurse practitioners,
physician assistants, and certied nurse midwives provided cost-effective, quality
care, improving access to care in rural communities [19].
In 2000, Mary Mundinger published a landmark study in the Journal of the
American Medical Association (JAMA). This was remarkable in that a nurse was
the primary author, and the study was a randomized trial of primary outcomes in
patients treated by a nurse practitioner in an ambulatory care setting [42]. The study
concluded that patients treated by the nurse practitioner or physician had the same
degree of satisfaction and outcomes. This study was unique in that the nurse practi-
tioners in the study were in an autonomous practice, having the same authority,
responsibility, and patient population as physicians in comparable settings.
Crossing the Quality Chasm published by the Institute of Medicine (IOM) in
2001 had three recommendations for the healthcare workforce: (1) realign teaching
to utilize evidence-based practice, (2) modify regulation and scope of practice to
allow for innovative models of healthcare for efcient and effective delivery of care,
and (3) examine the liability system to both support change and maintain account-
ability for providers [43].
The Future of Nursing also published by the IOM in 2010 envisioned “a trans-
formed healthcare system providing seamless, affordable quality care that is acces-
sible to all, patient centered, and evidence based, and leads to improved healthcare
outcomes” [44]. The report had four recommendations that support nurse practitio-
ners. The rst was to ensure that nurses practice to the full extent of their education
and training. This was a further call to action to expand the scope of practice regula-
tion at the state level. The second recommendation was to improve education. This
was already occurring with the development of doctoral programs and a commit-
ment to require the doctorate as the entry into practice. The third recommendation
was to provide opportunities for nurses to assume leadership and serve as full part-
ners in healthcare redesign and improvement efforts. The nal recommendation was
to improve data collection for workforce planning and policymaking [44]. It is
important to note that the report was published in 2010 when the Affordable Care
Act (ACA) was passed in Congress, affording healthcare insurance to approxi-
mately 32 million uninsured individuals.
“Health care dollars and regulatory sense: The role of advanced practice nurs-
ing” published in the Yale Journal on Regulation presented an overview of scope of
practice laws from a legal perspective [45]. The 1992 publication was sent to all the
legislators and sold more copies than any other edition of the Yale Journal on
Regulation. Barbara Safriet, the Dean of the Yale Law School, reviewed two decades
of research on nurse practitioners. The evidence supported that APRNs particularly
B. Sheer
19
nurse practitioners and nurse midwives provide comparable care at a lower cost than
physicians. The review concluded that it was indisputable that nurse practitioners
are cost-effective healthcare providers and recommended reducing restrictive barri-
ers to allow them to practice to the full extent of their education and scope. She was
a frequent speaker at NP conferences throughout the next decades consulting with
many states on regulatory language.
Regulation
The primary purpose of regulation is to protect the public. Licensure for the profes-
sions is regulated by state boards which act independently from each other creating
a lack of consistency from one state to another. Authority to diagnose, treat, pre-
scribe, and bill for such services is dened by each state. Allowable practice in one
state did not transfer to a neighboring state. This often requires multiple licenses and
vigilance on the part of the nurse practitioner to understand the scope of practice
within each state.
Physicians were the rst healthcare practitioners to gain legislative recognition
[45]. They dened their scope of practice in broad terms. One state dened practice
of medicine as diagnosis, treatment, prescribing, or administering treatment to any
human ailment physical or mental. With this broad denition, other professions had
to carve out a scope of practice separate and distinct from that of medicine [45].
Nursing regulation began in the 1900s as voluntary registration. By 1930 licen-
sure or registration was mandatory and required a certain level of education. The
early regulation did not conict with other professions. The ANA document in 1955
stated nurses were to care for patients and follow the orders of the physicians
although, as previously stated, this did not reect practices happening at the Henry
Street Settlement, the Frontier Nursing Service, and Indian Health Service and was
obsolete from the outset [20].
The roles of nurses universally were changing. As technology was increasing,
tasks that had been medicine’s domain were delegated to nurses. This was particu-
larly apparent in the intensive care units (ICUs). Quick action may be the difference
between life and death. The ICU nurses were, in fact, diagnosing and treating emer-
gencies. They were starting intravenous lines, administering cardiopulmonary
resuscitation (CPR), and performing other tasks traditionally performed by physi-
cians. In response to the changing landscape, institutions and organizations granted
privileges to nurses beyond the legislative and ANA scope of practice.
The advent of the nurse practitioner role in the 1960s called for signicant
changes in regulation. With the expansion of nurse practitioner programs, nurse
practitioners were functioning beyond the boundaries of traditional nursing and the
scope dened in nurse practice acts. A federal government report stated that func-
tions of nurses were changing because of their competence to perform a greater
variety of functions [44].
In 1972, Idaho became the rst state to recognize nurse practitioners in statute
and issued a separate license in addition to the RN license [46]. The advanced
Evolution in Healthcare: The Journey from a US Demonstration Project…
20
practice license required an unencumbered RN license, advanced education, and
direct supervision that could be accomplished by physicians, mentored practice, or
peer review. The rules and regulations were jointly promulgated by the Idaho State
Board of Nursing and the Idaho State Board of Medicine [46]. Any acts of diagnosis
and treatment needed to be agreed upon by both boards leading to a variety of
guidelines or protocols in practice settings.
In the 1990s more state boards were requiring national certication by a certify-
ing body that could ensure that their examinations were psychometrically sound and
legally defensible. This led the certifying bodies to seek accreditation for their
examinations.
The debate for licensure and secondary licenses continued at the state level.
Some State Boards of Nursing wanted to amend the “nurse practice act” by deleting
terms such as “the prohibition of acts of diagnosis and treatment” or adding the term
“nursing diagnosis.” Boards expressing this philosophy believed that advanced
practice nurses were practicing nursing and should be governed by one license
which needed to be amended to accommodate expanded practice. Other states were
following Idaho’s lead in requiring a secondary advanced practice license. Each
state functioned independently and, as discussed previously, utilized different titles
for those attaining the secondary license. A nurse practicing in two states may have
needed four licenses to practice: an RN license and an advanced practice license in
each state. Faculty supervising nurse practitioner students in multiple states needed
multiple licenses [45, 46].
Rules and regulations and governance varied in each state. Advanced practice
nursing may fall under the jurisdiction of single boards or multiple boards. They
may be governed by the Board of Nursing, the Board of Medicine, Board of
Consumer Affairs, Joint Boards of Nursing and Medicine, or Advisory Boards com-
posed of advanced practice nurses, physicians, pharmacists, and public members.
The composition of the boards also varied from state to state. All of which means
that nursing and advanced practice nurses could be regulated by professions and
advisors who were not nurses. In the United States, nursing is the only group that
could be regulated by another profession [45]. Some medical boards revised the
Medical Practice Act to authorize physicians to delegate diagnosis and treatment to
nurses with specic education. This put the advanced practice nurse directly under
the physician and their discretion to delegate.
Safriet postulated that from a regulatory position, all state boards should seek
uniformity by using a title such as advanced practice nurse (APN), requiring spe-
cic levels of education, national certication, which should be governed solely by
the Board of Nursing. If other professionals were regulated by their own profession,
it is a logical conclusion that nursing should be regulated by the Board of Nursing.
The variation of regulation in each state set the stage for professional turf wars.
The Board of Medicine being involved in the regulation of nurse practitioners and
other advanced practice nurses created a conict of interest. It was within their pur-
view to restrict practice to avoid competition.
A variety of stipulations restricted advanced practice nurses from functioning to
the full extent of their education. These included collaborative agreements, written
B. Sheer
21
guidelines, protocols, direct supervision, and a requirement for the physician to be
located on premises. In rural practices the physician could be available by phone
and not actually present. Occasionally rural practices were located on the border of
two states creating a logistical nightmare for the nurse practitioner [46].
The regulation of professions is designed to protect the public; however, scope of
practice was often determined by location. Nurse practitioners in private practices
with physicians present were often required to collaborate and agree on a patient
plan prior to discharge. This step took additional time in waiting for the physician
and eroded patient condence. It was less cost-effective if the nurse practitioner
spent time waiting for the physician to collaborate and review the plan for every
patient [46].
The same nurse practitioner in the same state practicing in a rural clinic would
function independently and make decisions on a treatment plan without consulta-
tion. Most states made exceptions and allowed nurse practitioners to function more
independently with specic underserved populations [46]. As a result, nurse prac-
titioners found their place lling a need in rural areas, as well as the inner city.
Nurses were innovative creating new models of care. They could be found in clin-
ics, in inner-city housing projects, working with the homeless, HIV/AIDS popula-
tions, and others in need. Nurses told their stories about going to where the need
was greatest. This could be a watering hole to meet with an indigenous population
reluctant to seek care or equipping a van to travel to isolated communities in
Appalachia.
In a 60-minute segment entitled “The nurse will see you now,” Morley Safer
highlighted the differences of the scope of practice in different settings [47].
Columbia University began a nurse-managed center on Madison Avenue, an afu-
ent area of NewYork City. This created outrage from the American Medical
Association. Their concern was quality of care. They felt nurse practitioners were a
cheap substitute for medical care. The president of the AMA Nancy Dickey stated,
“if nurses wanted to practice medicine they should go to medical school if not they
needed to practice under the supervision of a physician.”
The segment contrasted this concern by visiting two well-established rural health
centers operated independently and run by nurse practitioners. Nancy Dirubbo and
Mona Counts had long-standing practices in rural New Hampshire and Appalachia,
respectively. Some of the patients in these practices had never seen another pro-
vider. Safer concluded that if a nurse practitioner is competent to practice in rural
and underserved urban settings, they are competent to practice in all settings. It was
only when the nurse practitioners moved into an afuent area that quality became a
concern.
Physician’s attitudes have changed over the years from early support to mounting
campaigns against the legislative expansion of nurse practitioner practice that would
allow full practice authority.
A review of medical literature through the years 1967 to 1982 illuminates a shift
in attitudes [48]. The rst nurse practitioner program was designed to ll a need in
rural areas and make a signicant difference in the lives of children. Well-child
exams were performed, and acute and chronic illnesses in childhood were managed
Evolution in Healthcare: The Journey from a US Demonstration Project…
22
by experienced nurses with additional assessment skills. This was an extension of
the role of public health nurses. A benet was seen by all. Access was increased and
physicians could focus on children needing more specialized care. Private practice
physicians saw the new role as a way to expand their practices and see additional
patients. The nurses were functioning under existing practice acts. Initially there
were a limited number of nurse practitioners and physicians who worked in collab-
orative practices. They saw the new role as benecial for both the patients and the
practice. Quality of care was not an issue. There was agreement that most of the
pediatric primary care could be managed by nurse practitioners. Prescribing was not
part of legal practice, but nurses had been responsible for immunizations as a nurs-
ing role. In some instances, nurse practitioners were prescribing medications. State
licensure laws did not present an obstacle to practice, and there was no mention of
practicing medicine without a license.
In 1978, the IOM recommended that licensing laws should authorize nurse prac-
titioners to provide services including diagnosis and provide medication when
appropriate with the supervision of physicians [49]. The American College of
Physicians supported the need to amend laws but reiterated that the ultimate respon-
sibility for diagnosis and treatment remained the responsibility of the physician.
Some progressive physicians like Dr. Barbara Bates saw the roles of the physician
and nurse being different but complementary and understood the traditional roles of
the physician and nurse were being challenged.
The literature in the 1960s and 1970s was positive and saw the new role as a solu-
tion to access to care. Nurse practitioners were accepted and utilized to provide
needed services particularly to underserved populations. If the nurse practitioner
functioned in a collaborative practice with physician oversight, they were cost-
effective, delivered quality care, and were a great asset to providing primary care to
those in need. The relationship became strained when reimbursement for nurse
practitioners and advanced practice nurses was possible [48].
Reimbursement turned the tide from acceptance to competition. The traditional
relationship between physicians and nurse practitioners was being tested and under-
going a signicant change. Physicians saw this as a challenge to their domain and
began actions to save their exclusive domain in healthcare. Physicians had inuence
with insurance companies and advocated that nurse practitioners not be reimbursed.
This would restrict practice regardless of scope of practice.
The AMA declared war on expanded scope of practice regulation for nurse
practitioners and other nonphysician healthcare providers. For over 30years, the
AMA has monitored state and federal legislation. As part of their advocacy, their
goal is “to safeguard the practice of medicine opposing nurse practitioner and
other nonphysician attempts to inappropriately expand their scope of practice”
[49]. Since 2019 they have been able to prevent over 100 pieces of legislation
from being enacted. The group has awarded more than two million dollars from
the Scope of Practice Partnership to prevent legislation expanding scope of prac-
tice for nurse practitioners and other nonphysician providers. More than 105
national, state, and specialty medical organizations are members. The focus was
no longer on the distribution of equitable healthcare for all populations in a
B. Sheer
23
cost-effective manner by utilizing the best provider. The new focus was about sav-
ing the medical domain. When physicians began to understand the ramications
of reimbursement and prescriptive authority, they obstructed the expansion of
nurse practitioner service in any way they could. Noncompete clauses were added
to contracts assuring that if the nurse practitioner left the practice, she could not
practice within a 50-mile radius to assure that patients would not follow the nurse
practitioner to another site.
In 2011, the Federal Trade Commission evaluated laws and state policies restrict-
ing the practice of nursing and found that stringent requirements for physician over-
sight may be considered anticompetitive. The restrictions served to protect the
interests of the medical profession rather than the best interests of the consumers
[50]. Reimbursement and prescriptive authority were additional challenges to nurse
practitioner practice.
Reimbursement
Receiving reimbursement for services provided by nurse practitioners has been an
uphill struggle over time. There is a complex web of provider eligibility require-
ments that vary from state to state and within a state. The rules are ever changing,
and the amount of reimbursement varies from 70 to 100% of the physician rate for
the same service. Reimbursement depends upon many factors such as the state,
regulation, and type and location of practice. Medicaid, Medicare, third-party insur-
ers, and managed care organizations all have different rules, and often the rules vary
within the state. Reimbursement options do not support nurse-managed centers or
nurse-owned practices [51].
The rst federal legislation allowing reimbursement was an amendment to the
Social Security Act in 1974. This amendment included nurse practitioner services
under Medicare and Medicaid [51].
In 1977, the Rural Health Clinic Service Act allowed Medicare reimbursement
for nurse practitioners practicing in federally designated rural and underserved
areas [51]. Medicaid reimbursement followed, which included all family and pedi-
atric nurse practitioners by 1989. In 1997, under the Balanced Budget Act, signed
by President Clinton, nurse practitioners could bill directly for Medicare services in
any setting [51, 52]. Rates varied from 75 to 100% of physician reimbursement,
depending upon the state. A portion of Medicaid benets are derived from managed
care insurers [52]. The managed care insurers set the policies as to who and who
cannot receive payment. If managed care insurers elect not to reimburse for nurse
practitioner services, there is no reimbursement. Therefore, the policy directly
restricts nurse practitioner practice. The value of nurse practitioner services becomes
dependent upon the state, the scope of practice, and the ability to be reimbursed for
the service and not for competence and the ability to provide quality cost-
effective care.
Managed care organizations often require the listing of a primary care provider.
To be listed as a provider or part of a team, the nurse practitioner needs to be
Evolution in Healthcare: The Journey from a US Demonstration Project…
24
credentialed by the managed care organization. The credentialing process is not
standardized and may vary within a state. States with more restrictive regulations
requiring supervision are less likely to attract nurse practitioners.
Research has demonstrated that states with full scope of practice and reimburse-
ment at 100% of the physician rates accept more Medicaid patients. They are more
likely to be in rural and high-poverty areas [50]. Patients in these areas were more
likely to be seen by nurse practitioners.
Under Medicare nurse practitioner services are reimbursed at 85% of the physi-
cian rate. If billed under the physician’s provider number, the practice can receive
100% reimbursement for the service. This is called “incident to” billing and there
are restrictions to this billing. The physician must be on site and needs to see the
patient for the rst visit, any new complaint, and at least once a year. This is coun-
terproductive in practices where patients are routinely seen on an annual basis. With
incident “to billing,” nurse practitioners become invisible because they are not pro-
viding services under their own provider number. Many practices discouraged nurse
practitioners from applying for their own provider number because the revenue
would be 85% vs 100% [52].
Managed care organizations often will not contract with nurse-managed centers.
Nurse-managed health centers (NMHCs) serve diverse populations and provide a
safety net for healthcare in their communities. Funding becomes a signicant chal-
lenge depending on state regulations, and the interest of third-party insurers. Most
insurers do not support nurse-managed centers or independent nurse practitioner
practices, forcing those centers to rely on grants and philanthropy which may not be
sustainable [53]. The NMHC centers are not-for-prot and usually have a sliding
scale for payment. In 2010, the 200 NMHCs in operation had an estimated two mil-
lion encounters per year. If they operated to capacity, the cost would be less than
other care in the same geographical area. A barrier to these centers is the inability
for insurers to credential nurse practitioners limiting the ability to be reimbursed. Of
the few nurse practitioners that are credentialed in NMHCs, only half were reim-
bursed the physician rate [54, 55].
Reimbursement is more of an issue in some states than scope of practice.
Reimbursement is an inconsistent patchwork of ever-changing rules and regula-
tions. The current system does not support nurse-managed centers or independent
nurse practitioner practice which has proven to be cost-effective with appropriate
numbers of patients enrolled. The current systems of Medicare, Medicaid, and
third-party insurers create an unequal eld when nurse practitioners cannot be
credentialed. Some states have enacted “any willing provider” legislation. This
allows any willing provider with appropriate credentials to provide a service.
Unfortunately, not all “any willing provider” legislation included nurse practitio-
ners. Reforming reimbursement schemes to allow nurse practitioners to receive
100% of the physician reimbursement for the same service and credentialing
nurse practitioners on reimbursement panels would be a step in more equitable
payment schemes [55].
B. Sheer
25
Even with the Affordable Care Act, over 28 million or 8.6% of the population
remain uninsured. Nurse practitioners have proven they can ll the gap and could
continue to offer alternative solutions for healthcare delivery. The issue of reim-
bursement needs to be resolved, or the United States will continue to have the some
of the worst healthcare outcomes among developed nations.
Nurses continue to nd ways to deliver healthcare to underserved populations
despite restrictive legislation and practices. Prescriptive authority is another restric-
tion that has been addressed in a fragmented manner. Prescriptive authority not only
varies from state to state and setting to setting but also includes specic drug classes
that can be prescribed or are prohibited.
Prescriptive Authority
Prescriptive authority is paramount to nurse practitioner practice and is granted by
state legislation. Pearson, in an annual update, dened prescriptive authority in
three categories: dependent, independent, and none [56]. These annual updates have
tracked the progression of states expanding prescriptive authority to nurse practitio-
ners from very few states in 1990 to all 50 states and the District of Columbia hav-
ing some form of prescriptive authority by 2020.
Prescriptive authority can be acquired in a variety of approaches [57]. Statutory
authorization is through a nurse practice act, pharmacy law, a medical practice act,
or a combination of the above [57]. This allows the greatest independence. A second
method is an opinion rule which is an interpretation by an attorney general. This can
be challenged. The third method is through delegation under the authority of a phy-
sician. This usually includes a written agreement between a physician or institution
and the nurse practitioner and needs approval of both the Board of Medicine and the
Board of Nursing. The nal option is under a Board of Pharmacy waiver which can
be withdrawn any time.
In 1983, 43 states had statutory or regulatory references to advanced practice
nurses [58]. Of these 24 had an “additional acts” clause in the denition of nursing
practice, and 24 had a specic section in the law which addressed advanced prac-
tice. Six states required a master’s degree for a clinical nurse specialist, and three
states required a bachelor’s degree for nurse practitioners. Ten states had advisory
committees to assist with advanced practice rule and implementation. In 27 states
prescriptive authority was regulated by the Board of Nursing, and in 16 states it was
regulated by the Board of Health, Board of Medicine, or Joint Boards of Medicine
and Nursing.
In 1996, all states except Illinois and Oklahoma had statutory authority [56]. In
the Pearson Report, Georgia is listed as having prescriptive authority with some
degree of physician oversight; however, in more recent literature, Georgia is listed
as the last state to attain prescriptive authority in 2006. Perhaps it’s a matter
of degree.
Evolution in Healthcare: The Journey from a US Demonstration Project…
26
In the early days, there was a requirement to be licensed or certied as an
advanced practice nurse in the state, and many were beginning to require proof of a
recent pharmacology course [56].
Requirements differed from state to state, requiring collaborative agreements,
written protocols, a formulary, and a reverse formulary that listed drugs excluded.
Washington and Alaska were the rst states to allow independent prescribing.
Nurse practitioners were creative in prescribing and providing medications for
their patients. Even when they had regulatory authority to prescribe, there were still
barriers in place such as pharmacies not honoring the prescriptions. There were
unique options that were utilized. Nurse practitioners or staff nurses would call the
prescription into the pharmacy under the physician’s name or the nurse practitio-
ner’s name if accepted. Within a facility, prescriptions could pre-signed by the phy-
sician, signed with physician’s name, cosigned with the nurse practitioner and
physician name, or requested for the physician to sign for each individual patient
[59]. Another way that facilities handled prescriptions was to ll them in-house.
Planned parenthood utilized protocols and stocked medications that could be
distributed.
The following stories demonstrate how nurse practitioners in three different set-
tings, within one state, collaborated with colleagues to utilize creative solutions for
prescribing.
Real-Life Stories by Nurse Practitioners
Academic Medical Center
Nurse practitioners related interesting stories about how prescriptions were handled
in different clinics and ofces. In one hospital, the outpatient nurse practitioners
were given prescription pads pre-signed by the department director to use in their
ofces. One day an NP ran out of the pre-signed prescriptions and went to the direc-
tor’s ofce and requested additional prescriptions. Realizing she had forgotten
something, she went back to the director’s ofce to nd the secretary signing the
prescription pad with the physician’s signature. The nurse practitioners realized that
they could not sign the prescriptions, but the secretary could.
Private Pediatric Group Practice
In another scenario a pediatric nurse practitioner was hired into a pediatric practice
group. The group was assured that the PNP had the legal right to sign prescriptions.
The group, however, decided that they were more comfortable leaving signed pre-
scriptions to be lled out. After each session the physician and the PNP did chart
review. About a month later, one of the pediatricians asked if the PNP could co-sign
the prescriptions so if the pharmacy had a question, they would know who had pre-
scribed the medication. A little later at a group meeting, the pediatricians asked if
the PNP was comfortable signing her own name without a co-signature. On the rst
day of ofcially signing the prescriptions, there was a knock on the door to announce
the pharmacist was on the phone. Armed with the nurse practice act, the PNP
B. Sheer
27
answered the call ready for the defense. The pharmacist was just calling to see if the
drug could be substituted for a lower-cost antibiotic. There was no issue about the
signature nor was there ever an issue in the community.
Primary Care Community Center
A nurse practitioner was asked to cover pediatric services at a community primary
care center during the summer. The pediatrician was going on leave and the center
decided to hire a nurse practitioner. This was the rst nurse practitioner to work
without a physician in the clinic. The nurse had prescriptive privileges under the
rules and regulations of the nurse practice act. At that time some of the chain phar-
macies were refusing to honor nurse practitioner prescriptions. The director of the
center discussed the issue with a local independent pharmacist, located close to the
clinic, and he agreed to honor all nurse practitioner prescriptions. Patients were told
the local pharmacy would honor the prescriptions, but they were free to go any
pharmacy they wished. If they encountered a problem, they were to have the phar-
macy call the clinic, and a physician would write the prescription. The local phar-
macist was delighted, at the increase in business, patients received their medications
in a timely fashion, and there were no calls to the clinic about problems with pre-
scriptions. The whole situation was considered comical because a staff nurse rou-
tinely called in the prescriptions rather than the physicians, and the call ins were
always lled without question.
These are just three stories of how nurse practitioners were able to overcome
barriers to deliver care to the community. Today, it may seem difcult to believe that
some physicians were willing to pre-sign prescriptions, knowing that an NP would
ll in the medication order. This is widely considered an illegal act, but it is an act
that was undertaken by some physicians to nd a way to deliver cost-effective care
to an underserved populations.
One of many outcome studies completed in 1998, evaluating the effectiveness of
APN prescriptions in 25 primary care sites in Louisiana, concurred with previous
ndings that APN prescriptive authority was benecial to the patients [60]. Of par-
ticular interest in this study, participating physicians who worked with nurse practi-
tioners supported nurse prescribing. This was in opposition to the stance taken by
the Board of Medicine in the state. Hence, in this instance physicians who had direct
contact with the nurse practitioners were supportive of nurse practitioner prescrib-
ing, while those with no contact were not as supportive or opposed nurse practitio-
ner prescribing.
Nurse practitioners have been committed to clarifying prescribing in each state,
but this occurred again in piecemeal fashion. Changing legislative laws at times
required compromise. This may be in the form of a formulary, collaborative agree-
ment or oversight by a joint practice committee. Sometimes it entailed only pre-
scribing certain classes of medications. In one state the nurse practice act was
expanded to grant prescribing authority but conicted with pharmacy law which
listed authorized prescribers and excluded nurse practitioners. Therefore, nurse
practitioners could legally write prescriptions, but the pharmacist was not autho-
rized to ll them.
Evolution in Healthcare: The Journey from a US Demonstration Project…
28
Nurses were persistent if a legislative bill did not get passed, they continued to
lobby and had it introduced during another session. The AMA continues to oppose
legislation, but through networking and persistence, nurse practitioners have pre-
vailed in most states. In dealing with persistent challenges at the state and national
levels, nurse practitioners realized the need for networking and political actions.
The ANA was not allocating signicant resources to legislation addressing the
expansion of nurse practitioner boundaries at the state and national levels. In
response specialty organizations proliferated creating some dissonance.
Lack ofUnity: TheFormation ofNurse
Practitioner Organizations
Box 1 Nurse Practitioner Organizations
Organizations
AACN American Association of Colleges of Nursing
AANP American Academy of Nurse Practitioners/American Association of Nurse
Practitioners
AANPCB American Association of Nurse Practitioners Certication Board
AAP American Academy of Pediatrics
ACNP American College of Nurse Practitioners
AMA American Medical Association
ANA American Nurses Association
ANCC American Nurses Credentialing Center
CCNP California Coalition of Nurse Practitioners
ICN APNN International Council of Nurses / Advanced Practice Nursing Network
NAACOG National Association of American College of Obstetricians and Gynecologists
NANN National Association of Neonatal Nurse Practitioners
NANPRH National Association of Nurse Practitioners in Reproductive Health
NAPNAP National Association of Pediatric Nurse Practitioners (originally National
Association of Pediatric Nurse Associates and Practitioners)
NCC National Certication Corporation
NCGNP National Council of Gerontological Nurse Practitioners
NCSBN National Council of State Boards of Nursing
NLN National League for Nursing
NPACE National Association of Nurse Practitioners Continuing Education
NYSCONP New York State Coalition of Nurse Practitioners
Nurse practitioners throughout the United States were pushing the boundaries of
practice. Their numbers were increasing, and there were questions emerging regard-
ing educational programs, scope of practice, reimbursement, and prescribing. There
was a need to network since practice was expanding beyond the existing
legislation.
The ANA was not an early supporter of nurse practitioners, but in 1972, they added
the Council of Primary Health Care Nurse Practitioners (CPHCNP), to meet addi-
tional needs of emerging roles. The council failed since it was not able to meet the
growing needs of nurses in specialty practices. The emergence of the new organiza-
tions resulted in loss of membership [61]. ANA was no longer the voice of all nurses.
B. Sheer
29
Over the next few years, nurse practitioner specialty organizations proliferated
both on the state and national levels. A group of pediatric nurse practitioners met
informally, organized, and formed the National Association of Pediatric Associates
and Practitioners in 1973. They were invited but declined to join an ANA council
under the maternal-child division, preferring to be independent.
Between 1978 and 1984, the California Coalition of Nurse Practitioners (CCNP),
the National Organization of Nurse Practitioner Faculties (NONPF), the National
Association of Nurse Practitioners in Reproductive Health (NANPRH), National
Association of Nurse Practitioners Continuing Education (NPACE), the NewYork
State Coalition of Nurse Practitioners (NYSCONP), the National Council of
Gerontological Nurse Practitioners (NCGNP), and the National Association of
Neonatal Nurse Practitioners (NANN) were formed [20].
In a call for unity, six national nurse practitioner organizations sponsored a
national nurse practitioner forum called the “Coalition for Practice: Future Markets,
Future Models.” The meeting was attended by 310 nurse practitioners who met to
develop a framework to unify nurse practitioners. This became known as the
“Chicago Meeting of 1985.” What emerged was the formation of the American
Academy of Nurse Practitioners (AANP) to represent family nurse practitioners and
the National Alliance of Nurse Practitioners (NANP). The Alliance was an organi-
zation of organizations with three major goals to (1) monitor legislative and political
activities, (2) develop marketing and public relations materials, and (3) increase
communication to provide a rapid response to legislative and other issues needing
immediate attention and a unied voice [62, 63].
The Alliance met twice a year with rotating sponsorship of the meeting. During
its existence several fact sheets were published and distributed for the political
agenda, and each year all the member organizations agreed upon a legislative
agenda. This enabled all organizations lobbying to bring the same message to the
US Congress. NANP published “A Vision for the Year 2000” and several other posi-
tion papers including a position on certication and one on the acute care nurse
practitioner [62].
In response to the need for increased lobbying and setting a political agenda,
NONPF sponsored an invitational leadership summit in 1993. At the end of the
summit, a SWOT analysis (strengths, weaknesses, opportunities, and threats) team
was formed to further the agenda. The result was the formation of the National
Nurse Practitioner Coalition (NNPC) which shortly changed its name to the
American College of Nurse Practitioners (ACNP). Their mission was to focus on
legislative issues and lobbying. In 2013 AANP and ACNP merged forming the
American Association of Nurse Practitioners.
From a historical perspective, signicant time and energy was spent in organiza-
tional activities. Nurse practitioners through their networking and organizational
leadership have been able to make great strides. Unfortunately, this has fallen short
of a unied coordinated effort. The nurse practitioners from the United States shared
this part of our history with other nations hoping to avoid some of our shortcomings.
Having a unied voice to speak for all nurse practitioners would provide a powerful
platform for change.
Evolution in Healthcare: The Journey from a US Demonstration Project…
30
The University of Colorado held an annual continuing education conference at
the Keystone Conference Center. Leaders of the national organizations were invited
to become conference advisors and present at a keynote forum. The forum provided
a platform to discuss organizational agendas, network, and have an open discussion
on current events related to nurse practitioner practice and regulation.
International Collaboration
In 1991 Barbara Stilwell from the United Kingdom (UK) was an invited participant
at the Keystone Conference. She had attended a nurse practitioner program in the
United States and with a colleague, Barbara Burke-Masters, initiated the role of the
nurse practitioner in the United Kingdom working with homeless and inner-city
populations. Based on their experiences, there was support for the development of
the rst nurse practitioner program at the Royal College of Nursing (RCN) in
London. The program admitted 20 students who were funded to attend the Keystone
Conference in the following year. During their visit to the United States, the new
UK nurse practitioners were able to visit practices of experienced nurse practitio-
ners. The idea of hosting a UK/US conference in London emerged. The purpose of
a joint conference was threefold to (1) highlight the role of the nurse practitioner as
an international phenomenon, (2) support the UK movement with credible speakers
from the United States and the United Kingdom, and (3) provide a forum for net-
working and interactions [64].
In November 1992, Dr. Ann Smith from the University of Colorado and Dr.
Barbara Sheer from the Keystone Conference Advisory Board met with Barbara
Stilwell, Mark Jones the community health advisor for RCN, Penny Lawson a new
graduate, and Dr. Geoff Roberts a physician supporter, to plan the rst international
nurse practitioner conference. The conference took place at the Café Royal on
August 6–8, 1993, hosted by the Royal College of Nursing and the University of
Colorado Health Science School of Nursing, with 350 international participants in
attendance. Many in attendance from other nations desired information on the new
role. Dr. Loretta Ford gave an inspiring keynote address which was met with an
enthusiastic response. With the success of the conference, the Royal College of
Nursing decided to continue the conference on an annual basis.
The following year the Keystone Conference led by Ellen Lemberg celebrated
the international community by inviting international nurse practitioners represent-
ing 35 countries including the United Kingdom, Canada, Australia, New Zealand,
Spain, Yemen, Swaziland, and South Africa. The nurse practitioner movement was
gaining momentum internationally. A few of the international participants were
nurse practitioners who were working within the connes of US Embassies.
To continue the momentum, annual conferences were hosted by the Royal
College of Nursing, the University of Colorado, and the American Academy of
Nurse Practitioners. The conferences were held in London; Edinburgh, Scotland;
Birmingham, England; and Melbourne, Australia. Each conference attracted repre-
sentatives from additional countries. It was decided to begin to support other nations
B. Sheer
31
with developing roles to host the conferences. This would increase visibility in
those nations and add credibility to the developing role.
There were commonalities in the global role development regardless of the
nation or region. Universal issues included role denition, scope and nature of prac-
tice, educational preparation, regulatory mechanisms, and healthcare policy. At
each conference the progress of each nation was shared, strategies discussed, and
national leaders supported. By 1996, the group recognized a need for an ongoing
communication network. The International Council of Nurses (ICN) represented
nurses globally, but there were several issues with membership restrictions.
The ICN was not a direct individual membership organization. At that time ICN
was an organization composed of one national organization from each nation. In the
United Kingdom, the member organization was the Royal College of Nursing
(RCN). In the United States, the member organization was ANA.The initial confer-
ences were supported by RCN and AANP, a nonmember organization. The collabo-
ration presented a problem for ICN as the conference was moving into more
countries. Another issue was that many of the developing nations did not have mem-
bership in ICN.If a network was to be formed, it needed to be inclusive not exclu-
sive with individual, not organizational, members.
With persistence and assistance from Fadwa Affara the ICN representative, an
agreement was negotiated. In a departure from existing policy, the ICN allowed a
unique structure. The nurse practitioner network would be established under the
umbrella of ICN with individual membership. In 1999, at the ICN Centennial
Congress in London, a forum was held to clarify the nature of advanced practice and
describe the nature of the network. A survey was developed to identify advanced
practice roles throughout the world [65].
An effort to develop a denition of the role was problematic due to diversity of
cultures and inconsistencies in language, titling, scope, education, and regulation
throughout the world. Consensus was reached on the title “International Nurse
Practitioner/Advanced Practice Nursing Network” (INP/APNN). The network was
launched at the eighth international conference in San Diego on October 1, 2000.
The development of the network served as a prototype for ICN networks. Individual
membership is free to all nurse practitioners, advanced practice nurses, policymak-
ers, and others interested in the expanded role. It provides updated information on
research, healthcare policy, and practice.
Many US and UK nurse practitioners provided early leadership for the group
including Sue Cross, Dr. Madrean Schober, and Dr. Rosemary Goodyear, as chairs
of the core steering group. Other US representatives chaired the subcommittees and
participated in the development of the committees. Leaders from other nations with
established roles added international representation. The network has provided
guidance in suggesting a master’s degree as the entry level. Many nations lacked an
educational infrastructure to provide education at this level. This early denition
allowed developing nations to set a goal for future direction. Revisions were made
as practice around the world continued to evolve.
In 2006, Schober and Affara identied trends and issues in 24 countries. The
issues included titling, scope of practice, competencies, diagnosis, and prescribing
Evolution in Healthcare: The Journey from a US Demonstration Project…
32
[66]. This was the rst comprehensive look at advanced practice around the world
and provided a valuable resource for all nations.
The expansion of nursing was following global trends. In 1990 the World Health
Organization (WHO) issued a goal of “health for all” which focused on equitable
resources for people of all nations. Previous denitions of health as the absence of
disease or inrmity were replaced by a goal dening health as a state of complete
physical, mental, and social well-being and a right of all people [66].
Following the establishment of the WHO goal of “health for all,” the United
Nations developed the “Millennium Development Goals “and later the “Millennium
Sustainable Goals.” Many of these goals are within the scope of nursing. The eight
millennium goals are to (1) eradicate extreme poverty and hunger, (2) achieve uni-
versal primary education, (3) promote gender equality and empower women, (4)
reduce child mortality, (5) improve maternal health, (6) combat HIV/AIDS and
other diseases, (7) ensure environmental sustainability, and (8) develop global part-
nerships [68].
Nursing represents the largest global healthcare workforce [67]. Throughout the
world nurses have made a signicant impact in promoting gender equality, reducing
child mortality, improving maternal health, and combatting diseases such as HIV/
AIDS and other diseases in underserved populations. Nurses with or without addi-
tional education and titling have lled the roles of caregiver in the community func-
tioning in the interest of public health. They have gone door to door providing
services for women and children, staffed clinics in villages for HIV/AIDS and
malaria, provided immunization clinics, and have educated the public on health
promotion and disease prevention.
The concept of expanded practice was spreading within the context of the indi-
vidual nation’s healthcare system. Each healthcare system offered unique needs and
opportunities. The nurse practitioner movement responded to the needs and oppor-
tunities in the nation. In the United Kingdom, the initial focus was on primary care.
The Netherlands began in acute care. They were experiencing a shortage of nurses
in acute care, and patients needing transplants were being sent to other nations for
treatment. The rst program developed by Dr. Petri Roodbol addressed the need for
expert acute care, led a higher status for nurses, and decreased the shortage [69].
Thailand took a different approach and began with regulation rather than educa-
tion. They had support and were able to pass regulation to add 4000 advanced prac-
tice nurses in 7years, to care for underserved rural populations. Once the regulation
was established, they were able to develop the educational infrastructure. Other
nations, including Canada, Australia, New Zealand, South Africa, and Botswana,
were also developing more sophisticated educational programs for nurse practitio-
ners [69].
The network has continued to expand and support the development of nurse
practitioners and advanced practice nurses throughout the world. There are over
100 countries in the NP/APNN network. Globally, the educational level for
advanced practice nursing is increasing, with some nations requiring a doctorate.
Boundaries are expanding and regulations are continuing to be updated. Networking
B. Sheer
33
has made a difference in offering nurses the ability to strategize their next steps.
Nurses of the world have joined together to provide cost-effective accessible care
to all. They continue to make a difference in reaching the Millennium Development
and Sustainable Goals. The transformation will take years but will be worth
the effort.
Nationally and internationally nurses are being recognized for their contribu-
tions. The IOM study in 2010 called for removing barriers to scope of practice and
increased level of education for nurses [44]. More recently the World Health
Organization (WHO) published “Global Strategic Directions for Nursing and
Midwifery 2021-2025.” This document presents evidence-based practices that can
contribute to achieving to universal health coverage and other population health
goals [70]. The transformation of nurses as an international force enabling cost-
effective accessible care is well underway.
Reaching Consensus intheUnited States
The paradigm of traditional healthcare is shifting, and boundaries are becoming
uid. Regulation on a state-by-state basis is no longer a viable option with the
advent of telemedicine and virtual visits. The “consensus model,” endorsed by 44
national organizations, provides a blueprint for the future [71]. The purpose is to
standardize regulation related to advanced practice nurses and provide for mobility
from one state to another.
The components of the model are licensure, accreditation, certication, and edu-
cation (LACE). The rst assertion is that all educational programs must be accred-
ited by a national accreditation body and new programs must receive preapproval to
ensure program standards are met.
Education will be at the graduate level with core courses of pathophysiology,
physical assessment, and pharmacology taken together as a group. The specialty
courses will follow with a population focus: family/individual across the lifespan,
adult gerontology, neonatal, pediatrics, women’s health, and psychiatric mental
health. The program must include the prescribed clinical hours of direct patient
contact.
Graduates must sit for a national certication examination that is psychometri-
cally sound and legally defensible. Licensure will be in one of the four advanced
practice roles: nurse practitioner, clinical nurse specialist, nurse midwife, and nurse
anesthetist. The title designation for all four roles will be APRN.
Adoption of the APRN regulatory model by individual states will eliminate the
inconsistency in practice. Advanced practice nurses will be able to move from state
to state and will no longer need multiple licenses to practice. Standardization will
assure the public that all advanced practice nurses will have the same competencies.
The movement to the doctoral level of education will solidify consistency. This
progress has been slow occurring over 50years. It has been a journey with highs and
lows but is only the beginning.
Evolution in Healthcare: The Journey from a US Demonstration Project…
34
The Journey
This chapter has chronicled the journey of nurse practitioners from the few deter-
mined individuals in the rst class at the University of Colorado who were educated
to provide care for underserved children to the thousands of nurse practitioners who
now provide care in diverse settings throughout the world.
On the journey, nurse practitioners traveled through the maze of legislation, reg-
istration, reimbursement, and scope of practice. They have had supporters and
detractors. The secret was to gather the supporters and others on the journey to
travel together. Networking was and is key: the journey is more enjoyable and much
easier to accomplish with colleagues. Networking began as telephone trees and has
moved to social media in the past 50years.
Each victory provided a steppingstone for another victory. Each study provided
additional information. The quality of care provided by nurse practitioners is no
longer questioned. The effect of full scope of practice has been realized in many
cases and is an asset. Dr. Loretta Ford, in her presentation at the rst international
conference, stated, “the role and idea was described, discussed, debated, dissected,
and defended, as well as deplored, denounced, depreciated and damned.” In the
1990s there were over 1000 studies of nurse practitioners making it the most studied
profession. Nurse practitioners have moved beyond the need to prove they deliver
cost-effective competent care and have developed innovative models to deliver care
to all populations throughout the world [72].
The rst AANP State Award for Excellence was announced in 1991 at a confer-
ence in Washington DC.As each recipient took the stage, they related their story
and why they were selected. Each story was more compelling than the next. The
range of innovative models for the distribution of care was extensive. The stories
ranged from providing primary healthcare to indigenous populations at the water-
hole to providing coffee, sandwiches, and healthcare care to the homeless popula-
tion living under the bridge. There were also stories of setting up inner-city clinics
for HIV/AIDS patients and maternity services for uninsured women. This was a
time of healthcare reform, and these stories represented a new paradigm for the
distribution of healthcare. A corporate sponsor who was in attendance thought the
ceremony should have been taped and sent to all the legislators. This was the real-
ization of healthcare reform [personal experience, Washington DC 1991].
Responding to social change over the years, full scope of practice has been real-
ized in 26 states, the District of Columbia, and 2 US territories. In response to the
Covid-19 epidemic, additional states have granted temporary full scope of practice
to nurse practitioners. Five states requiring physician collaboration suspended the
restriction. Again, in times of crises, nurse practitioners can practice autonomously.
Currently there are more than 355,000 nurse practitioners licensed in the United
States. In an AANP survey, over 81% of Medicare and 78.7% of Medicaid patients
were seen by nurse practitioners [73]. Many of the nurse practitioners practice in
underserved areas and specic populations within urban areas. This has been an
ongoing journey, but the journey was never the goal.
The real story is the impact the nurse practitioner journey has had on the patients.
The small group of early nurse practitioners expanded over the years and on their
B. Sheer
35
journey and took care of the indigenous people at the waterhole, the initial HIV/
AIDS patients that were ostracized, and those in housing projects with no access to
care. The history demonstrates the transformation of healthcare in response to social
changes in society and advancements in technology. The focus was on holistic care
to the patient whether in the ICU or the villages. Each person had a voice and nurse
practitioners listened. The goal has always been about equitable distribution of cost-
effective, accessible quality care.
In 60 interviews from 2000 to present of the Fellows of the American Association
of Nurses Practitioners, a common theme voiced was that despite the challenges the
nurse practitioner role is the best profession, and even with the benet of hindsight,
they would not have changed their career path. Through our history we can appreci-
ate the path to success. The history demonstrates persistence, networking, and the
acknowledgment that each small step is signicant over time.
Celebrating our past, Dr. Loretta Ford donated a portion of her historical docu-
ments to the Bates Center for the Study of the History of Nursing at the University of
Pennsylvania. Members of the AANP History Committee and her family celebrated
this milestone in preserving nurse practitioner history. Dr. Ford and the nurse practi-
tioners that followed demonstrate how a small, dedicated group can alter history.
Dr. Barbara Sheer chair of the AANP History Committee and Dr. Loretta Ford with her family
reviewing the “Ford Collection” at the Bates Center
Evolution in Healthcare: The Journey from a US Demonstration Project…
36
Nurse practitioners and advanced practice nurses are a global force and are mak-
ing great strides toward the ultimate goal of “health for all.” Victor Hugo once said,
“There is one thing stronger than all the armies in the world and that is an idea
whose time has come.” The idea that a small group can make a difference in a global
community is an idea whose time has come.
This chapter is dedicated to all the nurse practitioners throughout the world who
believed they could make a difference in establishing “health for all.”
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Evolution in Healthcare: The Journey from a US Demonstration Project…
41
The Global Emergence oftheNurse
Practitioner Role
MadreanSchober
Introduction
As countries assess the efcacy of their healthcare services and strive to provide
universal healthcare (UHC) to diverse populations, there is a need to identify solu-
tions that enhance access to care and close existing gaps in provision of healthcare
services. As a foundation for UHC, the World Health Organization (WHO) recom-
mends reorienting healthcare systems toward primary healthcare (PHC). In addi-
tion, WHO emphasizes the central role of nurses in achieving UHC and the WHO
Sustainable Development Goals (SDGs) by recommending that healthcare systems
maximize the contributions of the nursing workforce in order to achieve UHC [2, 3].
The concept of advanced practice nursing and the advanced practice nurse (APN) is
one option that is consistent with this perspective and is evolving globally. The
nurse practitioner (NP) is one of the common APN roles that are emerging world-
wide. Nurse practitioner initiatives have appeared in disparate regions internation-
ally for over ve decades.
This chapter provides the International Council of Nurses’ (ICN) denition for
an NP and identies factors contributing to this global trend. The sensitive nature of
country context is revealed along with how the local or national interpretation of
who this nurse is determines what services this healthcare professional provides.
Country and regional exemplars are described to underscore the variations in the
promotion and development of nurse practitioners but are not intended to be an
exhaustive list of nations implementing NP roles and advanced levels of nursing
practice. Additional chapters in this book provide in-depth country and regional nar-
ratives of NP development and implementation.
M. Schober (*)
Schober Global Healthcare Consulting, Indianapolis, IN, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_2
42
The International Council ofNurses’ Nurse
Practitioner Definition
The International Council of Nurses provides the following NP denition in the
ICN Guidelines on Advanced Practice Nursing 2020 [1]:
A Nurse Practitioner is an Advanced Practice Nurse who integrates clinical skills associ-
ated with nursing and medicine in order to assess, diagnose and manage patients in pri-
mary healthcare (PHC) settings and acute care populations as well as ongoing care for
populations with chronic illness. (p.6)
The ICN Guidelines on Advanced Practice Nursing 2020 goes on to describe a
scope of practice for the NP [1]:
The focus of NP practice is expert direct clinical care, managing healthcare needs of popu-
lations, individuals and families, in PHC or acute care settings with additional expertise in
health promotion and disease prevention. As a licensed and credentialed clinician, the NP
practices with a broader level of autonomy beyond that of a generalist nurse, [using]
advanced in-depth critical decision-making and works in collaboration with other health-
care professionals. NP practice may include but is not limited to the direct referral of
patients to other services and professionals. NP practice includes integration of education,
research and leadership in conjunction with the emphasis on direct advanced clinical
care. (p.19)
The scope of practice for the NP differs from that of the generalist professional
nurse in the level of accountability and responsibility required to practice.
Establishment of a scope of practice is a way to inform the public, administrators,
and other healthcare professionals about the services the NP can provide.
Factors Influencing Consideration oftheNurse
Practitioner Concept
The NP concept often develops out of identied healthcare needs along with moti-
vation by individual, practicing nurses who envision that healthcare services pro-
vided by NPs can enhance care to diverse populations. In addition, development of
the NP concept forms part of the global reconceptualization of the current and future
healthcare workforce as being at the forefront of meeting Sustainable Development
Goals (SDGs) as dened by the United Nations (UN) and developed by the World
Health Organization (WHO) [2]. In acknowledging that nurses and midwives are
central to primary healthcare (PHC), WHO also acknowledges that achieving health
for all will require investments in education and job creation for nurses who play a
critical role in health promotion, disease prevention, and delivering PHC and com-
munity care. There is increasing acknowledgment that all nurses and those in
advanced clinical roles such as NPs should be educated, recognized, and authorized
to practice to their full potential [3–6]. Identifying NPs as a potential for
M. Schober
43
strengthening the healthcare workforce places these healthcare professionals at the
forefront in the global plan to signicantly diminish the complex factors that
adversely affect health and access to healthcare.
This section identies international incentives and motivators that contribute to
the consideration and promotion of APN initiatives, including the NP role and level
of practice. The potential for considering the concept of advanced practice nursing
is shaped by the country or regional context [1]. Four main themes are identied as
providing momentum for launching a new initiative or continuing to sustain a sys-
tem that is already in place [7–9]:
• Public demand for improved access to healthcare services and delivery
• An identied healthcare need for provision of healthcare services
• An answer to skill mix and healthcare workforce planning
• A desire for the advancement of nursing roles to enhance professional
development
Additional factors that inuence these four main themes and warrant discussion
when developing a plan or framework for APN that includes NP development
[1, 7–9]:
• Strong education programs for the generalist nurse that provide a robust founda-
tion for advanced clinical education specic to the NP role
• Flexible and realistic education alternatives that not only educate the competent
NP, but offer options when a country is in a transitional process to establish an
NP presence
• Clinical career pathways for advanced clinical practice
• Effective mentorship and nursing leadership to support and promote the
NP concept
• Links to governmental and nongovernmental agencies aligned with international
expertise to establish a professional standard, credentialing process, and
regulations
No single starting point is viewed as pivotal when launching a successful and
sustainable NP initiative. In addition, global development in some countries fol-
lows parallel paths for other APN roles such as the CNS (clinical nurse specialist)
or NA (nurse anesthetist). The sensitive nature of country or local context warrants
advanced assessment of the specic setting(s) in which the NP will practice [1, 10].
Motivation and specic drivers alone do not fully describe the complexities
involved when proceeding to integrate the NP concept into healthcare systems.
However, identifying a driver or drivers provides a stronger foundation for launch-
ing and sustaining a successful NP initiative. Country and regional exemplars of
NP initiatives are provided later in this chapter. These exemplars demonstrate fac-
tors that inuenced the beginning development and promotion of an NP presence
in select nations.
The Global Emergence oftheNurse Practitioner Role
44
Approaching Global Nurse Practitioner Development
An NP scope of practice is built on the scope of practice dened for a generalist
professional nurse and expands beyond that scope in terms of function, expertise,
and accountability based on advanced education [1]. To be effective, NP practice
must be anchored within the national and local healthcare system(s) and tailored to
meet the needs of the population. This means that globally, NP practice, while shar-
ing many similarities, also looks different in different parts of the world. Therefore,
a range of approaches rather than a single prescriptive solution for dening an NP
initiative ideally offers exibility and a grounded process for development.
Discussions seek to dene the NP focus on changes in boundaries of nursing
practice. A country’s stakeholders and decision-makers will likely see this as a para-
digm shift from a more traditional view of nursing practice and collaborative prac-
tice with other healthcare professions [11].
NP practice often exists in settings where the NP provides primary healthcare
services; thus prescriptive authority and the ability to make an initial and/or differ-
ential diagnosis as part of therapeutic management are seen as prerequisite for the
NP to practice to the full potential of the role. Recognition of these elements of the
role enables the NP to function at a level appropriate to their scope of practice under
the professional standard and regulations of the country where they work. Even
though these features are seen as central to NP practice, conversation related to
nurse prescribing and diagnostic decision-making often stimulates lively debate
when promoting new NP initiatives [10, 11]. It is the view of this author that NP
prescriptive authority and use of a common diagnostic language are ways to attain
consistency of care in provision of healthcare services as the world strives for uni-
versal healthcare.
Country Exemplars
The changes supportive of NP development and implementation take place over
years, at times following decades of discussion and decision-making under diverse
and complex circumstances. In this section, country exemplars have been selected
to present illustrations of initial development as the NP concept emerged in a nation
or region and to further highlight initiatives experiencing sustained success. The
exemplars are not meant to be an exhaustive list of all countries with an NP pres-
ence, but to demonstrate similarities and yet diversity with which countries seek to
integrate a new nursing role into their healthcare systems. Emphasis is on portraying
country proles that developed and integrated the NP concept tailored to country
needs, healthcare context, and resource capabilities. In addition, country exemplars
were chosen that clearly relate to the NP presence in primary care and PHC in com-
munities and where the role is consistent with the ICN denition for the NP.
The global emergence of NPs is often attributed to the origins of the NP role in
the USA in 1965 [12]. Where there is evidence of this association, country proles
include mention of adaptation of the USA NP model or collaboration with USA
M. Schober
45
mentors. The country illustrations demonstrate the somewhat simultaneous NP
development that emerged in diverse regions globally from the 1960s over time.
International surveys conducted from 2001 to 2014 found that anywhere from 25 to
60 countries were in various stages of exploring or implementing NP/APN roles
[11]. Based on membership in the ICN NP/APN Network, over 100 nations indicate
a level of interest in advanced nursing practice, although this does not necessarily
mean an active presence of APNs or NPs (www.icnnpapnetwork.wildapricot.org).
The author is aware of international collaboration between multiple countries
other than the USA.As successful NP initiatives became more visible, representa-
tives or delegates from countries with a thriving and effective NP presence are able
to offer guidance to newly emerging projects and proposals worldwide. This inter-
country collaboration speaks to the continued and heightened interest along with
success of NPs globally.
Australia
The Australian health system is jointly coordinated by all levels of Australian gov-
ernment—federal, state, territory, and local. The aim is to provide health and well-
being for all Australians through evidence-based policy, well-targeted programs,
and best practice regulation. Medicare and the public hospital system provide free
or low-cost access for all Australians to most of these health services. Private health
insurance provides a choice outside of the public system. For private healthcare
both in and out of hospital, the consumer contributes to the cost of their healthcare
(www.health.gov.au/about- us/the- australian- health- system).
The prediction of a shortfall in medical graduates choosing primary care as their
preferred option contributed to the consideration of APNs as one of the strategies in
Australia to cope with this decit. In October 1990 the rst NP committee convened
in New South Wales (NSW). This led to the formation of a steering group and the
beginning of the NP movement at the NSW Nurses’ Association Annual Conference
[13, 14]. In January 1994, NP pilot projects were established to evaluate NP models
in rural and remote areas, midwifery, well women’s screening, emergency services,
urban homeless men services, and general medical practice. The outcome of the
evaluation found that NPs were effective in their roles and provided quality health-
care services [14–16]. The authorization process was formalized in 1999 paving the
way for the rst NP endorsement in 2000.
The Australian College of Nurse Practitioners (ACNP) is the national representa-
tive body for NPs and APNs in Australia (www.acnp.org.au). ACNP is active in
advancing nursing practice and improving access to healthcare and denes NPs in
Australia as registered nurses with the experience and expertise to diagnose and
treat people of all ages with a variety of acute or chronic health conditions. Based
on master’s degree education, NPs practice autonomously and collaboratively with
other healthcare professionals in a variety of locations [17]. The only regulated
advanced practice role in Australia is the role of an NP.Registration for NPs is
endorsed by the Nursing and Midwifery Board of Australia (NMBA) to enable the
The Global Emergence oftheNurse Practitioner Role
46
NP to practice within their scope using the NP title, which is protected by law
(www.health.act.gov.au).
As the NP initiative emerged in Australia, nursing leaders and regulators pro-
moted a careful and strategic approach to development and implementation of NPs.
As a result, the NP role and title are protected by legislation. Registration with the
Nursing and Midwifery Board of Australia as an endorsed NP is a requirement to
practice in this role. The rst legally authorized NPs in Australia were recognized in
2000 and 2001. Within 9 years, following initial development in NSW, all Australian
states and territories had achieved ofcial recognition and a legislative framework
for NP practice. The driver for this dramatic change in Australian healthcare, as
envisioned by pioneer nursing leaders, was a commitment to patient-centered care
and a patient-centered health service [13].
NPs in Australia are present in a variety of settings that include primary care,
acute care, specialty medical services, and community care [14] with numbers
increasing in response to identied gaps in service delivery. Even though there is
evidence that NPs enhance quality of care and improve access to healthcare ser-
vices, there continues to be a need for robust political support for NPs to practice to
their full potential.
Refer to Chap. 23: The NP Role and Practice in Australia for an in-depth descrip-
tion of role development and implementation.
Botswana
Universal healthcare is offered to all citizens in Botswana through a public health-
care system, but privately run healthcare is also available. The government operates
98% of all medical facilities (www.moh.gov.bw). A nominal fee may be charged for
some healthcare services in the public sector, but sexual reproductive health ser-
vices and antiretroviral therapy services are free. The decentralized healthcare sys-
tem in Botswana is comprised of 27 health districts, including mobile locations,
clinics, and hospitals (www.borgenproject.org/healthcare- in- botswana).
Developments in provision of healthcare services were a result of societal needs
and demand; in particular a shift of emphasis from hospital-based care to PHC in
the late 1970s led to the establishment of the family nurse practitioner (FNP) pro-
gram in Botswana [18]. Country independence from the UK in 1966, a need for
healthcare reform, and a shortage of physicians triggered the need for nurses to
accept increased responsibilities for PHC services. The nurses accepted these
increased responsibilities but demanded further education to meet the healthcare
needs of the country [19].
The Ministry of Health, through the then National Health Institute, responded by
establishing the rst family nurse practitioner (FNP) advanced diploma program in
1981. The 1-year post-basic program was established to educate nurses in advanced
skills to provide comprehensive PHC services for common problems of the popula-
tion in Botswana. In 1989 there were estimated to be 80 graduates identied as
FNPs who were willing to work in the remotest communities [20]. In response to
M. Schober
47
the country’s healthcare needs and consumers’ demands, the length of the education
program was extended to 18 months, and revisions to the curriculum for the diploma
program took place in 1991 and 2001, and in 2007 a four-semester format was intro-
duced. However, the program did not achieve identication resulting in a master’s
degree even though the education is comparable.
As of May 2020, the diploma program was at an advanced stage of revision at the
Institute of Health Sciences (IHS) [formerly called the National Health Institute]. In
addition, the University of Botswana offers a master’s degree program for the FNP
with discussions underway to determine possible options to matriculate the two
FNP options so that the University of Botswana could recognize prior learning at
the IHS diploma program [21].
Refer to Chap. 19: The NP Role and Practice in Botswana for an in-depth descrip-
tion of role development and implementation.
Canada
Canada has a universal healthcare system funded through taxes for medically neces-
sary healthcare services provided on the basis of need, rather than the ability to pay.
This means that any Canadian citizen or permanent resident can apply for public
health insurance. Each province and territory has a different health plan that covers
different services and products (www.canada.ca/en/services/health.html). The orga-
nization of Canada’s healthcare system is largely determined by the Canadian con-
stitution, in which roles and responsibilities are divided between the federal,
provincial, and territorial governments.
The origins of advanced practice nursing in Canada can be traced to the efforts
of outpost nurses who worked in isolated areas in the early 1890s but were largely
unrecognized within the Canadian healthcare system. Since the 1960s, APN roles
became more formalized [22]. To overcome a physician shortage in rural and remote
areas, the primary healthcare NP (PHCNP) was introduced in the early 1970s, but
by the 1990s the APN movement (NP and CNS) came to a standstill. The factors
contributing to this included a greater availability of physicians, lack of a legislative
framework or recognition in the nursing career structure, and poor public awareness
of the APN concept.
As a result, NP educational programs were discontinued until the 1990s. The
interest in NPs as cost-effective healthcare professionals in PHC was renewed in the
1990s by healthcare reform, an increased demand for access to PHC, and the need
for integrated healthcare services. Formal legislation and regulation for NPs started
in 1998 and all the provinces and territories now have it. NPs work across many
settings and are well positioned to meet the ever-growing complexity and needs in
Canada’s healthcare system [23].
At the request of regulatory bodies in Canada, the core competencies for NPs
were updated, resulting in the Canadian Nurse Practitioner Core Competency
Framework. In 2016, the Canadian Council of Registered Nurse Regulators pro-
duced new Entry-Level Competencies for NPs in Canada as a result of the Practice
The Global Emergence oftheNurse Practitioner Role
48
Analysis Study of Nurse Practitioners [23]. The study showed that NP practice is
consistent across Canada, with NPs using the same competencies in all Canadian
jurisdictions and across three streams of practice (family/all ages, adult, and pediat-
rics) included in the analysis. The Practice Analysis also indicated that the differ-
ence in NP practice in Canada lies in client population needs and context of practice,
including age, developmental stage, health condition, and complexity of clients.
Refer to Chap. 11: The NP Role and Practice in Canada for an in-depth descrip-
tion of role development and implementation.
Republic ofIreland
The Republic of Ireland has a dual healthcare system, consisting of both private and
public healthcare options. The public healthcare system is regulated by one govern-
ment department, the Health Service Executive (HSE) (www.gov.ie/en/ & www.
hse.ie/eng/). The mission of the Department of Health, which is made up of 12 divi-
sions, is to improve health and well-being of people in Ireland by delivering high-
quality health services and getting the best value from health system resources.
In 1996, the concept of an emergency NP was proposed in the James’s Hospital
Dublin. This initiative was intended to address a specic service need identied for
patients with nonurgent clinical presentations to the emergency department. It was
the rst role of its kind in the Republic of Ireland and subsequently developed across
a broad range of 30 nursing specialist areas [11].
A fundamental change experienced by the Irish nurses occurred with the publica-
tion of the Commission on Nursing, a blueprint for the future [24], and the subse-
quent development of the National Council for the Development of Nursing and
Midwifery. The Commission on Nursing provided an opportunity for all Irish nurses
to shape the future of clinical practice by outlining strategies to advance the nursing
profession.
In 1998, the establishment of a clinical career pathway leading from initial nurs-
ing registration to advanced practice was recommended by the Commission on
Nursing. This career ladder was created to retain expert nurses in direct patient care
and served to develop clinical nursing and midwifery expertise. The development of
advanced nurse practitioner/advanced nurse midwife roles and services was part of
the strategic development of the overall health service reform in the country [25].
The Republic of Ireland has established frameworks and standards for the expan-
sion of nursing and midwifery roles including practice standards as established by
the Nurse Midwifery Board of Ireland that have been essential to role development.
It is envisioned that nurses, such as NPs, will acquire the knowledge and skills to
provide better patient care along with the efcient use of resources. In addition,
there is an expectation that positive clinical outcomes are demonstrated [11].
The Irish Association of Advanced Nurse/Midwife Practitioners (IAANMP) was
established in 2004 to provide support to nurses and midwives practicing at an
advanced level in the Republic of Ireland [26]. In addition to peer support for its
members, the Association has been instrumental in ensuring progression of a vision
M. Schober
49
of advanced practice nursing at a national and international level by noting that
APNs, such as NPs, are integral to healthcare solutions by providing safe and effec-
tive healthcare.
Refer to Chap. 16: The NP Role in Ireland for an in-depth description of role
development and implementation.
Jamaica
Healthcare in Jamaica is free to all citizens and legal residents at government hospi-
tals and clinics (www.jamaicans.com/health- care- in- jamaica/). This includes pre-
scription drugs. Private physicians and clinics are widely available if the consumer
has the funds or insurance to cover the cost. The introduction of free public health
services to its citizens in 2008 to make healthcare accessible to all Jamaicans facili-
tated a dramatic increase in patients and resulted in an overload on the healthcare
professionals. This situation along with scarcity of resources continues to challenge
the Jamaican effort to provide UHC to its citizens (www.borgenproject.org/
healthcare- in- jamaica/). Jamaica’s medical infrastructures often do not match the
demand of its patients. In 2019 the Minister of Health and Wellness announced an
upgrade in public health facilities, in addition to developing more sophisticated
healthcare technology.
In July 2017, the island of Jamaica celebrated 40years of NPs providing health-
care services. Discussions on the expanded role of the nurse in Jamaica began in
1972. Twenty-ve experienced nurses entered the rst NP program in 1977. The NP
program was established as a cooperative effort by personnel from the Ministry of
Health (MOH), University of the West Indies (UWI), Pan American Health
Organization (PAHO), and PROJECT Hope [7]. Throughout the early years Project
Hope (USA) provided staff, equipment, and faculty in addition to textbooks, jour-
nals, and audiovisual equipment. The rst group of NPs began practice in 1978. The
MOH was the employer of the NPs with the nurses assigned mainly to provision of
PHC services (personal communication H.McGrath 6/6/22).
Education of nurses as NPs was a response by the MOH to provide staff for the
public health sector as the country was experiencing an acute shortage of physi-
cians, especially in the rural areas. NP education began as an Advanced Nursing
Education Unit based on the US NP concept. The rst cohort consisted of 18
FNPs and 7 pediatric NPs with the course of study offered as a 1-year certicate.
The pediatric specialty was discontinued in 1979, and mental health was intro-
duced in 1997 (personal communication H.McGrath 6/6/22). In 2002, the NP
program became fully university based at UWI and was upgraded to the master’s
level [7].
Desiring improved NP representation, especially for legislative issues, the
Jamaica Association of Nurse Practitioners (JANP) was founded in 2009 to promote
advanced nursing practice, advocate for access of affordable quality care for the
population, as well as give NPs a voice internationally (https://www.facebook.com/
JamaicaAssociationOfNursePractitioners). Even though Jamaica has been the
The Global Emergence oftheNurse Practitioner Role
50
leader of NP education and practice in the Caribbean Region, the island nation con-
tinues to face challenges in gaining explicit legislation supportive of NP practice.
Refer to Chap. 12: The NP Role and Practice in Jamaica for an in-depth descrip-
tion of role development and implementation.
New Zealand
New Zealand’s healthcare system is a universal public system. With the 1938
Social Security Act, New Zealand brought into law universal and free healthcare.
The Act requires that all New Zealand citizens have equal access to the same stan-
dard of treatment in an integrated, preventative healthcare system. The govern-
ment pays for the majority of healthcare costs using public tax money meaning
that healthcare for citizens and permanent residents is either free or low-cost
(www.internationalinsurance.com). There is also an option to choose medical
insurance for private healthcare.
In New Zealand the shift to population-based and PHC services combined with
a realization by the government that nurses do have untapped potential to provide a
greater range of services ignited interest in introducing NPs into the healthcare
workforce [27]. The APN concept was initially recognized in New Zealand in 1988
at two levels. The New Zealand Nurses’ Organization’s (NZN0) credentialing pro-
cess certied nurses as nurse clinicians or nurse consultants (clinical) in an attempt
to promote the concept of advanced practice in nursing; however, it was difcult to
differentiate the difference between these two roles. The NP concept was then intro-
duced in 2000 and the NZNO phased out its earlier certication process in 2006.
The government of New Zealand, while recognizing nurses were already provid-
ing some services at an advanced level, established a task force in 1998 to identify
barriers to provision of optimal healthcare services by nurses. The Ministerial
Taskforce on Nursing identied barriers to nursing practice and examined strategies
to remove barriers and release the unused nursing potential. The task force recom-
mended development of an APN model, and it was agreed that this role should be
the NP.In addition, nursing leaders determined the title nurse practitioner should
have a separate scope of practice that is regulated and the title should be endorsed
by the national regulator, the Nursing Council of New Zealand. The New Zealand
Gazette (the government’s journal of constitutional record) published the rst NP
scope of practice in 2004 [28]. The presence of a supportive Chief Nursing Ofcer
at the Ministry of Health was critical to the success achieved in obtaining govern-
ment acknowledgment that regulation, formal recognition, and employment of NPs
would improve health outcomes of the population [27, 28]. The rst NP was
endorsed in New Zealand in 2001 [21, 28]. In 2015, the Nursing Council of New
Zealand (NCNZ) no longer restricted NPs to a specic area of practice and intro-
duced a new more general scope of practice [28].
Refer to Chap. 22: The NP Role and Practice in New Zealand for an in-depth
description of role development and implementation.
M. Schober
51
UK (England, Northern Ireland, Scotland, Wales)
The National Health Service (NHS) provides residents of the UK healthcare ser-
vices based on clinical need, not ability to pay. There are different eligibility
criteria across the nations of the UK.Since devolution in the late 1990s, the
respective governments in England, Scotland, Wales, and Northern Ireland have
been responsible for organizing and delivering healthcare services (www.euro-
healthobservatory.who.int). The NHS budget is funded primarily through general
taxation.
Dr. Barbara Stilwell is considered to be one of the rst NPs in the UK as well as
a trailblazer and inuencer driving the UK NP initiative. Upon receiving an honor-
ary doctorate at London South Bank University in 2016, Barbara Stilwell com-
mented on her contribution to inspiring the UK NP movement:
The idea of nurse practitioners was inspired by my experiences as an inner-city health visi-
tor… working in Birmingham, dealing with a lot of families from the Indian sub-continent.
Women would come to the clinic wanting to talk about sensitive things like family planning,
screening or childbirth and there were no female doctors to help them. It was also very
clear to me that nurses’ skills and knowledge were being under-used. I happened to read
something about nurse practitioners in the US and thought, why don’t we have something
like that here? We set up a trial clinic and I wrote an article for the Journal of Advanced
Nursing. Peggy Nuttall, one of the grandes dames of nursing, read it and offered me a schol-
arship to go and study in the nurse practitioner programme in North Carolina [USA]. It all
started from there. [29]
Dr. Stilwell practiced alongside physicians in an inner-city setting from 1982 to
1985 adapting the US model of examination, diagnosis, and treatment that included
a focus on long-term health goals [30–34]. Her experiences and research informed
the curriculum for the Royal of College of Nursing (RCN) NP diploma course. Dr.
Stilwell’s conclusion was that a NP is dened not merely by transference of tasks
from other healthcare professionals, but by autonomy of practice involving case
management.
The rst education collaborations in the UK arose in the 1990s as a result of the
implementation and franchise of the RCN “Nurse Practitioner” Diploma. The rst
cohort of NPs was educated in the UK in 1990–1992 (personal communication K
Maclaine, 05/2022). This cohort subsequently traveled to NP conferences in the
USA.Some remained in the USA to be mentored by US NPs. In 2000 the rst NP
course transferred from RCN to London South Bank University.
In addition to RCN formulating initial NP education, the RCN Advanced Nurse
Practitioner Forum began to hold annual NP conferences in the 1990s. These were
primarily focused on the UK market with international representatives participating
on an individual basis. The conferences rotated around the UK and facilitated dis-
cussions related to the global emergence of the NP concept that preceded and led to
the launching of the ICN NP/APN Network.
The RCN franchise also brought together a small group of UK university repre-
sentatives that began to meet on a regular basis to share their educational
The Global Emergence oftheNurse Practitioner Role
52
experiences and expertise. A key part of the stimulus for NPs in the UK included
setting up the UK NONPF (National Organization for NP Faculty) in 2001, based
on the US NONPF.This helped support NP education which was a key grassroots
driver for NPs in the UK in getting it off the ground and collectively lobbying for
standards and high-level recognition. UK NONPF has evolved to become the
Association of Advanced Practice Educators (AAPE UK) that represents a collab-
orative network of higher education institutions (HEI’s) across the UK who are
providers of advanced clinical practice programs of education for interprofessional/
multiprofessional groups. AAPE UK includes representation of advanced nurse
practitioners along with other advanced healthcare professionals (www.hallammed-
ical.com/partners/appe/).
Development of the advanced nurse practitioner (ANP) in the UK is often
described as a single approach in development; however, the ANP has emerged dif-
ferently in the four nations of the UK (England, Northern Ireland, Scotland, Wales).
Following devolution of the UK around 2005/2006, each country now has a separate
government with the individual countries determining their own health policy and
approaches. These differences are reected in how ANP has progressed in each
nation [11, 35].
Issues including inconsistent health policy, education, regulation, and lack of
title protection have plagued the UK since the inception of the NP concept. Lack of
regulation led to a decision by the RCN in 2012 to change the title to advanced
nurse practitioner in order to bring clarity to the role. Unique to the UK, advanced
practice as a whole has now moved, or is moving, toward a multiprofessional
approach recognizing advanced practice as a level of practice rather than a specic
role [35]. This multiprofessional approach indicates that educational programs for
allied health professionals are considered to be multiprofessional with study pro-
grams leading to the title advanced clinical practitioner. However, many nurses
who undertake these programs of study still use the title advanced nurse practitio-
ner as advocated by RCN [25]. Ongoing challenges and the complexity of the con-
text in the UK continue to impact NP development.
Refer to Chap. 14: The NP and Practice in the United Kingdom for an in-depth
description of development.
International Influence
Visible support for the NP concept by international organizations can provide the
authority and advocacy that an initiative may need to convince key stakeholders
and healthcare decision-makers of the benets of NPs. When a scheme is viewed
as part of global advancement for universal healthcare services versus only a local
or national directive, this backing offers an increased level of credibility for con-
sideration of an NP proposal. Sections 2.5.1 and 2.5.2 provide examples of how
international entities promote the advancement of nursing practice that
includes NPs.
M. Schober
53
International Council ofNurses (ICN)
The launching of the ICN Nurse Practitioner/Advanced Practice Nursing (NP/APN)
Network in 2000 signaled the advent of a new era in the recognition of the progres-
sion of the NP concept and advanced practice nursing worldwide. Representatives
from 25 countries, displaying their national ags, gathered for this momentous
event in San Diego, California, USA, to provide encouragement, inspiration, and
energy for what was recognized as a global trend [11]. ICN sought organizational
support to follow trends and new developments in this new eld of nursing. Since
that time, enthusiasm continues to grow, and interest in advanced practice nursing,
including the NP concept, has progressed. This progression has been positively
inuenced by international organizations such as ICN and WHO (World Health
Organization) [1, 2].
In 2000, although there was increased attention for advanced practice nursing,
there was also uncertainty as to the intent and function of this classication of
nurses. ICN had been observing the global growth of APNs since 1994 [7].
Subsequent to the launching of the NP/APN Network, along with recognition of
this ambiguity, ICN took the rst step in 2002 to recommend a denition, scope
of practice, and characteristics for a nurse practicing in an advanced capacity and
role [36]. At the time, the intent was to provide a benchmark to refer to and offer
points for countries to discuss as they developed the APN concept sensitive to
country context. Over time discussions have matured and research on the subject
of advanced practice nursing has increased. It is worth noting that the recognition
of this trend by ICN and the ICN NP/APN Network has had a lot to do with lend-
ing credibility and encouragement in support of the global emergence of NPs.
Through the expertise of its NP/APN Network members, ICN continues to review
the relevance of its ofcial position on APN roles, including NPs, as well as to
follow this global trend.
World Health Organization (WHO)
As an agency of the United Nations, WHO emphasizes international cooperation
aimed at improving and providing universal healthcare worldwide. Although its
emphasis is not specic to nursing, WHO can inuence the extent of attention given
to the advancement of nursing/midwifery and the contributions nursing profession-
als can make in achieving SDGs [2]. Working in collaboration with ICN, in addition
to an array of other partners, WHO efforts have the potential to strengthen support
for nursing/midwifery and further ensure that NPs are visible in discussions of
effective and quality healthcare.
The WHO Global Strategic Directions for Nursing and Midwifery 2021–2025
presents evidence-based practices and an interrelated set of policy priorities that can
help countries ensure that midwives and nurses optimally contribute to achieving
universal health coverage and other population health goals [2]. This document
The Global Emergence oftheNurse Practitioner Role
54
includes a strategic direction to establish and strengthen nursing leadership and ser-
vice delivery that acknowledges the inuence and effectiveness of advanced prac-
tice nurses. The policy priority emphasizes adaptation of workplaces to enable
midwives and nurses to maximally contribute to service delivery in multidisci-
plinary teams. In addition, it is noted that laws and regulations can intentionally
restrict midwives and nurses from practicing to the full potential of their education,
sometimes due to “turf” issues with other groups of healthcare professionals.
Recognition of this issue includes a call to action to update legislation and regula-
tions in order to optimize these roles in practice settings.
In addition, WHO regional ofces have provided support to strengthen accep-
tance of advancing expanded roles for nurses. The WHO Eastern Mediterranean
Regional Ofce (WHO-EMRO), aware that advanced nursing practice and nurse
prescribing was a growing trend, held a meeting of country representatives in
Pakistan in 2001 to discuss these topics and identied strategies for progress in the
region [27].
The World Health Organization-South East Asia Region (WHO-SEAR)
[27] in making the case for a more flexible global nursing and midwifery
workforce provided a conceptual framework in 2003 to assist countries to
develop strategies to strengthen coordination between education and practice
with service needs. The emphasis was on developing skills and competencies
for nurses that correspond with service requirements and health priorities for
the region.
In 2013, members of the Pan American Health Organization (PAHO), the
Americas’ regional ofce of WHO, passed a resolution to increase access to quali-
ed healthcare workers in PHC-based health systems, urging education and imple-
mentation of APNs. In 2014 the WHO-PAHO regional leaders established a working
plan to support the expansion and professionalization of advanced practice nursing.
The plan included goals for education, regulation, and scope of practice of the APN
role. Through prioritizing the preparation and professionalization of APNs in Latin
America, there is an expectation that the presence of APNs will enhance the quality
of PHC and offer a solution to disparities in universal healthcare in the region. In
order to move this agenda forward, the Universal Access to Health and Universal
Health Coverage: Advanced Practice Nursing Summit in 2015 hosted by PAHO/
WHO fostered collaboration between nursing leaders and institutions in North
America with those in Latin America and the Caribbean in order to outline priorities
for APN implementation [11, 37].
When effective, inuence by international organizations provides the capacity
to strengthen support for a heightened NP presence by facilitating discussion
forums, providing workshops or webinars and conferences, as well as offering
consultancy expertise. In addition, publications and resources arising from the
international community can incentivize healthcare planners and key decision-
makers to consider integration of NPs in enhancing PHC and universal health-
care services.
M. Schober
55
Conclusion
The NP concept emerged in the USA in 1965 with the collaboration of a nurse and
a physician (Dr. Loretta Ford and Dr. Henry Silver) responding to an identied need
to improve healthcare services for underserved children. Country proles in this
chapter demonstrate global emergence of the NP role in disparate regions of the
world. Motivation for new initiatives was driven at times by individual nurses who
identied a healthcare need and saw the potential for nurses to enhance healthcare
services. In addition, nongovernmental and governmental agencies pursued innova-
tive solutions to pressing healthcare needs as their countries sought to provide PHC
in community settings. Nurses with advanced education and skills have been repeat-
edly identied as an effective option. This trend and the growth of the NP phenom-
enon continue to increase worldwide undoubtedly based on a foundation of the
international successes of early NP initiatives. In addition, increased global visibil-
ity of a growing NP presence has added to the discussion that these nurses are a
valuable option for provision of diverse healthcare services and universal healthcare.
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6. McGee P, Inman C.Advanced practice in healthcare: dynamic developments in nursing and
allied health professionals: introduction. 4th ed. Oxford, UK: Wiley Blackwell; 2019. p.
xv–xviii.
7. Schober M.An international perspective of advanced nursing practice. In: McGee P, Inman C,
editors. Advanced practice in healthcare: dynamic developments in nursing and allied health
professionals. 4th ed. Oxford, UK: Wiley Blackwell; 2019. p.19–38.
8. Buchan J, Temido M, Fronteira I. etal. Nurses in advanced roles: a review of acceptability in
Portugal. Revista Latinao-Americana de Enfermagem 21 (Spec.) 2013: 38–46.
9. Delemaire M, LaFortune G.Nurses in advanced roles: a description and evaluation of experi-
ences in 12 OECD countries. Paris: OECD Publishing; 2010. OECD Health Working Papers,
No. 54. https://doi.org/10.1787/5kmbrcfms5g7- en
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Nature; 2017.
11. Schober M.Introduction to advanced nursing practice. Cham, Switzerland: Springer
Nature; 2016.
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12. Lusk B, Cockerham AZ, Keeling AW.Highlights from the history of advanced practice nurs-
ing in the United States. In: Tracy MF, O’Grady ET, editors. Advanced practice nursing: an
integrative approach. 6th ed. St. Louis, Missouri: Elsevier; 2019. p.1–24.
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from www.acnp.org.au/history . Accessed June 9, 2022.
14. Lowe G, Plummer V.Advanced practice in nursing and midwifery: the contribution to health-
care in Australia. In: McGee P, Inman C, editors. Advanced practice in healthcare: dynamic
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The Global Emergence oftheNurse Practitioner Role
59
Differentiation ofInternational
Advanced Practice Nursing Roles: NP
andCNS
MadreanSchober
Introduction
The global emergence of advanced practice nursing and the establishment of the
concepts of the nurse practitioner (NP) and the clinical nurse specialist (CNS) have
resulted in robust discussions when attempting to differentiate the distinctive fea-
tures of these roles and levels of nursing practice. Internationally, with increased
parallel development of both the NP and the CNS, their denitive characteristics
have become blurred as key stakeholders attempt to identify these nurses and inte-
grate them in a variety of healthcare systems. In spite of this, the two roles remain
largely distinct, albeit with some overlap in actual practice and development.
This chapter provides historical backgrounds for both the NP and the CNS, not-
ing differences in the stages of initial development. In addition, this chapter strives
to differentiate and clarify traits that are viewed as characteristic of the NP and the
CNS.The aim is to highlight key similarities and differentiate distinct differences,
but it is not intended to be an exhaustive depiction of the NP and the CNS.For in-
depth descriptions and more detailed discussion of the two roles and level of prac-
tice, the author recommends the reader review the ICN Guidelines on Advanced
Practice Nursing 2020 [1] and additional APN, NP, and CNS publications [2–6].
Historical Background oftheNP andCNS
This section sets the stage for an enhanced understanding of how the NP and the
CNS evolved. These background narratives offer continuity and a basis for current
thinking that in turn provides a foundation for understanding the two roles in order
to facilitate effective support for practice and policy.
M. Schober (*)
Schober Global Healthcare Consulting, Indianapolis, IN, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_3
60
Historical Background oftheNP
The establishment of the rst pediatric NP program at the University of Colorado in
1965 marked the inception of the NP role in the USA.Initiated as a demonstration
project, the 4-month program was designed to prepare nurses to provide compre-
hensive well-child care and manage common health problems. As a result, the pedi-
atric NP (PNP) role emerged [7]. While this was seen as a landmark occurrence, the
PNP role is also viewed to be modeled informally on services provided by visiting
nurses in disadvantaged communities as early as 1893. However, it was during the
1960s the NP was rst described formally and implemented in outpatient pediatric
clinics as part of a response to a shortage of primary care physicians.
The emergence of the NP was not without signicant intraprofessional contro-
versy. The initial education and preparation of the NP based on a nursing model
began to shift to an overlap with the medical model, essentially stepping over the
invisible medical boundary into the realm of curing [7, p.17]. Despite this contro-
versy, at the same time, healthcare consumers were demanding accessible, afford-
able, and responsive healthcare services [7]. At the grassroots level, there was an
emerging and growing acceptance of the NP concept, and in the 1970s there was a
heightened visibility of NPs in a variety of healthcare settings, especially in primary
healthcare (PHC). Controversy and support characterized the growth of NP num-
bers in the USA as key stakeholders, healthcare planners, and other healthcare pro-
fessionals met the challenges of developing and implementing the NP presence.
As the American NP gained prominence, the NP concept was also noted interna-
tionally as countries searched for answers to growing PHC needs. Many nations
attribute the introduction of NPs in their healthcare systems to the observed success
in the USA; however, to overcome a physician shortage in rural and remote areas,
the NP also emerged in Canada based on the presence of outpost nurses providing
PHC to underserviced populations more than 100years ago. The primary healthcare
NP (PHCNP) was developed in answer to this need and subsequently appeared in
the urban areas in the 1970s with a second-wave revival of the PHCNP concept in
Canada in the 2000s [8]. Refer to Chap. 2 for global examples of NP initial develop-
ment including the Canadian history and Chapter 11: The NP Role and Practice
in Canada.
The NP concept often emerges as a response to identied healthcare needs, espe-
cially to underserved or disadvantaged populations. As numbers of NPs continue to
increase and practice patterns diversify, comprehensive PHC remains a common
focus of NP practice.
Historical Background oftheCNS
The CNS evolved out of the increasing complexity of nursing care and increasing
technological advances in provision of healthcare services, especially in hospital
and institutional settings. The origin of the CNS emerged from an identied need
for specialty practice in nursing [1, 7, 9]. Psychiatric CNSs as well as nurse anesthe-
tists and nurse midwives led the way. In the USA the growth of hospitals in the
1940s as well as the development of medical specialties and related technologies
further stimulated the evolution of the CNS [2, 7]. Postgraduate courses in specic
M. Schober
61
areas of nursing practice became available, usually at the master’s degree level.
These nurses were considered to practice at a higher degree of specialization than
that already present in nursing and are viewed as the originators of the contempo-
rary CNS role. CNS origins were seen to be positioned more comfortably within the
traditionally understood domain of nursing practice and thus were able to progress
essentially unopposed [2, 11].
In Canada, CNSs rst emerged in the 1970s as the provision of healthcare ser-
vices became more complex. The initial emphasis was to provide clinical consulta-
tion, guidance, and leadership to nursing staff managing complex and specialized
healthcare in order to improve the quality of care and to promote evidence-informed
practice. The CNSs focused on complex patient care and healthcare system issues.
The CNS role has developed over time including a multifaceted prole that includes
direct clinical care in a clinical specialty as well as indirect care through education,
research, and support of other nurses and healthcare staff. CNS leadership contrib-
utes to specialty program development and facilitation of change and innovation in
healthcare systems [12].
Although the CNS concept originally emerged in hospital and institutional set-
tings [1, 9, 12], the role has evolved to provide specialized care for populations with
complex and chronic conditions in outpatient, emergency department, home, com-
munity, and long-term care settings. Even though nurses who practice in various
specialties may consider themselves to be specialized nurses, the designated CNS,
educated at an advanced level, has a broader and extended range of accountability
and responsibility for improvements in the healthcare delivery system in addition to
direct clinical care.
Terminology
As the concepts of the NP and the CNS have evolved, it is worth noting that the use
of the term specialist in nursing can be traced to a time when it was used to desig-
nate a nurse who had completed a course beyond that of a generalist nurse in a
specialty area or who had extensive experience and expertise in a specic clinical
practice area. Following the introduction of the NP concept, words such as expanded
role and extended role were used implying a horizontal movement to encompass
expertise from other healthcare disciplines. Development of the NP concept included
extension of the nursing role that became more inclusive as nurses acquired addi-
tional advanced skills and knowledge. In addition, NPs were working at an advanced
level of clinical practice with expanded and enhanced levels of autonomy, responsi-
bilities, and accountability in the provision of healthcare services. Over time, since
the 1980s, terminology and thinking that addresses advanced practice suggests a
more vertical or hierarchical progress encompassing graduate education within
nursing, rather than a simple expansion of expertise based on knowledge and skills
used by other healthcare disciplines [7]. In order to facilitate a common understand-
ing of the NP and CNS, this section provides denitions for the NP and CNS that
are the ofcial positions of the ICN [1].
Dierentiation ofInternational Advanced Practice Nursing Roles: NP andCNS
62
Definition ofNurse Practitioner (NP)
An NP is an advanced practice nurse who integrates clinical skills associated
with nursing and medicine in order to assess, diagnose, and manage patients in
primary healthcare (PHC) settings and acute care populations as well as ongo-
ing care for populations with chronic illness [1, p.6]. NPs are generalist profes-
sional nurses, who after additional education (minimum master’s degree for
entry level) are autonomous clinicians educated to diagnose and treat conditions
based on evidence- informed guidelines that include nursing principles that
focus on treating the whole person rather than only the condition or the disease.
The NP brings a comprehensive perspective to healthcare services by blending
clinical expertise in diagnosing and treating health conditions, including pre-
scribing medications, and an added emphasis on disease prevention and health
management [1, p.18].
Definition ofClinical Nurse Specialist (CNS)
A CNS is an advanced practice nurse who provides expert clinical advice and care
based on established diagnoses in specialized clinical elds of practice along with a
systems approach in practicing as a member of the healthcare team [1, p.6]. A CNS
is a nurse who has completed a graduate program (master’s or doctoral degree)
specic to CNS practice with an emphasis on providing advanced specialized exper-
tise when caring for complex and vulnerable patients. The combination of advanced
specialized nursing care and a systems approach of the CNS integrates direct and
indirect clinical healthcare services.
Definitive Continuum fortheNP andtheCNS
In an effort to distinguish the NP and CNS roles, Bryant-Lukosius [12, 13] claried
the essential distinctions between these two categories of nurses through an
advanced practice nursing continuum model. In placing clinical practice as a core
feature, the model emphasizes that the CNS focuses more on indirect care support-
ing clinical excellence from a systems approach, while the NP focuses more on
direct patient care within diverse clinical settings. While this research demonstrated
that there are many common features between the NP and CNS, the main difference
between the NP and CNS is viewed as related to greater CNS participation in non-
clinical (indirect) activities related to support of systems, education, publication,
professional leadership, and research. In addition, study ndings demonstrated that
participation in direct clinical care was high for both the NP and the CNS, but dif-
ferences in scope of practice were reected in greater NP focus in diagnosing, pre-
scribing, and treating various conditions or illness. Similar to these ndings,
additional research [10, 14, 15] underscores that NPs engage in direct clinical care
activities to a greater extent than CNSs.
M. Schober
63
ICN Position ontheClarification ofAdvanced Practice
Nursing Designations
In providing Guidelines on Advanced Practice Nursing 2020 [1], ICN took an of-
cial position on the clarication of advanced nursing designations. The intent of the
guidance paper is to promote continued discourse on the concept of advanced prac-
tice nursing while also seeking consistency in how APNs are identied and inte-
grated into diverse healthcare systems globally.
The ICN position advises that not only do educational programs need to be specic
to NP or CNS practice but relevant policies and a professional standard are needed to
promote the inclusion of NP and CNS roles into provision of healthcare services.
To support and facilitate the potential for the NP and the CNS, ICN proposes that
there is a need to:
• Promote clarity of CNS and NP practice.
• Identify how these nurses contribute to the delivery of healthcare services.
• Guide the development of educational curricula specic to the CNS and NP.
• Support these nurses in establishing advanced practice (CNS or NP) roles and
levels of practice.
• Offer guidance to employers, organizations and healthcare systems implement-
ing the CNS and NP.
• Promote appropriate governance in terms of policy, legislation and credential-
ing [1] p.23.
Tables 1, 2, and 3 are offered by ICN in an attempt to bring clarity to these two
categories of advanced practice nurses. Table1 identies characteristics of the CNS
and the NP.Table2 compares the similarities between the CNS and NP.Table3
identies attributes that differentiate the CNS and NP.
Table 1 Characteristics of clinical nurse specialists and nurse practitioners
Clinical nurse specialists Nurse practitioners
Dened scope of practice in an identied
specialty
Comprehensive scope of practice specic to the
NP with activities that include prescribing,
diagnosis, and treatment management
Provides direct and indirect care usually to
patients with an established diagnosis
Commonly provides direct clinical care to
patients with undiagnosed conditions in
addition to providing ongoing care for those
with an already established diagnosis
Works within a specialist eld of practice Works generically within a variety of elds of
practice and settings
Works in dened practice populations (e.g.,
oncology, pain management, cardiology)
Works with multiple diverse practice
populations
Works autonomously and collaboratively in a
team, using a systems approach, with nursing
personnel or other healthcare providers and
healthcare organizations
Works autonomously and in collaboration with
other healthcare professionals
(continued)
Dierentiation ofInternational Advanced Practice Nursing Roles: NP andCNS
64
Table 2 Similarities between clinical nurse specialists and nurse practitioners
CNSs and NPs
• have a master’s degree as a minimum educational qualication
• are autonomous and accountable at an advanced level
• provide safe and competent patient care through a designated role or level of nursing
• have a generalized nursing qualication as their foundation
• have roles with increased levels of competency that is measurable
• have acquired the ability to apply the theoretical and clinical skills of advanced practice
nursing utilizing research, education, leadership, and diagnostic clinical skills
• have dened competencies and standards which are periodically reviewed for maintaining
currency in practice
• are inuenced by the global, social, political, economic, and technological milieu
• recognize their limitations and maintain clinical competencies through continued
professional development
• adhere to the ethical standards of nursing
• provide holistic care
• are recognized through a system of credentialing
Source: With permission. https://www.icn.ch/system/les/2021- 07/ICN_APN%20Report_EN.pdf
Clinical nurse specialists Nurse practitioners
Frequent shared clinical responsibility with
other healthcare professionals
Assumes full clinical responsibility and
management of their patient population
Works as a consultant to nurses and other
healthcare professionals in managing complex
patient care problems
Conducts comprehensive advanced health
assessments and investigations in order to make
differential diagnoses
Provides clinical care related to an established
differentiated diagnosis
Initiates and evaluates a treatment management
plan following an advanced health assessment
and investigation based on conduct of
differential diagnoses
Inuences specialist clinical and nursing
practice through leadership, education, and
research
Engages in clinical leadership, education, and
research
Provides evidence-based care and supports
nurses and other healthcare professionals to
provide evidence-based care
Provides evidence-based care
Evaluates patient outcomes to identify and
inuence system clinical improvements.
Frequently has the authority to refer and admit
patients
May or may not have some level of
prescribing authority in a specialty
Commonly has prescribing authority
Source: With Permission. https://www.icn.ch/system/les/2021- 07/ICN_APN%20
Report_EN.pdf
Table 1 (cotinued)
M. Schober
65
Table 3 Differentiating the clinical nurse specialist and the nurse practitioner
Advanced practice nursing
Clinical nurse specialist Nurse practitioner
Education Minimum standard of a master’s
degree
Accredited program specic to the
CNS
Identied specialty explicit to CNS
practice
Minimum standard master’s degree
Accredited program specic to the NP
Generalist—Commonly PHC or
Acute care explicit to NP practice
Denition Expert advanced practice clinicians
providing direct complex specialty
care along with a systems approach to
the provision of healthcare services
Autonomous clinicians who are able to
diagnose and treat conditions based on
evidence-informed guidelines
Scope of
practice
Job
description
Specialty practice aimed to ensure
and develop the quality of nursing,
foster the implementation of
evidence-based nursing, and support
the hospital or organization’s strategic
plan for provision of healthcare
services by providing direct and
indirect healthcare services. The CNS
provides leadership in advancing
nursing practice including research
and interdisciplinary education
Comprehensive healthcare practice,
autonomous examination, and
assessment of patients that includes
initiating treatment and developing a
management plan. Management
commonly includes authority to
prescribe medications and therapeutics
and conducting referrals along with
monitoring acute and chronic health
issues, primarily in direct healthcare
services. Practice includes integration
of education, research, and leadership
in conjunction with the emphasis on
direct clinical care
Work settings Commonly based in hospital or
healthcare institutional settings with a
specialty focus
Commonly based in PHC and other
out-of-hospital settings or acute care
Regulation Legally protected title Legally protected title
Credentialing Licensure, certication, or
authorization by a national
governmental or nongovernmental
agency specic to practice as a
CNS.Submission of evidence of
completion of a CNS program from
an accredited school of nursing
Licensure, certication, or authorization
by a national governmental or
nongovernmental agency specic to
practice as an NP.Submission of
evidence of completion of an NP
program from an accredited school of
nursing
Policy An explicit professional standard
including specic criteria and policies
to support the full practice potential
of the CNS
An explicit professional standard
including specic criteria and policies
to support the full practice potential of
the NP
Source: With permission. https://www.icn.ch/system/les/2021- 07/ICN_APN%20Report_EN.pdf
Dierentiation ofInternational Advanced Practice Nursing Roles: NP andCNS
66
Conclusion
There is a continued need to promote discussion to clarify the characteristics and
value of the NP and the CNS in order to effectively meet the changing healthcare
demands of diverse populations and healthcare systems globally along with
addressing the changing dimensions of nursing practice. Both the NP and CNS
represent innovations that have challenged the status quo of the nursing establish-
ment and the manner in which healthcare services are provided in diverse settings.
This chapter highlights key aspects of the NP and CNS roles. In addition, the chap-
ter attempts to promote an ongoing dialogue in order to provide a convincing foun-
dation for moving forward in support of the potential of these advanced
practice nurses.
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Nurse Practitioner Education
andCurriculum: AUS Focus
ElizabethMillerWalters, TracyVernon-Platt, AshleyKellish,
ManishaMittal, andSeanDeGarmo
Introduction
The foundation for nurse practitioner (NP) practice requires sound educational
preparation. Worldwide, there are a multitude of ways to become an NP.Today the
complexity of patient situations and healthcare delivery as well as changes in prac-
tice continue to alter the landscape of healthcare. Changes in practice over the
decades have required new approaches to NP education including understanding
policy, process, outcome measurements and analysis, healthcare nance, and evi-
dence-based methods to plan and implement care [1].
History andEvolution ofNP Education
The need for consistent and formal nursing education was obvious to Florence
Nightingale when she opened the rst science-based nursing school in London in
1860 [2]. This approach to nurses’ training would eventually transform nursing into
a profession and alter how healthcare was delivered. One hundred years later, from
this focused area of general nursing education, the NP role emerged with various
methods of NP education.
E. Miller Walters
American Nurse Credentialing Center, Silver Spring, MD, USA
University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC, USA
e-mail: elizabeth.walters@ana.org
T. Vernon-Platt · A. Kellish · M. Mittal
University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC, USA
e-mail: tevernon@email.unc.edu
S. DeGarmo (*)
American Nurse Credentialing Center, Silver Spring, MD, USA
e-mail: Sean.DeGarmo@ana.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_4
70
Before the concept of the advanced practice nurse (APN) emerged, the legal
scope of practice for nurses excluded diagnosing and treating medical issues.
Nurses were expected to follow the nursing process as well as carry out physi-
cian orders. In the 1960s the physician shortage was peaking in the United
States, and it became evident that this shortage, along with limitations for nurses
to make medical diagnoses, restricted access to healthcare for the medically
underserved, especially children in urban and rural areas [3]. Advances in care
delivery and technology identied that there would be a need for a new type of
primary care provider. Further, several policies also assisted with the develop-
ment of the NP role including the Hill-Burton Act of 1946 that provided funding
to hospitals and other health facilities, the development of Medicare and
Medicaid in 1965, and the Comprehensive Health Manpower Shortage Act of
1971. This legislation provided economic resources to expand the US healthcare
system dramatically [3].
The rst program for nurse practitioners was founded in 1965 at the University
of Colorado by a nurse, Dr. Loretta Ford, and a pediatrician, Dr. Henry K.Silver [4].
As faculty in Public Health Nursing at the University of Colorado, Dr. Ford identi-
ed a need for pediatric providers. According to her, “…the pediatric nurse practi-
tioner role, was devised to improve the health and wellbeing of children by
increasing access to providers fully able to provide care” [4]. From that point, the
role of the NP has evolved and grown to include all ages from neonates to older
adults and diverse healthcare settings including acute care, primary care, and spe-
cialty settings. Development of the NP role in the United States initially focused on
populations rather than generalists, which has resulted in difculty in regulation and
licensing. Certication areas include family health, adult-gerontology primary care,
psychiatric- mental health, adult-gerontology acute care, pediatric-primary care,
pediatric-acute care, neonatal, and women’s health/gender related. The urgency of
nurses to ll these advanced roles resulted in several postbaccalaureate certicate
programs, most including less than one year of training and not including a bachelor
of science degree [5].
By 1973, there were over 65 NP programs in the United States, mostly offered
as postgraduate certicates, while some granted master’s degrees [3]. As NP pro-
grams proliferated, legislative initiatives altering state laws and nurse practice
acts supported NP role expansion. By the mid-1970s, many states began propos-
ing laws granting prescriptive authority to NPs. Additional issues that continued
to face NPs were the lack of recognition as “primary care providers” by managed-
care plans and achieving legal authority to medically manage patients within the
NP scope of practice without physician supervision or collaboration. Because of
the expanding NP role, by the 1990s the National Organization of Nurse
Practitioner Faculties (NONPF) published a statement calling for NP education to
be grounded at the graduate level [3]. This initiated a shift away from certicated
NP programs and spurred discussion regarding the best academic methods to edu-
cate NPs on the complex knowledge and skills needed to enter advanced prac-
tice roles.
E. Miller Walters et al.
71
Education forNPs
NP graduate education is designed to build upon the foundational knowledge and
experience obtained as a professional nurse. The objective of any educational pro-
gram, regardless of disparities in international education standards, must be to pre-
pare NP students for advanced clinical practice in a safe and effective manner.
US Entry into Practice
Currently in the United States, NPs must earn a graduate degree in nursing and may
be required to pass a national certication exam in order to begin their practice as
an NP [6]. For several decades after NONPF promoted graduate-level education as
the degree for NP entry in the profession, the progression of nursing education
swirled around the “entry into practice” debate for both registered nurses (RNs) and
NPs. In 2011, the Institute of Medicine responded to increasing demands in nursing
and healthcare with a statement afrming nurses must promote seamless academic
progression by seeking higher levels of education and training through innovative
education systems [7]. The nursing community realized that the key issue is the
need for a highly educated NP workforce not the educational entry point.
The ongoing relationship between education and practice will endure. One can-
not think about clinical issues and nursing education in silos. Instead, practice and
education combined play primary roles in discovering improvements for every NP
population focus area.
Global Entry toPractice
In 2002, the International Council of Nurses (ICN) recommended a master’s degree
as the entry-level degree for the APN.Since that time, the worldwide development of
the NP role has matured to meet the healthcare needs of communities but not uni-
formly [8]. The fact that in 2022 nearly all countries reported the master’s degree as
the primary level of education for APNs is evidence the 2002 ICN recommendation
has had an impact [8]. ICN recognizes that the context and identication of advanced
nursing vary in different parts of the world and many countries may not share the
goal of a master’s degree as the minimum NP requirement [6]. Different nations have
disparate standards regarding minimum education requirements for registered nurses.
It is not surprising that NP standards vary from country to country as well [9].
Several nations face barriers such as funding and lack of resources that impact
how they approach changing educational requirements for APNs. Regardless, the
ICN recommendations serve as a blueprint for countries who are starting or evolv-
ing their NP education programs.
To meet the minimum requirements of a master’s degree for APNs, some nations
have been sending NP students to other countries that offer NP programs at a
Nurse Practitioner Education andCurriculum: AUS Focus
72
master’s level and then relocating them back to their home country upon completion
of the program. With the proliferation of online education, educating future NPs
from around the world in a virtual platform has become an even more promising
method of ensuring APNs everywhere are master prepared. Virtual platforms have
been instrumental in providing didactic opportunities for students globally. However,
clinical components of APN education are important for competency of APN stu-
dents. Many online or virtual programs assist students in ensuring that their clinical
needs and hours are met through virtual touch points between faculty, students, and
preceptors.
Another limitation impacting global NP educational requirements is the title for
advanced practice nurses. In some countries, the title of APN and NP vary, setting
specic educational standards to each respective title. For example, in the United
States, APN is an umbrella term for registered nurses with graduate education and a
national certication, with the NP role falling under the APN title. The ICN clearly
denotes both APN and NP roles. The varying entry to practice to the APN or NP role
worldwide is a barrier for the excellent patient care that NPs and APNs deliver.
NP Educational Path toPractice
The path to practice as an NP can be distinct for each NP.In 2010, The Future of
Nursing: Leading Change, Advancing Health was published by the Institute of
Medicine which recognized the unique role nurses play in the complex healthcare
system within the United States. Key takeaways from the report included that nurses
should practice to the full scope of their education and training and that nursing
education should be improved where nurses could achieve higher levels of educa-
tion. This report has helped to shape the direction of graduate nursing education in
the United States [7].
NONPF was established in the 1970s as a guiding framework for NP curricula.
The organization now represents most NP programs in the United States as well as
some programs in Canada and the United Kingdom [10]. NP programs must pro-
vide an educational framework that prepares new graduate NPs to enter practice
with core competencies for safe and effective practice. Starting in 1990, NONPF
published NP Role Core Competencies to ensure that NPs had the “knowledge,
skills, and abilities that are essential to autonomous clinical practice” [11].
In addition to the NONPF core competencies, the American Association of
Colleges of Nursing (AACN) created Essentials for graduate education. These
Essentials address domains that “represent the essence of professional nursing prac-
tice and the expected competencies for each domain” [12]. The AACN Essentials
were revised during 2020 and 2021. The new Essentials focused on four key areas
of healthcare: wellness and disease prevention, chronic disease management, regen-
erative/restorative care, and hospice/palliative care. From those key concepts, ten
domains were created that align with the changing landscape of healthcare and con-
sider a wider view across the spectrum of wellness to illness including
E. Miller Walters et al.
73
patient- centered care, professionalism, and interprofessional experiences.
Competencies within the domains are leveled to focus on either pre-licensure or
graduate-level education, with an emphasis on Doctor of Nursing Practice (DNP)
for entry into practice for NPs [12].
In the United States, as NP programs develop and revise their curricula, the
NONPF competencies and AACN Essentials must be foundational to all curricular
decisions. There has been a shift to competency-based educational preparation. This
is to ensure learners graduate with “a system of instruction, assessment, feedback,
self-reection, and academic reporting that is based on students demonstrating that
they have learned the knowledge, attitudes, motivations, self-perceptions, and skills
expected of them as they progress through their education” [12]. The move to
competency- based education also aligns with the graduate’s ability to transition into
practice smoothly. Once in practice, the NP is held accountable to competencies
within their population area, so this work was done to augment a more seamless
transition [12].
With successful completion and graduation from an accredited NP program, the
NP graduate is eligible to sit for the standardized national certication exam. These
competency-based exams focus on prociency and knowledge in providing
advanced care to patients. The exams are legally defensible and psychometrically
anchored, and the certication programs are accredited by the Accreditation Board
of Specialty Nursing Certication (ABSNC) and the National Commission for
Certifying Agencies (NCCA).
NP Curriculum Development
The curriculum establishes the depth and breadth of requisite knowledge and skills for
student success in the NP program as demonstrated through NP student learning experi-
ences, testing, and overall evaluation [13].
In 1974, NP educators held their rst national meeting. Between 1976 and 1980,
NONPF focused on establishing curriculum guidelines for NP education. During
this time the National Task Force for Family Nurse Practitioner Curriculum and
Evaluation developed its guidelines, and, in 1980, the University of New Mexico
published curriculum guidelines for Family Nurse Practitioner Curriculum planning.
The professional role of the NP relies on research and nursing theory, which, in
turn, are dictated by the educational model of the NP program. NPs are responsible
to analyze, synthesize, and apply knowledge to their practice. Further, NPs must
understand how to integrate current research into patient care [14].
A crucial move toward furthering the educational preparation of NPs is standard-
izing curriculum within NP programs worldwide. Currently, educational content is
based on opposing curriculum models: both “specialist” and “generalist.” Concerns
regarding dening a singular curriculum model include [1] a lack of resources to
move curriculum in a singular direction and [2] ensuring that all APN competencies
are in line with the singular curriculum direction.
Nurse Practitioner Education andCurriculum: AUS Focus
74
To clarify curriculum direction, the ICN has taken the rst step by clarifying
terminology and untangling mixed denitions for APNs that persist worldwide [6].
The ICN proposed this denition of the APN in 2020:
a generalist or specialized nurse who has acquired, through additional graduate education
(minimum of a master’s degree), the expert knowledge base, complex decision-making
skills, and clinical competencies for Advance Nursing Practice, the characteristics of which
are shaped by the context in which they are credentialed to practice (adapted from ICN,
2008). The two most commonly identied APN roles are clinical nurse specialist (CNS)
and NP [6].
Curriculum Design
Globally, curriculum includes similar content and structure. Two main tenants of
global NP or APN curriculum are addressing the professional role and autonomous
practice [14]. Within the professional role content, the following are topic areas that
are generally covered in NP and APN programs worldwide: research and nursing
theories, leadership and collaboration, and organizational, political, economic, reg-
ulatory, and legislative issues [14]. APN and NP educational programs also include
content related to becoming an autonomous practitioner including health promotion
and disease prevention. These general themes are provided in foundational, clinical,
and didactic courses.
Competency andCurriculum Mapping
The AACN Essentials and the NONPF competencies should be used in parallel
when designing and revising curricula for NP programs. In 2021, AACN published
the updated Essentials: Core Competencies for Professional Nursing Practice. The
major difference is that these essentials now align with all undergraduate and gradu-
ate students and are competency-based. Domains are leveled for the pre-licensure
student and graduate-level (advanced-level nursing) education and are based on
achieving a set of competencies within each one. This is a very different approach
than prior updates and will improve the transition into practice tremendously [12].
To ensure these frameworks are met, faculty should map content across the program
and create crosswalks in the form of tables or charts to ensure the concepts repre-
sented in the Essentials and competencies are included within the courses. These
tables should be adapted for each course to highlight for learners how the course
content and objectives align with the Essentials and competencies. A mapping tool
could also be developed for specic advanced practice areas that demonstrate to
learners how their program is preparing them to meet with Essentials and competen-
cies when they graduate from the program and enter practice as an NP.
The process of developing a mapping tool includes six steps: deciding which
areas of the curriculum to map, completing a curriculum needs assessment, map-
ping the current curriculum, mapping the new curriculum, implementing the cur-
riculum changes, and evaluating it [15]. The rst step in curriculum mapping is to
decide which areas of the curriculum to map so that faculty can identify gaps or
needs in the curriculum. Then a needs assessment should be completed. Faculty
should identify any of the requirements for program accreditation (e.g., AACN
E. Miller Walters et al.
75
Essentials, NONPF competencies). Faculty can consider mapping curricular con-
tent to certication testing domains as well. Next, it is imperative to map the current
curriculum including the course content, lectures/modules, and supportive course
materials to the identied requirements for program accreditation. Mapping the cur-
rent curriculum will help faculty to identify gaps and duplications in the curriculum
related to program accreditation. The next step is to map the new curriculum based
on the gaps and duplications from the current curriculum. Implementing the cur-
riculum changes includes revising the new course content from lectures/modules,
assignments, and supportive course materials based on the new curriculum. Finally,
ongoing evaluation is vital for students. Utilizing continuous quality improvement
methods for evaluating the curriculum can allow for frequent updates of course
content as accreditation standards and evidence-based guidance changes [15]
(Figs.1 and 2).
Innovations inNP Education
The future of NP education is bright. There are many new educational modalities
that aim to address the needs of NP students and the growing faculty shortage.
Further, there are efforts to standardize entry into practice.
DNP asanEntry toPractice
Although the goal of ensuring a DNP is the entry-level degree for the NP by 2025in
the United States, this transition has been discussed by governing bodies since the
early 2000s. In October of 2004, the AACN published a position statement support-
ing the DNP practice degree for entry into practice for advanced practice registered
nurses (APRN) across four areas: certied registered nurse anesthetist (CRNA), NP,
clinical nurse specialist, and certied nurse midwife. Starting in January 2022, all
CRNA students must matriculate into a doctoral program. NONPF has stated that
NP programs should shift to DNP only by 2025 [17]. Their conclusions were based
on the increasing complexity of healthcare with individuals and populations. The
consensus is that with doctorly prepared NPs in clinical practice settings, quality of
care and patient outcomes will improve [18].
The DNP is a practice degree that focuses on quality improvement, which differs
from a Doctor of Philosophy (PhD), which is based on research. DNP-prepared
nurses focus on implementation science and evidence-based practice. According to
the Centers for Medicare and Medicaid Services (CMS), quality improvement
allows healthcare teams to close gaps in care and systematically standardize best
practices [19]. This federal recognition of the need to implement quality improve-
ment frameworks to address care needs is a testament to the DNP in practice. The
DNP is trained specically to close the gap between research and practice and
develop ways to improve care in a sustainable fashion [20]. In combination with the
medical and PhD partners, a DNP-prepared NP can truly engage in improved patient
Nurse Practitioner Education andCurriculum: AUS Focus
76
1. Remember/Understand
2. Apply
3. Analyze
4. Evaluation/Create
Foundations of Scholarly Writing
Leadership, Role & Collaboration
Health Promotion Theory & Population Health
Information Systems and Technology Improvement
Health Systems Policy, Economics & Financial Plannin
g
Quality & Safety
Biostats & Epi
Foundations of Evidence based Practice
Evidence based Practice Methods
Advanced Pharmacology & Therapeutic
Advanced Physiology and Pathophysiology
Advance Health Assessment
Diagnosis & Management- Intro to Diagnostic Reasonin
g
DNP System Thinking Seminar I
Health Management I - Didactic
Health Management I - Clinical
DNP System Thinking Seminar II
Health Management II - Didactic
Health Management II - Clinical
DNP System Thinking Seminar III
Health Management III - Didactic
Health Management III - Clinical
DNP System Thinking Seminar IV
Practice and System Final Clinical
Total
Credit Hours (80) 23333333344333333343454580
Clinical Hours (1000) 180240 280300 1000
Domain 1
1.1Perform a comprehensive, evidence-based assessment. 22233444
1.2Use adva nced clinical judgment to diagnose. 1222 22 33 4
1.3Synthesize relevant data to develop a patient- centered, evidence-based plan of care.12233444
1.4Manage care across the health continuum including prescribing, ordering, and evaluating
therapeutic interventions. 1222 33 44 4
1.5Educate patients, families, and communities to empower themselves to participate in their
care and enable shared decision makin
g
.1233 44 444
Domain 2
2.1Demonstrate an investigatory, analytic approach to clinical situations.1123234
2.2Apply science-based theories and concepts to guide one’s overall practice.1 123332234
2.3Leads scholarship activities which focus on the translation and dissemination of
contemporar
y
evidence into practice. 1244
Domain 1: Patient Care
Domain Descriptor: Designs, delivers, manages and evaluates comprehens ive patient care.
Domain 2: Knowledge of Practice
Domain Descriptor: Synthesizes established and evolving scientific knowledge from diverse sources and contributes to the generation, translation and dissemination of health care knowledge and practices
Fig. 1 Example curriculum mapping template (NONPF 80 credit DNP proposed program of study to the Common Advanced Practice Registered Nurse
Doctoral-Level Competencies) [16]
E. Miller Walters et al.
77
•Review map for
currentcourses and
assignments aligning
with comps/essen!als
•Determine which
coursesand
assignments will
contribute to your
progress in the
program.
Semester
Start
•Review themap for
comps/essen!als you
have worked on so far.
•Writea brief
reflec!onon how your
efforts are leadingto
APRN prepara!on and
share with your
faculty.
Mid-
Semester
•Finalizeany work
towards
comps/essen!als.
•Submitmap and
examples of work in
Sakai. Be sure to
review with lead
faculty/advisorduring
the next advising
session
Semester-
End
Fig. 2 Example curriculum mapping student tool
care at all levels [9]. Yet, the debate about the value of the DNP continues due to the
lack of standardized programs, uncertainty over DNP practice versus master’s-pre-
pared NPs, and the domination of DNP programs to prepare educators and admin-
istrators [21].
NP Education Delivery Methods
NP educational programs vary in delivery type either completely online, a hybrid of
online and on-campus opportunities, or more traditional delivery methods of in-
person instruction.
In-Person
In-person educational programs refer primarily to learning experiences where stu-
dents meet face to face in a physical location with their instructors and peers accord-
ing to a course schedule. This helps to establish a rapport with faculty and build
relationships among students. This traditional method of instruction also allows
students to take advantage of campus services. However, this requires a signicant
time commitment and travel to campus, and many students may prefer an online
format and hybrid options discussed below.
Online andHybrid
Conventionally, hybrid learning refers to a combination of asynchronous and syn-
chronous learning experiences where the synchronous learning takes place in-
person at a college campus. Since the evolution of online learning resources and the
COVID pandemic, many institutions offer virtual synchronous learning experi-
ences. The terms hybrid and online learning experiences are used relatively inter-
changeably. Some institutions use “online” terminology for learning experiences
that are entirely asynchronous, where the onus is on the learner to complete all their
assignments and readings independently. These programs may offer in-person
immersion experiences for a few days during the semester. Some institutions use the
word “hybrid” to refer to a combination of remote and in-person experiences. While
other institutions use the word “hybrid” to denote a combination of asynchronous
Nurse Practitioner Education andCurriculum: AUS Focus
78
experiences and virtual synchronous learning experiences. In our discussion, we
refer to online learning as the modality where students have a combination of asyn-
chronous and synchronous learning experiences and are not required to be present
at a physical college campus.
Recognizing the need for more nurses in our workforce and the cost and time
constraints, online programs offer exible opportunities for students. Blended learn-
ing programs where nurses can complete their course work asynchronously while
working part-time or full-time in their clinical practice and applying their knowl-
edge to improve their skills can address the workforce needs. The combination of
hands-on practice and time to reect, work in small groups at their own pace, and
acquire new knowledge to advance their careers can be a sustainable solution. As
the aging nursing faculty retire, this also creates a scalable solution for universities
to offer short, synchronous teaching sessions and engage faculty who are not limited
to being in a physical location for the didactic lectures and class discussions. Video
conferencing tools have made a lot of progress, especially since the pandemic. A
combination of educational technologies can be implemented to ensure engage-
ment, student collaboration, and frequent communication with and among teaching
faculty. Further, the advances in simulation tools, the utilization of standardized
patients, and the integration of immersive and virtual realities are facilitating inno-
vative solutions to educational challenges.
Supervised Clinical Practice
Each of these delivery types require supervised clinical practice. The translation of
the didactic components into practice through supervised clinical practice is an
essential component of NP education, yet these components vary among titles and
roles worldwide. The recommended number of direct or indirect clinical hours
under supervision lacks consistency worldwide. The majority of programs report
500hours of clinical practice, with a range of 300 to 1490hours, worldwide [8].
Innovations in supervised clinical practice hours are being studied. Recently,
some programs have explored the option of virtual precepting for NP students [22].
Virtual precepting during telehealth visits may be an option for increasing the access
to preceptors for NP students. It is noted that standards for virtual precepting must
be established [22].
Instructional Design forAdult Learners
It is imperative that NP faculty utilize adult learning theory to design meaningful
and effective course instruction. Since 1980, Malcolm Knowles has been credited
with the theory of adult learning. He explained how andragogy, which pertains to
adults, is different from pedagogy, which discusses learning among children.
Specically, adults need to know why they are learning something, how it will help
them with their work, and how they might be able to connect this to prior knowledge
or skills [23]. Adults like to oversee their own learning. Relevance is an important
component of adult learning. This makes it more important to offer short,
E. Miller Walters et al.
79
just-in-time training sessions for adults that allow them multiple opportunities to
make connections and apply their new knowledge and skills.
As we design programs for adult learners, instructional designers and faculty
must bear in mind these principles to create engaging learning experiences. The
importance lies in the connections that adults can establish with the content and
among each other. Adequate social presence and faculty presence that helps to make
these connections, without isolating learners, are important components of adult
learning programs.
The future of healthcare calls for digital literacy, which can be established
through a well-designed online nursing program. By integrating online course qual-
ity standards such as the Quality Matters framework and engaging instructional
designers to collaborate with faculty and institutions to create meaningful online
learning experiences, we can move the needle on nursing education.
Interprofessional Education andPractice
In recent years, the momentum to educate professionals as teams has grown.
Another important addition to the NP curriculum is interprofessional education and
practice (IPEP). According to the Institute of Medicine in 2015, interprofessional
teams are able to coordinate care better, improve patient care outcomes, and poten-
tially improve the cost of care [24]. To that end, in 2015, the Health Resources and
Human Services Administration (HRSA) recommended several opportunities to
improve access to interprofessional education including funding ideas and complete
support of growing programs. There is still much work to be done, but successful
IPE programs across the country are showcasing their outcomes in graduating the
prepared interprofessional.
Simulation
Simulation education modalities are another important tool for augmenting the tra-
ditional NP education models. Simulation methodologies offer the opportunity to
design systematic and standard approaches to gaining knowledge, developing skills,
and enhancing critical thinking as an NP [25]. To fully implement the new
competency- based approaches to developing practice, the use of simulation meth-
ods and assessment will be paramount.
Simulation has grown tremendously in both scope and technology over the last
20years across the healthcare profession [25]. From emergency management to
innovative team-based scenarios, simulation can augment NP instruction in a valu-
able way. The COVID-19 pandemic accelerated the use of other technologies that
support hybrid simulation as well as virtual reality and online gaming [25]. All of
these opportunities now exist to provide NPs the chance to learn and make mistakes
in a safe environment [26]. The use of sound debrieng post simulation as well as
guided reection can also drive critical thinking skills and improve knowledge
Nurse Practitioner Education andCurriculum: AUS Focus
80
overall [27]. To that end, all NP programs must nd ways to engage in simulation
activities throughout their program. Connecting the objectives of simulation activi-
ties to the competency-based competencies can help maintain the direct connection
to academic goals while promoting a skilled and safe graduate.
Conclusion
NP and APN education vary in delivery method, content, and entry to practice glob-
ally. However, there is a call to action to standardize NP and APN education world-
wide. Innovations in global NP education include delivery methods (in-person
versus virtual), the inclusion of interprofessional education and practice to NP pro-
grams, and the use of simulation. NP curriculum must be based on a set of stan-
dards, for example, NONPF, AACN, or ICN standards. The strategy to ensure NP
curriculum is meeting global or national standards is to map the NP curriculum to
global or national standards. Despite the ongoing need for global standardization of
NP education, there has been so much work done since the development of the NP
role in the 1960s. NPs and APNs have been providing excellent care to patients
around the world for over half of a century.
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Nurse Practitioner Education andCurriculum: AUS Focus
83
NP Practice Competencies
MaryBethBigley, ElizabethMillerWalters, JoshuaEvans,
andSeanDeGarmo
Introduction
Professional health educators have dened practice competencies for years. Practice
competence is the ability to successfully and efciently demonstrate a mastery of a
set of skills [1]. Competencies are designed to be observable, realistic, and measur-
able. The denition of competencies and competence most familiar to educators in
the United States is that of the American Association of Colleges of Nursing
(AACN), an adoption of Frank, Snell, and colleagues [2, 3].
Competencies: An observable ability of a health professional, integrating multi-
ple components, such as knowledge, skills, and attitudes [2].
Competence: The array of abilities (knowledge, skills, and attitudes) across mul-
tiple domains or aspects of performance in a certain context. Competence is multi-
dimensional and dynamic. It changes with time, experience, and settings [2].
Practice competence is attained through the assessment of NP competencies;
they are important in dening an NP’s scope of practice. The key to designing a set
of competencies is that they can be measured. Once all the competencies have been
M. B. Bigley
National Organization of Nurse Practitioner Faculties, Washington, DC, USA
e-mail: mbbigley@nonpf.org
E. M. Walters
American Nurse Credentialing Center, Silver Spring, MD, USA
University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC, USA
e-mail: Elizabeth.walters@ana.org
J. Evans
University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC, USA
S. DeGarmo (*)
American Nurse Credentialing Center, Silver Spring, MD, USA
e-mail: Sean.DeGarmo@ana.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_5
84
observed and evaluated, a determination can be made that the NP student has dem-
onstrated the skills necessary to safely move into the workforce.
This chapter describes the way in which competencies and competency-based cur-
ricula are developed. Although the ICN/APNs is working toward global competencies,
there is not a standard consensus on global advanced practice nurse (APN) competen-
cies. This chapter suggests domain and competencies based on a review of the Strong
Model, as well as competencies from countries that have published them [4].
Frameworks to incorporate competencies into an APN school or program are included.
How Are NP Competencies Developed?
The development of competencies has progressed differently from country to coun-
try. In some counties, regulatory bodies propose competencies, while in others, it
may be a professional organization. For example, the Canadian Entry-to-Practice
Competencies for Nurse Practitioners underwent an extensive revision in 2018.
Beginning in 2012, the Canadian Council of Registered Nurse Regulators estab-
lished a national working group of representatives from all Canadian nursing regu-
latory bodies. Surveys were sent to Canadian NP education programs to help
ascertain gaps between education and competency. After a robust practice analysis,
the competencies were pilot tested with practicing NPs. The combined information
led to the release of the 2018 Canadian Entry-to-Practice Competencies for Nurse
Practitioners [5].
Similarly, in the United States, AACN—a professional organization representing
schools and programs of nursing—embarked on revisions to competencies for all
levels of nursing. Experts were appointed to a workgroup and input was solicited
multiple times from stakeholders. This iterative process led to the April 2021 release
of The Essentials: Core Competencies for Professional Nursing Education. The
document indicated a need for specic NP competencies, as it provided competen-
cies for all APNs.
In 2020, the National Organization of Nurse Practitioner Faculties (NONPF)
began to revise the 2016 NP Role Competencies. Completed in April 2022, they
scaffolded down from the AACN Essentials and dened the specic knowledge and
skills necessary for NPs. The competency revision processes included obtaining
feedback from faculty, deans, and other stakeholders at multiple points during the
drafting period. The nal 2022 NONPF NP Role Core Competencies are integrated
with and complement the registered nurse (RN) and APN competencies.
In many professions, standard documents that outline NP practice competencies
and ofcial competencies are one and the same. This is the case in England and
Australia. Standards for NPs in Australia are built and expanded upon RNs’ require-
ments. A master’s degree is necessary [6]. In England and surrounding Nations such
as Wales, Scotland, and the Republic of Northern Ireland, advanced practice is
viewed as a level of practice and not just a role [5].
The Australian National Nursing and Midwifery Registration Board (NMBA) of
the Australian Health Practitioner Regulation Agency focuses on NP clinical attri-
butes including research, education, and leadership that can be applied to clinical
M. B. Bigley et al.
85
care. Research is tailored toward processes to improve upon evidence-based care
and quality management, education related to focus of care, and leadership and the
support of others through clinical supervision or mentoring [6]. These attributes are
blended with four focused standards for NPs. These focused standards require that
an NP (a) assesses and uses diagnostic capabilities, (b) plans care and engages oth-
ers, (c) prescribes and implements therapeutic interventions, and (d) evaluates out-
comes and improves practice [6].
England, Wales, Scotland, and Northern Ireland begin the framework by dening
advanced practice. The Royal College of Nursing denes advanced practice as a
level of practice, rather than a type of practice. NPs are educated at the master’s
level in clinical practice and have been assessed as competent in practice using their
expert clinical knowledge and skills. They have the autonomy and authority to act
and can make decisions in the assessment, diagnosis, and treatment of patients. The
core role and function follow four pillars of practice as per NP’s standards. These
are through clinical and direct care, leadership and collaborative practice, improv-
ing quality and developing practice, and developing self and others [5].
Regardless of the process used to develop competencies or the national organiza-
tion responsible for leading the system, leadership must consider including all inter-
ested parties in the process. For example, regulatory agencies, accreditors, certiers,
educators, and health system and patients’ representatives may be considered for
participation, as well as the Ministry of Health and other health professional lead-
ers. Competencies inuence the scope of practice requirements, certication and
licensing policies, accreditation standards, and institution credentialing. Many
experts have also emphasized the importance of competencies being written to sup-
port competency-based education that meets social and patient needs. Therefore,
the NP competencies create a foundation of education that is driven by the needs of
the patient and society. The drafting and release of NP competencies is an extensive
process and one that should not be rushed.
How Are NP Competence Established?
In 2020, the ICN published the Guidelines on Advance Nursing Practice, in cele-
bration of the International Year of the Nurse and Midwife by the World Health
Organization. It was a call for the progression of APN globally, as well as a work-
force to promote, prevent, and manage illness to the full scope of practice [7].
Communicating the role of the APN was critical to facilitate an understanding for
others who inuence the profession, such as the public, policymakers, and
educators.
The Guidelines introduces the concept of an NP and articulates that NP prac-
tice is an extension of individual basic nursing practice education. Supported by
ICN/APN and acknowledged in several different countries’ documents, there
are several assumptions commonly found. One assumption is that an NP is an
RN who has advanced clinical training beyond their initial professional RN
preparation. Other commonalities include the idea that (a) NP competencies
build on RN competencies to expand upon the knowledge, skill, and abilities
NP Practice Competencies
86
achieved at that level; (b) NPs practice in coordination/collaboration with
healthcare professionals and other individuals; and (c) NP programs have a clin-
ical component [7].
Additional shared elements found in some countries’ NP competencies docu-
ments (but not all) include the following: (a) NPs require graduate nursing edu-
cation; (b) NPs are educated to practice across setting and individual populations;
(c) NPs are licensed, independent practitioners and can practice autono-
mously [7].
Prior to the release of the 2020 Guidelines, earlier work dened the global fea-
tures of NP scope of practice and the competencies. In 2017, the ICN/APRN
Network Research subgroup compared the Strong Model of APN and the ICN/APN
Competencies with APN competencies from 19 countries [4].
The Strong Model (2000) outlines domains and the associated competencies:
• Domain 1: Direct Comprehensive Care (15 competencies)
• Domain 2: Education (6 competencies)
• Domain 3: Support of Systems (9 competencies)
• Domain 4: Research (6 competencies)
• Domain 5: Publication and Professional Leadership (6 competencies) [4]
The ICN/APN Network Research subgroup work has been fundamental in den-
ing global APN competencies. The subgroup found that 19 participating countries’
programs supported many of Domains 1–4 elements, but Domain 5 was less likely
to be represented in the program’s curriculum [4].
These researchers continue to explore this and other methods of analysis, such as
cluster mapping, to understand the global landscape of APN education and compe-
tencies. Sastre-Fullana and colleagues’ (2021) secondary analysis of the informa-
tion provided by the 19 countries that participated in the ICN/APRN Network
Research subgroup found that by employing the Strong Model and mapping the
information, users may visually identify common concepts and linkages. Their nd-
ings revealed wide variation in the APN programs globally. The author remarked
that more work is needed in this area to propose a core set of competencies that will
work for APN education globally [8].
A review of published NP competencies from different counties and the ICN/
APN Network Research subgroup report revealed commonalities. These competen-
cies are similar to the Strong Model domain competencies. As the APN scope of
practice evolves, the terms used have also evolved to reect education knowledge
and skills at the advanced level. For example, the science of practice describes the
translation of research to practice, which is more commonly seen in APN programs
[9]. This section depicts common elements that are used to formulate program NP
competencies. It is not inclusive but describes some general competencies that are
found in different countries’ published competencies documents, including AACN
Essentials, CNO’s Entry-to-Practice Competencies for Nurse Practitioners,
NONPF’s NP Role Core Competencies, NMBA’s Nurse Practitioner Standards for
Practice, and RCN’s Advance Level Nursing Practice.
M. B. Bigley et al.
87
Science ofPractice
The use of evidence and best practice informs practice decisions. This element
aligned with aspects of the Strong Model Domain 4, which includes research NPs
integrating, translating, and applying scientic knowledge into practice daily [4].
The NP’s role in the research environment is to translate research discovery into
practice for all members of the healthcare team. NP and nurse researchers frequently
collaborate on study design to provide the practice components to the nurse
researcher. Also included in this element is the science of quality improvement (QI).
QI is important because it focuses on implementing new knowledge and evidence
into practice or the healthcare delivery systems.
In general, this competency would include:
• Applying theories, research, guidelines, and best practices from nursing and
other sources to inform practice
• Critically appraising current and emerging evidence from diverse sources to
inform practice decisions
• Evaluating quality and outcome using quality improvement principle
• Participating in quality improvement to develop a new system of care
• Participating in research
• Implementing quality improvement and research into practice
• Using information to manage risk and build a culture of patient safety
• Contributing to the evaluation of NP practices on patient outcomes
Care ofanIndividual andPopulation
This element is highly representative of the NP and a major factor in determining
scope of practice. The person-centered approach of NPs providing care requires
knowledge, skills, and abilities at an advanced level. It is very similar to the Strong
Model Domain 1 (direct comprehensive care). Management of care may be pro-
vided to an individual [4]. However, care management must consider the family and
community. Care can be provided in different settings for individuals with routine
health needs, as well as stable, chronic, acute, or critical conditions. Partnering with
the patient to achieve individual self-care outcomes and patient education is central
to this element. It frequently overlaps with competencies in other elements speci-
cally related to interprofessional team care and care that is population-specic, cost-
effective, and safe.
Competencies to achieve this for individuals include:
• Incorporating health promotion in an individual’s care plan
• Integrating advanced assessment, by:
– Obtaining comprehensive or focused health, family, social, spiritual, and
medical information
– Conducting a physical examination based on age and history
NP Practice Competencies
88
– Ordering test(s) and/or performing procedure(s) both for preventive care and
history and
– Identifying health risk factors and social determinants of health factors.
• Diagnosing actual or potential health problems and needs by:
– Analyzing physical nding
– Distinguishing normal, variation of normal, and signs of pathology, and
– Utilizing diagnostic reasoning to formulate an actual or differential diagnosis.
• Managing care for the individual in the context of the family and social struc-
tures by:
– Developing a mutually acceptable, cost-conscious, and evidence-based
plan of care
– Using pharmacological and non-pharmacological interventions
– Communicating health ndings and plan of care
– Respecting patients to make an informed decision about care, including end
of life decisions
– Developing a patient communication plan based on literacy and
– Collaborating with other healthcare providers.
• Evaluating outcomes of care by:
– Assessing the effectiveness of the plan of care
• Promoting self-care
• Creating community partnerships to support self-care management
Competencies to achieve this for populations include:
• Assessing population and subpopulation health risks and health needs using
available data
• Collaborating with the community and public health providers to promote health
and manage disease
• Collaborating with the community to develop and disseminate health messages
• Contributing to a culture of patient safety
• Incorporating diversity, safety, and socioeconomic determinants of health and
using culturally competent care when planning and providing healthcare services
Health Systems Practice
NPs work in systems that inform patient and population care delivery models.
Informing the health system’s practices, policies, and procedures as well as engag-
ing in QI efforts to improve the system leads to safe, quality, and equitable care.
Strong Model Domain 3 (support of systems) outlines competencies that are indi-
rect inuencers of patient care. Additionally, communication technology and infor-
mants have grown over the years and can be used to understand models of care and
services. A selection of competencies in this element includes:
• Collaborating in strategic planning to inform practice improvements
• Optimizing practices, policies, and procedures based on best practices and
evidence- based care
M. B. Bigley et al.
89
• Advocating for nancial policies and regulations to enhance the value of care
delivery
• Identifying communication technologies and tools to maximize individual and
population health
• Designing system improvement that provides safe, quality, and equitable care
• Designing preparedness structures to address disasters and public health
emergencies
• Demonstrating collaboration and leadership on an interprofessional team
Leadership ofSelf andOther
The fourth element establishes competence to build leadership knowledge and
skills to inuence the professions and professional identity. The Strong Model
Domain 5 (publication and professional leadership) inuences the competencies
in this element, but expands on the professional leadership of self. NPs profes-
sional maturity is developed over time, but starts with a good role model, ethical
principles, and the understanding of legal parameters of practice. Membership
in organizations that dene nursing and medical practice provides a platform to
inform practice and grow leadership skills. Engagement in organizations where
policies and best practices are dened is encouraged. Essential to this element
is one’s health, safety, and well- being. This element’s competencies may
include:
• Demonstrating an NP professional identity
• Articulating the NP role in clinical, political, and professional contexts
• Demonstrating accountability to practice within the regulatory standard and
scope of educational preparation
• Developing writing, negotiation, and inuencing skills to advocate for practice
improvement
• Developing scholarship for oneself and the NP profession
• Acting as an educator to students and all health professionals
• Fostering a professional work environment that promotes respect, equity, inclu-
sion, and trust
Various countries articulated NP competencies differently. Nevertheless, they
likely have several, if not all the elements described above. The above list is a sam-
ple of competencies that can be expanded on and added to with specic knowledge
and skills each individual nation deems important [4–6, 9, 10].
How toUse Competencies Documents at theInstitutional Level
Most academic institutions are accredited by a national commission. Through the
accreditation process, initial materials provided to the commission include the insti-
tution’s mission, vision, and institutional outcomes. Institutions, schools, and/or
programs, such as a nursing program, write their specic program outcomes, goals,
NP Practice Competencies
90
and priorities based on the institution’s outcomes. Program outcomes are usually
broad and used to develop the program of study, or the curriculum. The curriculum
is comprised of courses that support learning and produce competent graduates.
Each course has learning objectives and course outcomes. This pathway ensures
school/program outcomes are congruent with the institution’s stated outcomes and
these outcomes become specic/narrow focus at the course level. Specic assign-
ments in courses are written to ensure students can meet the course objective, while
the student outcomes show how students will achieve these objectives. In other
words, the objectives focus on the desired learning, while the outcomes focus on the
learning that occurred.
Courses and course objectives should be thought of as a progression of mile-
stones that systematically build on prior coursework to achieve course outcomes
and together achieve program outcomes. For this to be successful, course objectives
are written to be measurable, and the course assignments must be observable.
Hence, course objectives and assignments are tied to achieving competencies and a
competent graduate (Fig.1).
Ins!tu!onalOutcomes,
Mission,Vision & Values
School/Program of Nursing
Outcomes
NP Track Outcomes
NP Course Objec!ves
NP Student Learning
Outcomes
NP Student
Competence
Fig. 1 Institution outcome to student competence
M. B. Bigley et al.
91
Students improve their knowledge base over time; therefore course sequencing
and course objectives are designed to allow the learner to master the knowledge and
skills needed to progress to higher-level courses.
Frameworks toEvaluation Competencies
Several frameworks can be used to measure student competencies over time. Many
faculty use Bloom’s taxonomy in the development of course objectives. When using
this method, a program of study that builds on prior coursework to create the optimal
sequence of course objectives can be achieved. When using this method, you can
advance the verbs for sequence of course objectives to achieve a program of study
that builds on prior coursework. This framework recognizes that there is an order to
learning. According to Bloom’s taxonomy, the lower level of learning is skills of
knowledge, comprehension, and application. By achieving this level, learning can be
achieved at a higher level, with skills of analysis, creation, and evaluation (Fig.2).
Understanding a program of study’s design and the relationship of program out-
come to course outcome and objectives assists in mapping competencies to indi-
vidual courses. For example, using the competency, Diagnosing Health Needs, a
student achieves learning at many levels and in several courses:
1. In a foundational course, such as Population Health, the student gains knowledge
related to the health needs that are more prevalent in different populations and
age groups.
Fig. 2 Bloom’s taxonomy. Armstrong P.Bloom’s Taxonomy. Vanderbilt University Center for
Teaching; 2010. https://cft.vanderbilt.edu/guides- sub- pages/blooms- taxonomy/. Accessed 31
Oct 2022
NP Practice Competencies
92
2. In advance science courses, the student gains the knowledge of advance physiol-
ogy and pathophysiology.
3. In advanced health assessment, the student learns the technique to gather perti-
nent information and performs the pertinent physical exam.
4. In rst-level clinical courses, the student applies what is learned.
5. In a diagnostic reason course, the student interprets and analyzes the informa-
tion to form a diagnosis.
6. In advanced-level clinical, the student formulates a plan and evaluates it.
It is the achievement of course objectives and outcomes as well as measurable
competencies that determine a student’s level of competency.
Another framework used in evaluating NP clinical competency across the curricu-
lum is the PRIME or PRIME-NP (Professional Behaviors Reporter, Interpreter,
Manager, Educator/Evaluator) framework [11, 12]. The PRIME-NP framework uses
the Objective Structured Clinical Examination (OSCE) method of assessment for stu-
dents’ clinical competence [11]. Standard rubrics that evaluate student clinical com-
petence at their expected level (e.g., reporter, interpreter, manager, or educator/
evaluator) aid in determining student prociency [11]. Examples of indicators of clini-
cal competence for professionalism include punctuality, teamwork, and respectful-
ness. Reporters must develop strong interviewing skills and gather and clearly
communicate patient information from the history, physical exam, and any diagnostic
testing [11]. Interpreters must be able to create differential diagnoses that are com-
plete and comprehensive, as well as describe the rationale for the working diagnoses
[11]. Managers must be able to manage patients and the healthcare team; examples of
indicators for meeting this domain include providing patient-centered care, including
incorporating the patient or family values into the plan of care, addressing social
determinants of health, and providing team-based care [11]. Finally, educators/evalu-
ators must provide self-reection for the next steps to their preceptor or faculty [11].
A third framework for evaluating the achievement of clinical competencies is the
Mastery Rubric for the NP (MR-NP) [13]. The MR-NP was developed based on the
Mastery Rubric, which is a curriculum development and evaluation tool. MRs
require three elements, including a list of knowledge, skills, and abilities (KSAs), a
developmental trajectory, and performance-level descriptions (PDLs).
MR-developed curriculums generate actionable evidence that should be used to
make curricular decisions [13]. The MR-NP was designed to align national compe-
tencies for NPs with curriculum standards. There were several key areas of KSAs
developed so that “an NP curriculum can go beyond simply aligning with or includ-
ing, the competencies” [13]. The MR-NP framework can be utilized to promote
both learning and competency assessment for students and faculty [13].
Competency-Based Education
A chapter on competency would not be complete without mentioning competency-
based education (CBE). An early denition dened CBE as “a data-based, adaptive,
performance-oriented set of integrated processes that facilitate, measure, record and
M. B. Bigley et al.
93
certify within the context of exible time parameters that demonstrate known,
explicitly stated and agreed on learning outcomes that reect successful functions in
life roles” [14]. Health professionals’ education has recommended CBE for years.
AACN denes competency-based education as “a system of instruction, assess-
ment, feedback, self-reection, and academic reporting that is based on students
demonstrating that they have learned the knowledge, attitudes, motivations, self-
perceptions, and skills expected of them as they progress through their education”
[2]. Other organizations dene the term differently, including the US Department of
Education, which more narrowly denes it as education “that organizes academic
content according to competencies—what a student knows and can do—rather than
following a more traditional scheme, such as by course” [15].
The common thread to the above denitions is obtaining mastery of the content,
based on dened learning outcomes. Competencies are determined based on the
skills and knowledge necessary to function safely in the workplace. They are
assessed using competency-based assessment tools that measure a student’s ability
to apply theory to practice.
The 2017 Macy Report, Achieving Competency-Based, Time-Variable Health
Professions Education, indicates four factors to achieve a successful CBE program:
1. An agreed-upon set of observable and measurable competencies.
2. A program of study goes beyond curriculum expectations to dene program
outcomes.
3. An environment for time-variable education and active learning.
4. A development program for faculty [16].
The experts who contributed to the Macy Report had the following vision:
With the achievement of competency-based, time-variable health professions education, we
envision a health care system in which all learners and practitioners are actively engaged in
their education and continuing professional development to improve the health of the pub-
lic. In this system, learners and faculty partner to co-produce learning, all practitioners are
life-long learners, and all health care environments place a high value on learning [16].
The evaluation of students using competency-based assessment (CBA) tools that
measure a student’s ability to apply theory to practice is vital to the development of
CBE.As NP education moves toward CBE, the development of assessment tools is
critical. However, the development and validation of CBA has just begun; it will
take time for CBE and CBA to become the norm.
Conclusion
This chapter described several countries’ processes to create NP competencies. A
list of competencies is provided based on elements commonly referenced in inter-
national competencies documents, as well as the domain of the Strong Model.
Understanding the ways in which competencies t into an academic structure and
their relationship to institutional and program missions, visions, and outcomes will
NP Practice Competencies
94
help countries build a framework as they embark on creating their own practice
competencies. A brief description of CBE and CBA concludes the chapter.
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The Nurse Practitioner asaLeader
JoycePulcini, NancyStreet, andStevenPurcell
What Is Leadership?
Denitions of leadership vary by discipline, ranging from business frameworks to a
more nuanced term used by academics, local department heads, and nonprot orga-
nizations. Strategic, passionate, deliberate, focused, goal oriented, and inspirational
are some of the terms used in dening leadership and those who assume this role.
Terms such as transformational and transactional invoke thinking linked to leader-
ship style [1–3]. Transactional leaders supervise, organize, and oversee performance
of a team, or group of followers. Rewards motivate effort and achievements. This
style of leadership is noted to be effective during an emergency or crisis and with
focused projects [4, 5]. Transformational leadership inspires employees or follow-
ers, centered on their shared vision for their work [5, 6]. Newer leadership models,
notably those in healthcare, incorporate the concept of well-being [7]. Leaders are
valued as followers look to them for guidance and direction. It is said that the best
leaders lead by example [8, 9].
Nursing leaders are responsive to individual clinicians, nursing cohorts, interpro-
fessional teams, and importantly patients and families. They commit to inspiring
innovation in the healthcare setting to ensure quality patient care delivery [10].
Leaders are responsible to patients and their families, who remain central to nursing
J. Pulcini (*)
George Washington University School of Nursing, Washington, DC, USA
e-mail: pulcinjo@gwu.edu
N. Street
School of Nursing, Massachusetts College of Pharmacy and Health Sciences,
Boston, MA, USA
e-mail: Nancy.Street@mcphs.edu
S. Purcell
Greenwich Hospital Emergency Medicine, Yale New Haven Health System,
Greenwich, CT, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_6
96
practice. Empowering team members to realize their potential as patient experts,
full of purpose, is core to nursing leadership.
Worldwide, advanced practice nurses (APNs) work in a variety of settings, part-
nering with fellow nurse colleagues, physicians, and medical ofces in the delivery
of primary and specialty healthcare. Recognizing regional variation in their scope of
practice, we maintain that APNs are seen as transformational leaders in healthcare,
serving as clinical resources, mentors, and role models for colleagues.
Calls for increasing nursing leaders and leadership competencies in the profes-
sional workforce resonate across the globe. Toward this end, it is widely recognized
that leadership skills are not necessarily innate and can be developed through educa-
tion and ongoing renement [11–13]. This knowledge promotes the notion that
most people are capable of leading with sufcient training [6, 14] and sets the stage
for continued leadership development and education.
The Nurse Practitioner asLeader
Leadership can be seen in many spheres of nursing practice. The spheres include
clinical leadership, organization leadership, educational leadership, and profes-
sional leadership.
Nurse practitioners (NPs) are by denition clinical leaders. Leadership is associ-
ated with power. Their power is derived from expert knowledge and clinical out-
comes and from their position as a clinicians who interact regularly with patients
throughout the lifespan. As highly educated healthcare providers, they are natural
leaders, but that leadership must be shaped and developed as the NP begins to see
beyond their own practice to the larger community, the nation, and the world.
Leadership should grow as practice shapes the NP’s perspective and understanding
of the need to advocate for social change within the larger community [15].
Patient advocacy is an essential component of leadership as professionals have a
social obligation to examine broader issues and advocate for improved health and
social conditions. Advocacy also includes helping patients learn to navigate their
world as they acquire chronic health conditions and the resulting nancial effects of
changing family dynamics, advancing chronic disease, and the social consequences
of illness. Leadership in advocacy also involves lobbying for broader social change
as well as for professional advancement for nurses and nurse practitioners.
Beyond the clinical realm, nurse practitioners also may be leaders in professional
or clinical organizations. This type of leadership is essential for the advancement of
the profession and for improvement of healthcare. Some nurse practitioners may
wish to remain in practice at the clinical level, and others are drawn to administra-
tive positions within their organization and have much to offer as leaders. Leadership
in professional organizations is also essential for advancement of the profession. As
older NPs retire or move on, young leaders are needed to continue and foster the
expansion of the role at all levels. In a similar vein, young NPs are needed to begin
to teach the next generation of nurse practitioners as faculty in educational pro-
grams. The USA has experienced a shortage of nurse educators as have many other
J. Pulcini et al.
97
countries in the world [16]. Motivating nurses to take on these higher-level roles in
healthcare organizations or educational institutions must take a priority as we move
forward.
Vision ofNP Leadership
What does it take for a NP to evolve into a leadership role? Today, advanced practice
nurses come to the workplace with advanced education and clinical expertise and
are often elevated to the rank of nurse leader. This rise to inuence and power among
nurses is more often assumed, not chosen, as academic standing and experience
translate to increased competencies and authority.
Many factors come into play here but rst and foremost is the NP’s view of them-
selves as a potential leader. We always speak of the four C’s when speaking about
leadership:Condence: Condence comes with time especially for new NPs, and
the work environment can foster or hinder this important prerequisite for leadership.
Competence: Leaders often start with informal leadership opportunities such as chairing
committees or leading initiatives at the local level in their position. Strong clinical compe-
tence also builds over time to the point that the NP feels that they can take on more and
more responsibility for patients. This competence is important for those who will follow
and accept this person as a formal leader.
Credibility: Integrity and credibility go hand in hand. A leader must be seen as being
credible in order to take on more responsibility. Leaders must have the respect of their peers
if they are to be successful.
Credentials: A leader should of course have the appropriate credentials for practice, but
they may choose to take on further credentials specic to leadership to enhance their posi-
tions. These credentials may take the form of academic preparation, certications, fellow-
ships, or awards, which verify that objective bodies also value the nurse’s abilities.
Mentorship is noted to be a critical component for leadership development and
practice in many regions of the world. A mentor creates an environment in which
the NP is ready and willing to take the next step and helps the person to evolve as a
leader. The mentor assures the NP that they are ready for the leadership role, provid-
ing invaluable support, as many nurses are hesitant or not envisioning their own
leadership potential. Securing a robust network of leadership mentors has proven
challenging across many regions and often leaves many early nurse leaders at a loss.
It is critical that other nurses and allied health professional colleagues ll this gap
by providing guidance and mentorship.
A Global Lens
Global shortages in healthcare professionals currently exist and are projected to
remain for decades to come, further driving pervasive health inequity seen through-
out the global community. The largest gaps are seen in low- and middle-income
The Nurse Practitioner asaLeader
98
countries [17, 18]. In helping to address this shortfall, APNs functioning in advanced
clinical, administrative, and educational leadership roles, typically in primary care
and resource-poor settings, are working to ll gaps in care and improve access.
Despite the increasing number of APNs and favorable public and professional per-
ception of their role in international settings, countries have unique challenges in
implementing, regulating, and monitoring APNs. Optimizing the scope of practice
and expanding the nurse workforce in order to aid the global call for universal health
coverage (UHC) and meet the 2030 Sustainable Development Goals (SDGs) are
challenges to be met by new and existing APN leaders [19, 20].
Analysis of the impact of the nursing profession, including that of APNs, is dif-
cult to obtain. International recognition of the value of the APN is often encum-
bered not only by a lack of contextually relevant and robust research on patient
outcomes but also by failure to recognize the value added of integrating the profes-
sion into areas with shortages of health professionals. Empirical data is needed,
especially as APN roles exist in approximately 70 countries today [21, 22].
International consensus on progressive policy action for addressing health work-
force issues, access to care, and integration of APRNs is in its early stages.
Organizations such as the ICN NP/APN Network [23], represented by nurse leaders
from around the world, are working to dene the role and inform a policy agenda
with advocacy and research, evidence-based implementation strategies for the APN
role. The evolution of policy frameworks beyond theory is critical to legitimizing
APN role development. The Brown framework [24], which helped conceptualize
role legitimacy and the scope and competencies of advanced practice nursing, is tied
practice to outcomes in diverse environments. It also laid the groundwork for APN
policy action. Bryant-Lukosius and DiCenso [25] introduced the PEPPA framework
or participatory, evidence-based, patient-focused process for advanced practice
nursing role development, implementation, and evaluation, which is still being
applied to APN roles across diverse global settings. In order to succeed in promot-
ing a change or the evolution of context-specic APN/NP roles, a leader uses evi-
dence and sound methodology to engage stakeholders and inspire colleagues. The
strength in the application of the global lens of APN/NP leadership must be increas-
ingly qualied by and contingent upon empiricism.
Global nurse leaders are individuals who are able to affect change by molding
policy frameworks to be socially and culturally relevant so as to mobilize key stake-
holders to build upon, promote, and execute new APN role development as progres-
sive action toward UHC and meeting the SDGs. Rosa etal. [26] dene several
“everyday actions” nurse leaders can take to meet these goals, including but not
limited to advocacy for the full scope of nursing practice authority without barriers;
advancement of gender equality; expansion of nursing roles to provide greater
emphasis on public health, disease prevention, and the promotion of wellness; part-
nering with communities to leverage nurses’ voices; and seeking leadership posi-
tions to drive health-related decisions.
The need to leverage APNs as nurse leaders was further highlighted by the sud-
den onset and omnipresence of the COVID-19 pandemic. The International Year of
the Nurse and the Midwife in 2020 demonstrated both proof of the determination
J. Pulcini et al.
99
and capability of the nurse and the tragedy of high frontline health worker morbid-
ity, mortality, and burnout as the pandemic quickly overwhelmed health system
capacity around the world. APNs were and continue to be heavily utilized during the
COVID-19 pandemic. In the USA, where scope of practice and autonomy vary by
location, state-level governments selectively suspended requirements to hold col-
laborative agreements with physicians to grant APNs and NPs full practice author-
ity. APNs “stepped up” to the task and fullled vital roles in a time of perilous nurse
and physician shortages. This crisis highlighted APN competency to perform at the
highest level of their training where prior to COVID-19, many APN roles in the
USA were constrained by political and policy barriers [27, 28].
Conclusion
The Future of Nursing 2020–2030 report [29] calls on all nurses across all work
settings to serve as leaders. This seminal global report provides a framework for
future nursing leadership. This decade marks a milestone for nursing with recogni-
tion from international organizations such as the World Health Organization and the
Robert Wood Johnson Foundation, along with increasing attention from media out-
lets and government agencies throughout the COVID-19 pandemic.
Amidst this call for leadership, we recognize that many nurses from across the
globe are assumed to be leaders due to their education and clinical expertise, rather
than hired or appointed for such roles. This differs from most disciplines, including
our physician colleagues and hospital administrators who seek leadership positions,
with formal academic training and mentorship.
As we move onward, embracing the call from the Future of Nursing report
(2021), we recognize the current examples of exceptional leadership by advanced
practice nurses globally. Their stories of the road less traveled inspire future genera-
tions of nurse leaders. Cultural and social structures surround nurses in their com-
munity and workplace. These broader inuences have a profound impact on the
scope of professional practice, advancement within systems, and a leader’s capacity
for authority. Academic training and mentorship for emerging nursing leaders is
critical to developing the future workforce. Advanced education in nursing should
include core courses in management and nance. Programs should be nancially
supported by healthcare organizations that employ nurses, higher education institu-
tions, and governments, in order to secure a robust workforce of nursing leaders.
Advanced practice nurses and nurse practitioners have taken leadership roles
across the healthcare spectrum. Combining their patient care expertise with their
knowledge of nursing science sets them apart in healthcare leadership, policy,
development, and innovative care delivery. Today, we watch Cori Bush and Lauren
Underwood take the lead in the US Congress, using their nursing backgrounds to
inform legislation that motivates community health and well-being, including hous-
ing, transportation, and climate platforms. Nonprot sectors are beneting from the
leadership of distinguished nurses. Nurses are leading academic institutions around
the world, including public and private universities.
The Nurse Practitioner asaLeader
100
Advocacy for continued focus on educating the future workforce, advancement
of the role, and embodying advanced practice nurses’ full scope of practice is our
way forward. While leadership has many denitions and roles, the need to ll gaps
in human resources for health and practice in diverse global settings is necessary to
strive to achieve UHC and meet the 2030 SDGs [19]. Coalitions around the world
have formed and are evolving to dene and implement APN/NP roles. In sub-
Saharan Africa, for example, the Anglophone Africa Advanced Practice Nurse
Coalition collaborates with local stakeholders to promote and implement the role in
English-speaking Africa [30]. African APN leaders, in collaboration with colleagues
from nations with comparatively well-established APN roles, such as the USA and
UK, are positively disrupting traditional health systems in resource-challenged
environments. The outlook for the APN/NP leader is bright but more work needs to
be done. An APN/NP leader in global health is an individual who aligns a high level
of training and education to the needs of their community through culturally and
socially sensitive action and advocacy for UHC and SDGs in the ght for health as
a human right.
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The NP andResearch: AGlobal
Perspective
PatriciaF.FlanneryPearce
Purpose
The purpose of this chapter is to present an overview of the many contributions of
nurse practitioners internationally to research. The knowledge and skills of NPs are
sought increasingly on the global stage. Although the NP roles and responsibilities
are continuing to develop fully in some countries, contribution to research is an
important area that reects involvement of NPs in practice, education, advocacy and
policy, leadership, and science. Exemplars in each of these areas and across multiple
countries will be introduced and highlighted in this chapter, to provide understand-
ing of the substantial research contributions.
Background
The value and contributions of nurse practitioners (NPs) to healthcare and the gen-
eral well-being of patients are substantial and well-documented. The role of the NP
was developed initially in the United States over 50 years ago, with the work of Drs.
Silver and Ford [1–3]. Initial work of the NP was in pediatric care, but the role was
quickly integrated into other populations and migrated into a wide range of settings
in the United States (USA), as early as the 1970s in Canada, and 1980s in the United
Kingdom (UK) countries and Africa. As the role has spread throughout the world,
each country or location has developed its unique foundation for the role and dealt
with obstacles as well as supports in dening, operationalizing, and evaluating the
P. F. F. Pearce (*)
Loyola University New Orleans (ret.), New Orleans, LA, USA
San Francisco, USA
Louisiana State Board of Nursing, Baton Rouge, LA, USA
e-mail: ppearce@loyno.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_7
104
role and related outcomes [4]. Along with changes in advanced education, scholarly
projects, evidence-based practice projects, and quality assurance initiatives have
increased substantially, but are beyond the scope of this review.
Emphasizing the importance of research to the role of the NP, the term research
is represented 51 times in the International Council of Nurses guidelines for NP and
Certied Nurse Midwife (CNM) [4] and in the information in the varying countries
represented in the guidelines (Africa Coalition, Canada, Republic of Ireland, Japan,
Netherlands, UK, and USA). Published research parallels the level of development
within the country of origin, typically beginning with the parameters of the NP role
and practice responsibilities, including scope, prescribing, setting, educational
parameters, effectiveness, and patient preferences and responses. Statutory and pol-
icy regulations for locations are integrated in each country, inuence practice
strongly, reect the unique culture in which the roles are set, and demonstrate the
rising centrality of the role within the healthcare systems across the globe. The pur-
pose of this chapter is to present a synthesis of research contributions of NPs glob-
ally. Exemplars of published research related to NPs across multiple countries will
be presented in detail.
Process
A systematic electronic search approach to published literature was undertaken for
this chapter. Electronic searches were completed in PubMed (Library of Medicine)
and the Comprehensive Index of Nursing and Allied Health Literature (CINAHL),
the Cochrane library, and the Johanna Briggs Library of Systematic Reviews, as the
primary sources for locating indexed scientic literature. Search terms included
nurse practitioner, advanced practice, research, and international. Publications
from any year were included. Citations were retrieved and downloaded into
EndNote® (v.20, Clarivate) and duplicates were removed. A total of 483 references
remained, with publication dates spanning 1981 through 2022. Then records were
discarded or retained based on initial assessment of title and abstract information,
including only those publications representing nurse practitioners, research endeav-
ors of any type, and any country of origin. If inclusion/exclusion could not be deter-
mined by title and abstract, a full copy of the article was reviewed. Full text articles
were reviewed for all articles included in this chapter. The International Council of
Nursing (ICN) guidelines [4] were added to the literature database for context.
Additional publications were identied and added to the library during review of
full text articles. Retained articles were labeled for country association within the
EndNote® (v.20, Clarivate) library, based on author country or focus of the research.
Reports tting qualitative, quantitative, and mixed paradigms were included.
Reports utilizing any research design were included. Reports constituting system-
atic reviews, scoping reviews, and literature reviews were included. However,
research proposals (e.g., research study proposals, scoping review protocols, sys-
tematic review protocols, interventional research proposals) were excluded.
Additionally, evidence-based practice and quality assurance projects were excluded
P. F. F. Pearce
105
unless clear research design and methods were provided. Items discarded included
those articles reecting varying use of the term international, such as international
units (e.g., of medication or lab testing) that were not specic to NP-related research.
Reports were excluded if there was lack of clarity regarding sample or basis of the
research. For example, an article was excluded because there was no way to deter-
mine country distribution/setting of the sample derived from Facebook members,
with authors from the USA.
The research design in the preponderance of the reports was descriptive, whether
quantitative or qualitative. A total of 70 published articles were deemed relevant for
inclusion for the topic. These reports represented research completed in 23 different
countries (see Table1) by 300 unique authors. Authorship for the combined articles
reected a range of 1–22 authors, with average per published article of 4.4
(median=3; mode=3) for the total of 300 unique authors. The preponderance of
author lineups represented a single country (range 1–7 countries). A particular chal-
lenge in identifying country of origin is related to the complexity of multiple col-
laborators across the globe. Determination of country afliation and focus is
challenging. One example is provided by Spies and colleagues [5] representing a
case study emphasizing cross-country monitoring for APRNs in Hungary, with
authors afliated in seven countries: USA, Canada, Hungary, New Zealand, Ireland,
Finland, and Uganda. An example of single-country author and focus is Bonnel [6],
a French investigator, focusing strictly on France. Sastre-Fullana and colleagues [7]
represent investigators from 7 countries, focusing on data from 19 different
countries.
Search Term Precision. One of the search challenges met was assuring deni-
tional clarity for the term international in electronic indices searched. Using inter-
national as key search term provided broad scope for nursing and other areas, but
there is no clear denition regarding what type of work qualies as international.
For the purpose of this chapter, international was used as a linchpin for observations
from any country in the world, or about any other country in the world. Author rep-
resentation represents authors across the globe, and research reported represents
study activities in a total of 23 different countries. Given the scope of the book and
this chapter, publications included in searches with keyword international were
included, regardless of country of origin or whether the articles retrieved repre-
sented single-country or multicountry effort in design or in author representation.
Including all published research is beyond the scope of the chapter, but a substantial
sampling of available articles is included in this review.
Table 1 Countries represented in published research included in this review
Australia France Netherlands Switzerland
Canada Haiti New Zealand Taiwan
Chile Hungary Scotland Tanzania, Republic of
Denmark Ireland, Republic of Slovakia Uganda
England Israel South Africa United States
Finland Japan Sweden
The NP andResearch: AGlobal Perspective
106
Similarly, the search term Nurse Practitioner is a unique identier term in MeSH
headings, but links specically to Nurse Practitioner, Pediatric Nurse Practitioner,
and Family Nurse Practitioner (MeSH listing), not specically linked to any other
types of nurse practitioners. A challenge in searching for and then assessing reports
was in assuring that for inclusion in this review, the research reported was focused
on nurse practitioners and some facet of their work, outcomes from their practice,
or NP-related policy. Because there are multiple labels across countries for the role
of the nurse practitioner, the differentiation is challenging. Reports were excluded
because of the lack of identiable NP credentials, inability to clearly identify NP
participants or outcomes from those of other practitioners, or focus on other than
NP work. Articles with less precise terms, such as district nurse, were included only
if the article reected a clear corollary with nurse practitioner, such as in Blanck and
Engström [8]. Additional exclusions were due to the less precise term use, which
precluded determining whether or not NPs were included. Less precise terms
included health care provider, health practitioner, general nurses, and general
practitioner. For examples of exclusions based on precision of role labeling, see
Kline and colleagues [9] in Australia or de Wet and colleagues [10] from Scotland.
Publications were excluded if the focus was clearly on registered nurses or general
nurses only or referenced as practice nurses [11].
Author country afliation was tabulated in this review for understanding of the
breadth of NP work internationally. However, author country afliation is only one
facet of international representation and does not necessarily represent the country
of research participants; thus it is a limitation in process. For example, authors
Würtz, Jensen, and Ergerod [12] are all based in Denmark, but the research these
authors reported involved intentional selection of NP participants from Sweden,
Norway, England, and the USA.
Included in the Guidelines on Advanced Nursing Practice [4] are denitions dif-
ferentiating Advanced Nursing Practice, Advanced Practice Registered Nurse, and
Nurse Practitioner. Advanced Practice and Nurse Practitioner were used as key-
words in searches for this chapter, but the terms are not as clear in the related litera-
ture as they are used in the ICN guidelines. It is important to note that over 300
articles retrieved from the searches were excluded based on irrelevance in terms of
nurse practitioners although captured in searches with terms specic sufciently to
exclude.
Findings
Published Research Patterns Across the World. There is a developmental pattern
reected in published research reports that sequences through topics and complex-
ity—as the NP role initiates, is implemented, and expands in varying countries. The
research reects a similar sequence that evolves into an iterative pattern, cycling
back continually. In locations developing the NP role initially, published research
highlights clarication in context of culture, conceptualization, and operationaliza-
tion of the NP role, including parameters for education and experience within the
P. F. F. Pearce
107
country. In these areas, research was reported on developing the role utilizing sur-
veys and focus groups or interviews completed by nurses and nurse managers
regarding perceptions of the roles (e.g., Sweden; see [13]). As the NP role pro-
gresses, investigators circle back to the issues and questions, updating, expanding,
and reporting on further developments—thus continuing the discussion.
Additionally, as the NP role becomes more developed and institutionalized in the
locations, patterns in reported research continue to expand and clarify roles and
parameters, but enlarge to include effectiveness in the NP role, educational recom-
mendations and requirements, intricacies of practice scope, as well as the role
within the healthcare system. Acceptability to others, including patients, is reported
crossing countries with new development of the NP role through the more experi-
enced countries. Patient satisfaction with NP care management is included in
research reports at this developmental level. For countries with the most developed
NP role, research emphasizes reports on health outcomes and cost-effectiveness.
Initial research reects emphasis on single-country, sequencing with more role
experience, into multiple-country research.
Nurse Practitioner Roles, Parameters, and Characteristics. Research related to
NP role and parameters abound in the published literature, spanning a wide range of
years as well as geographic locations. Examples reported in the 1990s include
Becker and colleagues [14] reporting on NP-managed anticoagulant clinics in the
USA.Nzimakwe and colleagues [15] reported on NP primary care in South Africa,
identifying advantages and disadvantages in the role, as the NP role is evolving in
South Africa. In Japan, Eklund [16] discussed the role of the neonatal NP, delineat-
ing the more limited scope of the NNP and movement toward expanding the role.
Suzuki and colleagues [17] later reported there were about 600 registered NPs in
Japan and completed descriptive survey with responses from 100 of those NPs.
Although there were inroads reported in Suzuki etal. [17], at least 11% of the
respondents indicated working at RN level.
As NP roles migrated and acceptance increased, comparisons with other health-
care providers also expanded. Mills and colleagues [18] completed a secondary
analysis utilizing the 1992 National Hospital Ambulatory Medical Care Survey,
exploring patient visits with nurse practitioners (NPs) and physician assistants
(PAs) (N=2847) and demonstrating that NPs provided substantially more health
promotion services in women’s and children’s services than other providers. Mills
and colleagues also demonstrated that in rural areas, more patients were seen by
physician assistants than NPs, while NPs spent more time in counseling and educa-
tion with patients.
The roles, parameters, and characteristics of NPs and their practices continued to
be explored in the 2000s through a range of research initiatives in a variety of coun-
tries. Mundinger and team [19] demonstrated in a USA-based study that there were
no signicant differences between NPs and MDs, in care or satisfaction ratings, or
care outcomes with 6-month follow-up. In addition, there were comparisons with
NPs and CNSs. In 2003, Ball and colleagues [20] explored NP and CNS roles in
critical care in the UK, the USA, Australia, New Zealand, and Canada with a sample
of 39 NPs and CNSs. Ball etal. found that NPs reported a greater emphasis on direct
The NP andResearch: AGlobal Perspective
108
care, while in-patient care, quality of care, and successful outcomes were para-
mount in both roles. DiCenso and team [21] detailed key barriers and facilitators in
CNS and NP roles, working toward recommendations for practice in the Canadian
system. Bonnell [6] completed a review of literature on the developing role of the
NP in France. Bonnell details a lengthy list of published research representing
France and other countries. MacLellan and Levett-Jones [22] utilized an ethno-
graphic approach to explore the growing acceptance of the NP role and detailed
several stories from NPs as they navigate challenges. Aaron and colleagues [23]
reviewed patterns of role migration and integration, identifying possibilities for NPs
in Israel to provide safe, high-quality care. In a qualitative study, Cooper etal. [24]
explored next steps focused on internationally qualied health practitioners, includ-
ing APRNs, in Australia to accommodate for extensive migration of individuals
practicing in healthcare. Espinoza etal. [25] explored possibilities of advancing to
master’s level education in Chile, focused on preparing APRNs for practice. Scope
of practice in Taiwan was the focus of several reports [26–29], and the impact of
practice outcomes on NPs in Taiwan was also assessed [30]. Chen and colleagues
[31] explored burnout in NPs in Taiwan, demonstrating burnout related to work-
place stress, transition challenges, and other factors, with ndings similar to other
researchers, while Wei had documented positive role perception and satisfaction in
NP role [32]. In Australia, Poot and colleagues [33] documented that NPs had lower
prescribing rates for potentially inappropriate medicines (PIMs) in the elderly, than
other prescribers, including 129 NPs ordering over 12,000 prescriptions.
Nurse practitioner roles in Australia and New Zealand continue to be explored
and validated. Chang and colleagues [34] used a Delphi technique to validate an
instrument for measuring roles and performance parameters for NPs. Carryer etal.
[35] discussed role expectations and related policy and educational patterns in New
Zealand and Australia. Scanlon [36] provided detailed information regarding regu-
latory requirements for NPs in Australia, focusing on the role parameters and NP
scope of practice. Parker and colleagues [37, 38] explored patient preferences and
satisfaction, identifying the challenges in understanding the NP role continued, but
that most patients were satised with their care. MacLellan [22] completed an eth-
nographic study of experience of NPs and transition to practice. These reports all
detail the trials and tribulations of the NP role in Australia, while highlighting some
of the positive outcomes reached with the hard work of NPs. Later Carrryer and
team [39] completed research with 3255 RNs and NPs to better understand role
parameters and scope. Domain-specic responsibilities were identied and pre-
sented, providing a substantial foundation for education of and policy related to the
NP role in Australia and New Zealand.
In Slovakia, Halász and colleagues [40] surveyed 584 NPs, demonstrating a
young (M=41years; range 24–60years), predominantly female (95%) sample,
with advanced degrees (97%) and with practice settings predominantly in institu-
tional care (82%), split between governmental and private positions. Numerous
questions about practice, guidelines, education, and leadership were posed in the
research. The iterative nature of understanding role parameters is a pattern in several
countries.
P. F. F. Pearce
109
Expanding beyond NP role parameters, research explored scope of practice,
practice patterns, networks, and organizational climate in several studies conducted
in different countries. Examples include a practice-based network emphasis was
completed by Deshefy-Longhi and colleagues [41] in the USA.A sub-study com-
parison of NP networks and physician-run networks was completed using a survey
designed by the Agency for Healthcare Research and Quality (AHRQ). Findings
indicated positive practice patterns for NPs. Researchers recommended additional
study with NPs and their patient encounters to further substantiate the positive out-
come of NPs and their patients. Luo and colleagues [42] explored organizational
empowerment in acute care NPs in Taiwan, nding that empowerment was low and
satisfaction at only a moderate level. Higher job satisfaction was related to higher
empowerment in the cross-sectional, national sample (N=946) [42]. An interdisci-
plinary health model in primary care integrating a USA-based team with partners in
Haiti was detailed in a report focused on the importance of partnerships in care
delivery [43].
There is increasing emphasis on research with practice, research, and service
partners reected in the published literature. Ryder and colleagues [44], represent-
ing an investigator team from Australia and Ireland, demonstrated positive outlooks
of NPs (N=10) who were interviewed. NPs identied needs for innovative leader-
ship and academic partners for research; participants felt high optimism and resil-
ience were critical, and all of these areas required collaborative relationships and
partner building for success. In Sweden, Blanck and Engström [8] reported on pre-
scriptive practices, as well as the relationship of practices to informal and formal
structural power. Findings in Blanck and Engström [8] demonstrated in sample of
150 a lower frequency of prescribing and equivocal commentary regarding struc-
tural power.
A more comprehensive view of roles and parameters was employed by Sastre-
Fullana and colleagues [7] in an attempt to sort out confusion and to clarify NP roles
from across the world utilizing secondary analysis and mapping techniques, with
visual analysis and semantic networking. In the study, Sastre-Fullana etal. mined
information from 19 countries located in Africa, Australia, Asia, Europe, and North
America. The original data was from an ICN report on NP roles in 19 countries. The
Sastre-Fullana report provides substantial detail regarding role parameters for direct
and indirect care, education, support, professional leadership, and publications,
sharing the mapping in graphics that are complex and comprehensive, but serve as
highly usable graphical displays for understanding the breadth of NPs globally.
In addition to a more comprehensive understanding of the NP role on a global
basis, research continues in highly targeted areas, such as education. Chao and col-
leagues [45] completed a survey (USA) of NP program faculty (N=49) ascertain-
ing that most NP faculty believed nutrition content was important for NPs and that
most programs included nutrition content. Würtz, Jensen, and Egerod [12] reported
results of a qualitative, descriptive study focused on comparing the pediatric NP
education and role in four countries, highlighting the differences and similarities, as
well as the criticality of NP-based care in pediatrics and family focus. Targeted
information such as educational content is helpful in understanding existing
The NP andResearch: AGlobal Perspective
110
parameters in NP education, helping to provide guidance. Education of NPs was
also the focus in Mboineki and colleagues [46] for initiating formal programs of
education for NPs in the Tanzanian system. Although Würtz and colleagues and
Mboineki and colleagues [46] utilized small samples in their qualitative designs,
small samples are expected in qualitative design, to obtain a rich understanding of
the phenomenon of interest.
Exploring NP practice in wound care indicated challenges in tertiary settings,
with a need for clinical protocols and scope of practice development [47]. MacLellan
and colleagues [48] explored transition to practice with new NPs, using content
analysis for repeated sequential qualitative interviews over rst year of practice. The
overall outcome indicates success in the NP role, with emphasis on turmoil and
tenacity in the process.
Expanding NP Roles. The expanding role of the NP is highly visible in the pub-
lished literature. Allen and Fabri [49] evaluated the roles of the NP working in a
community-based care of the aging in Australia, demonstrating successful extended
practice setting. Similarly, Asimus and colleagues [50] demonstrated a successful
pressure ulcer prevention program across 41 Australian facilities, with a pressure
ulcer prevalence reduced to 16% and use of appropriate devices increased by 45%,
with substantial cost savings. In a Canadian patient cohort (N=113), patient satis-
faction with care from NPs in emergency department visits was assessed, demon-
strating positive outcomes in attentiveness, comprehensiveness of care, and role
clarity [51].
In the USA, Cole and Kleinpell [52] completed a thoughtful commentary on the
acute care NP role and the tremendous potential foreseen. Considine and col-
leagues [53] subsequently reported a prospective, exploratory, descriptive study in
Australia (Victoria), reviewing 476 patients managed by emergency department
nurse practitioners. Considine etal. demonstrated the effectiveness of the NP in the
emergency department and documented time in focus as well as patient require-
ments during ED stay. Expanding and changing roles were represented in a report
from New South Wales in 2013. Li and colleagues [54] completed grounded the-
ory-based research completed in two large metropolitan hospitals in New South
Wales. Nurse practitioners reported a distinguishable change in clinical decision-
making, with heightened responsibility, but also reported frustration with a stan-
dard of comparison with physician-based care. In the Netherlands, Boeijen, Peters,
and van Vught [55] completed an exploratory, qualitative descriptive study with ten
NPs, emphasizing the value added that NPs contribute to healthcare. The NPs were
from 12 different specialty areas in outpatient care, with experience between 3 and
13years. The NPs highlighted the importance of care and cure focus, competency,
and holism.
Focusing on NPs working in orthopedics specialty, Coventry and colleagues [56]
completed a retrospective cohort study utilizing records (N=301) of older aged
(≥65years) patients with hip fracture in West Australia to evaluate length of stay
(LOS) and simple cost, modeling on patients before and after the NP role was insti-
tuted. Coventry etal. [56] demonstrated cost savings, as well as a statistically sig-
nicant decrease in LOS.
P. F. F. Pearce
111
Emphasizing roles and NP education and parameters across countries, Currie
and colleagues [57] reported on a comparison of the NP in emergency department
in the UK, Australia, and New Zealand. Currie [57] found reports of private practice
models in ve countries, with reports emphasizing elements of models of care and
responsibility practice reimbursement, collaborative parameters, and related legisla-
tive issues. Subsequently, Currie [58] completed a review of the published literature
regarding private practice models.
Coleman [59] completed a cross-sectional study across metropolitan, regional,
and remote rural clinics in Australia, assessing patients with chronic kidney disease
satisfaction with NP-managed care. Coleman demonstrated positive feedback from
patients regarding their care.
A recent contribution to the understanding of NP practice was a descriptive study
by Adams and colleagues [60] focused on organizational climate for practice in
New Zealand, with 136 primary care/NPs responding. Adams and colleagues [60]
found that NPs could practice independently and autonomously with support and
were supported by administration, but note less resource support than physician col-
leagues were given. This information is well-positioned for use in policy and advo-
cacy for NPs in New Zealand.
As the NP role is explored, a comparison to physicians is frequently made. In the
Netherlands, Dierick-van Daele and colleagues [61] completed a prospective trial of
1500 patients in 15 practices, reviewing records to assess quality of care. Results
indicated NP consultations were longer in time, had more follow-up consultations,
and had more extended revisit invitations, but care was comparable in this
Netherlands cohort. Gysin and colleagues [62] used a qualitative, descriptive design
to include NPs and GPs in Switzerland to ascertain perceptions of NP added value
in practice, understanding the NP role, and the political and legal obstacles in intro-
ducing the role. Pioneering GPs and APNs acknowledged the value added and
obstacles to NP practice.
In a specic practice area of screening colonoscopy, NPs and physicians were
compared in a prospective randomized clinical trial with 50 NPs and 100 MDs [63].
In this study, there were no complications in either group (patients randomized to
NP or MD), with slightly higher satisfaction with NPs and slightly higher adenoma
detection rate by MDs. Sharp [64] completed a retrospective chart review in adoles-
cent health, documenting fatty liver among a group of adolescents at the Mexico-
USA border.
Steinke and colleagues [65] provide literature-based information on successful
collaboration in clinical partner relationships that are essential for successful cross-
country research, utilizing four partners for the discussion. Subsequently Steinke
and colleagues [66] published on the positive experiences of NP students in global
experiences as part of their educational experiences. Successful collaboration is
represented in Steinke etal. work [65, 66] as critical for developing a global expe-
rience to facilitate understanding of healthcare systems external to the NP’s
home base.
Comprehensive Reviews. With migration of the NP role globally, changing
roles and responsibilities, and emphasis of the NP on high-quality, cost-effective
The NP andResearch: AGlobal Perspective
112
care, there is a ourishing interest in compiling comprehensive views on a number
of topics related to NPs and their practices. The growing body of comprehensive
reviews focused on nurse practitioner roles and substantial contributions to health-
care overall. Systematic reviews and scoping reviews typically included publica-
tions from a wide span of countries, unless there was a specic scientic rationale
for specically limiting the countries represented. In electronic searches for this
chapter, there were 241 systematic reviews and 24 scoping reviews, including 33
systematic reviews and 7 scoping reviews from the Johanna Briggs Institute
Library and 1 item from the Cochrane Library found in the primary searches. The
single item located in Cochrane mentioned NPs in two of the included studies, but
did not explicate sufciently to retain for this chapter. Three of the items from JBI
were retained [67–69]. These were generated from Australia, Canada, and the
USA, but provided expansive searches in focus on the expanding roles of NPs in
countries with well-advanced NP roles. The specic areas demonstrated evidence
of successful professional endeavors for NPs working in three specic settings:
adults with intellectual and developmental disabilities and team-based primary
care [67], NP effectiveness in nursing homes [68], and the experiences and effec-
tiveness of NPs in orthopedic settings. Donald and colleagues [70] focused inter-
nationally and emphasized cost-effectiveness of NP care, notably focusing on the
methodological strengths and weaknesses of 43 clinical trials and including a
wide variety of variables regarding hospitalization, mortality, morbidity, and sat-
isfaction with care. Donald and colleagues [70] detailed varying roles of the NP
and CNS.They determined low risk of bias and recommended further studies be
supported.
An additional scoping review was reported by Chavez and colleagues [71],
focusing on NP care of the elderly, including 13 published reports, the majority of
which included comparison of NP- and MD-provided care. Chavez and colleagues
provided an extensively detailed review demonstrating several different models of
care provision, cost, and patient satisfaction, all with demonstrated NP
effectiveness.
An extensive scoping review of prescribing practices among Australian nurse
practitioners was complete by Fong and colleagues [72], followed with an online
survey regarding prescriptive practices [73]. Prescriptive authority was enacted in
parts of Australia in 2001. Fong and colleagues explored effectiveness of prescrib-
ing and behavioral outcomes.
A US and Canada team, Hurlock-Chorostecki and colleagues [74], completed a
scoping review focused on NPs in interdisciplinary teams. The review divided mate-
rials into literature reviews and primary research, including patient outcomes, work-
force, credentialing, and settings. Details regarding NP role understanding, with
several studies emphasizing contrast in role with physician assistant role were
included. Additional detailing involved the acute care NP role, reecting nine pub-
lications emphasizing hospital setting NP role. The publications included in the
review were drawn from countries with well-established NP roles.
P. F. F. Pearce
113
Limitations
Precision electronic searches are challenging, notably in the term international.
Because there is a variety of labels used for nurse practitioners across the world,
determining the meaning of the term is challenging. Further, the chapter is focused
on contributions of nurse practitioners in research, but NPs can be hidden in other
research, as authors or contributors to research, and there is no easy manner in
which to identify those contributions. Despite these limitations, a substantial body
of relevant published literature was identied and integrated for this chapter.
Discussion
Across the world, the role of the NP is well-developed and well-established in some
countries, while continuing to evolve in other countries. Research completed with
or by nurse practitioners has developed in parallel with the international migration
of the concept of the nurse practitioner. Investigators explored in the research the
varying roles and requirements for NPs in different countries, with consideration of
education, practice outcomes, role responsibility, and advocacy and policy. The NP
role is fairly well-established in most countries, but research on NP role continues
as the role migrates and expands. The iterative pattern, cycling continually back to
NP role parameters, continues to clarify the role and expectations in each country.
As the NP role becomes imbedded in the healthcare culture, attention is focused on
patient outcomes as well as more fully developed policy and local and national lev-
els. Additional research related to effective practice and patient outcomes would
build that foundation. An investigation of evidence-based and quality assurance
projects would add to the discussion of changes in the healthcare system, as well as
the discussion of patient outcomes and practice improvements.
Further research related to policy initiatives is critical, and sharing understanding
of nuanced policy in any country or location is critical for comprehending the role
in context. Increasing country-based initiatives to address policy issues related to
practice must also be evidence-based; thus the work in research will serve practice,
education, advocacy and policy, research, and leadership in all areas.
Technical Attention to Benet Visibility of Publications. Searching for and col-
lecting relevant published literature regarding research endeavors of nurse practitio-
ners in varying countries is challenging and could be strengthened to assure visibility
of NP-based research. Heightening visibility of the tremendous work done by NPs
would be strengthened with meticulous attention to the following:
• Keyword development and assignment, including nurse practitioner, especially
if the term is not included in the title or easily identiable in the article
abstract [75].
• Clearly labeling the research design in the abstract and the body of the paper.
The NP andResearch: AGlobal Perspective
114
• Title wording precision [76, 77].
• Inclusion of keyword nurse practitioner would also be helpful, especially if the
term is not included in the title or easily identiable in the article abstract [75].
• Assuring author credentials are clearly visible would be helpful for searches in
which those credentials are critical factors (visibility of author credentials varies
between and across journals).
• Thoughtful keyword listing to include the names of the country (or countries) in
which the research is completed.
Completion of Proposed Research. There were at least 12 published protocols for
research that were excluded for the purpose of this chapter. The importance of fol-
lowing through on these protocols, to produce the proposed research, cannot be
understated. The protocols represent topics of marked interest to NPs, for example,
including understanding NP role in Eastern Mediterranean countries [78], breast
health in Arabic countries [79], methadone users and hepatitis C internationally
[80], and practice standards and continuing education (Australia) [81]. Fully exe-
cuted, these protocols would contribute substantially to scientic knowledge.
Conclusion
The role of the NP has migrated and been further developed across the globe. Nurse
practitioners are challenging prevailing models of care and changing the healthcare
system and making substantial contributions, as reected in research NPs have pub-
lished and that are integrated in this review. NPs are positively enhancing patient care,
healthcare systems, and effective change in policy and advocacy. Although there is
increased publication of robust research involving NPs, continued and escalated
research is needed to improve understanding of the health challenges practitioners face
with their patients or clients, and best practices to resolve illness and promote health are
essential. Further understanding economics and cost of care in terms of cost and benet
for patients/clients, as well as cost of care from an organizational standpoint, are impor-
tant in assuring resource allocation is appropriately managed. The proliferation of evi-
dence-based practice projects, quality assurance initiatives, and DNP scholarly projects
warrants an understanding of the individual and collective contribution to healthcare
that these endeavors represent, but that are not included in this review.
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Nurse Practitioner Outcomes Evaluation
RuthKleinpell, AprilN.Kapu, BrigitteWoo,
andZhouWentao
Introduction
The nurse practitioner (NP) role is recognized globally as an advanced practice regis-
tered nurse (APRN) who has acquired expert knowledge, complex decision- making
skills, and clinical competencies for expanded practice [1]. NP models of care are
models of care that are expanding as new role opportunities evolve. Therefore, identi-
fying outcomes of NP care remains essential to advancing APRN practice. A recent
report from the US Department of Health and Human Services, Health Resources and
Services Administration, National Center for Health Workforce Analysis, addresses
how the novel coronavirus disease 2019 (COVID-19) pandemic has impacted health-
care and cites the role of APRNs including NPs, who are uniquely positioned to lead
and support strategies for epidemic and pandemic responses [2].
Many studies have been conducted to demonstrate the impact of NP roles on
quality of care, clinical outcomes, patient satisfaction, and cost of care [3–15]. More
than three decades of research demonstrates that NPs provide high-quality, cost-
effective, safe care that results in positive patient outcomes and satisfaction [16].
A number of individual studies as well as synthesis reviews have consistently
identied the value of NP care in primary care, acute care, and other settings. An
analysis of over 150 studies identied that the co-management of patients by a phy-
sician and NP can reduce individual workloads, avert burnout, enhance the quality
of care, and expand access to care [17]. A study comparing primary care NP to
primary care physicians or jointly attributed clinicians found that patients cared for
R. Kleinpell (*) · A. N. Kapu
Vanderbilt University School of Nursing, Nashville, TN, USA
e-mail: ruth.kleinpell@vanderbilt.edu
B. Woo · Z. Wentao
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine,
National University of Singapore, Singapore, Singapore
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_8
120
by NPs had lower rates of hospital admissions, readmissions, and inappropriate
emergency department (ED) use, as well as low-value imaging [3]. Similarly, the
same researchers found in another study that patients cared for by primary care NPs
had a lower risk of preventable hospitalizations, use of emergency room services,
and other healthcare resources [5].
In a study of over 806,434 patients from 530 Veterans Affairs facilities, patients
assigned to NPs were less likely to utilize primary care, specialty care, and inpatient
services; had no difference in costs; and experienced similar chronic disease manage-
ment compared to MD-assigned patients [7]. In a concise review of over 50 studies of
NP care in acute and critical care settings over a 10-year period between 2008 and
2018, the results identied impact of the NP role in various ways including improved
patient ow and clinical outcomes including reducing complications and improved
patient care management with reduced time on mechanical ventilation, increased use
of clinical practice guidelines, improved laboratory test use, and increased palliative
care consultations, among other areas of impact [12]. Table1 outlines the variety of
outcome metrics that have been used to demonstrate NP outcomes.
The American Association of Nurse Practitioners outlines additional studies and
meta-analysis that have been conducted to highlight the impact, outcomes, and
value of the NP role [19].
Table 1 Common metrics used to highlight impact of the NP role
Quality/safety metrics
Catheter-associated urinary tract infection rates
Pressure ulcer incidence
Postsurgical glycemic control
Patient satisfaction rates
Role-specic metrics
For example, NP-led CHF clinic: rates of patient follow-up; ED and hospital readmission rates
Traditional outcome parameters
Length of stay
Readmission rates
Costs of care
NP care-specic metrics
Blood pressure control
Glucose control/HgA1C
Smoking cessation
Lipid management
Fall rates
Nosocomial infection rates
Restraint use
Medication compliance
Quality of life (pain management)
Patient knowledge
Patient self-efcacy
Patient satisfaction
Nurse satisfaction
Nurse retention rates
NP, nurse practitioner; CHF, congestive heart failure; ED, emergency department; HgA1c, hemo-
globin A1c. Adapted with permission from Kleinpell [18]
R. Kleinpell et al.
121
Demonstrating Outcomes ofNPs
Ongoing healthcare restructuring continues to change the way in which care is
delivered, and as NP roles expand, the measurement of outcomes is an important
parameter by which NP care can be evaluated. Healthcare restructuring continues to
change the way in which care is delivered, and as APRNs’ roles expand, the mea-
surement of outcomes is an important parameter by which APRN care can be evalu-
ated. Knowledge of the process of identifying outcomes of NP practice and available
resources that provide helpful information is essential for all NPs regardless of prac-
tice specialty or setting. The American Association of Nurse Practitioners devel-
oped a toolkit to outline the steps in assessing outcomes of NP practice (Fig.1) [20].
The process involves identifying the focus of NP care, whether it relates to a specic
NP-led initiative or aspect of NP care; identifying the specic outcome(s) to mea-
sure; obtaining the data, ideally through electronic medical records or other auto-
mated reports; and evaluating and disseminating the results.
While a number of outcome measures exist, identifying the metrics that are most
impacted for a specic NP role or an aspect of care is essential. Table2 outlines
additional considerations for identifying NP outcome metrics.
Fig. 1 NP outcomes
toolkit. (Adapted with
permission from AANP
[20])
Table 2 Considerations for identifying NP outcome metrics
What are outcomes valued by the practice/organization?
Has there been an NP-led initiative that could result in comparison of outcomes?
Is there an opportunity to implement an NP-led project that could result in comparison of
outcomes?
Has there been a new practice guideline implemented by the NP team that could result in
comparison of outcomes?
Is there an opportunity to implement a new practice guideline that could result in comparison of
outcomes?
What electronic data capture or records are available?
How can data reports be generated and provided to the NP team?
Consider identifying metrics as positions are developed/formed
Aim to capture metrics that reect NP role activities
Garner information systems support for data abstraction and ongoing reporting
Adapted with permission from Kleinpell [18]
Nurse Practitioner Outcomes Evaluation
122
Showcasing NP Impact
The COVID-19 pandemic has provided a unique opportunity to further identify
impact of the NP role. In the exemplar below, the impact of the pandemic on NP
practice and the role that NPs played provides information on how the value of the
NP was highlighted.
Exemplar: Highlighting theImpact oftheNP Role During
theCOVID-19 Pandemic
Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee, USA, lev-
eraged its NP workforce from the beginning of the pandemic as the rst COVID-19
cases came to Tennessee in early March 2000. First, the NPs launched a community
hotline to eld telephone calls from the community. Thousands of calls came in
each day; most inquiries were related to signs and symptoms, questions about trans-
mission, isolation, and whether to seek testing. The NPs developed a script and a
frequently asked question and answers (FAQ) guide, working with technology
experts to establish the phone line and collect data in the electronic medical record.
They held daily trainings to train other NPs, nurses, and medical residents on how
to work the hotline. They updated the script and FAQ daily as science evolved and
more was learned about the virus. Interestingly, the NPs were the rst to identify
commonalities that later became key indicators of the virus. For example, in March
of 2020, several callers complained of loss of taste and smell. The NPs reported this
information to the Infectious Disease Center at VUMC.Within days, loss of taste
and smell was noted to be a key symptom of COVID-19. NPs were front and center
to the evolving knowledge and learnings.
Next, NPs led the development and management of community testing centers.
They helped construct temporary clinic sites in parking lots and garages, commu-
nity centers, churches, convention centers, and coliseums. They developed proto-
cols for assessment, diagnosis, testing, and treatment. Most NPs worked at these
sites in addition to their usual clinic or hospital work.
One NP team, whose primary service was to provide telehealth and home care
services, established a program to see symptomatic patients in their home, which
was especially helpful for homebound persons. They developed protocols for the
use of personal protective equipment (PPE), assessment, testing, and treatment
when caring for homebound patients. When the NPs were not visiting the patient in
the home, they would follow up with telehealth visits.
NPs were working in the ED and throughout the hospital’s acute and critical care
wards. NPs collaborated and constructed an additional temporary ED in an adjacent
parking garage, called the “epod” to ofoad the volume of the main ED.In the acute
R. Kleinpell et al.
123
and critical care areas, NPs expanded their teams and learned to cross cover in areas
experiencing higher volumes. They worked closely with other members of the
healthcare team to establish standards for care of the COVID-19 patient. They also
navigated virus precautions to avoid transmission and developed standards for
informing and involving family members in care, including the use of virtual tech-
nology when applicable.
And lastly, as vaccinations became available in the USA in December of 2020,
NPs led the establishment and implementation of the vaccination centers to aid with
vaccination rollout to thousands and thousands of Tennessee residents. NPs have
worked with community leaders, healthcare volunteers, and the Vanderbilt
University School of Nursing faculty and students to assure vaccination education
and injections are accessible to everyone. Still in 2022, these NPs are providing
mobile vaccination services to many underserved communities.
VUMC provides but one example of the efforts championed by NPs throughout
the pandemic [21–23]. There are many examples of NP-led pandemic initiatives
throughout the world. There is great opportunity to engage in collaborative schol-
arly review of this topic with NPs in many countries. The learnings from each NP
and groups of NPs could lead to improved disaster preparedness, planning, and
management in the future and on a global scale.
Exemplar: Emphasizing theImpact ofNP-Led Initiatives
toImprove Patient Care Outcomes
The COVID-19 pandemic prompted the need to shift nonurgent, subacute health
services from tertiary hospitals to the community. In Singapore, the polyclinics are
public outpatient healthcare centers nested within the precinct of residential neigh-
borhoods. An APRN-led service was initiated at the polyclinic to bring specialist
atrial brillation (AF) care from the hospital to the polyclinic.
The APRN-led AF clinic served at a “one-stop shop” for patients to receive
care for common chronic conditions and AF.The APRN leading the AF clinic,
originally trained as a generalist, received additional training to manage AF.The
APRN worked with a family physician to render AF care, and clinical decisions
were supported by an electronic decision support ow sheet. In the clinic con-
sults, the APRN provided routine patient education, supplemented by a webpage
(https://nice- af.wixsite.com/livingwithaf). This webpage provided context-spe-
cic AF content and was available in English and simplied Chinese. In addition,
patients at the APRN- led AF clinic benetted from fast-tracked appointments for
hospital-based investigations such as treadmill electrocardiogram, Holter studies,
and transthoracic echocardiogram. Lastly, the APRN could consult a hospital-
based cardiologist through telecommunication whenever necessary. According to
Nurse Practitioner Outcomes Evaluation
124
the patient’s condition, the APRN-led AF clinic appointments recurred every 3 to
6months.
Preliminary evaluation of the APRN-led AF clinic reported signicant improve-
ments in several patient-reported outcomes: AF-specic quality of life, AF knowl-
edge scores, medication adherence, patient satisfaction, and depression scores.
Additionally, there were no adverse safety indications in the clinical outcomes,
namely, cardiovascular hospitalization and stroke incidence, as well. The positive
impacts on the patient outcomes in the APRN-led AF clinic were attributed to the
consistent high-quality patient education and counseling by the APRN [15]. Besides
the APRN, another feature of the AF clinic was the team of healthcare providers,
whose consistent presence facilitated patient-provider rapport and more personal-
ized care. The APRN-led AF clinic integrated care for the patients. Patients no lon-
ger had to visit multiple clinicians to have their other chronic conditions reviewed.
This APRN-led AF service in the community received local media attention for its
ingenuity and positive outcomes. It was also a great opportunity to increase public
awareness and acceptance of APRNs.
Besides the above initiative, APRN-led rheumatology services in Singapore have
shown to receive higher patient satisfaction and improved disease knowledge and
medication adherence [24]. The similar outcomes have been demonstrated in
APRN-led psychiatric services. A 2-year follow-up of these patients displayed sig-
nicant correlations between satisfaction with APRN services and mental health
recovery and general self-efcacy, respectively [25].
The measurement of NP outcomes can be integrated into practice through
targeted efforts including collecting baseline data prior to implementing an
NP-led initiative, using role-specic metrics that reect the focus of NP care,
planning for outcome evaluation when any new role is established, and building
in outcome assessment as a part of the ongoing professional practice evaluation.
A number of resources exist that can be useful for identifying NP impact. Table3
provides a listing of websites resources of outcome metrics that can be useful
for NPs.
R. Kleinpell et al.
125
Table 3 Websites resources of outcome metrics
American Association of Nurse
Practitioners Outcomes Toolkit
https://www.aanp.org/images/documents/practice/NP_Patient_Outcomes_Toolkit.pdf
National Health Service of Scotland
Advanced Nursing Practice Toolkit
https://www.advancedpractice.scot.nhs.uk/activity- analysis/stage- 2.aspx
National Quality Forum https://www.qualityforum.org
Agency for Healthcare Research and
Quality Indicator examples
a. Prevention indicators
b. Inpatient quality indicators
c. Patient safety indicators
d. Pediatric quality indicators
https://www.qualityindicators.ahrq.gov
Centers for Medicare and Medicaid
Services Hospital Value-Based
Purchasing Program
a. Clinical processes of care
measures examples
b. Hospital-acquired condition
measures
c. Patient experience of care
measures
https://www.cms.gov/Medicare/Quality- Initiatives- Patient- Assessment- Instruments/Value- Based- Programs/
HVBP/Hospital- Value- Based- Purchasing; https://www.cms.gov/Medicare/Quality- Initiatives- Patient-
Assessment- Instruments/HospitalQualityInits/OutcomeMeasures
The Joint Commission National Patient
Safety Goals examples
https://www.jointcommission.org/standards_information/npsgs.aspx
National Database of Nursing Quality
Indicators
https://www.nursingandndnqi.weebly.com/ndnqi- indicators.html
“Capturing Impact” toolkit from the
Shefeld Hallam University
https://www.research.shu.ac.uk/hwb/ncimpact
National Association of Neonatal Nurses
Quality Metrics Position Statement #3068
https://www.nann.org/uploads/Quality_Metrics_Position_Statement_Final.pdf
Adapted with permission from Kleinpell [18]
Nurse Practitioner Outcomes Evaluation
126
Summary
Globally, NP roles are continuing to evolve. The ongoing changes in healthcare
continue to impact the way care is delivered and provide NPs with opportunities to
demonstrate their value. Measuring NP outcomes is important in showcasing the
impact of their care [25, 26]. Having knowledge of the process of assessing out-
comes of practice is important for all NPs. The collective impact of NP care can be
established only through continued focus on assessing outcomes of their care.
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Nurse Practitioner Outcomes Evaluation
Part II
NP Country Exemplars
131
The Nurse Practitioner intheUSA: Role
Exemplars
MaryEllenRoberts andJoyceKnestrick
Introduction
Nurse practitioner practice has evolved in the decades since the role of the advanced
practice nurse practitioner started in the 1960s in the USA.Currently, nurse practitio-
ners (NPs) in the USA practice in almost every healthcare setting which include
private practices, clinics, hospitals, emergency and urgent care sites, federal health-
care agencies such as the Veterans Administration (VA), nursing homes, retail clin-
ics, school/university clinics, home health, and health departments. This chapter will
discuss a brief history of the NP role in the USA, describe the impact of regulation at
the national and state level on the NP role, present the roles of the NP in the USA,
and present exemplars of the NP role in the primary care and acute care settings.
Development oftheNP Role intheUSA
As early as the 1960s, nurses began to tend to the primary care needs of children and
families. Nursing identied gaps in the state of healthcare related to prevention of
disease, family health, and health promotion. Nursing leaders established that
This chapter will discuss the role of the nurse practitioner in the USA and provide exemplars of the
acute care nurse practitioner (ACNP) role, the primary care family nurse practitioner (FNP) role,
and the psychiatric/mental health nurse practitioner (PMHNP) role. The exemplars showcasing
NPs include an innovation by an acute care NP to provide consistent quality and affordable care in
an acute care setting, the development of a community health center to serve low-income patients,
and the increased access to mental healthcare provided by a PMHNP.
M. E. Roberts (*)
College of Nursing, Seton Hall University, South Orange, NJ, USA
J. Knestrick
George Washington University School of Nursing, Washington, DC, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_9
132
nurses provided quality healthcare and improved access to healthcare services for
children and families. The scope of the nurse evolved, and the nurse began to prac-
tice in roles similar to the primary care physician, which was the catalyst to the NP
role. In 1965, Dr. Lorretta Ford (RN) and Dr. Henry Silver (MD) started the rst
nurse practitioner (NP) program at the University of Colorado [1]. The new role was
initially developed to provide care for families to ll the primary care needs of chil-
dren in rural areas. Health promotion, disease prevention, and family health were
important aspects of the NP role. The NP role continues to evolve to meet the chal-
lenges of providing high-quality, cost-effective, access to healthcare for primary,
specialty, acute, and chronic care in the USA.Although primary care was the initial
aim, the role continues to evolve based on the changing healthcare needs of the
populations in the USA.Nurse practitioners now specialize as pediatric primary or
acute care NPs, family nurse practitioners, adult and geriatric primary and acute
care NPs, women’s health NPs, and psychiatric/mental health to be consistent health
NPs. For nearly 60 years, NPs have been making advances in providing and improv-
ing access to healthcare to patients across the healthcare spectrum, including some
of the most vulnerable and underserved populations in the USA.
Legislative Efforts
Although multiple organizations have joined to address legislative efforts related to
nurse practitioner practice, licensure, and reimbursement, the American Association
of Nurse Practitioners (AANP) has served as the leader in the policy arena. AANP
is a national nurse practitioner organization formed by the merger of the American
Academy of Nurse Practitioners (Academy) and the American College of Nurse
Practitioners (ACNP) [2]. In the early 1990s, the Academy began advocacy on
behalf of nurse practitioners and assisted with signicant legislative changes to pro-
pel the NP role. Reimbursement for services provided by NPs was paramount to the
Academy. NPs provided services for federal government employees but were not
able to be paid for the services. This prompted the Academy to develop information
in the policy arena to educate legislators regarding the role on the NP and the
increased access to care provided by NPs for federal workers. The Academy worked
to assure NPs were recognized by the Federal Employee Health Insurance as pro-
viders and were able to be directly reimbursed for services. Eventually the work of
the Academy also led to the implementation of national legislation to provide direct
payment to NPs caring for rural patients receiving Medicare which is a federal
health insurance program for people 65 years of age and older, with disabilities or
with end-stage renal disease in the USA.This groundbreaking legislation known as
the Balanced Budget Act of 1997 became Public Law 105-33 and recognized NPs
as Medicare providers and allowed them to receive payment for all eligible services
under Medicare, similar to physician reimbursement [3]. This legislation was the
catalyst which enabled the Academy to work with states to recognize NPs under
Medicaid (joint state and federal programs that provide health coverage to eligible
low-income patients) and by private insurance panels [4]. AANP has an ofce of
M. E. Roberts and J. Knestrick
133
state government affairs and federal government affairs that continually work to
monitor federal and state issues that impact NP practice, licensure, and reimburse-
ment issues [5].
Geographical andDemographical Concerns intheUSA
Geographically the USA is very diverse. The country is bordered on the north by
Canada, the sound by Central America, and the east and west by the Atlantic and
Pacic Oceans. Within the 50 states, nurse practitioners work in rural, suburban,
and urban areas. There are many denitions that distinguish these areas from one
another which often leads to confusion. Sometimes population density is the den-
ing concern; in other cases it is geographic isolation. Small population size typically
characterizes a rural place. Rural areas are further constrained by physician short-
ages [6] and nancially stressed hospitals with operating margins often too narrow
to invest in upgrades to optimize care delivery [7]. As a result of these challenges,
rural populations may engage with the healthcare system differently than their
urban counterparts. Understanding the healthcare use of individuals in rural areas
may yield insights into addressing these growing health disparities and the care that
nurse practitioners provide.
Urban areas are another unique geographical part of the USA.According to US
Census Bureau, urban is dened as areas that represent densely developed territory
and encompass residential, commercial, and other nonresidential urban land uses [8].
As part of urban areas, nurse practitioners are vital to the care of the underserved,
underinsured, and those without healthcare.
It is hard to dene a suburb. Suburbs have several denitions; the most used one
is census- convenient because it is easily constructed using publicly available census
data [9], pg. 4. “This denition conceptualizes suburbs as remainders in relation to
the political boundaries of cities. Though there are several variations of this deni-
tion, the basic structure treats cities as places or tracts that fall within principal cities,
while suburbs encompass any space that falls outside of categorized cities but within
metropolitan area boundaries” [9], pg. 4. The importance of knowing the geographi-
cal denitions in the USA cannot be emphasized enough in relation to the role of the
nurse practitioner since the area often dictates the practice and autonomy of the
NP.There are over 350,000 NPs practicing across the USA, providing care to indi-
viduals from all communities, socioeconomic class, and demographic backgrounds.
According to the AANP [10] National NP Survey, “NPs described themselves as
White (79.4%), Black/African American (8.1%), Asian (4.3%), American Indian/
Alaska Native (0.5%), Native Hawaiian/Other Pacic Islander (0.2%) or Multiracial
(2.3%). A majority (95.0%) described themselves as not Hispanic or Latino, while
5.0 percent indicated they were Hispanic/Latino. On average, clinically practicing
NPs were 49 years old, and approximately 90.6 percent were female. Respondents
were also geographically diverse, with a large concentration of NPs located in the
South. Additionally, when asked about their military background, 7.3 percent of
NPs indicated current or previous active duty military service” [10].
The Nurse Practitioner intheUSA: Role Exemplars
134
Consensus Model
In 2009 the National Council of States Boards of Nursing (NCSBN) adopted through
the endorsement of 48 national organizations the APRN Consensus Model. This
model which includes the four APRN categories including the nurse practitioner fur-
ther claries the role of APRNs in the USA. “In this APRN model of regulation there
are four roles: certied registered nurse anesthetist (CRNA), certied nurse-midwife
(CNM), clinical nurse specialist (CNS), and certied nurse practitioner (CNP). These
four roles are given the title of advanced practice registered nurse (APRN). APRNs
are educated in one of the four roles and in at least one of six population foci: family/
individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s
health/gender-related or psych/mental health” [11], pg. 6.
Nurse practitioners providing care along the wellness-illness continuum is a
dynamic process in which direct primary and acute care is provided across settings.
Nurse practitioners are members of the health delivery system, practicing autono-
mously in many diverse areas including family practice, pediatrics, acute care, geri-
atrics, and women’s health. Educationally NPs are prepared to diagnose and treat
patients with undifferentiated symptoms as well as those with established diagno-
ses. “Both primary and acute care NPs provide initial, ongoing, and comprehensive
care, including taking comprehensive histories, providing physical examinations
and other health assessment and screening activities, and diagnosing, treating, and
managing patients with acute and chronic illnesses and diseases. This includes
ordering, performing, supervising, and interpreting laboratory and imaging studies;
prescribing medication and durable medical equipment; and making appropriate
referrals for patients and families” [11], pg. 9. The holistic care of a patient and fam-
ily includes health promotion, disease prevention, health education, and counseling
as well as the diagnosis and management of acute and chronic diseases. Nurse prac-
titioners are prepared to practice in primary care and acute care settings which have
separate national competencies and separate certication exams based on population.
Scope of practice is derived from educational preparation, the validation of the
education via the attainment of national board certication in a population, and
licensure that grants the legal authority to practice. Scope of practice is further
delineated by the patient’s needs and is not setting specic.
Once certied as a nurse practitioner in a specic population, the NP can choose
to specialize in a specic area such as emergency, dermatology, gerontology, cardiol-
ogy, and oncology. Specialty exams are available for nurse practitioners practicing in
select areas. These exams are usually administered by specialty organizations.
Nurse Practitioner Roles intheUSA
According to the American Association of Critical Care Nurses [12], acute care
nurse practitioners (ACNPs) are educated, certied, and licensed to care for those
individuals who are physiologically unstable, technologically dependent, critically
ill, and highly vulnerable to complications, have rapidly changing conditions, or
M. E. Roberts and J. Knestrick
135
have an illness which is chronically complex. Since scope of practice is dened by
the patient’s needs, an acute care nurse practitioner may care for patients who fall
within their scope of practice in any setting.
The primary care nurse practitioner, as dened by the National Organization of
Nurse Practitioner Faculties in collaboration with the American Association of
Colleges of Nursing, is one who is educated, certied, and licensed to provide com-
prehensive, chronic, continuous care characterized by a long-term relationship with
the patient. A primary care nurse practitioner may work in almost any setting pro-
vided that the needs of the patients for whom they are providing care do not require
the expertise of an acute care nurse practitioner due to acute onset physiologic
instability.
Both the acute and primary care nurse practitioner may lead interprofessional
teams, evaluate and diagnose medical and nursing conditions, develop treatment
plans, and monitor the response to treatment. They are educated, certied, and
licensed to provide restorative care in emergent and non-emergent situations.
Nurse Practitioner Programs
In the USA, nurse practitioner programs are offered at the master’ degree in nursing,
post- masters’ certicate, or as Doctor of Nursing Practice (DNP). Several factors
inuenced the move to graduate education in the USA.The demand for structured
NP programs and the complexity of patients seen by NPs increased; therefore NP
education moved to the graduate level. In the late 1980s, over 90% of NP programs
were at the master’s or post-master’s degree level.
In addition to primary care, NPs began to answer the need for hospital-based
roles, and in the 1990s, the role of the acute care NP began to emerge. NONPF cre-
ated the National Task Force on Quality Nurse Practitioner Education (NTF) in
1995 and published the Criteria for Evaluation of Nurse Practitioner Programs. The
Commission on Collegiate Nursing Education revised its Standards of Accreditation
to include the Criteria for Evaluation of NP Programs in 2005. The responsibilities
of the NP began to change, and healthcare needs of the USA increased in complex-
ity. Complex issues of billing and managing a practice impacted NP practices and
specialization called for healthcare providers including NPs to develop pathways
for addressing unmet educational needs. The changes prompted nursing to move
advanced practice to the Doctor of Nursing Practice (DNP). Schools are transition-
ing master’s programs to the DNP.
In 2014, approximately one-fourth of the NP programs transitioned to the
DNP.Although the MSN remains the entry into NP practice, programs continue to
move from the master’s programs to the bachelors to DNP (BSN-DNP). The move-
ment to the DNP is in line with the Future of Nursing report and NONPF’s [13]
initiative to move to the DNP by 2025.
In addition, NONPF recently revised the NTF Standards to improve the quality
and rigor in NP programs. NONPF recommends a minimum of 750hours in all
The Nurse Practitioner intheUSA: Role Exemplars
136
programs of direct patient care, noting that the student may need additional hours if
competencies are not met.
Nurse practitioner programs apply for accreditation by nursing certication bod-
ies. The purpose of accreditation of programs is to ensure that nursing education
programs meet the standards of quality across the USA.Accreditation of programs
advances the profession and greatly enhances the rigor and overall quality of care
provided by NPs. In the USA there are three national nursing accreditation bodies
which are recognized by the US Secretary of Education: the Commission on
Collegiate Nursing Education (CCNE, https://www.aacnnursing.org/CCNE), the
Accreditation Commission for Education in Nursing (ACEN, https://www.acenurs-
ing.org), and the NLN Commission for Nursing Education Accreditation (CNEA,
https://cnea.nln.org).
Nurse Practitioner Certification
Most states in the USA require national certication of the NP for licensure.
Certication authorizes NPs to demonstrate their population expertise and vali-
dates their knowledge to employers and patients. Certication programs assess
the competencies of graduate nurse practitioners to provide safe effective high-
quality care. Certication programs are accredited by the American Board of
Specialty Nursing Certication (ABSNC) and the National Commission for
Certifying Agencies (NCCA). The ABSNC is the only accrediting body speci-
cally for nursing certication. ABSNC accreditation is a peer-review mechanism
that allows nursing certication organizations to obtain accreditation by demon-
strating compliance with the highest-quality standards available in the industry.
The NCCA is the private not-for- prot accrediting branch of the Institute for
Credentialing Excellence (ICE), which is the national standard-setting organiza-
tion for credentialing groups including certication boards, licensing boards, and
associations. The NCCA uses a peer-review process to establish accreditation
standards; evaluate compliance with the standards; recognize programs that dem-
onstrate compliance, monitor, and enforce continued compliance; and serve as a
resource on quality certication.
Candidates for certication sit for the exam that aligns with graduate education,
role and population. Candidates must have successfully completed:
• The APRN core (advanced physical assessment, advanced pharmacology, and
advanced pathophysiology)
• The NP educational program’s required number of faculty-supervised direct
patient care clinical hours
• The nationally recognized competencies of the nurse practitioner role and the
population
• Completion of a nationally accredited graduate, postgraduate, or doctoral educa-
tional program that is accredited by a nursing accrediting organization recog-
nized by the US Department of Education and/or the Council for Higher
Education Accreditation
• Current, active, professional nurse licensure in the USA
M. E. Roberts and J. Knestrick
137
Table 1 Nurser practitioner certication bodies in the US
Table of nurse practitioner certifying bodies Certication type*
American Academy of Nurse Practitioners Certication Board FNP, AGNP, ENP
American Association of Critical Care Nurses Certication
Corporation
ACNP-AG
American Nurses Credentialing Center FNP, AGPCNP, AGACNP,
PMHNP
National Certication Corporation NNP, WHNP
Pediatric Nursing Certication Board CPNP-AC, CPNP-BC
Depending on certication agencies, other requirements may be required to sit
for initial certication.
Once initially certied, nurse practitioners must recertify and maintain certica-
tion through a variety of ways including:
• Continuing education
• Pharmacology hours
• Clinical practice
• Current RN licensure
• Table 1 lists the bodies that certify NPs in the USA.
Certication type
Family nurse practitioner FNP
Adult-gero primary care nurse practitioner AGNP
Adult-gero acute care nurse practitioner AGACNP or ACNP-AG
Psych mental health nurse practitioner PMHNP
Neonatal nurse practitioner NNP
Women’s health nurse practitioner WHNP
Pediatric nurse practitioner (primary care) CPN-BC
Pediatric nurse practitioner (acute care) CPNP-AC
Emergency nurse practitioner ENP (specialty)
Could you add some information about NP salary and NP education fees in the
USA? According to the US Bureau of Labor Statistics, the mean annual salary for
nurse practitioners is $118,040. This salary varies by state and region of the country.
California is the highest-paying state at $151,830 and Tennessee at $95,120.
Typically the nurse practitioners in the West and Northeast have the highest-paying
salaries. Salaries vary by specialties with psychiatric/mental health with the highest
salary and pediatrics the lowest [14].
The cost of education varies by degree (MSN or DNP as entry) and type of
school. Typically private schools are more expensive where a state or public school
is not. It is difcult to estimate the cost of education due to the many variables asso-
ciated with cost.
Exemplar oftheAcute Care NP
In the hospital intensive care unit (ICU), the ACNP functions collaboratively with
the critical care provider team consisting of the ACNP, attending physician (inten-
sivist), one or two critical care medicine fellows, clinical pharmacist, and other
The Nurse Practitioner intheUSA: Role Exemplars
138
members of the delivery team, including bedside nurses, primary care nurses, and
respiratory therapists. The ACNP manages the patient from admission to discharge
from the unit.
The day begins with a clinical huddle, or meeting, with the team members who
provided care during the previous night, highlighting changes in patients’ condi-
tions, and providing information on new patients. The ACNP then participates in
patient rounds, examining the patient. All data is reviewed by the ACNP including
vital signs, lab studies, EKG and rhythm strips, all radiological studies, and a review
of medications, continuous infusions, and uid balances. Based on the clinical
examination and review of data and with input from members of the delivery team,
a comprehensive plan of care is devised for the patient. The ACNP assumes varying
roles during these patient-focused rounds (e.g., presenting and reviewing data,
doing the physical examination, writing orders, calling consultants). During this
time, the ACNP notes issues to be addressed later; treatment outcomes to be evalu-
ated; planned procedures, culture, and diagnostic test results to review; family con-
ferences; and expected admissions and discharges. Once rounds are complete, the
ACNP will begin to address some of the specic issues on their work list.
Once this is complete, the ACNP begins to see their patients to provide the care
needed for the day. This includes transfer orders if warranted, evaluating the appro-
priateness of interventions, and determining if changes to medications or other
therapies are needed. The ACNP reviews each patient’s history and physical (H&P)
and restarts home medications that are appropriate to the patients’ comorbidities.
They write transfer orders and collaborate with the bedside nurse to ensure that all
patient care issues have been addressed in the orders. Patient and family education
are an important part of the day. During the day, the ACNP may perform other inva-
sive procedures, such as inserting arterial lines, central venous lines, dialysis cath-
eters, chest tubes, and nasoduodenal feeding tubes and performing thoracentesis,
endotracheal intubation, and removal of intra-aortic balloons. Health promotion and
protection assessment and intervention are integral to the ACNP’s role but in differ-
ent areas than one might expect in the primary care setting. For example, in the ICU,
the ACNP addresses stress ulcer prophylaxis, preventing complications from immo-
bility, promoting skin integrity, and optimizing nutritional support.
Throughout the day the ACNP will monitor and provide problem-focused care in
response to changing patient needs and condition. The ACNP will provide care for
such issues as hypotension, hypertension, low cardiac output, low urine output,
bleeding, low oxygen saturation, fever, difculty with ventilation or ventilator
changes, agitation and delirium, mental status changes, inadequate pain manage-
ment, arrhythmias, electrolyte abnormalities, and problems with lines or catheters.
Patients are seen multiple times during the day, and the ACNP may perform directed
physical examinations, formulating a treatment plan, and reassessing clinical nd-
ings to evaluate response to therapy. Management options may be reviewed by con-
sultants from other teams, such as cardiology, renal, and infectious diseases, to
coordinate care and treatment plans.
New admissions are another component of the ACNP’s day. Review of orders,
physical exam, and plan of care will be part of the ACNP responsibility for newly
admitted patients.
M. E. Roberts and J. Knestrick
139
At the end of the day, a clinical huddle is done with the oncoming shift, and a
continuous plan of care is developed with the incoming members of the team.
As a permanent member of the team, the ACNP provides needed continuity to
care. The ACNP is instrumental in developing clinical protocols and communicat-
ing care expectations to other members of the team. The ACNP interacts with social
services, case managers, physical and occupational therapists, and nutritional con-
sultants. Discharge planning is an integral part of their day. Quality improvement is
an essential part of the ACNP’s role. (See exemplar below.) Research initiatives and
activities round out the role of the ACNP.
A recent implementation of an acute care APN-led COPD discharge education
program to decrease 30-day readmission rates has shown that the work of the acute
care NP results in improved patient outcomes. This resulted in a cutting-edge and
state-of-the-art discharge education program at a major medical center. The primary
outcomes were decreased 30-day readmission rates. This was achieved by establish-
ment of a 7-day pulmonary follow-up to evaluate signs and symptoms which require
an emergency pulmonary visit; importance of inuenza and pneumococcal vaccina-
tion; proper inhaler technique utilizing the 10-second breath hold with “teach back”
method; importance of physical activity and pulmonary rehabilitation (PR); home
oxygen needs; home nebulizer needs; importance of proper nutrition; assessment of
anxiety, depression, and gastrointestinal reux (GERD); and assessment for the saf-
est discharge location based on the patient’s risk for readmission. This NP-led ini-
tiative has resulted in clinically signicant ndings as a suitable approach to
decrease 30-day readmission rates with outcomes including improved quality of
care, a multidisciplinary transition of care COPD DISCHARGE PLAN 6 approach
to the patient with COPD, decreased nancial burdens for this medical center, and
implementation of pulmonary evidence-based guidelines. A recent study of this
population in the facility in which this took place resulted in the following ndings:
149 subjects were included in the pre-intervention cohort and 214 subjects were
included in the post-intervention cohort. Thirty-day readmission rates were lower in
the post-intervention cohort compared to the pre-intervention cohort, 22.4% vs.
38.3% (p=0.001). A reduction in 60-day and 90-day readmission rates was also
observed, 13.7% vs. 40.3% (p<0.001) and 10.1% vs. 32.2% (p<0.001), respec-
tively [15].
This innovation by an acute care NP shows an effective way to provide consistent
quality care in an acute care setting, while decreasing hospital readmissions and
providing high-quality, affordable patient care.
Exemplars ofthePrimary Care NP
In the best-case scenario, the primary care nurse practitioner practices autono-
mously in collaboration with other healthcare professionals in settings such as a
clinic, private practice, convenient care, community clinics, and health centers.
Since the role of the family nurse practitioner (FNP) is the certication of 70% of
NPs in the USA [1], this exemplar will focus on the FNP role. However, there are
pediatric nurse practitioners (PNP), adult geriatric nurse practitioners (AGNP), and
The Nurse Practitioner intheUSA: Role Exemplars
140
women’s health nurse practitioners (WHNP) who practice in the primary care areas,
and the practice is similar to the FNP but each has unique specialized areas.
In the USA there are 26 states with full practice authority (FPA). In states with
FPA, state laws permit NPs to evaluate and diagnose patients, order, and interpret
tests, initiate, and manage treatments and prescribe medications without any regula-
tory restrictions exclusively under the licensure authority of the State Board of
Nursing. The National Academy of Medicine recommends this model [1]. In the 13
reduced-practice states, the state practice and licensure laws reduce the ability of
NPs to engage in at least 1 element of NP practice. In the reduced-practice states,
state laws require a career-long collaborative agreement that is regulated with
another healthcare provider (often a physician) for the NP to provide patient care or
limits the setting of the NP practice [1]. An example of a setting limitation would be
permitting the NP to practice with FPA but only in a rural area, not an urban area.
The remaining 11 states restrict NP practice to engage in at least 1 element of NP
practice. The state laws in restricted practice states require career-long supervision,
delegation, or team management by another healthcare provider for the NP to pro-
vide care [1]. Regardless of the licensure, NPs in every state provide quality,
evidence- based primary care to patients. In all 50 states, primary care nurse practi-
tioners assess patients with acute and chronic illness, provide wellness visits, use
diagnostic reasoning to make diagnoses, order laboratory and diagnostic testing,
prescribe medications (in all 50 states), provide patient education, and focus on
health promotion and disease prevention. Since NPs are part of the community
served, the NP is aware of the needs related to the social determinates which
impact health.
The following is an exemplar of the impact a FNP had in the practice setting. A
family nurse practitioner (FNP) provides primary care for patients across the lifes-
pan (birth to death). A FNP in a rural area noticed that many of the residents of the
area were uninsured or underinsured. Geographically the area was somewhat iso-
lated with limited public transportation, and the closest tertiary care hospital was
over 50miles away. Therefore, the members of the community did not access the
healthcare system until the disease process was severe and costly to the patient,
family, and the healthcare system. In addition, children were behind in screenings
and immunizations. The Medicare—national insurance for citizens over the age of
65—population were also limited on provider choices in the community. The FNP
worked with the community to develop a NP-run community health center. The
center worked to provide services on a sliding scale based on income for the unin-
sured. The FNP worked to help patients access Medicaid (a state and federal insur-
ance program for low-income populations). The center also worked to have NPs
recognized on private insurance panels so that all members of the community had
access to care. The center provided primary care services which included health and
wellness visits, care of acute and chronic medical conditions, education, and select
laboratory services. The FNP worked with local hospitals and healthcare systems to
recognize NP providers and to accept orders for laboratory, diagnostic procedures,
and other services such as physical and occupational therapy. As the clinic grew,
several FNPs and a WHNP joined the practice. Eventually the practice added a
M. E. Roberts and J. Knestrick
141
medical assistant, a registered nurse, a social worker, a diabetic educator, a recep-
tionist, and a medical billing specialist. Since the practice was in a reduced-practice
state without FPA, a physician was hired as a collaborator; however, the FNP
remained the medical director. The staff lived in the community and the clinic
worked to educate and train staff from within the community. The clinic provided
immunizations and health screenings and eventually added a mobile van to improve
access to care.
The NPs in the community health center provide patient-centered, evidence-
based care that is sensitive to the social determinants of health in the community.
The results of their work included improved access to care and improved childhood
screenings and immunization rates, more patients with diabetes reached an A1C of
7 or less, and patients with hypertension were in line with the current guidelines. In
addition, the use of the higher-cost emergency room care decreased. Prevention
programs such as smoking cessation and diabetes education were offered in the
clinic as well as in the community, which contributed to improved health outcomes
which was the mission of the community health center.
Exemplars ofthePsychiatric/Mental Health NP
As an advance practice nursing role that has developed in response to the increased
need for mental health services in the USA, psychiatric/mental health NPs
(PMHNPs) can see people of all ages for mental health issues. PMHNPs may also
see specialty populations such as pediatrics, adolescents, and geriatrics. The
PMHNP can conduct a comprehensive mental health assessment; provide individ-
ual, group, couple, or family therapy; prescribe medications; order and interpret lab
and diagnostic testing; and educate and counsel patients. The PMHNP may practice
autonomously depending on the state laws or may work in a practice with other
clinicians. The PMHNP works in collaboration within the healthcare team to opti-
mize the patient’s overall health [16].
The following is an exemplar of a PMHNP in an urban setting. A registered nurse
working in a mental health unit in a local hospital had difculty making follow-up
appointments as patients were discharged from the mental health unit. The RN dis-
covered the wait time for a noncrisis mental health appointment in her community
averaged 6–9 months. At rst the RN considered obtaining a Doctor in Nursing
Practice (DNP) to become an FNP, but after careful consideration, entered a DNP
program for PMHNPs. After graduation, the new PMHNP began to practice in a
community mental health clinic. Within a year, the PMHNP had a full panel of
patients and was able to round in the hospital mental health unit that started the
quest to improve access to mental healthcare. The NP also initiated group mental
health activities in conjunction with the clinic and the inpatient unit to improve
access to services. The NP was able to inuence and mentor other RNs in the unit
to consider becoming a PMHNP, growing the practice and increasing the mental
health services in the community. The work of the PMHNP was important to the
community as the NP was a member of the community she served. The NP was
The Nurse Practitioner intheUSA: Role Exemplars
142
aware of the cultural norms of the community, the support services available, and
the community stigma related to mental illness. This resulted in an improved trust
within the community toward mental health services.
Conclusion
In conclusion this chapter provides an overview of role of the nurse practitioner in
the USA.Nurse practitioners hold a variety of roles in different patient populations
as dened by the Consensus Model for advanced practice. The capacity to change is
crucial in a profession that is rapidly changing. Role development for the nurse
practitioner is a two-phased approach according to [17]: role acquisition through
education and role implementation after graduation.
Nurse practitioner role development in the USA has been described as dynamic,
complex, and situational [17]. Each state has various laws that govern nurse practi-
tioner licensure and practice with full practice authority recognized as the preferred
model in which nurse practitioners may practice autonomously. Frameworks for
geographical areas and exemplars of the nurse practitioner role are presented. The
nurse practitioner role will continue to evolve in response to organizational and
healthcare system changes as well as societal demands for the high- quality patient-
centered care provided by nurse practitioners in the USA.
References
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all- about- nps/np- fact- sheet
2. Haymarket media. Merger unies NP voice on capital hill. Clinical Advisor. 2013.
3. Balanced Budget Act of 1997 Public Law 105-33. https://www.govinfo.gov/content/pkg/
PLAW- 105publ33/pdf/PLAW- 105publ33.pdf
4. American Association of Nurse Practitioners TimeLine. 2022a. https://www.aanp.org/about/
about- the- american- association- of- nurse- practitioners- aanp/historical- timeline
5. American Association of Nurse Practitioners TimeLine. State practice environment. 2022b.
https://www.aanp.org/advocacy/state/state- practice- environment
6. Rabinowitz HK, Paynter NP.The rural vs urban practice decision. JAMA. 2002;287(1):113.
https://doi.org/10.1001/jama.287.1.113- jms0102- 7- 1.
7. Kaufman BG, Thomas SR, Randolph RK, Perry JR, Thompson KW, Holmes GM, Pink
GH.The rising rate of rural hospital closures. J Rural Health. 2015;32(1):35–43. https://doi.
org/10.1111/jrh.12128.
8. U.S.Bureau of Labor Statistics. 2021. https://www.bls.gov/oes/current/oes291171.htm.
Accessed 2 Feb 2023
9. Airgood-Obrycki W, Rieger S.Dening suburbs: how denitions shape the suburban land-
scape. 2019. https://www.jchs.harvard.edu/sites/default/les/Harvard_JCHS_Airgood-
Obrycki_Rieger_Dening_Suburbs.pdf. Accessed 21 Sept 2022
10. American Association of Nurse Practitioners. The state of the nurse practitioner profes-
sion. 2020.
11. Consensus model for APRN regulation: licensure, accreditation, certication & educa-
tion. 2008. https://www.ncsbn.org/public-les/Consensus_Model_for_APRN_Regulation_
July_2008.pdf.
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12. American Association for critical care nurses (AACN). AACN Scope and standards for adult-
gerontology and pediatric acute care nurse practitioners 2021.
13. NONPF. Standards for quality nurse practitioner education, 6th Edition. 2022. https://cdn.
ymaws.com/www.nonpf.org/resource/resmgr/ntfstandards/ntfs_nal.pdf.
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uploads/sites/11/2020/09/SalarySurvey_Slides_2020_v3.pdf.
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Fetherman B, Dimitry EA, Cerrone F, Shah CV.Decreasing Hospital readmissions utiliz-
ing an evidence-based COPD care bundle. Lung. 2022;200:481–6. https://doi.org/10.21203/
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17. Tracy ME, O’Grady ET. Hamric and Hanson’s advanced practice nursing: an integrative
approach (6th Ed). 2019. 9780323447751, 0323447759.
Mary Ellen Roberts DNP, ANP-BC, FAANP, FAAN, is an associate professor at Seton Hall
University. She is past chair of the American Academy of Nurse Practitioners Certication Board,
past president of the American Academy of Nurse Practitioners, and past chair of the Fellows of
the American Academy of Nurse Practitioners.
Joyce Knestrick PhD, FNP-BC, FAANP, FAAN, is an associate professor at The George
Washington University. She is a past president of the American Association of Nurse Practitioners.
The Nurse Practitioner intheUSA: Role Exemplars
145
The NP Role andPractice inCanada
MinnaMiller, NatashaProdan-Bhalla, andStanMarchuk
Introduction
Canada is the world’s second largest country based on area that covers nearly
10million square kilometers from the Atlantic Ocean in East to the Pacic Ocean in
the West, to the Arctic Ocean in the North, with 10 provinces and 3 territories and a
population of 38million [1]. Canada has 304,558 licensed registered nurses [2] and
7136 licensed nurse practitioners (NPs) [3]. Canadians enjoy a not-for-prot, pub-
licly administered, universal healthcare system funded by taxes that provides access
to hospital and practitioner/physician services to all residents based on need, not
ability to pay [4]. The primary care crises of the past several decades have posi-
tioned NPs in key roles to help meet population healthcare needs with improved
access to care. In this chapter we present the historical context and current state of
NP role development, education, regulation, and practice in Canada, highlight
Canadian NP leadership examples, and illuminate unique Canadian contributions to
NP role development, implementation, and evaluation globally.
M. Miller (*)
Department of Pediatrics, Division of Respiratory Medicine, British Columbia Children’s
Hospital, Provincial Health Services Agency, Vancouver, BC, Canada
International Council of Nurses NP/APN Network, Geneva, Switzerland
Canadian Centre for Advanced Practice Nursing Research, McMaster University,
Hamilton, ON, Canada
N. Prodan-Bhalla
Ministry of Health, Government of British Columbia, Vancouver, BC, Canada
S. Marchuk
BC Cancer Agency- Radiation Oncology, Provincial Health Services Authority,
Vancouver, BC, Canada
Nurse Practitioner Association of Canada, Ottawa, ON, Canada
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_10
146
Historical Evolution ofNP Role, Education, Regulation,
andPractice
The early beginnings of advanced practice nursing (APN) in Canada date back to
the 1890s to outpost nurses who worked in the isolated areas of the north [5, 6]. It
was not until the 1960s that APN roles became more formalized with Dalhousie
University in Halifax, Nova Scotia, developing the rst nurse practitioner (NP)
program in the country to prepare graduates to work in the remote nursing stations
of the north [6, 7]. The key drivers for the NP role implementation in the late
1960s and early 1970s were the new, publicly funded universal medical insurance
program, perceived physician shortage/maldistribution, and a movement toward
increased medical specialization [6]. The Boudreau report (1972) [8] and subse-
quent joint statement by the Canadian Nurses Association (CNA) and Canadian
Medical Association joint committee (1973) [9] supported the implementation of
the NP role with recommendations for legislative changes for advanced practice
and university programs to prepare NPs for both rural and urban settings [7–9].
NP role implementation into primary care settings was further supported by a
landmark Canadian randomized controlled trial documenting NP care equiva-
lency to physician care within the same settings [10]. While a number of univer-
sity programs preparing NPs were developed between 1970 and 1983, most were
closed by 1983 due to lack of provincial/territorial legislation, absence of renu-
meration mechanisms, perceived oversupply of physicians in urban settings, poor
public awareness of the role, and limited support from health professionals and
policy makers [7].
However, healthcare reforms of the 1990s resulted in a renewed interest in NP
role development with a need to contain healthcare costs, optimize resources, and
shift focus from acute care to community-based primary care with greater emphasis
on health promotion and disease prevention. Simultaneously a shortage of medical
residents and lack of continuity of care for hospitalized patients in acute care further
prompted the introduction of NPs with graduate-level preparation into these set-
tings [6].
The Pan-Canadian Nurse Practitioner Initiative (CNPI) [11] provided the impe-
tus for a more robust nurse practitioner role implementation into the Canadian
healthcare system with related toolkit [12] and frameworks [13, 14] recommend-
ing a standardized approach to NP role legislation/regulation, education, and
practice. A 10-year retrospective review of the CNPI ([15], p.4) reported signi-
cant progress on many of the 2006 recommendations, including an overall evolu-
tion of the NP role further supported by harmonization and expansion of the scope
of practice across jurisdictions, Pan-Canadian title protection, common role
description, and adequate professional liability coverage, with 28 schools across
the country offering at least 1 NP program in 2014. Standardization of a master’s
degree NP education was signicant for role advancement [15]. The Canadian
M. Miller et al.
147
Nurses Association has played a key role in the promotion and implementation of
NP roles across the country. It managed the CNPI budget of $8.9million in
2004–2006, engaged stakeholders, and produced numerous related documents
and reports. The Canadian Nurses Association together with the Canadian
Association of Advanced Practice Nurses hosted the 2008 International Council
of Nurses NP/Advanced Practice Nurse Network Conference with over 600 par-
ticipants from over 31 countries [7].
Current State ofNP Roles, Education, Regulation, andPractice
Legislation to enact the NP role in Canada took many years to be actualized with the
province of Alberta being the rst to pass legislation in 1996 and the Yukon Territory
the last in 2009 [6]. As of December 2022, there were 9235 licensed NPs in Canada,
with the most populous provinces, Ontario (n=4626) and Quebec (n=1217) hav-
ing the most robust NP workforce, followed by British Columbia (890), Alberta
(n=812) and the Yukon (n=24) with the least number of NPs [3] . Nurse practitio-
ners work in urban, rural, and remote areas of the country in primary care, long-term
care, palliative care, and acute care in a range of specialties including oncology,
cardiology, respirology/pulmonology, dermatology, and surgical services [3]. NPs
can also work in medical aesthetics [16] and can provide medical assistance in
dying, MAiD [17].
While title protection, graduate education, and autonomous practice are common
in all provinces and territories, variability in 30 of the 38 NP scope of practice
activities was identied by the Canadian Institute for Health Information (CIHI)
[18]. The regulation and education of NPs and delivery of health services is a pro-
vincial/territorial responsibility; thus a standardized national approach is challeng-
ing. NP education is available in ve streams. Table1 illustrates the NP stream of
education offered in each province/territory, the respective university, and the regu-
latory body that governs NP scope of practice. Entry-to-practice requires graduate-
level education and completion of a written certication exam for all provinces/
territories. In addition, British Columbia and Quebec require an observed structured
clinical exam (OSCE) for licensure.
A national study by Scanlon etal. [19] found that NPs used the same competen-
cies across all provinces/territories regardless of their practice stream and that NP
practice was consistent. These results support a greater harmonization of NP cre-
dentialing requirement and a national approach to NP examinations while some
variations across jurisdictions exist. Variability in credentialing and entry-to- practice
exams limit the ease of mobility across jurisdictions [19]. Similar to other countries
with established NP roles, research demonstrates that NP care is safe, effective,
efcient, and patient centered and is comparable to that of their physician col-
leagues [20].
The NP Role andPractice inCanada
148
Table 1 Province/territory, type of NP education available, name of academic institution offering
NP education, and name of regulatory body for NPs
Province/
territory
Types and
number of NP
programs
offered Universities offering NP programs
Regulatory bodies
for NPs (scope of
practice)
Yukon None None Yukon Registered
Nurses Association
Northwest
Territories/
Nunavut
None None Registered Nurses
Association of the
NorthWest
Territories and
Nunavut
British
Columbia
Primary health
care (4)
Thompson Rivers University,
University of British Columbia,
University of Northern British
Columbia, University of Victoria
British Columbia
College of Nurses
& Midwives
Alberta Primary health
care (2)
Adult (1)
Neonatal (1)
Athabasca University, University of
Alberta
College of
Registered Nurses
of Alberta
Saskatchewan Primary health
care (2)
Saskatchewan Polytechnic/University
of Regina
College of
Registered Nurses
of Saskatchewan
University of Saskatchewan
Manitoba Primary health
care (1)
University of Manitoba College of
Registered Nurses
of Manitoba
Ontario Primary health
care Adult (1)
Pediatric (1)
Lakehead University, Laurentian
University, McMaster University,
Queen’s University, Ryerson
University, University of Ottawa,
University of Windsor, Western
University, York University, University
of Toronto
College of Nurses
of Ontario
Quebec Adult (3)
Mental health
(5)
Neonatology
(2)
Pediatrics (2)
Primary health
care (7)
Université de Montréal, Université de
Sherbrooke, Université du Quebec à
Chicoutimi, Université du Quebec à
Rimouski, Université du Quebec à
Trois-Rivières, Université du Quebec
en
AbitibiTémiscamingue
Université du Quebec en Outaouais,
Université Laval, Université McGill
Ordre des
inrmières et
inrmiers du
Québec
Newfoundland
and Labrador
Primary health
care (1)
Memorial University College of
Registered Nurses
of Newfoundland
and Labrador
Prince Edward
Island
Primary health
care (1)
University of Prince Edward Island College of
Registered Nurses
of Prince Edward
Island
(continued)
M. Miller et al.
149
Table 1 (continued)
Province/
territory
Types and
number of NP
programs
offered Universities offering NP programs
Regulatory bodies
for NPs (scope of
practice)
New Brunswick Primary health
care (2)
Université de Moncton, University of
New Brunswick
Nurses Association
of New Brunswick
Nova Scotia Primary health
care (1)
Dalhousie University Nova Scotia
College of Nursing
Unique Canadian NP Leadership Examples
The Nurse Practitioner Association ofCanada
The Nurse Practitioner Association of Canada (NPAC), established in 2017, is the
national professional voice for nurse practitioners, representing the profession to
organizations and governments, nationally and internationally. NPAC is recognized
as a national leader, engaging and advising on health and social policy issues that
impact the development and delivery of health and social services to Canadians.
NPAC’s engagement includes ensuring a NP perspective is present to inform and
shape public policy in primary care, acute care, long-term care, and home and com-
munity care. NPAC’s advocacy includes working with ministries of health, mental
health, and addictions along with justice and nance. The association participates in
numerous initiatives to raise the awareness of the nurse practitioner role and how
the profession contributes to the delivery of health services in Canada.
The Principal Nursing Advisors Task Force
At the federal level, NPs are providing an advanced practice nursing lens as mem-
bers of the Principal Nursing Advisors Task Force, comprised of key nursing leaders
from all provinces and territories who meet monthly. This group is a Task Force of
the Health Canada Committee on Health Workforce, providing key expert advice
and policy recommendations on a variety of workforce issues, including imple-
menting better pathways for internationally educated nurses and workforce mobility
across provinces and territories. A Vision for the Future of Nursing in Canada [21]
sets out the key policy recommendations for all nursing designations in Canada.
Nurse Practitioner-Led Clinics
Nurse practitioner-led clinics (NPLCs) have been a great success in Canada, pro-
viding access to primary care for those who did not previously have a regular pri-
mary care provider [22, 23]. In 2007, the NPs in northern Ontario were successful
in leading the introduction of the rst NPLC in the province, after 20months of
The NP Role andPractice inCanada
150
lobbying the provincial government, negotiating funding for the clinic with the
Ministry of Health, developing a business plan, establishing a unique NP leader-
ship governance structure, and organizing clinic operations [24, 25]. Since 2007,
NP-led clinics have become an established model of care in Ontario, with 25 clin-
ics in operation. More recently British Columbia (BC) has opened its rst three
such clinics in 2020, with early data showing increased attachment to primary care
providers with good outcomes. The BC model of care, like the Ontario model, is
interdisciplinary and interprofessional, with a block of funding going to the pro-
viders in the clinic to deliver a wide range of services. In addition to pioneering
NPLCs in Ontario, the province has also pioneered the rst NP-led hospital model
in Whitby at Lakeridge Health with NPs as the most responsible providers/hospi-
talists [26, 27].
Nursing Policy Secretariat
In British Columbia, one of Canada’s largest provinces, NPs have provided leader-
ship as executive directors at the Nursing Policy Secretariat (NPS) in the Ministry
of Health. The NPS was established in 2011 after the provincial government and the
provincial bargaining unit for nurses recognized the need for nursing leadership and
vision within the Ministry of Health. Initially a Chief Nurse Executive role was
established on a temporary basis to discuss and identify priority recommendations
[28] in order to develop better supportive policy for nurses across the province. One
of the key focus areas has been to optimize NP scope of practice, remove legislative
barriers, and implement NP-led primary care clinics.
Nurse Practitioner Leaders inChief/Executive/Director Roles
Two Canadian provinces, Ontario (ON) in 2018 and British Columbia (BC) in
2020, have appointed a NP as the provincial Chief Nursing Ofcer within their
respective governments, ensuring the voice of nurses is at the senior executive level
in government. In increasing numbers, NPs are in executive positions as executive
directors/vice presidents within healthcare organizations having oversight of inter-
disciplinary staff, participating in key senior executive discussions and policy mak-
ing [26, 29]. The VP of Quality and Safety, Clinical Informatics, and Chief of
Nursing and Allied Practice in Provincial Health Services Authority in BC is a NP
who oversees the quality and safety in the health authority in collaboration with the
VP of Medicine. Both the ethics and clinical informatics team also report to her
providing a very broad yet integrally linked portfolio for high-quality practice.
This role, as well as others across the country, includes 1 day a week of clinical
practice to maintain NP licensure and bedside lived experience. Furthermore, NP
leadership roles as department heads and medical directors through the amendment
M. Miller et al.
151
of hospital acts have enabled NPs to be recognized as medical staff alongside phy-
sician colleagues [30, 31]. These roles provide oversight and monitoring of quality
medical care provided by NPs as well as facilitate access to care by permitting NPs
to be the most responsible providers to admit, discharge, and maintain continuity
of care.
Unique Canadian Contributions toNP Role Development,
Implementation, andEvaluation Globally
Canadian Centre forAdvanced Practice Nursing Research
Dr. Alba DiCenso held the inaugural research chair in advanced practice nursing
(APN) from 2001 to 2011 with a focus on building APN research capacity and
expertise within the country. With its $3.5million funding from the Canadian gov-
ernment’s health research agency, the program accepted 24 graduate students from
5 provinces and completed 48 APN-specic research projects with hundreds of
related publications and presentations [32]. Once the funding ended, the Canadian
Centre for Advanced Practice Nursing Research (CCAPNR) was established at
McMaster University to continue the legacy. The impact of the CCAPNR team
contributions thus far is signicant. Since 2011 the team has secured funding in
excess of $23million for 102 peer-reviewed grants and nearly $2million for 24
capacity- building initiatives and contracts. Additionally, it has published 210 arti-
cles in peer- reviewed journals, provided hundreds of presentations at various con-
ferences/forums, and provided leadership locally and globally to advanced APN
role implementation and development through education, policy, and regulation
[32, 33].
The PEPPA andPEPPA-Plus Frameworks
The PEPPA framework, a participatory, evidence-based, patient-focused process for
APN role development, implementation, and evaluation framework (Fig.1), was
developed to provide researchers, policy makers, administrators, and clinicians a
nine-step guide to optimize the development and utilization of APN roles [32, 34].
Key strategies emphasize stakeholder engagement and development of goal- and
outcome-oriented APN roles to address unmet patient health needs [35]. In Canada,
ministries of health and nursing associations have recommended the use of the
framework as best practice for APN role implementation. Outside of Canada, it has
been utilized in 21 countries across the world to support APN role implementation,
evaluation, and related policies, education, and research with implementation tool-
kits also readily available [32]. The PEPPA-Plus framework was subsequently intro-
duced to provide more enhanced guidance for APN role evaluation [35].
The NP Role andPractice inCanada
152
Fig. 1 The PEPPA framework: A participatory, evidence-based, patient-focused process for APN
(PEPPA) role development, implementation, and evaluation framework [34]
Conclusion
The integration of NPs into the Canadian healthcare system over the past few
decades has been impressive as are the contributions to NP role advancement glob-
ally. However, far too many Canadians still do not have a primary care provider or
timely access to needed services. There is also disparate deployment of NPs across
provinces. The Vision for the Future of Nursing in Canada calls for a pan-Canadian
approach to the NP regulatory framework, integrated entry-level NP education,
and optimized scope of practice, while the ICN promotes massive investment in
education (faculty development and students) and nursing leadership capacity
building. NPs in a wide range of practice settings and roles can provide strategic
leadership with vision and purpose toward equitable access to care, documenting
outcomes, measuring economic impact of NP care, and collecting the evidence
needed to advocate for new models of care based on patient and population needs
as they arise.
M. Miller et al.
153
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The Nurse Practitioner Role andPractice
inJamaica
HeatherMcGrath
Introduction
The name Jamaica is derived from the Arawak word Xaymaca “land of wood and
water” [1]. It is the largest English-speaking Island in the Caribbean and is situated
90miles south of Cuba, 600miles south of Florida and 100miles south-west of
Haiti. It is approximately 146miles long, 51miles wide with an area of 4,411
square miles [2].
There are approximately 3million people living in Jamaica which consists of a
multi-racial population of African, European, East Indian and Chinese descents.
English is the main language, but the creole “Patios” is spoken by most Jamaicans.
There are two cities: Kingston located at the south-east border of the island and
Montego Bay—the tourism mecca which lies at the north-west of the island. Jamaica
is renowned for its warm climate, lovely white-sand beaches, popular reggae music,
delicious meals and dominance in track and eld [2].
There are thirteen parishes in Jamaica which are classied into three counties. In
the health care system there are four Regional Health Authorities (RHAs) which are
further subdivided into Parish Health Departments. Each Health Department is
divided into Health Districts and consists of a number of Health Centres depending
on the population of the community. There are three levels of care offered: primary
(clinic), secondary (hospital) and tertiary (specialist hospital). Presently, public
health care in Jamaica is offered free of cost.
Nurse Practitioners (NPs) have been an asset to the Jamaican Health Sector,
especially in Primary Health Care, for over 40years [1]. They deliver comprehen-
sive quality care to the Jamaican populace across all life cycles. However, there is
no regulatory framework in place and barriers to NP care remain.
H. McGrath (*)
St James, Jamaica
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_11
158
Historical Evolution oftheNP Role, Regulation andPractice
After conceptualization of the role in 1972 and exploratory meetings in 1973, the
Nurses Association of Jamaica (NAJ) submitted a proposal to the Minister of Health
in 1974 for the commencement of training of Nurse Practitioners [3].
In July 1977, the rst cohort of NP students, eighteen Family Nurse Practitioners
(FNPs) and seven Paediatric Nurse Practitioners (PNPs), were admitted to a new
programme in response to an acute shortage of Medical Doctors in the rural areas [4].
The training was offered at the Advanced Nursing Education Unit (ANEU) in
Kingston and was introduced as a 1-year certicate programme [3]. The ANEU
identied a programme coordinator, Dr Linnette Jackson Myers, who was a
Registered Nurse before obtaining her degree in medicine. Project HOPE (Health
Opportunities for People Everywhere), a non-prot international global humanitar-
ian and health organization dedicated to assisting developing countries improve
health, provided funding for books, audiovisual aids and salary for faculty members
for the rst 3years [5]. In 1978 all the twenty-ve Nurse Practitioners entered the
workforce.
In 1980, the Minister of Health recommended that a legislation be enacted to
provide legal coverage to NPs. It was proposed that, upon completion of their train-
ing, graduate NPs would carry out their functions as outlined by their training insti-
tutions. This included the categories of patients to be seen, drugs to be prescribed
and the laboratory tests that could be ordered. This was formalized into a protocol
in 1985. The physician community opined that the Nurse Practitioners were not
adequately trained to assume this responsibility. Although NPs were well prepared
to take on the role of Advanced Practice Nurses (APNs), the issue of not being able
to prescribe independently proved to be a challenge [5].
In 1993, the NP education curriculum was revised by the NP Programme
Coordinator, Dr Leila McWhinney-Dehaney and the duration of training was
increased to 18months. A preceptorship system was introduced whereby NPs were
required to spend the nal 3months of their training in the clinical area under the
guidance of the supervisory NP or the most senior NP.A Medical Doctor provided
oversight, while the supervisor ensured that the practice of the NPs was aligned with
what they were taught. This revision included the introduction of the Mental Health/
Psychiatry track in 1995. In 2000, the NP programme was upgraded to the master’s
level and was transferred to the University of the West Indies School of Nursing [5].
NP Education
At the inception of the NP role in Jamaica, the minimum entry requirements
included Registered General Nurse, Registered Midwife, or acceptable substitute
post-basic course certication and a 5-year post-registration practice. The major
curriculum components were general subjects aimed at broadening skills in com-
munication, social interaction, scientic problem solving, nursing and medical sub-
jects. There was a 6-week core curriculum followed by a two-stranded specialist
H. McGrath
159
curriculum of 18weeks consisting of medical topics relevant to each subgroup. This
period was followed by 6months of internship. Subsequently, changes were made
including increased paediatric content of the FNP course, re-organization of con-
tent, hours devoted to research/epidemiology, increased pharmacology content and
modication of the student evaluations [6].
Currently, the entry requirements include 5years post-Registered Nurse experi-
ence, undergraduate degree or graduate degree. The applicant is expected to submit
a portfolio and attend an interview. This thirty-two-credit programme is offered at
the master’s level for 2years at the University of the West Indies School of Nursing
(UWISON), the only training institution in the Caribbean. Courses to be covered
include three advanced nursing practicum seminars, pathophysiology for advanced
nursing practice, growth and development, general and special pharmacology, psy-
chopharmacology and research methods applied to nursing [3].
Scope ofPractice
The scope of practice for NPs in Jamaica is delineated in the Advanced Practice
Nurses Regulations under the Nurses and Midwives Act of 1964 [7]. The regula-
tions specify that APNs act according to the recommended standards established by
the Nursing Council of Jamaica (NCJ) on the recommendations of the Advanced
Practice Nurse Standards Committee. The Nurses and Midwives Act will authorize
Advanced Practice Nurses to independently act beyond the scope of practice of the
Registered General Nurse. The Nurse Practitioners should possess advanced com-
petencies and standards which are developed with their input and are reviewed regu-
larly to ensure relevance and appropriateness of practice, assessment, diagnosis and
management of clients based on up-to-date clinical data and best practices and
engage in practices that reect the ethical and legal principles of the profession of
nursing. Medical certicates can be issued for a maximum of 7days except in cases
where the client illness is infectious, for example chickenpox. However, they are not
permitted to issue certicates for police or court cases. They must refer the clients
to the Medical Doctor if the signs or symptoms are life threatening, laboratory evi-
dence of decreased function of a vital organ, and sexually transmitted disease in a
child [7].
All new clients with a chronic non-communicable disease (NCD) should be seen
by the Doctor but may be managed by the NP if so indicated by the physician.
Clients should not be managed by an NP for three consecutive visits. NPs must meet
medico-legal standards when writing prescriptions which include client’s name and
other identiers, name of health facility, dosage, route, frequency and duration of
drugs, instructions as to whether generic drugs may be substituted, directions for the
number of rells, prescriber’s name which should be clearly written, and include a
legible signature and practicing number [7].
NPs should prescribe drugs approved by the Pharmacy Council and the vital,
essential and necessary (VEN) list approved by the Ministry of Health and Wellness
except cases in which the client was already placed on the drug with desired
The Nurse Practitioner Role andPractice inJamaica
160
outcomes and demonstrates the ability to afford the same, and where it is absolutely
necessary and the situation is discussed with and approved by a physician. They do
not have the authority to prescribe certain hormonal substances such as, growth
hormones, anabolic steroids, infertility drugs and controlled substances. NPs are not
permitted to prescribe drugs for themselves or their family members [7].
The laboratory tests that they can order include blood, urine, sputum, vaginal
swabs, X-rays (such as chest, extremities and spine); ultrasound (such as neck,
abdomen, pelvis and lower limbs), mammogram and electrocardiogram. NPs can
perform minimally invasive procedures such as simple suturing, incision and drain-
age. Cosmetic treatments are not permitted [7].
Areas ofPractice
Two groups of Nurse Practitioners are currently in practice, the Family Nurse
Practitioner (FNP) and the Mental Health Psychiatric Nurse Practitioner (MHPNP).
There are approximately sixty Nurse Practitioners practicing in Jamaica. The major-
ity of the Nurse Practitioners work in the Primary Health Care setting; however one
NP is employed in the hospital setting. The roles and practice of NPs are very
diverse.
Family Nurse Practitioner
Nurse Practitioners provide a comprehensive range of services which are embedded
in their professional, ethical and legal standards. In providing care they use their
in-depth knowledge of the bio-psychosocial aspects of health and disease. They also
apply basic and advanced principles of health management, health promotion and
protection, and disease and injury prevention. They work under the clinical supervi-
sion of a physician as well as collaboratively with all members of the multidisci-
plinary health team [7].
The scope of practice for the Family Nurse Practitioner is based on approved
core competencies. The population in primary care family practice includes new-
borns, infants, children, adolescents, adults, pregnant and postpartum women and
older adults. They employ evidence-based clinical practice guidelines to guide
screening activities, identify health promotion needs and provide anticipatory guid-
ance and counselling addressing environmental, lifestyle and developmental
issues [7].
The FNPs obtain and accurately document a relevant health history for patients
of all ages and in all phases of the individual and family life cycle, perform and
accurately document appropriate comprehensive physical examinations, assess spe-
cic family health needs within the context of community assessment, conduct
home visits and implement appropriate interventions and follow-up. Clients who
are not able to visit the health centre are seen in their homes.
H. McGrath
161
They also order and interpret age, gender and condition-specic diagnostic tests
and screening procedures, formulate comprehensive medical diagnoses/differential
diagnoses, provide health promotion, and disease prevention interventions/treatment
strategies to improve or maintain optimum health for all family members, prescribe
appropriate selected pharmacologic and non-pharmacologic treatment modalities,
make appropriate referrals to other health care professionals and community
resources for individuals and families, assess and promote self-care in patients with
disabilities and perform suturing, drainage of abscesses, splinting and pap tests [7].
Mental Health/Psychiatric Nurse Practitioner
Mental Health/Psychiatric Nurse Practitioners (MH/PNPs) are educated and trained
to promote mental health. They assess, diagnose and manage persons with psychiatric
and psychosocial issues under the clinical supervision of a psychiatrist. They offer
comprehensive care to children, adolescents, adults and their families by performing
specic psychological and psychiatric services. MH/PNPs collaborate with all mem-
bers of the general health team and other agencies in the execution of their duties.
MHPNP Competencies
Identify and analyse factors that affect mental health such as genetics, family, envi-
ronment, trauma, culture and ethnicity, spiritual beliefs and practices, physiological
processes, coping skills, cognition, developmental stage, socioeconomic status,
gender and substance abuse.
MHPNPs perform a comprehensive assessment of mental health needs of a com-
munity, accurately document mental status and neurological examinations, order
appropriate laboratory tests, diagnose mental disorders utilizing standardized sys-
tems, evaluate potential abuse, neglect and risk of danger to self and others, such as
suicide, homicide and other self-injurious behaviours, and assist patients and families
in securing the least restrictive environment for ensuring safety. They also prescribe
pharmacologic agents for patients with mental health problems and psychiatric disor-
ders based on individual characteristics and manage psychiatric emergencies [7].
Nurse Educator
Nurse Practitioners are employed at the UWISON as undergraduate or postgraduate
educators. There are three FNPs, two are lecturers in the NP Programme and also
serve as co-investigators for research assignments for NPs and undergraduate nurs-
ing students. The NP educators are also required to conduct or collaborate with
other faculty members to conduct research as outlined in their job descriptions. One
NP educator serves on the NP Seminar Committee which is responsible to plan the
national seminar for NPs where continuing education hours are facilitated. This
forum also showcases research presentations by NPs (Table1).
The Nurse Practitioner Role andPractice inJamaica
162
Prescribing
In Jamaica, the practice of Nurse Practitioners varies within and across the four
Regional Health Authorities (RHAs). The discussions regarding legislation began in
the 1980s. Ministers of Health have made promises to address this issue but have
failed to see this to fruition.
In 2011, a recommendation was made for an amendment of the Nurses and
Midwives Act of 1964. It was necessary to formulate the competencies, standards and
scope of practice that would govern the practice of NPs. This document outlines and
describes the requisite knowledge, clinical skills and professional judgement that the
NP must exhibit in order to competently practice. The National Competency Framework
describes the scope of activities that Nurse Practitioners are expected to perform within
the health sector. This framework also provides a reference point for the designing of
the educational curricula and a basis for evaluating their performance [7].
A working group that included members of the Nursing Council, Nurse
Practitioners and Nurse Anaesthetists was established in 2014. The responsibility of
the working group was to formulate the competence, scope of practice and standards
for Advanced Practice Nurses (APN) in Jamaica using the International Council of
Nurses (ICN) framework. Four [4] consultative meetings were held over a four [4]
months period between September and December 2014. Members of the working
group reviewed existing frameworks internationally that addressed the competencies
and scope of practice for nurses in the public health system. A team met in 2016 and
completed the review of the document. During the period 2016 to 2021, several
attempts made to have this document nalized into protocol were unsuccessful [5].
In December 2021, a committee chaired by a Medical Doctor was formed by the
Ministry of Health and Wellness to consider granting of prescriptive rights to Nurse
Practitioners. The objective was to examine the training requirements including
continuing medical education associated with nurse prescribing and to solicit the
views of key stakeholders in relation to Nurse Practitioner registration. The commit-
tee was also tasked to complete a review of the competencies and scope of practice
document that was previously drafted and completed in 2016. A focus group discus-
sion with clients and Medical Doctors yielded positive results in support for the NPs
legislation. Currently, the NPs perform their duties utilizing their Registered Nurse/
Midwife licence. The proposed legislation by the members of the committee will
allow NPs to prescribe an approved list of drugs aligned to their scope and compe-
tencies within the public health system [8].
Table 1 Distribution of NPs
in Jamaica
Facility Number of NPs assigned
Secondary care (hospital) 1
Primary care (clinic) 55
University 3
Army 1
H. McGrath
163
Practice
In an effort to facilitate easy ow of patient care, some Nurse Practitioners are
offered pre-signed prescriptions to carry out their duties. Prescribing practice is
dependent on the location of the Nurse Practitioners (rural vs urban). In the urban
areas, more doctors are employed; hence the issue of offering pre-signed prescrip-
tions is of less importance. In this case, the prescriptions are signed by a physician
after the clients are seen by the NPs. In some rural areas where Medical Doctor
deployment is limited, NPs are expected to run clinics alone.
A Nurse Practitioner is assigned to one particular health centre within a
health district or number of health centres. It is a common practice for some NPs
to be assigned to ve different clinics over a 5-day span. There are no guidelines
on the number of clients to be seen per day. The number of clients seen is depen-
dent on the assignment of the NP in relation to the population that the health
centre serves.
The issue of prescribing is more critical in the case where the Medical Doctor
who is assigned at a particular health centre is unable to present at the clinic,
especially in more remote locations. If the NP assigned does not have an ade-
quate number of pre-signed prescriptions, these clients are asked to return on
another day to receive care. The reality is that some of these clients may not have
the resources to return; hence timely access to care is impacted. Those clients
who require urgent medical care are encouraged to travel long distances to
receive care when the NP is unable to prescribe the necessary medications for
the client.
In some instances, NPs triage clients. The two main categories of clients who
visit the health centres are (1) those with chronic diseases who are in receipt of an
appointment and (2) those who are unwell without an appointment. In some cases it
is not possible to offer care to all clients. The triage process facilitates an assessment
of the clients who do not have an appointment but who can be accommodated on
that day. The triage also assists with assessing those clients who should be seen
urgently.
Conducting health education sessions is the core responsibility of the NPs. These
are done in the clinics or during outreach interventions in the community. Frequently,
Nurse Practitioners are assigned to offer care inside clients’ homes [9]. These cli-
ents have difculty accessing care at the health centres due to transportation chal-
lenges and limitations in mobility. The NPs sometimes offer service alone. Clients
in the inrmaries (government facilities that house individuals who are homeless)
also benet from this type of care. Completion of medical examinations for school
admission and work is an independent role of the NP.In this case the Doctor’s sig-
nature is not required.
To facilitate bi-annual re-licensure, NPs are required to obtain forty continuing
education hours. This includes twenty-ve nursing, ten midwifery and ve non-
nursing hours.
The Nurse Practitioner Role andPractice inJamaica
164
Leadership
Professional
With respect to leadership roles, Jamaican Nurse Practitioners are a group of health
professionals that hold volunteerism within the profession and the country in high
regard. Nurse Practitioners have served in leadership roles within the Nurses
Association of Jamaica. Iris Wilson (FNP) served as president during 2000–2003
and Heather McGrath (FNP) was the third vice president from 2007–2008. The
Jamaica Association of Nurse Practitioners was formed in 2009. Since its inception,
four FNPs have served as presidents: Duet Less (2009–2012), Sherril Josephs-
Williams (2012–2014), Nisa Hall (2014–2016) and Heather McGrath (2016–2022).
Dr Leila McWhinney-Dehaney (FNP) is presently the chair for the Nursing
Council in Jamaica. Nurse Practitioners have also served as Chief Nursing Ofcer
for the Ministry of Health and Wellness: Thelma Campbell (deceased) and Dr
McWhinney- Dehaney. Heather McGrath joined the International Council of Nurses
Nurse Practitioner/Advanced Practice Nursing (ICN NP/APN) Networking in 2017
as the Caribbean representative. She is presently the global Membership Ofcer.
Heather McGrath commenced her role as editorial board member for the Journal of
the American Association of Nurse Practitioners in January 2022.
Technical/Clinical
Nurse Practitioners are utilized to coordinate programmes within the Ministry of
Health and Wellness. This includes non-communicable disease, HIV/STI, rheu-
matic fever, sickle cell and cervical cancer. The responsibilities include planning
outreach interventions, formulating operational plans, conducting audits, drafting
critical reports and assisting with policy frameworks.
NP Impact/Role During theCOVID-19 Pandemic
Nurse Practitioners have been a vital arm of management during the COVID pan-
demic. They played a pivotal role in the roll-out of the vaccination programme.
There were mass immunization campaigns where they were instrumental in observ-
ing the clients for adverse effects of the vaccine while others participated in the
administration of the vaccine [10]. NPs were assigned to work in the emergency
operations unit where they participated in the contact tracing process and assisted
with obtaining samples from clients.
At the clinic level, NPs in ve parishes are assigned to coordinate programmes
such as non-communicable disease (NCD). These programme coordinators ensured
that clients with NCDs had care facilitated in a timely manner. The opportunity of
telemedicine provided access to care for clients who were fearful to visit the health
centre. NPs also conducted health education sessions focusing on COVID-19in the
H. McGrath
165
communities. In an effort to facilitate continuing education hours, one NP organized
webinars during commemorative events such as Diabetes Week. She also facilitated
the sharing of best practices while participating in a research led by NPs in Canada
that examined the role of the APN during the pandemic.
Conclusion
Nurse Practitioners have served as a vital arm of the Jamaican public health system
for the past four decades. They offer quality care to clients across all life cycles.
Many other countries internationally and regionally have demonstrated that NPs
deliver comprehensive care safely. All stakeholders must act swiftly to ensure that
the required legislative framework for NPs is enacted to assure the Jamaican popu-
lace has access to these qualied health care providers across all settings to facilitate
Universal Health Coverage and access to care.
References
1. Jamaica information Service. https://jis.gov.jm.
2. Jamaica. https://kids.nationalgeographical.com.
3. Family Nurse Practitioner/ the UWI School of Nursing. https://www.mona.uwi.edu.
4. Seivwright MJ.Nurse practitioners in primary health care: the Jamaica experience part 1. Int
Nur Rev. 1982; 29(2):51–81. https://www.icn.ch.
5. Honoring Our Past-Nurse Practitioners Jamaica 40th Anniversary Magazine, (2017).
6. Cumper G.Neglecting legal status in health planning: Nurse Practitioners in Jamaica. Health
Policy Plann. 1986;1(1):30–6. https://www.jstor.org.
7. Competencies scope of practice and standards for advanced practice nurses. ministry of health
and wellness, Jamaica.
8. Allen I.Growth & jobs/advanced nursing practitioners to get prescriptive rights, 2022. https://
jamaica- gleaner.com.
9. Waugh-Brown V.Nurse practitioner: asset or liability for the health care system? 2022. https://
wwwjamaicaobserver.com.
10. Healthcare workers lauded for dedicated service during COVID-19. https://jis.gov.jm.
The Nurse Practitioner Role andPractice inJamaica
167
The Evolution oftheNurse Practitioner
Role andPractice intheUnited Kingdom
MelanieRogers andAnnabellaGloster
Introduction
This chapter discusses the evolution of the Nurse Practitioner (NP) role in the
United Kingdom (UK) and the move to multi-professional advanced practice roles.
In the UK, the provision of healthcare is a devolved responsibility for each of the
four countries, England, Scotland, Wales and Northern Ireland. Each country has its
own National Health Service (NHS). Specic country needs and policy have led to
the development of NP roles, in addition to the development of other advanced
practice roles for allied health professionals. This chapter provides an overview of
the development of the NP role in the UK with specic reference to each country.
Evolution oftheNurse Practitioner Role intheUnited Kingdom
The nurse practitioner (NP) role was rst recognised in the UK in 1988 [1]. Like
other countries, typical drivers included medical provision shortages, a European
edict to reduce the hours junior doctors worked, the changing needs of the popula-
tion and a desire to advance nursing [2, 3]. In the UK, NP developments have led to
holistic care which integrates the best of nursing with the best of medicine [4]. The
UK does not view the NP role as a substitute doctor or a task-shifting role, rather a
development of the nursing profession.
M. Rogers (*)
University of Hudderseld, Hudderseld, UK
e-mail: m.rogers@hud.ac.uk
A. Gloster
Health Education England, London, UK
e-mail: Annabella.Gloster@hee.nhs.uk
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_12
168
There has been a slow evolution of the NP role in the UK with local service needs
often driving sporadic NP role development rather than a national policy. However,
the role is now well accepted and well established. The NP role was pioneered
through the work of Barbara Stillwell and Barbara Burke-Masters who introduced
the role into primary healthcare in the late 1980s [5]. The NP was viewed to be a
role suitable for experienced nurses who could enhance patient care through the
development of health assessment and diagnostic skills to deliver independent
patient management in primary care. The development of NPs in secondary care
settings did not develop fully in the UK until the 2000s.
Nurse Practitioner Education
Education for NPs was pioneered in the 1970 but really began to evolve in the early
1990s when the Royal College of Nursing (RCN) established the rst training pro-
gramme for NPs in the UK in conjunction with the University of London. The RCN
is the UK’s largest nursing membership organisation and trade union [6].
The RCN programme of study was initially taught at diploma level and integrated
the key competencies of physical health assessment, differential diagnoses, patient
management skills underpinned by a robust knowledge of anatomy and pathophysiol-
ogy. The curriculum, which was a work-based modular approach was franchised, mak-
ing the programme available to other education institutions on a commercial basis
which later developed into an RCN accreditation system. The benet of providing an
RCN accredited programme was the consistency of the training which was bench-
marked to nationally agreed standards [7]. The move to franchise the London pro-
gramme allowed other universities to deliver the RCN accredited programmes which
still exist today at masters level.
Other universities soon followed the RCN lead and began to offer NP training;
however there was no standardised approach in course content, with NP roles vary-
ing in scope of practice, educational preparation and titles used [8]. Training pro-
gressed from diploma to degree level training and is now offered solely at master’s
level across the UK.There are no concrete plans in the UK to develop a Doctor of
Nurse Practitioner curriculum. However, some universities offer professional doc-
torates in advanced practice which enables NPs to pursue a specic clinical topic to
doctorate level in addition to traditional PhDs.
In 2008 a UK-wide proposal to support NP training was published called “The
Advanced Practice Toolkit” [9]. This document outlined four pillars of advanced
practice; clinical practice, leadership, education and research. In England, the
Department of Health developed a position paper [10] which proposed four themes
under which nurses working at an advanced level would be required to have compe-
tencies in following a structured curriculum at master’s level:
• Clinical/direct care or practice
• Leadership and collaborative practice
• Improving the quality and developing practice
M. Rogers and A. Gloster
169
• The development of self and others
The four pillars outlined within the Scottish toolkit have since been accepted in
all four UK countries as the basis for NP and advanced practice training [9].
Competencies within the four pillars serve as the foundation for educational prepa-
ration and work-based learning.
Due to the ongoing lack of regulation and title protection, the RCN published
guidance for NPs suggesting that those working at an advanced level of practice
having achieved the educational and practice competencies use the title Advanced
Nurse Practitioner to identify the “advanced” nature of the role [7]. The title change
was anticipated to bring greater clarity to the role, yet a 2017 study found 595 job
titles in the UK which were being used by 17,960 specialists which could be per-
ceived as being advanced [11]. This nding has led to further developments across
the UK to try to standardise advanced practice by educators, researchers, clinicians,
policy makers and regulators through the development of country-specic frame-
works in the UK.
Considering the lack of regulation in the UK for advanced practice it is interest-
ing to note that many “Royal Colleges,” where medical colleagues are credentialed,
have developed their own curricula and capabilities for advanced practice, for
example, the Royal College of Emergency Medicine, the Faculty of Intensive Care
Medicine and the Royal College of Surgeons for which advanced clinical
practitioner,s (ACPs) from all professions can apply. These colleges offer member-
ship (for a fee) and opportunity to receive credentialing for their role. Some view
this to be a reductionist approach for advanced practitioners within a bio-medical
model rather than advancing the nursing profession, whilst others embrace the spe-
ciality framework/curriculum to dene their scope of practice. Leary & MacLaine
[12] suggested this could support a view that advanced practice roles are merely
medical substitute roles.
Nurse Practitioner Prescribing
A pilot of nurse prescribing took place in the UK during 1994–1997 with a national
roll-out following from 1997–2001. Initially prescribing was limited to District
Nurses and Health Visitors who had a very limited formulary of mainly wound care
products and a few other medications such as Nystatin for infant thrush [13]. Several
other initiatives followed including extended prescribing from 2001–2009, supple-
mentary prescribing from 2003 and limited independent prescribing in 2006 [14,
15]. Supplementary prescribing allows the prescriber to develop a clinical manage-
ment plan with the patient and their doctor. The doctor initiates the mediation
needed and the prescriber can then continue ongoing prescriptions within the stipu-
lated management plan. This approach works well for long-term conditions for
example [16].
Independent prescribing, initially only available to registered nurses and phar-
macists, allowed a limited number of medications to be prescribed autonomously.
The Evolution oftheNurse Practitioner Role andPractice intheUnited Kingdom
170
Over time, the list has been extended to now include all medications within the
British National Formulary including controlled drugs if prescribing is within the
clinicians’ competencies. With the move in many parts of the UK towards develop-
ing the multi-professional workforce many other professions are also able to under-
take independent prescribing, for example: podiatrists, physiotherapists,
radiographers, paramedics and optometrists [17].
Nurse Practitioner training in the main includes prescribing as a compulsory
module in the UK.
Nurse Practitioner Regulation
Alongside the NP role developing in the UK there has also been a plethora of other
advanced practice roles developing. This has caused a major issue in terms of the
nomenclature [11]. Unfortunately, there has been repeated failures to regulate or
protect the NP title in the UK.Over the last two decades the NP role was acknowl-
edged as a discrete role which prompted consultation within the nursing profession
and its governing body. In 2005 the Nursing and Midwifery Council (NMC), the
regulatory body of all UK nurses, considered regulation of NPs; however, a later
review by the Council for Healthcare Regulatory Excellence (CHRE) stated that all
registered healthcare professionals must comply with standards set by their own
professional bodies and therefore separate regulation was not required for NPs [18].
They suggested that advanced practice does not need additional regulation because
career development, that includes advanced practice, is appropriately governed
through their own professional bodies via codes of conduct. The CHRE suggested
that employers have a responsibility to ensure their healthcare workforce meets the
standards set by their professional body for practice and therefore the NP must meet
their individual professional code of conduct. Governance to date is employer-led
with the aim of ensuring quality and appropriate standards are maintained to mini-
mise the risk to patients and protect the public.
To date there is no separate regulation for NPs or the multi-professional advanced
practitioners by their separate regulatory bodies and there are no requirements for
re-validation. Governance is still employer-led with the aim of ensuring quality and
appropriate standards have been met to protect the public and reduce risk to patients.
The Nursing and Midwifery Council is currently reviewing the regulation of NP
roles due to the multiple concerns regarding a lack of regulation with a recent
Council paper stating it is looking to approve new standards for advanced nursing
practice by 2025 [19].
Health Policy
Increasing life expectancy, the subsequent disease burden as well as European pol-
icy and legislation resulting in a reduction in availability of junior medical staff led
to a rise in the development of the NP and advanced practice roles in the UK to ll
M. Rogers and A. Gloster
171
the gap [20–22]. The application of advanced practice roles has enabled more effec-
tive use of skilled human resources in targeted areas of growth need, for example,
mental health, urgent and emergency care, and other speciality areas requiring ser-
vice transformation.
Implementing advanced practice roles has required changes to policy in the gov-
ernance and regulation of professions, as well as the development of nancial and
organisational support. Policy reforms around advanced practice in the UK have
been shaped by stakeholders including employers and clinicians and often the medi-
cal profession. Healthcare managers have been instrumental in supporting training
and implementation of these roles [8]. The advanced practice role has now grown to
include other professions and has begun to inuence workforce structures and ser-
vice redesign with innovations in healthcare services that are now entirely advanced
practice-led.
England
The NP role in England is attributable to the pioneering work of Barbara Stillwell
who introduced the role in the late 1980s into primary healthcare. The emergence of
NP roles into secondary care occurred much later and largely mirrored the emphasis
on clinical assessment, diagnosis and treatment as seen in the United States of
America [8]. Educational preparation was developed and led by the RCN as
described earlier, however soon expanded with other education providers develop-
ing and delivering their own programmes. This has contributed to the lack of stan-
dards required to underpin this role. The title and educational preparation have
varied ever since inception of the role. As it has often been at an employer level, it
has resulted in a plethora of job titles and an inconsistent underpinning evidence
base in comparison to countries where NP is regulated and rmly established.
Following the publication of The Scope of Professional Practice by the United
Kingdom Central Council for Nursing, Midwifery and Health Visiting, nurses were
liberated to take on roles that were previously in the domain of medicine and were
encouraged to make decisions much more independently [23]. The parallel develop-
ment of the NP role and advancing nursing practice may have contributed to the
confusion and distinction between nurses who took on extended roles and advanced
practice.
As advanced nursing practice moved into the twenty-rst century, the breadth of
roles and titles continued to develop with a current picture of many roles, titles and
job descriptions related to Clinical Nurse Specialist, NP and other advanced practi-
tioner titles. The move to recognise advanced practice as a level of practice rather
than a specic role has moved advanced practice towards a multi-professional
approach with the use of the title advanced clinical practitioner, (ACP) in England
[24] and Advanced Practitioner in the other three countries.
Health Education England (HEE) is a government body which supports the
delivery of healthcare to the patients and public of England by providing leadership
and coordination for all healthcare training and education in England. HEE has
The Evolution oftheNurse Practitioner Role andPractice intheUnited Kingdom
172
contributed to the development of a multi-professional approach for advanced prac-
tice including nurses, midwives, allied health professionals and pharmacists. HEE
published a multi-professional framework for advanced clinical practice in England
[24]. This framework reects a philosophical view of a level of practice with room
for all health professionals to develop an advanced scope of practice developed by
master’s level education [24].
The HEE multi-professional framework has been a driving force towards the
establishment of the HEE Centre for Advancing Practice and seven Regional
Faculties for Advancing Practice in each of the English regions. The Centre for
Advancing Practice oversees workforce transformation of advanced level prac-
tice, by the establishment and monitoring of standards for education and training,
accrediting advanced practice programmes and recognising education and train-
ing equivalence through the assessment of a portfolio. The accreditation and rec-
ognition of meeting the standards for education and training at present is not
mandatory for education providers or practitioners, but the aim of all these devel-
opments in England is for advanced practice standardisation, title protection and
regulation, which will ensure public safety and the advancement of all profes-
sions [24].
The regional faculties are working across their local systems to support transfor-
mation in practice, as they are uniquely placed to understand their own region’s
workforce requirements. Each faculty will identify workforce demand, commission
high-quality education and training, support communities of practice to drive ongo-
ing development and support to improve patient care through the development of
advanced practice.
Recent developments in England saw the introduction of an apprenticeship
model for the educational preparation for ACPs. The MSc ACP is dened by an
apprenticeship standard that denes an occupational role and sets out the knowl-
edge, skills and behaviours required to full it across four domains. The standard
was developed in collaboration with multiple stakeholders including, employers,
HEE and the Association of Advanced Practice Educators UK (AAPE UK).
The model is employer-led and requires a minimum of 20% off the job learning,
enabling clinicians to study whilst practising and contributing to service delivery. It
allows the employers to access funding for the development of ACPs through a
government levy which they pay into if they have an annual pay bill of more than
£3million.
The current English denition for advanced clinical practice is:
Advanced clinical practice is delivered by experienced, registered health and care practitio-
ners. It is a level of practice characterised by a high degree of autonomy and complex
decision-making. This is underpinned by a master’s level award or equivalent that encom-
passes the four pillars of clinical practice, leadership and management, education and
research, with demonstration of core capabilities and area specic clinical competence.
Advanced clinical practice embodies the ability to manage clinical care in partnership
with individuals, families and carers. It includes the analysis and synthesis of complex
problems across a range of settings, enabling innovative solutions to enhance people’s
experience and improve outcomes [24: p.8]
M. Rogers and A. Gloster
173
Scotland
Scotland initially recognised advanced level practice to only be in the remit of
nurses and utilised the same title as England: ANP.NHS Education for Scotland
[25, 26] developed an advanced practice toolkit which has been widely used across
the whole of UK to provide resources to support the development of advanced prac-
tice education and training.
The Scottish governments’ transforming roles programme was introduced in
2015 to ensure strategic oversight and governance of role developments that
were beyond traditional boundaries. The Scottish government committed to
funding 500 additional ANPs as part of this programme with a prerequisite to
include evaluation of the impact of this investment. The current phase of the
transforming roles programme is to support the development of allied health
professions and healthcare scientists to become advanced practitioners [27, 28].
The transformation programme is currently being evaluated and will focus on
educational impact.
There are three Advanced Practice Academies within Scotland covering the
north, west and east of Scotland. These Academies were established to support
governance and professional development for ANPs and Clinical Nurse
Specialists and are a collaboration of education institutions and Regional Health
Boards [29]. The academies have a multidisciplinary membership including
NHS board members, nurses, midwives and allied health professions as well as
academic representatives which facilitate shared learning across professions.
The Academies are now working towards a multi-professional approach to the
Advanced Practice roles. Recently pharmacists have joined the membership of
each Regional Board [29]. Each Regional Board has responsibility for maintain-
ing a data base of registered advanced practitioners and providing professional
development. The three Academies meet regularly to ensure a collaborative
approach across Scotland.
Additionally, a new initiative of Advanced Practice Educators has recently been
formed in Scotland to develop Advanced Practice Education called the Scottish
Advanced Practice Educators Network. This follows the successful inception of a
Welsh Educator Network (see below).
The Scottish government [28] continues to support the development of Advanced
Nurse Practitioners (in addition to other Advanced Practitioner roles) through pol-
icy that supports safe, effective and person-centred care.
The current Scottish ANP Denition is:
Advanced Nurse Practitioners (ANPs) are experienced and highly educated registered
nurses who manage the complete care of their patients, not focusing solely on any condi-
tion. ANPs have advanced level capability across the four pillars of practice: clinical prac-
tice, facilitation of learning, leadership, evidence, research and development. They also
have additional clinical-practice skills appropriate to their role [30].
The Evolution oftheNurse Practitioner Role andPractice intheUnited Kingdom
174
Wales
Wales followed in the footsteps of Scotland in 2009 by adopting the Scottish
Government Health Department’s Advanced Practice Toolkit [25]. The Post
Registration Career Framework for Nurses in Wales [33] offered the initial founda-
tion for the development of an Advanced Practice Framework. The Advanced
Practice Framework sets out guidance and key messages about a consistent, struc-
tured approach for the development of “advanced practitioners” across clinical,
education, management and leadership roles. Advanced practitioners in Wales are
expected to integrate all of the four pillars of advanced practice into their roles.
Health Education and Improvement 32 is responsible for supporting Advanced
Practice in Wales. Their Advanced Practice Framework has been perceived as key to
the workforce redesign and supporting robust Advanced Practice governance.
Development of Advanced Practice roles in Wales has increased dramatically since
2010 with targeted funding for Advanced Practice increasing year on year [32]. The
Advanced Practice Framework for Advanced Practice offers clear guidance for the
development implementation and evaluation of Advanced Practice roles through-
out Wales.
Advanced Practice is dened within the Welsh Framework as:
A role, requiring a registered practitioner to have acquired an expert knowledge base, com-
plex decision-making skills and clinical competencies for expanded scope of practice, the
characteristics of which are shaped by the context in which the individual practices.
Demonstrable, relevant Master’s level education is recommended for entry level. ([32], p.21)
It also states that:
Advanced practice should be viewed as a ‘level of practice’ rather than a specic role and
it is not exclusively characterised by the clinical domain but may also include those work-
ing in research, education, management/ leadership roles. ([32], p.10)
Current developments in Wales have seen the successful inception of an Advanced
Practice group of Educators forming a committee to drive Advanced Practice for-
ward (Wales Advanced Practice Educators Network) alongside the creation of the
Multi-Professional Advanced Practice Group Wales.
Northern Ireland
Northern Ireland uses the title Advanced Practitioner. Nursing and allied health pro-
fessionals have separate advanced practice frameworks set out in the Advanced
Nursing Practice Framework [34, 35] and the Advanced Allied Health Professional
Practice Framework [33]. Each framework identies the core competencies for the
role of the Advanced Practitioner and like all the UK countries the four pillars of
advanced practice are essential to these roles. Both frameworks acknowledge that,
in Northern Ireland, there has been a lack of understanding regarding the precise
M. Rogers and A. Gloster
175
nature of the Advanced Practitioner and confusion between that and the role of the
specialist practitioner. The frameworks document the fundamental differences
between the specialist and advanced practice roles and dene what advanced prac-
tice is, allowing for formal educational and clinical practice progression for each.
Definitions
An Advanced Nurse Practitioner in Northern Ireland:
practices autonomously within his/her expanded scope of clinical practice, guided by The
Code. Professional standards of practice and behaviour for nurses and midwives The
Advanced Nurse Practitioner demonstrates highly developed assessment, diagnostic, ana-
lytical and clinical judgement skills and the components of this level of practice [35: p.4].
The Allied Health Practitioner advanced practice role is dened as:
a role, requiring a registered experienced practitioner to have acquired an expert knowledge
base, complex decision-making skills and clinical competences for expanded/extended
scope of practice, the characteristics of which are shaped by the context in which the indi-
vidual practices. Demonstrable, relevant education is recommended for entry level to the
advanced practice role which is to be at master’s level or equivalent and which meets the
education, training and Continuous Professional Development (CPD) requirements [33].
Examples ofPractice fromtheUK
Primary Care
Gemma is a 29-year-old Advanced Nurse Practitioner working in primary care. She
undertook her master’s degree 3 years ago. Her day-to-day work involves all the
four pillars of practice.
Clinical Practice
She runs two clinics each day. Each clinic lasts for two and half to three hours.
Patients are allocated a 15-minute appointment. Gemma sees “all comings.” In
terms of her clinical work, she is only excluded from assessing pregnancy related
issues, for example listening for foetal heart sounds. Her clinic is varied including
acute and chronic presentations. Her most recent clinic included the following pre-
sentations: child with sore throat—Scarlatina, adult in their twenties with depres-
sion, 50-year-old woman with a hard breast lump, 78-year-old man with end stage
chronic obstructive airways disease, 20-year-old man with penile discharge,
40-year-old man with cough, fever and malaise—tuberculosis, 50-year-old woman
with perimenopausal symptoms, 58-year-old man with unexplained anaemia.
Gemma enjoys the variety of presentations. Although she works autonomously, she
meets with her medical colleagues for lunch where they have the opportunity to
The Evolution oftheNurse Practitioner Role andPractice intheUnited Kingdom
176
discuss difcult cases and have time for informal training together. Once a month
she has direct clinical supervision with a general practitioner.
Leadership andManagement
Gemma is the nurse lead for the practice which involves supporting and developing
a team of six colleagues. She works as role model by consistently demonstrating her
holistic approach to person-centred care and compassionate leadership. Her vision
is to encourage and support her team to offer the best care possible. She meets
weekly with the team to listen to any concerns and offer supervision and informal
training as needed.
In addition to managing the nursing team she is the practice lead for long-term
conditions. She has worked hard to redesign services and provision in response to
patient and staff feedback. She set up a monthly patient participation group where
she discusses service redesign and involves the patients in co-production of ser-
vices. Her work has been recognised locally and she often speaks to other primary
care providers about her leadership work with patients.
Education
Gemma integrates the education pillar in a number of ways, clinically with her
patients, with her colleagues and through her own professional development.
Clinically, she is passionate about empowering her patient to have the knowledge to
be able to make informed choices. She works hard to ensure health literacy to maxi-
mise patients’ health and wellbeing. Recently, she has been involved with col-
leagues at a local university, which teaches Advanced Nurse Practitioners, to
develop a series on online modules which includes evidence-based approaches to
women’s health as well as patient vignettes to support learning.
In terms of her own personal development Gemma accesses training and devel-
opment in her locality through a monthly professional development afternoon which
is run by a collaboration of primary care providers. She often is asked to present at
these events. She attends one or two conferences per year to increase her own
knowledge in specic areas and network with colleagues. Finally, she usually
accesses monthly professional updates either face to face or online to ensure she
continues to keep herself up to date.
Research
When Gemma completed her training, she viewed herself as naïve about research
methods and methodologies. To upskill herself she undertook a module at her local
university which gave her more condence in how she could integrate research in
her own clinical area. Weekly she works with colleagues in the audit group to look
at specic areas of practice which may need to be improved upon. She reviews
national guidance and presents audit ndings and updates to guidelines at the clini-
cal meetings that are held weekly at her practice. Recently, Gemma was asked if she
wanted to be involved in a research study looking at antibiotic prescribing during
Covid-19. Initially, she didn’t feel she had the condence to be involved in a study.
After talking with colleagues she felt encouraged to become involved in the research
M. Rogers and A. Gloster
177
team. She felt supported by the rest of the team and realised how enjoyable research
could be. She was able to take the ndings and discuss implications for practice
with her colleagues at the practice. These experiences have given her a new appre-
ciation for the importance of research in clinical practice.
Secondary Care
Mo is a 42-year-old Advanced Nurse Practitioner working in the Emergency
Department (ED). He undertook his master’s degree 10 years ago. His work involves
all of the four pillars of practice and covers both day and night shifts across the
24-hour service.
Clinical Practice
Clinically he sees all patients that may present to the ED.A medical consultant-
led safety huddle occurs at the handover of a shift to ensure responsibility for
immediate and ongoing care is transferred between healthcare clinicians. Patient
presentations include anyone who comes into the department either self-present-
ing or brought in by ambulance. His most recent shift included the following
presentations: 56-year-old with chest pain—myocardial infarction, 84-year-old
after a fall—fractured neck of femur, 42-year-old with abdominal pain, vomiting
and jaundice, 35-year-old with a major trauma—pedestrian hit by vehicle—mul-
tiple fractures to lower limbs and head injury and the care of a dying 94-year-old
patient.
Mo enjoys the variety and unpredictability of the presentations in the ED, work-
ing within a multi-professional team and learning continuously from his medical
colleagues and the wider multi-professional team. Although he works autono-
mously, he has the opportunity to discuss difcult cases with senior medical col-
leagues and has time for formal training together with other NPs.
Leadership andManagement
Mo is one of two lead NPs in the ED which has a developing team of 14 multi-
professional ACPs. He meets with the team of ACPs on a monthly basis and
approaches his role with compassionate leadership recognising the signs of staff
burnout in this eld checking on the wider nursing team, but also supporting junior
ACPs and trainees as they develop. He meets with the senior medical team on a
weekly basis and is able to advocate for, and ensure, all ACPs are supported and
supervised and that their voice is heard in decisions made relating to the team, ways
of working and the vision for the future for the ED team.
Mo has led multiple audits and pieces of work related to service improvement
which he shared nationally at conferences, and supported ACPs informally from
other hospitals who may be working alone but wanting to develop and grow more
NPs as part of their workforce. He is an advocate and active member of ED advanced
practice forums at a regional level.
The Evolution oftheNurse Practitioner Role andPractice intheUnited Kingdom
178
Education
On-the-job clinical teaching is core for professional development, and Mo has
opportunities daily for his own development but also to develop others. He is a role
model to others, motivating others to learn through active participation and to pro-
vide meaningful opportunities for developing the other team members’ skills and
knowledge. He empowers patients to have the knowledge to be able to make
informed choices and using appropriate opportunities to integrate health promotion
and providing lifestyle education.
In terms of his own personal development Mo has formal teaching sessions in the
ED on a weekly basis often with medical colleagues. The sessions involve discus-
sion of complex cases, new evidence and/or the management of particular presenta-
tions, audit ndings and root cause analysis of particular incidents. He is often
asked to present a case with the expectation to be able to justify his clinical reason-
ing and to explore the evidence base to support his management for peer learning.
Research
Mo has been involved in multiple clinical audits, and as part of a larger research
team when the department has been involved in major clinical trials. Presenting
ndings from clinical audit to the wider team can improve compliance in areas
where guidelines have not been used consistently or where safety issues have been
identied and need prompt action with a change in practice.
Mo uses the opportunity to revisit previous cases to learn from and to have time
to think more deeply, reecting on his clinical reasoning and exploring opportuni-
ties to research best practice and guidelines related to these cases, and to consider
any areas for improvement that could be made either personally or more widely in
terms of changing practice within the department. The importance of research in
clinical practice is recognised and integrated into everyday practice using best
available evidence and from his professional development both formally and
informally.
Conclusion
In 2022 Advanced Practice roles in the UK are mainly viewed as a level of practice
rather than an individual specic role. Key to this is the assimilation of the four pil-
lars of advanced practice where clinical work, education, research and leadership
are all viewed as important when working at an advanced level.
As with many countries grappling with workforce transformation there are many
challenges the UK faces. The UK comprises of four countries who have devolved
governments and specic service needs leading to varied approaches to advanced
practice. In relationship to nursing the UK still does not have standardised regula-
tion or title protection although there is progress in this area. Advanced Practice
Nurses continue to offer diverse roles and transferability of skills which have made
a signicant difference to workforce transformation and fundamentally to
patient care.
M. Rogers and A. Gloster
179
Acknowledgements Grateful thanks to our colleagues across the UK who have contributed to the
sections on Scotland—Colette Henderson, University of Dundee; Wales—Anna Jones, Cardiff
University, and Jonathon Thomas, Swansea University; and Northern Ireland—Donna McConnell,
Ulster University.
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ments/01_ExecSumary_Background.pdf.
26. NHS Education for Scotland. Advanced practice toolkit; 2018. http://www.advancedpractice.
scot.nhs.uk/.
27. Scottish Government (SG). Transforming Nursing Midwifery and Health Professions’
(NMaHP) roles: paper 2 advanced nursing practice; 2017. https://www.gov.scot/publications/
transforming- nursing- midwifery- health- professions- roles- advance- nursing- practice/.
28. Scottish Government. Advanced nursing practice- transforming nurs-
ing roles: phase two; 2021. https://www.gov.scot/publications/
transforming- nursing- midwifery- health- professions- roles- introduction/.
29. Advanced Practice Scotland; 2023. https://www.advancedpractice.scot.nhs.uk/uk- progress/
Scotland.aspx.
30. Chief Nurse Ofce Directorate (CNOD). Transforming Nursing, Midwifery and Health
Professions’ roles: pushing boundaries to meet health and social care needs in Scotland. Paper
2-advanced nursing practice; 2016.
31. United Kingdon Central Council (1992) Guidelines for Professional Practice. UKCC for
Nursing, Midwifery and Health Visiting.
32. Health Education and Improvement Wales. Workforce. 2021. Accessible at: https://heiw.nhs.
wales/workforce/
33. Welsh Assembly Government. Post registration career framework for nurses in Wales. Welsh
Government; 2009.
34. Department of Health, Social Services and Public Safety. Advanced nursing practice frame-
work: supporting advanced nursing practice in health and social care trusts. Belfast: Department
of Health; 2014.
35. Department of Health, Social Services and Public Safety. Advanced nursing practice frame-
work: supporting advanced nursing practice in health and social care trusts. Department of
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M. Rogers and A. Gloster
181
The NP Role andPractice inFinland
AnnaSuutarla, VirpiSulosaari, andJohannaHeikkilä
A. Suutarla (*)
Finnish Nurses Association, Helsinki, Finland
e-mail: anna.suutarla@nurses.
V. Sulosaari
Finnish Nurses Association, Helsinki, Finland
Turku University of Applied Sciences, Turku, Finland
e-mail: virpi.sulosaari@turkuamk.
J. Heikkilä
JAMK University of Applied Sciences, Jyväskylä, Finland
e-mail: johanna.heikkila@jamk.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_13
Fact Box—Health in Finland
Finland is situated in Northern Europe and is one of the Nordic welfare states.
The public sector has a duty to take care of the health and well-being of
Finland’s population of approximately 5.6million. According to the
Constitution of Finland (1999/731), the public authorities guarantee adequate
social, health, and medical services for everyone. Thus, public sector is the
organizer and primary producer of the health and social services, and the ser-
vices are mainly nanced by the state. Public health and social services are
either free of charge for clients, or there is a reasonable client charge. However,
an upper limit for the charges per calendar year exists, and clients don’t have
to pay beyond that. Public services are supplemented by the private sector
actors and the third sector. Furthermore, employers need to arrange preventive
occupational health care of their employees, some provide also medical care.
Private health care services are mostly nanced by the patients themselves or
through their insurances. Public service providers may also purchase services
from the private providers [1, 2]. In 2020, most of the Registered Nurses
(RNs) in Finland worked in public services and were employed by the
182
municipalities (83%), while others worked in private services (15%) or as
entrepreneurs (0.85%) (Finnish Nurses Association).
Finland has several success stories in public health and has world-class
results in many areas. Despite this, severe challenges remain, including unequal
access to care and inequalities in life expectancy by gender and socioeconomic
status. In 2019, almost 5% of the Finnish population reported unmet medical
care needs due to nancial reasons, geographical barriers, or waiting times. As
in many countries, the density of physicians is much greater in the major cities,
compared to remote and sparsely populated regions, thus reinforcing dispari-
ties in access to care [3]. Expanded and advanced practice roles in nursing have
been one solution to cope with the shortage of the physicians. These include,
e.g., RNs’ consultations and appointments for acute and chronic health condi-
tions in primary and specialized health care settings [4]. As the Finnish popula-
tion is aging and there are high numbers of people with noncommunicable
diseases (NCDs) and disabilities, the demand for health and long-term care
systems will rise [3, 5]. At the same time, the birth rate is falling, and the
working-age population is declining. This will cause a decrease in tax revenue
which is the main source to fund the public health services [3].
A major reform for organizing public health care, social welfare, and rescue
services took place from the beginning of 2023 as the services were transferred
from municipalities and joint municipal authorities (n=309) to self-governing
well-being services counties (total of 21 counties and the City of Helsinki and
the Hospital District of Helsinki and Uusimaa). This change in service provision
arrangements aims to reduce inequalities, improve the quality and availability of
services, and contain expenditure growth. The services are locally accessible,
and in addition to health centers and other health service units, online services,
mobile services, and services provided at home are available. Health promotion
and disease prevention remain as the cornerstones of the services [2].
Read more:
1. Social and Health Services. Ministry of social affairs and health. https://
stm./en/social- and- health- services. Accessed 1 Feb 2023.
2. Health and social services reform. Ministry of Social Affairs and Health.
https://soteuudistus./en/frontpage. Accessed 1 Feb 2023.
3. State of Health in the EU, Finland, Country Health Prole 2021. OECD
and European Observatory on Health Systems and Policies. https://www.
oecd- ilibrary.org/social- issues- migration- health/nland- country- health-
prole- 2021_2e74e317- en;jsessionid=yXvcgIgw2YqreVuH1747uv03JF
axIqg2k8qgm8Fn.ip- 10- 240- 5- 97. Accessed 29 Oct 2022.
4. Strengthening health systems through nursing: Evidence from 14 European
countries. World Health Organization and European Observatory on
Health Systems and Policies, 2019. https://www.ncbi.nlm.nih.gov/books/
NBK545724/pdf/Bookshelf_NBK545724.pdf. Accessed 29 Oct 2022.
5. Finland: health system review. World Health Organization 2019. https://
apps.who.int/iris/handle/10665/327538. Accessed 29 Oct 2022.
A. Suutarla et al.
183
Background
The level of autonomous practice is traditionally high among Registered Nurses
(RNs) in Finland, particularly in primary care, perhaps more so than in many other
countries. RNs’ (including public health nurses and midwives) independent appoint-
ments are a well-established part of both the primary health care [1, 2] and special-
ized health care services [2]. However, further education, scope of practice, work
description, and the titles of the RNs working in these positions vary by organiza-
tions and units [2]. In primary health centers, RNs are in many cases the rst and
often also the only points of contact for the patients. In 2019, for patients who came
to the nurses’ primary health care outpatient acute care appointment, in almost half
of the cases the RN was able to provide care to the patient without the need to con-
sult the physician at all. In 28% of the cases the RN consulted the physician and in
22% of the cases the RN referred the patient to the physician ofce during the same
day [1]. This data counted all the RNs working in these primary health care services,
not only Nurse Practitioner professionals. In 2021 out of the primary health care
RN/physician outpatient visits, 51% of the visits were cared for by RNs, and 49%
by physicians [3].
One example of primary care autonomous practice in Finland is Public Health
Nurses (worth 240 ECTS1 credits education, bachelor’s degree, EQF2 level 6). They
have an autonomous role, e.g., in maternity and child health centers, in school health
and occupational health services, and an autonomous practice and roles in, e.g.,
health check-ups, health promotion, advice in health problems, and vaccinations
[4]. Midwives (worth 270 ECTS credits education, bachelor’s degree, EQF level 6)
have a signicant autonomous role, e.g., in childbirth care.
Compared to the other WHO European region countries, Finland is among the
countries having the highest proportion of RNs in relation to the population. On the
other hand, the proportion of physicians is lower than the WHO European region
average [5]. In a comparison of the Organization for Economic Co-operation and
Development (OECD) countries, Finland is ranked among the rst ones in terms of
how many RNs there are in relation to physicians [6]. Keeping this in mind, one can
well state that Finnish health and social services rely heavily on the extensive role
of the nursing workforce.
In 2020, there were 75,299 RNs in the workforce, including midwives, public
health nurses, and paramedic nurses (Finnish Nurses Association). The clinical
career pathway from a Registered Nurse to Advanced Practice Nurse has been
described, but not fully implemented [7]. Advanced Practice Nursing (APN) roles
1 The acronym ECTS means European Credit Transfer System (also known as the European Credit
Transfer and Accumulation System). In Finland, one ECTS credit is 27hours of student’s work. 60
ECTS credits are the equivalent of a full year of study or work.
2 The acronym EQF means European Qualication Framework. It includes eight reference levels
describing what a learner knows, understands, and is able to do (learning outcomes). Bachelor’s
level degree (Registered Nurse education) is at EQF 6 level, Master’s level degree at EQF level 7,
and Doctoral degree at EQF level 8.
The NP Role andPractice inFinland
184
emerged around 2000, and the rst Nurse Practitioner (NP) programs were initiated
in 2006 [8]. Legislation allowing nurse prescribing was initiated in 2010 [9]. Finland
has been ranked among the top OECD and EU countries with established NPs in
primary care (Maier etal. 2017), implying that Finnish NPs work at high levels of
advanced clinical practice, extensive task-shifting has occurred, and it is combined
with regulatory reforms leading to a considerably expanded practice level [10].
In 2016, the Finnish Nurses Association’s group of experts published a report
describing the current Advanced Practice Nursing (APN) state in Finland. The
report also gave a vision and recommendations for the future, introducing a model
for the clinical career path in nursing which included the roles of Registered Nurse,
Specialist Nurse, and Advanced Practice Nurse (covering separately the roles of
Nurse Practitioner and Clinical Nurse Specialist(CNS)) [11]. In 2021 the APN
expert group was again convened to evaluate the current state and to further clarify
and implement the APN roles, and these efforts are ongoing.
Nursing Education inFinland
The Finnish higher education system has a dual model and comprises Universities as
well as Universities of Applied Sciences (UASs), both having a distinctive own role.
Universities engage both in education and in research and have the right to award doc-
torates. UASs are multi-eld institutions of professional higher education. UASs engage
in applied research and development. Higher education is tuition free in Finland [12].
Nursing education takes place at UAS.The entry degree is a bachelor’s level
degree on EQF level 6, worth 210 ECTS and takes 3.5years. Nurse education in
Finland complies the European Union’s Directive 2005/36/EC, amended by
Directive 2013/55/EU [13]. Therefore, the requirements in Finland are similar to
those elsewhere in the European Union and other collaborating European countries.
Other bachelor’s level (EQF level 6) nursing degrees are Public Health Nurse (worth
240 ECTS, 4years), Paramedic Nurse (worth 240 ECTS, 4years), and Midwife
(worth 270 ECTS, 4.5years).
After bachelor’s degree education RNs have options to continue to take a mas-
ter’s degree education either at UAS (90 ECTS) or university (120 ECTS), as well
as a doctoral degree at the university. There are ve universities offering master’s
and doctoral degree studies in nursing science. Eleven UASs offer master’s level
education in clinical nursing. Also, specialist nurse education is available (most
often 30 ECTS); however, this education does not award a degree.
Regulation
Based on the Act on Health Care Professionals (559/1994) [9], RNs in Finland need
to apply for licensing from the central government agency, the Finnish National
Supervisory Authority for Welfare and Health (Valvira), which keeps the register of
health care personnel. Licensing and registration is granted to three categories of
A. Suutarla et al.
185
bachelor’s level (EQF level 6) nurses: general nurses (RNs), public health nurses,
and midwives. Under Finnish law, licensing is granted altogether to 17 health care
professions. The practice of these professions is restricted to licensed professionals
only. In addition, nurse’s limited right to prescribe (EQF level 7) is regulated in the
legislation, and Valvira registers the specic qualication and grants the limited
right to prescribe [9]. A requirement for the limited right to prescribe medicines is a
written assignment given by the physician in charge at the health center where the
nurse is employed. The right to prescribe is always connected to the place of
employment. The government has subsidized nurse prescriber education since 2019
[14]. No other RNs’ specialized or advanced roles are registered by Valvira, includ-
ing the NP and CNS.
Even though the Nurse Practitioner (NP) role is recognized in the Finnish health
services there are no ofcial nation-wide regulation or titles, which is one of the
primary challenges for the NP role development in Finland. For NP job descriptions
there are a variety of titles. The Finnish Nurses Association recommends the use of
the Finnish title (“asiantuntijasairaanhoitaja”) [11], but in reality, this title might be
awarded to RNs with varying education and job descriptions.
The nurse prescriber education was launched in 2011in accordance with govern-
ment degree [15]. The development of the national curriculum, which ensures uni-
form implementation, was conducted in coordination with the Ministry of Social
Affairs and Health.
Based on the law [9] only physicians and dentists can decide on the medical
examination, diagnosis, and appropriate medical treatment of a patient. In accor-
dance with his or her education, work experience and job description, a licensed
health care professional (including RNs) can start the treatment of a patient based
on the patient’s symptoms, the information available and the patient’s need for treat-
ment as assessed by the professional. Therefore, nurse prescribers don’t make diag-
nosis, but base their prescriptions and treatment on symptom assessment. In the case
of continued medication, a physician has made the diagnosis earlier [9].
However, the Finnish Health Care Professionals Act [9] does not otherwise
describe in detail the tasks that are under the responsibility of physicians, RNs or
other health care professionals. In fact, the act is quite broad in its nature as it states:
A licensed or authorised professional or a professional with a protected occupational title
is entitled to practise the profession in question and to use the related occupational title. …
This provision notwithstanding, licensed and authorised professionals and those with a
protected occupational title may however carry out each other’s tasks, in accordance with
their training, experience and professional skills and knowledge, when this is reasonable
with regard to the organisation of work and supply of health services, unless otherwise
prescribed in this Act or by decree.
In one viewpoint, this kind of broad letter of the law gives exibility to organiz-
ing the services patients need, enables the development of an appropriate division of
duties between the health care professionals, and offers RNs clinical career pros-
pects. On the other hand, especially if implemented in an uncontrolled manner,
task-shifting, or a new division of duties does not necessarily ofcially recognize
The NP Role andPractice inFinland
186
the RNs’ increasing and more demanding work description and responsibility.
Gradually, the RNs’ work description may sometimes grow more demanding with-
out adequate further ofcial or degree education, recognition, title, or the wage
according to the demands of the work. This might be one hindrance in developing
the licensed Advanced Practice Nursing roles.
Regarding the division of the duties, the employer is responsible for evaluating
and ensuring that the personnel have the education, professional qualications, expe-
rience and skills required, and that all the legal and other requirements are met. Also,
the health care professional needs to maintain and evaluate own professional skills
and inform the employer if they are not sufcient for the changing and new tasks
[16]. The Finnish Nurses Association states that the development of the division of
duties between the social and health care professionals must be controlled. With
respect to both patient safety and the legal protection of health care professionals,
sufcient continuing education and opportunities to consult other professionals must
be ensured. Wages must also be proportional to the demands of the work [11].
Advanced Practice Nursing inFinland
The characteristics of the Advanced Practice Nursing (APN) in Finland are shaped
by the education system and legislation on education, regulation, and practice. The
two APN roles, Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS), are
recognized in the Finnish social and health care services, although neither of the
roles is registered or regulated.
Nurse Practitioner
Nurse Practitioner (NP) education takes place in the Universities of Applied
Sciences (UASs). However, the contents of the degree programs still vary. The rst
university-based Nurse Practitioner master’s education program has just started
(Åbo Akademi).
The UAS Master’s Degree in Health Care, including the Advanced Practice
Nursing degree program, is a 2-year education worth 90 ECTS credits. A require-
ment of 2years clinical experience is an entry requirement. Most master’s degree
students study part-time while working, often in clinical practice. In principle, one
can continue to university for doctoral studies after taking a master’s degree educa-
tion at UAS.However, some departments of nursing science may require so-called
bridging studies or research methodology prior to applying to the doctoral programs.
The UASs have autonomy in their curriculum development as the NP role is not
licensed and therefore regulations on education do not exist. As a result, there have
been great differences among the programs during the more than 10years of imple-
mentation of the NP role. As guided by the International Council of Nurses, ICN
[17], core competencies and master’s level education must underpin the preparation
to advanced roles. To enhance the quality of the education and unify the core
A. Suutarla et al.
187
competencies guiding the curricula and its implementation, a national network of
NP teachers was established in 2020. An expert group representing 13 UASs started
to prepare a consensus document on the core competences for the UAS NP degree
programs. The consensus [18] was based on expert panel workshop, cross-mapping
of six international NP competence standards/descriptions. The core competencies
(Fig.1) were formed as a framework intended to guide the development of the
advanced practice education in Finland, to support the collaboration between the
UASs, and to provide a tool in planning ACP (Advanced Clinical Practitioner) edu-
cation as not all students are RNs, but also allied health professionals.
It is still noteworthy that UASs have strong autonomy and they are not obligated
to follow the framework developed by the expert panel. One legal hindrance is that
based on the law regarding master’s education at UASs, clinical practice is not
acknowledged as a part of education. Within some programs clinical skills are prac-
ticed, e.g., in clinical skill labs which are held at the UASs, but this varies. There is
no national data on the different models to fulll the education and the clinical
components of the curricula. Thus, the clinical competence evaluation is part of the
programs. Due to this vagueness and variations, it can be sometimes difcult for the
employers to utilize the graduating professionals to their full extent, and this is to
create confusion and frustration, both for the NPs and the employers.
The assignments and master’s thesis are completed primarily in one setting with
one preceptor (who can be an experienced RN or a physician, and in addition the
student has teacher support). The number of hours allocated for assignments varies
between courses and programs. The master’s thesis amounts to 30 ECTS credits.
Examples of the thesis topics include “Development of chronically ill patient’s self-
care” or “Development of NP role within the organization.” The assignments and
master’s thesis are done in collaboration with the organizations and are evaluated
and rated against learning goals (competence-based curricula). Currently, the
Clinical exper!se and direct
clinical care
Health Assessment and Diagnosis,
Direct clinical care
Research and service
development
Evidence based prac!ce, Research and
development
Pa!ent educa!on and staff
development
Counselling and developing working
community, Counselling and
developing counselling of
clients/pa!ents and their family
Professional leadership
Renewing leadership, Quality
improvement and effec!veness
Fig. 1 Core and subcompetencies of the Finnish NP programs [18]
The NP Role andPractice inFinland
188
process to further develop the clinical training is under development. This requires
not only close collaboration with the health care organizations but also regulatory
and government support, for instance establishing trainee positions within the health
care system.
The NP programs vary depending on whether the program is generic or has a
specic focus on a certain specialist eld, e.g., palliative care or mental health. Most
of the programs within a specic eld of nursing are delivered by a network in
which each UAS has the responsibility to provide general studies on applied research
and development, health care services, and leadership for their students. In the net-
work implementation, each of the network UAS produces at least one course on the
specic nursing eld for students (20–30 ECTS). The network model supports the
possibility to have more narrow specialist foci in a small country like Finland. There
is no national coordination or guidance on which clinical specialty the degree pro-
grams are offered.
Nurse prescribing is not a routine part of the NP program, since the prescribing
education is regulated with national curriculum, competence requirements, and
national qualifying exams. However, the completed nurse prescribing education can
be included through recognition of prior learning as part of the NP studies. In some
UASs, the NP students can study the theoretical parts of prescribing education.
However, not all UASs offering clinical master’s degree education offer prescribing
education. Again, nurse prescribing is already regulated and registered and can be a
function of RNs.
Currently, the universities have had limited interest to provide clinically ori-
ented NP programs, as the focus of the university master’s degree programs has
been geared toward research and leadership to prepare students for management,
leadership, research, and teaching roles. However, in 2021 Åbo Akademi
University launched the rst university-based NP program. This pilot program
also includes clinical training, but not prescribing. The education is worth 120
ECTS, and it contains master’s thesis and will lead to master’s degree in Clinical
Caring Science.
As the NP is not a licensed professional role, it is not possible to identify the
quantity of NPs in Finland. Both specialist nurses and NPs often have independent
appointments with patients and they work in direct clinical patient care. As a dis-
tinction to specialist nurses, the NPs often integrate consultation, research and
development tasks, and teaching. In some organizations NPs work as team leaders.
The Finnish NPs work both in primary health care services and in specialist care
services [11].
One could argue, that when compared to ICN guidelines [17] the RNs in Finland,
having the educational component of master’s degrees (UAS or University clinical
Master’s) as well as prescription rights currently possess the advanced clinical and
academic skills that are required for the full NP role. Unfortunately, there is no
national data on the numbers of the RNs who have both qualications, or of their
scope of practice, work description, or of their titles in the workforce. There are
regions and organizations that have fully utilized these professionals, but the situa-
tion for Finland in whole cannot be fully described due to the lack of data.
A. Suutarla et al.
189
Clinical Nurse Specialist
Clinical Nurse Specialists (CNSs) work mainly in the university hospital settings [7]
in a role focusing on evidence practice development, staff education, and organiza-
tion strategy development [11]. The main difference between the CNS and NP is that
CNSs function typically more in system level activities [7] while NPs function more
in direct patient care [11]. Currently there are no consistent education programs for
Clinical Nurse Specialists (CNS), even though two universities in Finland have a
clinical nursing science program (University of Turku and University of Oulu).
Typically, the CNS positions have a minimum requirement of master’s degree
with Nursing Science as the major. The master’s degree in Nursing Science can only
be completed in the university. At the moment 73% of the Finnish CNSs have a
university master’s degree, 18% PhD, and 9% UAS master’s degree [19].
Unlike the Nurse Practitioner, the title and role of Clinical Nurse Specialist is
quite well established and acknowledged, although, like the NP, not regulated or
registered. The rst CNS positions were established in the early 2000s within uni-
versity hospitals [6]. At the moment there are more than 120 RNs with this title in
the Finnish health care workforce. More recently, the rst CNS roles have also been
introduced in primary health care services [19].
Nurses’ Limited Prescription Rights
Prescription rights require at least 3years of work experience and 45 ECTS credits
post-bachelor education. The education is not a master’s degree; however it has
been ofcially set on the same EQF level 7 as are master’s level degrees [20]. The
education includes the clinical skills that can be seen as essential for the NP role
(compare, e.g., ICN Guidelines on Advanced Practice Nursing, 2020). It does not,
though, include the “academic” competencies of research, education, and leader-
ship, that can also be seen as essential for the NP role. Although nurse prescribing
is regulated, there are no uniform titles in the workforce for the nurse prescribers.
National curriculum created by a national network gives a common structure and
content. The competence domains and number of performance criteria in each
domain are presented in Fig.2. The competence requirements on prescribing are
equal to medical and pharmacy education in universities.
The study period for prescriptive rights is approximately 15months with 20–22
contact days. During contact days, there are hands-on clinical patient examination
practices with live patients and in simulation. Monthly modules are designed to con-
nect clinical physiology, medicine, and pharmacology, latest clinical guidelines,
patient examination, and clinical nursing. The e-learning environment contains over
60hours of online lectures on pharmacology and numerous different tests and
assignments for students’ self-directed learning. The employer must agree on a phy-
sician that supervises the clinical learning during the studies. Competency is ensured
in education through objective structured clinical examination (OSCE), pharmacol-
ogy exam, case logbook and a national qualifying exam.
The NP Role andPractice inFinland
190
Fig. 2 Competence
domains of Finnish nurse
prescriber education
As of February 2023, 774 RNs, midwives and public health nurses have passed
the education and 84 are now in the educational system. There are currently 691
RNs with limited rights to prescribe in the Valvira register. The nurse’s right to pre-
scribe is restricted with regard to the medical conditions, the list of drugs and to
services. The decree [21] sets the list of conditions and drugs both for initiation of
the medication in acute illnesses and for renewing the prescriptions in chronic dis-
eases. The principles applied when creating these limitations were that the medical
conditions would be common and there would be existing evidence-based medical
guideline to follow. The drugs allowed for a nurse prescriber are considered the
rst-line safe medications. Nurse prescribing is permitted in the outpatient services
that are offered in the public health service system. As the nurses that have been
educated to this role are highly experienced, we observe that retirement from this
role is quick and the push to administrative roles is greater than for RNs in general,
which means these prescribers do not stay in the workforce for a long term.
Most RNs with limited prescription rights (nurse prescribers) in Finland work in
primary health care services. The role of nurse prescriber was initially developed to
enhance the population’s access to health care services in rural areas where there
was a decit of physicians. At emergency departments and at primary health care
outpatient acute clinics nurse prescribers have independent appointments, with
patients, where they conduct clinical patient examinations and full anamnesis of
patients as well as initiate laboratory tests. For patients with infectious diseases,
e.g., with pharyngitis, urinary tract infection, conjunctivitis, or mastitis, nurse pre-
scribers are allowed to prescribe certain antibiotics according to Current Care
Guidelines described in the act concerning medical prescribing [21]. They also
advise patients in the care of upper respiratory infections and explain why antibiot-
ics are not always needed. No physician appointment or conrmation is needed for
the treatment decisions nor for the medications. If the nurse prescriber identies
symptoms or conditions that are not in their scope of practice, they refer the patient
to a physician.
A. Suutarla et al.
191
At primary care outpatient clinics in health centers, nurse prescribers treat acute
patient groups at their appointments as well as patients with noncommunicable dis-
eases. They can conduct follow-up appointments for primary hypertension, coro-
nary artery disease, angina pectoris chest pain, hyperlipidemia, asthma, and Type 2
diabetes, during which they can continue the dened medication, including warfarin
for chronic atrial brillation. In these examples, the physician has previously made
the diagnosis and a treatment plan with the patient. This treatment plan is electronic
and available also for the RN to review. In Finland all prescriptions of medication
are electronic. There are no paper prescriptions at all.
In primary health care, occupational health services, and in student health care,
both starting care in infectious diseases and continuing medication for noncommu-
nicable diseases is applied in nurse prescribing. In addition to these, nurse prescrib-
ers are tasked with contraception counselling and family planning clinics. They can
start the contraceptives for their patients/clients, as well as prescribe vaccinations.
In 2021 the services where nurse prescribers work was extended to cover home care
and polyclinics of specialized medical care.
One can analyze the distribution of nurses with prescriptive rights regionally in
Finland based on data provided by Valvira. In 2021, there were 709 rights per place
of employment. Surprisingly, there was one well-being service county in the capital
area with no nurse prescriber services at all. A very low availability of the service
(0.2–0.11 rights/1000 inhabitants) was recorded in Lapland as well as in many
counties with large cities. Five counties were recognized as leaders in developing
nurse prescriber services with the availability of 0.28 to 0.47 nurse prescriber rights
per 1000 inhabitants. Within the period of 10years, nurse prescriber services have
not developed equally in different areas of Finland. The slow development of the
nurse prescriber services in some counties may relate to the better availability of
physician services and to the presence of medical faculties in some large cities [22].
Laapio-Rapi [23] has identied the critical success factors of nurse prescribing
in Finland, including a clear job description, a high number of client visits, and
predetermined client groups visiting the right specialists from the multidisciplinary
team in primary health care. Nurse prescribing is successful in units where the role
of prescribers is clearly dened and differs from the role of other nurses, either
entirely or in part.
Vision fortheFuture
Finland is undergoing major social and health care reform. The key objective of the
reform is to improve the availability and quality of public health care services
throughout Finland, as well as to curb the growth of costs [24]. To reach the objec-
tives, it is time to promote and capitalize on the APN roles, together with varying
stakeholders. For the systematic clinical career path, there needs to be a clearer
The NP Role andPractice inFinland
192
system framework between education, health, and the regulatory system, and the
framework needs to reect the health policy goals and population health needs.
Finland is an aging society, and the increase of noncommunicable diseases
(NCDs) is a signicant challenge. Citizens in Finland would benet from having
more advanced level trained, highly skilled nursing professionals that ensure the
timely access to care and treatment, including the prevention and health promotion
components of care. A functional division of duties between RNs and physicians
allows both occupational groups to appropriately utilize their skills. It is essential to
enable and protect RNs to practice to the full scope of their education and training,
also on an advanced level. Finland is among the top advanced digital economies in
the EU (Digital Economy and Society Index 2021), and NPs can also have a key
role in providing and developing the expanding digital services.
In the future, it would be important to consider whether the nurses’ prescribing
right would be benecial to be included in the master’s degree NP education, if the
NP role was licensed and regulated. This would also require having a nationally
formalized NP curriculum and regulation which would increase the transparency of
practice, and in that sense, also improve patient safety and the population’s trust in
advanced roles [11].
Due to multiple reasons, Finland is suffering due to severe lack of nursing pro-
fessionals [25, 26], thus recruitment and retention are crucial questions for the ser-
vices. Systematic clinical career possibilities, including salary development as part
of the career development, could be one solution to increase the magnetism of nurs-
ing. To have enough APNs in the services would be benecial also for all the RNs
and the nursing profession, as the APNs advocate for and develop nursing as a
whole, e.g., give consultation and support the implementation of coherent, evidence-
based nursing practices [11]. Recently, the Ministry of Social Affairs and Health has
launched a cross-ministerial strategic program (2022–2023) to secure the adequacy
and availability of social and health care personnel, including a statement on con-
tinuous professional development and career paths as essential elements for recruit-
ment and retention. Thus, it remains to be seen if the strategic program will support
the development of the APN roles in Finland.
The Finnish Nurses Association is lobbying for a well-resourced position of a
Governmental Chief Nursing and Midwifery Ofcer (GCNMO) with a mandate and
power to regulate, control, monitor, and guide the eld of nursing and midwifery on
the national level [26]. To have such a strong national role could ease the regulation
of the APN in Finland in the future.
To illustrate the current state of the career path to become a Nurse Practitioner, a
case including an imaginary vision for the future is presented (Fig.3). The hopes for
the future in Finland are high, as long as we can build a strong national collabora-
tion with shared aims.
A. Suutarla et al.
193
Fig. 3 The imagined clinical career path of the Finnish RN Sara Finn in 2022 and in the future
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The Nurse Practitioner Role in Ireland
DanielaLehwaldt andEmilyB.Lockwood
Background
The Republic of Ireland is an island located in north-western Europe in the North
Atlantic Ocean, west of the island of Great Britain. Ireland has a public healthcare
system, run by the government-funded Health Service Executive (HSE), alongside
private care settings. The current Irish system is primarily a tax-nanced public
system but with signicant out-of-pocket spending, mainly in primary care, and
with supplementary health insurance for private hospital coverage, with a 45% rate
of public participation [1]. Another 14% comes from private health insurance, while
out-of-pocket expenditure makes up the remaining 12% [1].
Currently, there are around 78,000 nurses and midwives registered to practice
in Ireland [2]. Between those registered and on the pathway to registration, there
are over 650 Registered Advanced Nurse/Midwife Practitioners (anonymous,
email correspondence). The policy’s aim within the country is to have 2–3% of
the nursing and midwifery workforce practising as Advanced Nurse/Midwife
Practitioners, which would see the registration number increase to 750 approxi-
mately (Department of Health 2019, https://www.gov.ie/en/press- release/715a21-
new- policy- on- advanced- nursing- and- midwifery- practice- launched- by- mi/#).
The Report of the Commission on Nursing [3] provided for the most signicant
expansion of roles in the history of Irish nursing and midwifery [4–6]. There are two
main titles referring to the specic role of Advanced Nurse Practitioner (ANP) roles
or Advanced Midwife Practitioner (AMP) in Ireland. The title ANP in Ireland
D. Lehwaldt (*)
School of Nursing, Psychotherapy and Community Health, Dublin City University Chair ICN
NP, APN Network, Dublin, Ireland
e-mail: Daniela.lehwaldt@dcu.ie
E. B. Lockwood
Emergency Department, University Hospital Waterford, Cork, Ireland
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_14
198
describes what is internationally known as the Nurse Practitioner (NP) [7]. Other
advanced practice roles developed in Ireland are the Clinical Nurse Specialist (CNS)
and Clinical Midwife Specialist (CMS), which will not form part of the discussion
in this chapter.
The rst Advanced Nurse Practitioner (ANP) role in Ireland emerged in
1998in emergency nursing with a farsighted pioneer named Ms Valerie Small,
accredited as an ANP in 2002 [5]. The primary rationale for this role was to
respond to changing healthcare needs including nancial constraints, consumer
demands and the desire to retain experienced nurses with a clinical career path-
way [5]. Since then, many more roles were developed and accredited.
Professional Frameworks
The ANP role in Ireland has been established within solid governance frameworks
of accreditation led by the work of the National Council for the Professional
Development of Nursing and Midwifery (NCNM). The framework for the establish-
ment of ANP/AMP posts ([5], p.5) dened roles as follows:
cANPs/AMPs promote wellness, offer healthcare interventions and advocate
healthy lifestyle choices for patients/clients, their families and carers in a
wide variety of settings in collaboration with other healthcare professionals,
according to agreed scope of practice guidelines. They utilise advanced
clinical nursing/midwifery knowledge and critical thinking skills to
independently provide optimum patient/client care through caseload
management of acute and/or chronic illness. Advanced nursing/midwifery
practice is grounded in the theory and practice of nursing/midwifery and
incorporates nursing/midwifery and other related research, management
and leadership theories and skills in order to encourage a collegiate,
multidisciplinary approach to quality patient/client care.
cAdvanced nursing and midwifery practice is carried out by autonomous,
experienced practitioners who are competent, accountable and
responsible for their own practice. They are highly experienced in
clinical practice and are educated to master’s degree level (or higher).
The postgraduate programme must be in nursing/midwifery or an area
which is highly relevant to the specialist field of practice (educational
preparation must include substantial clinical modular component(s)
pertaining to the relevant area of specialist practice).
cANP/AMP roles are developed in response to patient/client need and
healthcare service requirements at local, national and international
levels. ANPs/AMPs must have a vision of areas of nursing/midwifery
practice that can be developed beyond the current scope of nursing/
midwifery practice and a commitment to the development of these areas
([5], p.5).
D. Lehwaldt and E. B. Lockwood
199
The National Council for the Professional Development of Nursing and Midwifery
([5], p.7) identied four core concepts for Advanced Nursing Practice in Ireland:
cAutonomy in Clinical Practice An autonomous ANP/AMP is
accountable and responsible for advanced levels of decision-making,
which occur through management of specific patient/client caseload.
ANPs/AMPs may conduct comprehensive health assessment and
demonstrate expert skill in the clinical diagnosis and treatment of acute
and/or chronic illness from within a collaboratively agreed scope of
practice framework alongside other healthcare professionals. The
crucial factor in determining advanced nursing/midwifery practice,
however, is the level of decision-making and responsibility rather than
the nature or difficulty of the task undertaken by the practitioner.
Nursing or midwifery knowledge and experience should continuously
inform the ANP’s/AMP’s decision-making, even though some parts of
the role may overlap the medical or other healthcare professional role.
Expert Practice
Expert practitioners demonstrate practical and theoretical knowledge
and critical thinking skills that are acknowledged by their peers as
exemplary. They also demonstrate the ability to articulate and rationalise
the concept of advanced practice. Education must be at master’s degree
level (or higher) in a programme relevant to the area of specialist practice
and which encompasses a major clinical component. This postgraduate
education will maximise pre- and post-registration nursing/midwifery
curricula to enable the ANP/AMP to assimilate a wide range of
knowledge and understanding, which is applied to clinical practice.
Professional and Clinical Leadership
ANPs/AMPs are pioneers and clinical leaders in that they may
initiate and implement changes in healthcare service in response to
patient/client need and service demand. They must have a vision of
areas of nursing/midwifery practice that can be developed beyond the
current scope of nursing/midwifery practice and a commitment to the
development of these areas. They provide new and additional health
services to many communities in collaboration with other healthcare
professionals to meet a growing need that is identified both locally and
nationally by healthcare management and governmental organisations.
ANPs/AMPs participate in educating nursing/midwifery staff, and
other healthcare professionals through role-modelling, mentoring,
sharing and facilitating the exchange of knowledge in the classroom,
the clinical area and the wider community.
Research
ANPs/AMPs are required to initiate and co-ordinate nursing/
midwifery audit and research. They identify and integrate nursing/
midwifery research in areas of the healthcare environment that can
incorporate best evidence-based practice to meet patient/client and
service need. They are required to carry out nursing/midwifery research
The Nurse Practitioner Role in Ireland
200
which contributes to quality patient/client care and which advances
nursing/midwifery and health policy development, implementation and
evaluation. They demonstrate accountability by initiating and
participating in audit of their practice. The application of evidence-
based practice, audit and research will inform and evaluate practice and
thus contribute to the professional body of nursing/midwifery knowledge
both nationally and internationally ([5], p.7).
Following the Nursing and Midwifery Board of Ireland (NMBI) taking over the
registration of NPs in Ireland. The original four concepts were replaced with NP
domains under their required competency development. In 2017, the NMBI pub-
lished the Advanced Practice (Nursing) Standards and Requirements [8], which
forms the national education framework for NPs in Ireland.
These requirements set out the following competencies and domains: maintain-
ing professional values and conduct of the Advanced Nurse Practitioner; clinical
decision-making skills, knowledge and cognitive competencies. Communication,
interpersonal, management, team, leadership and professional scholarship compe-
tencies [8]. Please see Table1 which briey explains the domains of NP in Ireland
as follows:
Table 1 Nurse Practitioner competency domains Ireland (based on NMBI)
Domain 1: Professional values and conduct as an NP
The NP must demonstrate accountability and responsibility for professional practice and, as
lead healthcare professional, articulate safe boundaries and engage in timely referral and
collaboration for those areas outside his/her scope of practice, experience and competence. The
NP demonstrates leadership to support the well-being and health of those with acute and
chronic disorders, disability, distress and life-limiting conditions; and articulate and promote
the NP role in clinical, political and professional contexts [5, 8]
Domain 2: Clinical decision-making competencies
The level of clinical decision-making competencies includes a comprehensive, holistic health
assessment, using evidence-based frameworks to determine a diagnosis and inform clinical
autonomy, and utilising diagnostic investigations to inform clinical decision-making and
display comprehensive knowledge of therapeutic interventions, including pharmacological and
non-pharmacological advanced nursing interventions [5, 8]
Domain 3: Knowledge and cognitive competencies
The NP provides exemplary leadership in the translation of new knowledge into clinical
practice. Knowledge and cognitive competencies are based on formal education and extensive
clinical experience, ongoing reection, clinical supervision, and engagement in continuous
professional development. He/she educates others using an advanced expert knowledge base.
The NP demonstrates a vision for advanced practice nursing based on a competent expert
knowledge base that is developed through research, critical thinking and experiential learning
[8]
Domain 4: Communication and interpersonal competencies
The NP maintains effective communication with the healthcare team through sharing of
information in accordance with legal, professional and regulatory requirements [8]. The NP is
expected to facilitate clinical supervision and mentorship and utilise information technology by
legislative and organisational policies [8, 9]. The management and team competencies require
the NP to manage risk for those who access the service through collaborative risk assessments
and promote a safe environment
D. Lehwaldt and E. B. Lockwood
201
Domain 5: Management and team competencies
The NP promotes a quality care culture by proactively seeking feedback from persons receiving
care, families and staff on their experiences and suggestions for improvement. The NP
implements practice changes using negotiation and consensus building, in collaboration with
the multidisciplinary team (MDT) and persons receiving care
Domain 6: Leadership and professional scholarship competencies
Within this domain, the NP demonstrates clinical leadership in the design and evaluation of
services, engages in health policy development, implementation and evaluation. The NP
identies gaps in the provision of care and services pertaining to his/her area of advanced
practice and applies the best available evidence. He/she leads in managing and implementing
change [8]
Table 1 (continued)
Registration/Regulation
The ANP/AMP in Ireland is title protected and must be registered with the Nursing
and Midwifery Board of Ireland (NMBI) [8]. The following criteria apply for regis-
tration as an ANP/AMP with NMBI.
In order to register, the applicant must:
• be a registered nurse or midwife with NMBI;
• be registered in the Prescribers division.
1. Hold a master’s degree (or higher) in nursing/midwifery or a master’s degree
which is relevant, or applicable, to the advanced eld of practice. The programme
must be at Level 9 (i.e. master’s level) on the National Framework of Qualications
(Quality and Qualications Ireland), or equivalent. Educational preparation
must include at least three modular components pertaining to the relevant area of
advanced nursing/midwifery specialised area of practice, in addition to clinical
practicum.
• In recognition of services that span several patient/client groups and/or division(s)
of the Register, provide evidence of validated competencies relevant to the con-
text of practice.
https://www.nmbi.ie/Registration/Add- New- Division/Advanced-
Practitioners/Registering- as- ANP- AMP
National Education Framework
In 2017, the Nursing and Midwifery Board of Ireland (NMBI) published the
Advanced Practice (Nursing) Standards and Requirements, which set out the
national accreditation guidelines and educational standards for ANPs. It outlines the
standards and requirements for the approval of Higher Education Institutions, asso-
ciated Healthcare Providers and education programmes that lead to registration as
The Nurse Practitioner Role in Ireland
202
an Advanced Nurse Practitioner. https://www.nmbi.ie/NMBI/media/NMBI/
Advanced- Practice- Nursing- Standards- and- Requirements- 2017.pdf?ext=.pdf
Currently there are seven approved Advanced Nursing and Midwifery pro-
grammes available in the country ([2] https://www.nmbi.ie/Registration/Add- New-
Division/Advanced- Practitioners/Registering- as- ANP- AMP). Programmes are
generally provided on a part-time basis and run over a 2-year period. Advanced
Nurse/Midwife Practitioners in Ireland are registered by their specialised area of
practice, unlike in other countries whereby registration is in a more generic division
such as, for example, family nurse practitioner, nurse anaesthetist, etc. The ANP/
AMP proles published in 2010 and 2008 retrospectively showcase the various spe-
cialist areas where advanced roles have developed in Ireland.
The NMBI has also recognised the operational and strategic role and responsibil-
ity of the ANP in Ireland in the Advanced Practice (Nursing) Standards and
Requirements [10]. The patient population commonly identies ANP practice in
primary or acute care settings. The main goal in healthcare both globally and in
Ireland has been articulated as efciency, effectiveness, sustainable operational
governance, workforce planning and reduction in patient waiting times [6, 11, 12].
The reduction in medical stafng necessitated a transformation in healthcare and an
opportunity for the nursing profession to expand in roles such as the ANP, which
would impact the healthcare targets mentioned above [13, 14].
An evaluation of roles, known across Ireland as the SCAPE Project, refers to the
examination of ANPs’/AMPs’ roles and their clinical outcomes achieved. The
national study involved the use of an extensive variety of quantitative and qualitative
research methods and data collection tools [15]. The study demonstrated that patient
care provided by ANPs/AMPs improved patient morbidity, promoted continuity of
care and was cost-neutral. The main improvements found (strong and very strong
evidence) in patient outcomes were summarised in a later report on key perfor-
mance indicators [15]:
cReduced morbidity
• Decreased waiting times
• Earlier access to care
• Decreased re-admission rates
• Increased patient/client throughput
• Increased evidence-based practice
• Increased use of clinical guidelines by the multidisciplinary team
• Development of guidelines for local, regional and national distribution
• Increased continuity of care
• Increased patient/client satisfaction
• Increased communication with patients/clients and families
• Promotion of self-management among patients/clients
• Working to expand and develop scope of practice to include more complex care
provision
• High levels of job satisfaction
• Signicant multidisciplinary support for role
D. Lehwaldt and E. B. Lockwood
203
• Provision of clinical and professional leadership
• Audit and research conducted
• Overall, no additional cost for ANP service (staff costs and activity levels were
matched for ANP and non-ANP services. ANP services had decreased costs for
emergency department minor injuries and sexual health).
cSCAPE report http://www.tara.tcd.ie/handle/2262/68341
cKPI’s https://www.pna.ie/images/ncnm/KPI%20Discussion%20
Paper%203.pdf
Policy Directions
Due to the success of ANP development in Ireland over the last 22years, the
Department of Health (DoH) [6] launched the ‘ANP capacity-building strategy’ to
increase the capacity of ANPs in all areas of healthcare to maximise the nursing and
midwifery response to healthcare issues. The policy on the development of graduate
to advanced nursing and midwifery practice (2016) developed a new target of 2% of
advanced practitioners in nursing/midwifery workforce to create an initial criti-
cal mass.
Additionally, the ‘Sláintecare Action Plan’ [6] identied the ANP as a solution to
delivering care closest to the patient’s home, with the governance to do so [6, 12]. A
recent evaluation of ANP candidates in Ireland was undertaken to review the impact
and implementation of these roles, ndings recommended and performance to
improve patient access to services [16]. Collaborative Practice Agreements (CPA)
attached to a physician were removed from a requirement of ANP registration in an
attempt to limit constraints to ANP clinical autonomy [8]. However, the Ofce of
the Nursing and Midwifery Services Director (ONMSD) [16] evaluation reported
that Collaborative Practice Agreements have remained in organisations, which
attaches the ANPs scope of practice and prescribing rights to a physician’s and other
health professional’s operational decision-making [16].
Historically, an NP’s Collaborative Practice Agreement (CPA) was attached to
the physician’s registration, which has been a contentious issue, especially if CPAs
were viewed as constraining to NP clinical autonomy [17, 18]. Practice Standards
and Guidelines for Nurses and Midwives with Prescriptive Authority in Ireland [19]
were integrated into the removal of CPA attachment to a physician’s registration
[19]. The Board of the NMBI approved removing CPAs in 2017 as a requirement
for nurses’ and midwives’ registration and authority to prescribe. The clinical gov-
ernance for prescribing medicinal products is now determined by the local health
service provider’s medicinal product prescribing policy, procedures, protocols or
guidelines.
The registered nurse prescriber must prescribe within their scope of practice and
continue demonstrating competency while fullling their role [8]. The registered
nurse or midwife prescriber must also continue to audit their prescribing practice.
The Director of Nursing/Midwifery/Public Health Nursing/Services or their
The Nurse Practitioner Role in Ireland
204
designated person must have overall responsibility and authority for the governance
of registered nurse and midwife prescribing to ensure due diligence in their health
service provider [8, 16].
However, due to issues of control over NP practice, some organisations have
continued to assert CPA requirements, which remains a contentious issue [16, 17].
Conversely, NPs, by law, are not required to have a CPA which attaches the NP
scope of practice and prescribing rights to a physician’s and other health profes-
sional’s operational decision-making [8, 16, 18].
The World Health Organisation (WHO) marked the year 2020 as the ‘Year of the
Nurse and Midwife’. Little did the world realise the catastrophic impact that a pan-
demic was about to bring (WHO 2020). ANPs have proven themselves to be valu-
able, frontline decision-makers who will ‘step up’ and play their part in dealing with
COVID-19 and many other diverse healthcare challenges. However, this requires
full utilisation of ANPs clinical autonomy in healthcare and reports of underutilisa-
tion of ANP clinical autonomy have been evidenced in healthcare literature [20–22].
The ONMSD reported recently that only a third of the sample ANP candidates in
the evaluation study delivered complete levels of ANP clinical autonomy, speci-
cally in discharge and referral to other specialists [16].
In Ireland, studies such as Begley etal. [15], Blancheld and O’Connor [23] and
Ryder etal. [22] have demonstrated the added value of NPs, particularly concerning
improved healthcare indicators, improved key performance indicators (KPI) and
high levels of clinical and operational leadership to improve patient outcomes and
service need. Lockwood [17] reported high levels of clinical autonomy regarding
independent prescribing, diagnosis and completing full episodes of care and inde-
pendent admission and discharges without needing a physician [17].
NPs have shown to improve communication within the multidisciplinary team
(MDT), improving accessibility of healthcare services, cost improvements, devel-
oping innovative practices, reducing waiting times and improving patients pathways
[15, 16, 22, 23]. However, Lockwood [17] cautioned that NPs require time to
develop their autonomous practice.
Clinical Autonomy - the everyday life of a Nurse Practitioner. One example of
clinical autonomy is that Nurse Practitioners complete full episodes of care includ-
ing assessment, diagnosis, and treatment of patients without the presence of a medi-
cal colleague. This means that the Nurse Practitioner, following extensive supervised
practical training and master’s level education, has to become fully autonomous in
history taking, physical examination, ordering and interpreting diagnostic tests, and
in processing all of this information to arrive at a medical diagnosis. Nurse
Practitioners take a holistic approach; apart from the medical diagnosis they may
also identify socioeconomic, domestic and spiritual (and other) needs. The NP
needs to become fully autonomous in managing their patient caseload including
independent prescribing of pharmaceutical and non-pharmaceutical items. They
lead their patients and relatives competently through the treatment plan, educate
them as they go along about their condition and treatments, and they manage their
condition, whilst constantly interacting with services and allied healthcare
D. Lehwaldt and E. B. Lockwood
205
professionals for referrals and consults. They use the best available research evi-
dence and clinical protocols to ensure high quality care. In order to do this, they
need to be independently appraising research ndings and apply them to their set-
ting. They need to be crucially aware of their own levels of competences and their
expertise, and they need to know when to ask for assistance from a superior e.g. the
medical consultant. Whilst clinical autonomy goes way beyond that of any other
clinical nurse, Nurse Practitioners practice within their scope of practice and code
of conduct. This example is merely a snapshot of the autonomous role that Nurse
Practitioners take on in their direct clinical practice. In addition to their direct clini-
cal practice, Nurse Practitioners are leaders, educators in the classroom and at the
bedside, advocates, national and international networkers.
Conclusion
NPs in Ireland have been driving healthcare provision for the last 22years, with
many roles emerging in acute and primary settings. They have been shown to be
benecial to patients, services and care pathways. Ireland has developed the NP role
within solid professional, governance and education frameworks. Core domains of
practice and competencies are clearly dened and the role is a title protected through
registration with the NMBI.The registration of NP is a critical requirement in deter-
mining the full utilisation of the role in healthcare and reducing constraints to prac-
tice. Current healthcare policy requires NPs to impact and improve patient outcomes
and drive quality patient care. There are some obstacles and hurdles to overcome,
but overall the role has proven itself and is here to stay!
References
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review, 2018. https://www.hia.ie/sites/default/les/.
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3. Government of Ireland. Report of the commission on nursing: a blueprint for the future. Dublin:
Stationary Ofce; 1998. p.1–160. https://www.lenus.ie/bitstream/handle/10147/627027/
Report- of- The- Commision- on- Nursing.pdf.
4. Lockwood EB, Fealy GM.Nurse prescribing as an aspect of future role expansion: the views
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p.1–26.
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Development) Health Working Papers, No 54. Paris: OECD Publishing; 2010. https://doi.org/1
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D. Lehwaldt and E. B. Lockwood
207
Nurse Practitioner Development in
German-speaking Countries: Germany,
Austria, andSwitzerland
ElkeKeinath, AndreasDirksen, DanielaLehwaldt,
ManelaGlarcher, RolandEssl-Maurer, Christophvon Dach,
ChristianEissler, andMayaZumstein-Shaha
Introduction
Nurse Practitioner (NP) developments are a global phenomenon and they do include
German-speaking countries. Health care systems in German speaking counties such
as Germany, Austria and Switzerland have similar settings including community
care, outpatient care, inpatient hospital-based care and rehabilitation facilities [1],
E. Keinath · A. Dirksen
University Hospital Darmstadt, Darmstadt, Germany
e-mail: elke.keinath@mail.klinikum-darmstadt.de;
andreas.dirksen@mail.klinikum-darmstadt.de
D. Lehwaldt (*)
School of Nursing, Psychotherapy and Community Health, Dublin City University,
Dublin, Ireland
e-mail: Daniela.lehwaldt@dcu.ie
M. Glarcher
Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
R. Essl-Maurer
University Hospital, Salzburg, Austria
C. von Dach
Department of Health, Bern University of Applied Sciences, Bern, Switzerland
Solthurner Spitäler AG, Solothurn, Switzerland
Queen Margaret University Edinburgh, Musselburgh, UK
C. Eissler
Department of Health, Bern University of Applied Sciences, Bern, Switzerland
M. Zumstein-Shaha
Department of Health, Bern University of Applied Sciences, Bern, Switzerland
Faculty of Health, Department of Nursing, University of Witten/Herdecke, Witten, Germany
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_15
208
all of which are suitable for the development of advanced nursing. The main differ-
ence is that nurse education can be at various levels from mainly apprenticeship
training (e.g. Germany) to more academic (e.g. Switzerland). Without some of the
crucial regulatory aspects to sustainably develop advanced nursing, roles are overall
slowly implemented and the process is cumbersome. The following text describes
advanced nursing historical backgrounds, contexts and NP developments in
Germany, Austria and Switzerland. While there are some similar features, each of
the countries has specic aspects supporting or hindering NP developments and
these are explored and compared in this chapter.
The context of Nurse Practitioners in Germany
As mentioned in previous books of this series [2, 3], the introduction of Advanced
Practice Nursing (APN) roles in Germany commenced in the early 2000s and it has,
so far, mainly taken place in hospitals. In 2007, the “Sachverständigenrat zur
Begutachtung der Entwicklung im Gesundheitswesen (SVR)” recommended the
implementation of Advanced Nursing Practice (ANP) as an important aspect for
future developments within the German health care service [4].
Since then, Advanced Practice Nursing (APN) roles have been implemented,
albeit slowly. Considering the demographic and epidemiological challenges
Germany faces, there is an increasing need for prevention and health promotion to
reduce the impact of non-communicable diseases (NCDs) such as cancer, cardio-
vascular and chronic respiratory diseases and diabetes [5] have on the health care
service. The number of (elderly) patients requiring treatment is growing and the
severity of the disease or multimorbidity is increasing. This rising number of people
with chronic diseases contributes to the existing and increasing shortage of general
practitioners [6].
Based on paragraphs within the laws relating to the nursing professions and the
social code (§ 14 Pegeberufegesetz, § 63 Abs. 3c SGB V sowie § 64d SGB V),
German federal states are obliged from 1 January 2023 to carry out mandatory pilot
projects regarding the transfer of medical activities to qualied nurses. Currently,
these pilot projects are mainly contained to the management of patients with chronic
diseases such as diabetes, chronic wounds, dementia, arterial hypertension, pain,
nutrition, but also tracheostoma, acute and chronic respiratory conditions
(Bundesinstitut für Berufsbildung [7]).
Role Distinction
Considering the distinction between Clinical Nurse Specialist (CNS) and Nurse
Practitioner (NP) on the continuum of APN roles (ICN 2020a, p.24) the vast
majority of APNs currently practising in Germany are considered to be CNSs. The
role of NPs have been discussed as a possible solution for the lack of medical staff
in rural areas [8, 9]. However, the NP role is not about replacing doctors or
E. Keinath et al.
209
task-shifting; it is rather about autonomous practice with the responsibility for
complete episodes of care, from the initial contact to the end of the (care) episode
(ICN 2020). The role of Physician Assistant (PA) is relatively new and novel in
Germany. PAs are educated to obtain a range of medical knowledge and skills,
which opened up new perspectives for physicians and health care institutions in
terms of delegating medical tasks [10]. The nursing association Deutscher
Berufsverband für Pegeberufe (DBfK) positioned itself, saying that physician
assistants stand in competition to APN roles and are not viewed as a role for nurs-
ing ([11], p.1).
A nationwide or state-based registration as an APN/NP is currently not available
in Germany. Even registration as a qualied nurse is currently only possible in one
of 16 states in Germany, as nursing boards are only beginning to form in Germany.
Generally, nurse registration is voluntary and autonomous practice is not speci-
cally recognised in German law. Nurse education in Germany is mainly at appren-
ticeship level [12]. However there are bachelor’s degree programmes and master’s
level programmes available for advanced nurses [13].
The German Network ‘Deutschen Netzwerk APN & ANP g.e.V. (DNAPN)’
facilitates networking amongst advanced nurses in Germany. They run regular
workshops and APN and ANP congresses. Members are active in various working
groups related to regions and specialties. They share their knowledge and expertise,
and they publish together. One example is this chapter, which was written by mem-
bers of the AFG International, one of the working groups of DNAPN.
NP Research Developments inPrimary Health Care
While advanced nursing developments have traditionally focused more on CNS and
on hospital-based settings, it is acknowledged that research may assist in developing
NP roles within the primary health care setting (PHC) in Germany ([14], p.31; [15]).
A previous project looked at how acute referrals from nursing homes to hospitals
can be reduced by changing service provision in nursing homes. While the introduc-
tion of NP roles is not specically part of the study, the provisions such as additional
medical options as well as regular case conferences leading to specic, targeted
cooperation between the stakeholders (nursing, medicine, pharmacies, hospitals)
provided strong hints that an expanded nursing role may be central to reducing
acute referrals from nursing homes [16].
Over the last two to three years, there have been more specic studies regarding
APNs/NPs in PHC.One such project is called “FAMOUS” (Fallbezogene
Versorgung Multimorbider Patienten und Patientinnen in der Hausarztpraxis durch
Advanced Practice Nurses). This title can be translated into the following: “Case-
related care of multimorbid patients in general practice by Advanced Practice
Nurses.” “FAMOUS” is the rst study, in which APNs, after project-specic educa-
tion and preparation, are based in General Practitioner surgeries. They carry out an
in-depth, person- centred assessment, on which basis they develop individualised
treatment plans, which they implement and evaluate in consultation with the family
Nurse Practitioner Development in German-speaking Countries: Germany, Austria...
210
doctor and, if necessary, continuously adjust. The study is currently ongoing and
will be evaluated using a mix-method approach (Katholische Hochschule
Mainz [17]).
There are efforts by the Rhineland-Palatinate’s government to introduce nurses
with additional education so that they can perform preventative home visits in the
community. The main aim is to offer independent living to people over the age of
80years. NPs may assess, diagnose and advice on and improve elderly’s living
conditions, which will be strengthened and stabilised through the nurse practicing
autonomously at an advanced level. They may support social participation of elderly
people, and the need for hospital-based care may be avoided or delayed through
targeted NP interventions. The project commenced in 2015 across nine regions and
by 2021, there were 43 nurses working in this advanced community-based role
entitled “Gemeindeschwester plus.” (Ministerium für Arbeit, Soziales,
Transformation und Digitalisierung [18, 19]).
Until recently, the role that advanced nurses can play has not been fully realised
within the German health care service, nor has it been supported much politically.
Therefore, it can be seen as a success that in their coalition agreement for the com-
ing years 2021–2025 the government plans to introduce the new role of Community
Health Nurses (CHNs) for Germany as part of their aim to strengthen the PHC, cre-
ate PHC-centres and provide improved, low-threshold health care in disadvantaged
communities and districts.
Community Health Nursing is mentioned as an example how nurses can “sup-
plement professional care with medical activities” (ebd, p.64). The coalition
agreement only speaks about CHNs, and other nursing proles such as advanced
CHN, CNS or NP are not specically mentioned. Legally the Community Health
Nurse is a specialisation of a nurse, not a new occupational prole, and laws
relating to nurses are applicable to CHNs as well [20]. The Agnes Karl Society
for Health Education and Nursing Research, as part of the German Nurses
Association, (DBfK) published a brochure in September 2022 outlining tasks
and practice proles for Community Health Nurses along possible practice elds
such as PHC-centres, municipal or public health services as well as part of out-
patient care [21].
There are great expectations connected with CHN and the impact its introduction
will have on all areas of nursing: (a) because of the expansion of nursing competen-
cies (b) the needed, but yet to be installed, payment rights and (c) the required
master’s level education related to CHN [22]. However, given the growing resis-
tance of physicians towards the CHN role [23] a signicant amount of leadership
will be required from within nursing as well as from each APN in these novel roles
for Germany to show the possible impact [24].
The NP Role inAustria
ManelaGlarcher and RolandEssl-Maurer
E. Keinath et al.
211
History ofAPN inAustrian Health Care System
As in Germany and internationally, the complexity of the health care system, an
increase in chronic illnesses, demographic changes, and the associated rising costs
of health care provision are presenting all those working in the health care sector
with major challenges in Austria. The health care system is characterised by high
expenditure, especially on hospital inpatient care, with the third highest per capita
health care expenditure in the EU in 2019. A comparison of OECD countries dem-
onstrates that 40% of all deaths in Austria in 2019 were due to unhealthy lifestyles
and behavioural risk factors such as dietary risks, low physical activity, increased
alcohol intake and tobacco consumption. The number of physicians within the
country generally is comparatively high, but the ratio to general practitioners is low.
The average age of general practitioners is over 50years. Around 60% of them are
going to reach retirement age by 2025, which will cause a considerable decrease in
the number of medical staff [25].
These data illustrate that in the future, a reduced number of medical staff will be
available to care for an increased number of chronically ill patients. The care of
people with chronic diseases but also the prevention and early detection of diseases
as well as measures to promote health literacy in the Austrian population are thus
increasingly becoming the focus of nurses with advanced knowledge and skills
[26]. Considering the global trends, it becomes clear that in countries with a low
density of general practitioners, primary health care has been expanded much more
rapidly and APNs have also been integrated much more easily as a regular part of
professional health care workforce [27]. Advanced roles in nursing are a possible
solution to face these major changes.
Nevertheless, this development has not yet systematically emerged in Austria.
Reasons for this might include a late start of academisation, as until 2016 most
nurses were trained in hospital-based nursing schools in a three-year diploma course
[28], as well as missing nursing regulatory bodies and a strong focus on a physician-
centred health care system. Consequently, no concerted attempt occurred to transfer
nursing education to the tertiary sector.
Since 2016, Austria is characterised by a dual-nurse education system. Students
have the choice to either undertake a bachelor’s degree in nursing at a University of
Applied Sciences (180 ECTS credits—European Credit Transfer and Accumulation
System) or train in nursing at a hospital-based nursing school. However, training
programmes provided by hospital-based nursing schools will fade out by 2023.
The legal framework for nursing professionals in Austria is provided by the
Health Care and Nursing Act [29], which denes three groups of nursing
professionals:
• the registered nurse in general care (Diplomierter Gesundheits- und
Krankenpeger / Diplomierte Gesundheits- und Krankenpegerin (DGKP)
4600h of training),
• the specialised nurse assistant (Pegefachassistenz (PFA) 3600h of training), and
• the nurse assistant (Pegeassistenz (PA) 1600h of training).
Nurse Practitioner Development in German-speaking Countries: Germany, Austria...
212
Further professional qualications based on master’s programmes in Nursing
Science or Advanced Practice Nursing are not reected and regulated by law.
In general, master’s programmes usually require 90 to 120 ECTS credits and end
with the graduation after four semesters (or two years). Admission to the programme
is only possible with a bachelor’s degree or an equivalent and relevant degree pro-
gramme [30].
As of 2022, 11 universities of applied sciences in Austria currently offer a bach-
elor’s or master’s programme and four universities allowed to introduce doctoral
programmes in nursing.
Master’s programmes cover all areas from nursing pedagogy, nursing manage-
ment, advanced nursing practice to nursing science [31]. Master’s programmes in
Nursing Science primarily provide a broad understanding of nursing science, scien-
tic theories and research skills. Depending on the educational institution, further
focal points in the programme vary according to institute-related research activity.
Master’s programmes for Advanced Nursing Practice serve to provide in-depth
nursing and scientic professional training in order to qualify for nursing practice in
complex and special health care environments that require the application of scien-
tic knowledge and methods. Graduates work as clinical experts for evidence-based
and high-quality nursing care in all areas of acute inpatient, day-care or outpatient
nursing as well as in inpatient long-term care.
The master’s programmes qualify students for subsequent doctoral programmes.
The introduction of mandatory registration for the nursing profession in 2019
was also signicant for the professionalisation of nursing in Austria as it will allow
for even more targeted nursing training planning. However, no qualication levels
are currently mandatory and thus no APN levels are currently being recorded.
Despite this difcult situation for developments in nursing, a group of experts
from Germany, Austria and Switzerland started their work to promote advanced
nursing roles. The rst approach was achieved in 2013 with a position paper of the
German-speaking nursing associations Deutscher Berufsverband für Pegeberufe
(DBfK), Österreichischer Gesundheits- und Krankenpegeverband (ÖGKV), and
Swiss Nurses’ Association (SBK), which denes APNs as nursing experts who have
acquired expertise, decision-making skills and extended clinical practice for com-
plex situations. Furthermore, it was stated that a master’s degree is a prerequisite for
this designation [32]. Throughout their specialization these nurses are able to care
and support persons with specic health problems and their relatives in complex
situations [33]. Nevertheless, it also becomes evident that further differentiation of
the APN roles ‘Clinical Nurse Specialist’ (CNS) and ‘Nurse Practitioner’ (NP), as
is common internationally and also indicated by current guidelines (International
Council of Nurses (ICN), 2020) has not yet taken place in Austria.
Current State ofAPN inAustrian Health Care System
The rst foundations for APN development have been established and education
and training facilities are in place, although there is no legal regulation concerning
E. Keinath et al.
213
the training of APNs. Advanced Nursing Practice programmes have been success-
fully implemented at a few Universities of Applied Sciences (Polytechnics) (1) and
universities (2). Despite the possibility of master’s programmes for advanced prac-
tice nurses in Austria, currently there are no specic elds of activity or a dened
role and job title [26]. Instead, efforts are concentrated on role development, imple-
mentation and establishment of the qualication level “APN nursing expert” in dif-
ferent health care structures. Thus, APNs are also successively mapped in
professional career models, predominantly in the clinical area, analogous to the
qualication level model of the International Council of Nurses [34].
The numerous activities that have been set up so far are based on individual ini-
tiatives of pioneers who use international roles and Hamric’s integrative model of
advanced practice nursing [35–37]. The feedback from APNs in practice demon-
strates that the role is still unclear and that there exists a lack of structures and pro-
cesses to establish it. However, role clarity seems to be essential for a successful
APN implementation [38]. Activities of the rst APNs focus on health prevention
and promotion, patient education, promotion of health literacy of chronically ill
patients, e.g. through counselling and education, nursing development, develop-
ment and revision of nursing standards/standard operating procedures (SOPs), edu-
cation and training of the health care staff, research and teaching, especially in the
eld of evidence-based practice (EBP), as well as tasks in advanced care planning
and clinical leadership. Competencies in the eld of medical diagnostics and ther-
apy may only be assumed by APNs if ordered by a physician. Anamneses in the
sense of “clinical assessments in nursing” are carried out in individual cases accord-
ing to physician’s orders [39].
The Way Forward
The Austrian path is characterised by a strong commitment of individuals and pio-
neers who follow international best practices. The Austrian Association of Advanced
Nursing Practice (AAANP) is the national and international representative of ANP
in Austria and pursues the goal of making Advanced Nursing Practice known as a
specialisation and extension of the current nursing landscape in Austria and to con-
tribute to its implementation and development. In addition, networking of nurses
working in the eld of ANP is being promoted (Austrian Association of Advanced
Nursing Practice (AAANP)).
Since 2015, the Austrian ANP Forum has established itself in the community
through regular newsletters, numerous events and networking meetings with the
goal of making APN known in Austria and supporting its implementation in a wide
variety of areas. The initiators and members are committed to contributing to their
networks in the spirit of realising the APN role (ANP Forum Austria).
Austria has more graduates of APN master’s programmes every year, who
develop their role themselves or participate in career programmes of health care
institutions. Thus, APNs can now be found in all areas and settings of health care,
even if they are not (always) referred to as such. There is also an increasing number
Nurse Practitioner Development in German-speaking Countries: Germany, Austria...
214
of published studies dealing with role [40], or concept development [41], and expe-
riences in care delivered by APNs [42].
The eld of practical activity is consistently restricted to the legal framework by
law and cannot be compared to international roles. For example, APNs in Austria are
not allowed to make diagnoses or prescribe medication. Independent billing of nurs-
ing services with health insurance companies is also not possible. However, they are
allowed to give invoices, which have to be paid directly by the person being cared for.
In particular, APNs see great potential in following international best practice
models such as Family Health Nurse, School Nurse, Community Health Nurse, or
in primary care. It would also be conceivable for the future that APNs with setting-
and task group-specic specialisations, e.g. in paediatric and adolescent nursing,
psychiatric health care and nursing, intensive care and anaesthesia nursing, renal
replacement therapy nursing, hospital hygiene, wound care and stoma care, hospice
and palliative care as well as psychogeriatric care as dened in the Austrian Health
Care and Nursing Act §17 [2] [29]. In a report published in 2021 by the National
Nursing Task Force, reference is made to the future expansion of the establishment
of Advanced Practice Nurses Palliative Care in order to support relatives and enable
the persons to be cared for to remain at home for longer [43].
Advanced Nursing Practice inSwitzerland
Christophvon Dach, ChristianEissler, and MayaZumstein-Shaha
In Switzerland, the discussion regarding Advanced Nursing Practice commenced
at the beginning of the new millennium due to the move of nursing education to
tertiary level (see Table 1 below for overview of Swiss master and doctoral level
education offerings). With this change in the educational system, the question of
providing academic and further education in nursing practice became important
[44–47]. The Bologna Process, launched in 1999, created the European Higher
Education Area (EHEA), which was symbolically opened in March 2010. Important
points for Europe here are the three-tier study system with bachelor’s, master’s and
doctoral degrees, the European Credit Transfer System, cooperation in quality
assurance and the introduction of National Qualications Frameworks (NQF)
derived from the European Qualications Framework for lifelong learning. For
example, the NQF denes the underlying competence level of the Master of Science
in Nursing (MScN) degree programmes [48]. This level of competence is now also
reected in APN’s elds of action. In order for APNs to deliver extended nursing
care with integrated medical skills and to provide holistic care to patients, they need
highly specialised medical, ethical, humanistic and communicative knowledge of
health care and systems. APN education needs to address these elds. Thus, APNs
will be able to practice competently and face complex, unpredictable work contexts
that require new strategic approaches [44].
Today, a total of eight programmes exist on the MScN-level for Advanced
Nursing Practice all over Switzerland [51]. In all these programmes, about 200
E. Keinath et al.
215
Table 1 Overview of the timeline of Swiss master’s and doctoral education in nursing
Year
Master of Science
in Nursing/doctoral
programmes Focus Institutions
1997 Start of a joint
Master of Science
in Nursing
Research WE’G (Institute of further education in
health care), Switzerland, in
collaboration with the University of
Maastricht, Netherlands
2000 Master of Science
in Nursing, PhD in
Nursing
Research, Advanced
Practice Nursing
University of Basle, Institute of
Nursing Science, Switzerland
2009 PhD in Nursing Research University of Lausanne, Institute of
Higher Education and Research in
Health, Switzerland
2009 Master of Science
in Nursing
Advanced Practice
Nursing, Research
Careum, Kalaidos University of
Applied Sciences, Zurich, Switzerland
2010 Master of Science
in Nursing
Advanced Practice
Nursing
University of Lausanne, Institute of
Higher Education and Research in
Health in collaboration with the
University of Applied Sciences of
Western Switzerland
2010aMaster of Science
in Nursing
Advanced Practice
Nursing
Universities of Applied Sciences Bern,
Zurich and St Gall (joint curriculum),
Switzerland
2018 Master of Science
in Nursing
Nurse Practitioner University of Lausanne, Institute of
Higher Education and Research in
Health, Switzerland
2019 Master of Science
in Nursing
Programmes for Nurse
Practitioner (NP),
Clinical Nurse Specialist
(CNS) and Research
Bern University of Applied Sciences
Health, Switzerland
2019 Master of Science
in Nursing
Advanced Practice
Nursing, Research
Zurich University of Applied Sciences,
Switzerland
2019 Master of Science
in Nursing
Advanced Practice
Nursing, Research
OST University of Applied Sciences,
St Gall, Switzerland
2019 Master of Science
in Nursing
Advanced Practice
Nursing, Research
SUPSI University of Applied Sciences
Ticino, Switzerland
2021bMaster of Science
in Nursing
Psychiatric Mental Health
Nurse Practitioner
(PMHNP)
Bern University of Applied Sciences
Health, Switzerland
Legend: From 2000 onwards, all programmes followed the Bologna process. This process includes
the harmonization of study programmes by using so-called ECTS (European Credit Transfer
System). Thus, student and graduate mobility could be improved and fostered [49]. In addition, the
Bologna process includes a European Reference Framework for lifelong learning [50]
aThis joint programme of the Universities of Applied Sciences Bern, Zurich and St Gall was dis-
continued in 2018 and replaced by individual MScN-programmes at each University of Applied
Sciences (i.e. Bern, Zurich and St Gall)
bThe Bern University of Applied Sciences opened the PMHNP in 2019, to join the other three pro-
grammes: NP, CNS and Nurse Researcher
students are enrolled annually, with growing tendency. Currently, there are more
than 1000 graduates from these programmes. The majority of them work in an
Nurse Practitioner Development in German-speaking Countries: Germany, Austria...
216
inpatient setting in Advanced Practice Nursing-roles [52]. A smaller number are
educators and teach in the MScN-programmes. Only a few dozen are currently
working in home health care and medical practices of family physicians.
The high numbers of graduates working in inpatient settings is due to CNS roles,
which are well established for several decades. These nurse professionals are the
cornerstone of high-quality nursing care [46, 53–59]. Professionals in CNS roles
contribute to better patient care and provide interprofessional and team support
[60]. More recently, the demographic changes, severe penury of health care profes-
sionals and increasing costs have led to the establishment of NP roles in inpatients’
settings and general practice surgeries ([61–75]’ [52]). Most NP roles are at early
stages of development [62, 76]. Both CNS and NP contribute to better patient care
and interprofessional and team support [54, 56, 57, 60, 65, 66, 68, 70, 71, 73, 74,
77–79]. NP contribution in medical practices of family physicians is considered
positive. Evidence exists that NPs are predominantly looking after multimorbid per-
sons, thereby providing easier access to health care, better coordinated care, better
ow of information and family-centred care [54, 62, 66, 70–72, 77, 79]. Patients
feel safe, well cared for and experience improvements in physical and psychologi-
cal well-being as well as in daily activities [70, 71].
Whereas the implementation of APN roles in inpatient settings is less problem-
atic concerning legal and nancial issues, the integration in medical practices of
family physicians and other ambulatory care settings such as home health care is
challenging due to inadequate legal bases and nancial reimbursement problems
[80–82].
In 2020, the law of the Swiss Health Professionals came into effect. This law
provides a regulatory basis for health professional education in Switzerland. In this
law, it is maintained that the accepted entry to the nursing profession is on the ter-
tiary level and can be completed either at a School of Higher Education ending with
a Diploma in Nursing or at a University of Applied Sciences ending with a Bachelor
of Science in Nursing. In contrast, the MScN-degree is not included, and therefore
not regulated, in this law. In addition, inpatient settings are reimbursed through the
Diagnosis-Related Group (DRG) system, which is a case-mix complexity system
implemented to categorize patients with similar clinical diagnoses in order to better
control hospital costs and determine reimbursement rates [83]. As such, it can be
problematic to include health professionals of various backgrounds, including
APNs. However, in the outpatient settings such as in medical practices of family
physicians, the lack of legal regulation, and as a result the lack of acknowledgement
of APN as service providers, presents huge obstacles. These barriers limit the inte-
gration of APN in ambulatory and outpatient settings [80, 82].
With the increase of graduate education in nursing in Switzerland, regulation
was called for. In 2011, the Swiss Nurses’ Association (SBK-ASI), the Association
of Academically Prepared Nurses (VfP) and the then newly established interest
groups of nurses working as Advanced Practice Nurses (SwissAPN) published a
joint position paper on APN (Swiss Nurses’ Association (SBK)). In this position
E. Keinath et al.
217
paper, these associations agreed on the need for APN in the Swiss health care sys-
tem. It was maintained that APN needed to be academically prepared with at least a
Master of Science in Nursing degree with an APN focus. A year later, the Nurses’
Associations of the German-speaking countries, Austria, Germany and Switzerland,
published a joint position paper on Advanced Practice Nursing [84]. This position
paper dened the basic requirements for an APN role in the German-speaking part
of Europe. The required prerequisites, as also mentioned in the previous sections on
German and Austrian developments, were found to be a master’s degree in
APN.Based on these preliminary steps, the regulation organisation APN-CH was
founded in 2019 and started accrediting APN in 2020 [85]. The framework of the
Canadian Nurses’ Association serves as its orientation (2019). Any nurse profes-
sional who has obtained an MScN-degree with focus APN, working at least 40% as
APN in direct patient care and demonstrating at least 50h of supervised practice can
submit the transcripts and can obtain accreditation as APN.The regulation organisa-
tion APN-CH does not differentiate between the CNS or NP roles. Both roles are
accredited as APN.The founding members of the APN-CH regulation organisation
are the Swiss Nurses’ Association (SBK-ASI), the Association of Academically
Prepared Nurses (VfP) and the then newly established interest groups of nurses
working as Advanced Practice Nurses (SwissANP) as well as the Swiss Nurse
Leaders. As a result, the regulation is viewed as an important step in the establish-
ment of APN in Switzerland. Since the inception of APN-CH, more than 100 APN
have been accredited.
In 2021, the Swiss people voted on strengthening nursing and nursing education.
As a result, the national government and politicians are working to provide adequate
legal and nancial bases to improve general working conditions, legal regulatory
basis and nancial reimbursement systems for nursing. Hopefully, this will lead to
nurses as independent health care providers in Switzerland. At present, there are
standard operating procedures per diagnosis that allow joint agreement from the
medical professionals as well as APN on their area of work [86]. For APN in pri-
mary care, a scoping review has been published highlighting the various competen-
cies and a specic job description has been developed [69, 70, 87].
Conclusion
This chapter demonstrates that NP developments are slow but they are occurring in
German-speaking countries. Switzerland has the most developed NP roles out of the
three countries addressed in this chapter. However, some aspects such as master’s
level education, implementation and competency frameworks are similar. The fol-
lowing table below summarises the discussions from this chapter with regard to
educational, regulatory and practice-based backgrounds and contexts, which guide
APN/NP developments in German-speaking countries (see below in Table2):
Nurse Practitioner Development in German-speaking Countries: Germany, Austria...
218
Table 2 NP criteria comparison across German-speaking countries (in no particular order—
Nov. 2022)
Item Austria Germany Switzerland
Title protection No No Yes
Registration/
Credentialing
No No Yes
Commonly used
competency
framework
Hamric and Hanson’s
Integrative Model of
Advanced Practice
Hamric and Hanson’s
Integrative Model of
Advanced Practice
Hamric and Hanson’s
Integrative Model of
Advanced Practice,
Pan-Canadian framework
Education level Master’s degree Master’s degree Master’s degree
Needs assessment Locally Locally Locally
Implementation
framework
PEPPA PEPPA PEPPA
Level of
implementation into
practice
Beginning to be
implemented
Exploratory through
research projects
mainly
Beginning to be
implemented
Clinical career
pathways
Locally, not
standardised across
the country
Locally, not
standardised across
the country
Under development
Prescribing rights No No No
National/Regional
networks
2 2 1
Image campaign/
public awareness
Starting No Starting
Evaluation
framework
PEPPA plus PEPPA plus PEPPA plus
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Nurse Practitioner Development in German-speaking Countries: Germany, Austria...
225
The Nurse Practitioner Role andPractice
inBotswana
DeborahC.Gray, MabediKgositau,
andGaonyadiweLubinda-Sinombe
Introduction
The Republic of Botswana was the rst country in Africa to adopt the nurse practi-
tioner (NP) role, and one of the early adopters worldwide. It is still one of the few
countries in Africa to have formally established and implemented the NP role. This
chapter highlights the many interrelated factors and processes leading to the devel-
opment of the NP role in Botswana. It also describes the education, regulation,
scope of practice, and current status of NP clinicians in the country, as well as cur-
rent challenges and future directions.
Background
Country Profile
Botswana is a largely rural, landlocked country in the southernmost Africa bordered
by Namibia, Zambia, Zimbabwe, and South Africa. With a relatively small popula-
tion estimated at 2,346,179 and an area of 566,730 square kilometers [1, 2],
Botswana has the lowest population density in Africa, and is one of the most sparsely
populated countries in the world [3]. The two largest cities are, the capital Gaborone
D. C. Gray (*)
Old Dominion University School of Nursing, Norfolk, VA, USA
University of Botswana School of Nursing, Gaborone, Botswana
e-mail: dcgray@odu.edu
M. Kgositau · G. Lubinda-Sinombe
University of Botswana School of Nursing, Gaborone, Botswana
e-mail: kgositau@ub.ac.bw; sinombeg@ub.ac.bw
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_16
226
in the south with 208,000 residents and Francistown, in the north with 99,000 resi-
dents [4]. However, many of the country’s inhabitants are spread over the expanse
of the country’s primarily arid desert countryside in small rural villages.
Prior to independence in 1966, Botswana (then Bechuanaland) was a British
protectorate and one of the poorest and least-developed states in the world. However,
since the discovery of signicant diamond reserves in 1967, the Republic of
Botswana has gained international stature as a peaceful and increasingly prosperous
democratic state [5] with a re-distribution of resources such that it is the only coun-
try in sub-Saharan Africa to have achieved “upper middle income” status for its resi-
dents [6]. Furthermore, with these newly found resources the country set about
improving the welfare of its citizens with social reform initiatives in education,
infrastructure, and health care.
Health Care System
One of these reforms was the creation of a government-supported national health
care delivery system, based on the primary health care (PHC) model, which empha-
sizes accessibility to basic services. The current health care system in Botswana is
still dominated (98%) by the public sector [7] and organized into an extensive sys-
tem of 27 health districts across the country with different levels of care based on
the complexity of services provided. At the lowest level of care there are the 844
mobile health stops, 338 health posts, 171 clinics without beds, and 101 clinics
which can also care for inpatients. There are also 14 primary hospitals and 14 dis-
trict hospitals, with nally three national referral hospitals in the three largest cities,
representing the highest level of the system [8].
History ofNursing andtheNurse Practitioner Development
inBotswana
Early Years
Nursing has long played a predominant role in the country’s health and can be
traced back well before any formal health care, as part of female roles where
women took care of the sick at home as part of the house chores. In 1890 the rst
health facility in the then Bechuanaland was a small mission built in northern
Botswana by a Scottish medical missionary who engaged non-African white nuns
assisting him with the care of the sick. The idea of nursing training for local women
was realized in 1925 by the Seventh Adventist Church in the town of Kanye where
for the rst time three candidates from Botswana received on-the-job hospital-
based training in the mission hospital, with no written curriculum, no classroom,
and no stated hours or books [9]. Although similar efforts were made at several
small clinics and mission-style hospitals in the ensuing years, health care in the
country and consequently nursing, continued to be quite limited, until
D. C. Gray et al.
227
independence in 1966. After separation from the United Kingdom, the newly
established Republic of Botswana began to develop a government-run national
health care system with nurses becoming the basis of almost all care, which spurred
the nursing profession to expand signicantly. Hospitals were being built and
nurses were needed, not only at the bedside, but also to be the primary point of care
for the health care in clinics in the rural areas.
Thus, the idea of a training institution was borne through the Botswana Ministry
of Education, Health and Labour (BEHL) and the World Health Organization
(WHO), which resulted in the establishment of the National Health Institute
(NHI) in the capital city of Gaborone and afliated health training institutions
around the country, as per the Statutory Instrument No.96 [10] and 98 of 1969
[11]. The creation of the NHI, renamed the Institute of Health Sciences and
Afliated Institutions, provided the rst formal training of practical nurses, nurse
midwives, and later other allied health professionals in Botswana. Additionally,
the need to educate nurses at a higher level to provide the country with additional
nurse educators to train diploma-level nurses at the health training institutions
was later met by the creation of a Department of Nursing Education at the
University of Botswana [12].
Nurse Practitioner Role Development
The impetus for development of an advanced practice nurse practitioner role grew
from the Government Rural Development Policy of 1972 and the expanded national
health system in response to the WHO 1978 Alma Alta declaration for primary
health care (PHC). The act prompted the building of a large infrastructure of pri-
mary health care facilities to provide care to all of Botswana’s citizens across the
largely rural, sparsely populated country, thus bringing a need for signicantly more
health care providers able to provide medical services in these mostly rural settings
[13, 14]. At the time, the country was relying on a very few foreign-trained expatri-
ate missionary physicians, and primarily nurses to provide care in the few existing
facilities. With the expansion, nurses who made up the large majority of the health
care workforce at the time were seen as the cadre that could be posted in this new
expanded network of rural clinics to provide care. However, once implementation
began, these bedside trained nurses were not equipped with the assessment and
treatment skills to independently handle the common outpatient medical problems
encountered in the community and demanded further education to meet the primary
care needs of their patients [9].
Thus, in the late 1970s the Botswana Ministry of Health secured funds from the
United States Agency for International Development (USAID) for a collaboration
between Botswana and several universities with NP programs in the USA to develop
a post-basic diploma in Family Nurse Practitioner (FNP) program. The FNP role
was chosen because of its ability, generalist ability to care for the patient across the
lifespan. These initial future NP faculty and preceptors were nursing educators from
Botswana that were chosen to receive sponsorship to attend American universities
The Nurse Practitioner Role andPractice inBotswana
228
for graduate education as master’s prepared NPs. On return to the country, they
were given the responsibility to plan and initiate the rst nurse practitioner educa-
tion in Botswana. [9, 15]. The inaugural FNP program was initiated in 1981 at the
government-run training institution for nurses, the National Health Institute in
Gaborone, as a one-year post-diploma program, training the diploma prepared bed-
side nurse in advanced diagnosis and management with additional skills in dentistry
and minor surgery [16, 17, 18]. In 1991 after curriculum review with feedback from
graduates, the program was increased to 18 months of training to better prepare the
FNPs to independently handle emergency situations as the sole health professional
often in remote villages [19]. The advanced diploma FNP program was further
revised in 2001 with increased emphasis on comprehensive family health services
and again when a four-semester format was introduced [20, 18]. More recently, the
University of Botswana in 2005 opened a Master of Nursing Science (MNS) FNP
program, with its rst graduates in 2007. The full-time MNS is a four-semester
program consisting of didactic coursework, a research project, clinical practicum,
and internship [21].
Nurse Practitioner Role andScope ofPractice inBotswana
Nurse Practitioners inBotswana
Nurse practitioners in Botswana can, and do work as NPs in a variety of inpatient
and outpatient settings; however, most NPs provide much of the country’s primary
care in outpatient departments, urban and rural clinics, health posts, roadside mobile
stops, and schools. There are currently approximately 500 diploma prepared NPs
and 25 master’s prepared NPs in Botswana. Most NPs are employed by the govern-
ment as clinicians, administrators, or educators in public hospitals, clinics, health
training institutions; however some work in industry, or other private entities like
banks and schools. Nurse practitioners are included on the list of providers by the
country’s private medical insurance companies, and reimburse NP consultations at
roughly 65% of what is paid to a physician general practitioner, with no differences
in the charges for other services such as surgical procedures and basic medical
examinations. [19].
Licensure andRegulation oftheNurse Practitioner Role
The Nursing and Midwifery Council of Botswana (NMCB) is the statutory body
with the responsibility to regulate the nursing profession, including nurse practitio-
ner education, licensing, and practice. The family nurse practitioner is currently the
only recognized NP role in Botswana and there is no standardized certication
exam available or required for licensure as an FNP.There are two (2) educational
preparation levels of family nurse practitioners recognized by the NMCB: post-
basic diploma and master’s degree.
D. C. Gray et al.
229
Diploma Program Licensure
Pursuing a post-basic advanced diploma in FNP determines the type of registration
a nurse will be entered in upon completion of studies. The diploma program is
designed for registered nurse/midwives to enable them to provide comprehensive
primary health care services to individuals, families, and groups through assess-
ment, diagnosis, and management of common diseases, health promotion, and dis-
ease prevention. For post-basic FNP diploma, applicants must have a basic diploma
in general nursing with a minimum of two years of service as a general nurse and an
advanced diploma in midwifery. Students in this program acquire skills through
intensive theory from nursing, social and medical sciences, as well as public health
sciences and concentrated periods of clinical practice [20, 19]. Upon completion of
training, they apply to NMCB to be registered as nurses with a post- basic
diploma [22].
Master’s Degree Program Licensure
The master’s degree in FNP prepares a professional with advanced knowledge and
skill in the eld of nursing, with understanding of methods of enquiry and estab-
lished code of practice for the profession. Applicants for the master’s program must
have a bachelor of science in nursing and two years of nursing experience. Graduates
from the program will have the capacity to do research to add to the body of nursing
knowledge, assess, diagnose, and manage common primary health care problems.
They will also participate in the promotion, maintenance, and restoration of the
health of individuals, groups, families, and communities across the lifespan at pri-
mary level [23, 21]. Upon completion of training they may apply to NMCB to be
registered as a nurse specialist [22]. In August 2016, a title-protected licensure and
register was ultimately instituted in Botswana for nurse practitioners as one of the
nurse specialist advanced practice nursing designations; however, applicants must
have a master’s degree in FNP to be eligible for this Nurse Specialist-FNP licensure
from the NMCB [24]. Note that given that FNPs are educated at both the diploma
and master’s level, this nurse specialist licensure is currently not required for
employment as an FNP in Botswana.
Nurse Practitioner Scope ofPractice
The FNP role scope of practice in the country was initially outlined in a 1988 docu-
ment developed by the Nursing and Midwifery Council of Botswana and the
Ministry of Health Directorate of Personnel describing the duties of the family
nurse practitioner [25]. The National Health Institute [20] later dened FNP prac-
tice as the following:
Family nurse practitioner practice is an area of primary healthcare nursing concerned with
health promotion, health maintenance, and the provision of basic curative services. Its
essence is the diagnosis and management of common health problems presented by indi-
viduals, families, groups and communities throughout the lifespan. The practice includes
health assessment; ordering and interpretation of diagnostic investigations; diagnosis and
The Nurse Practitioner Role andPractice inBotswana
230
management of common health problems; referral and/or co-management of complex sec-
ondary level problems; provision of emergency care services; call management of chronic
disease conditions; and individual and family counseling and preventative care including
health education. (p.4)
Nurse Practitioner Prescriptive Authority
Prescriptive authority is the level or extent in which a clinician may prescribe and
administer specic medications and controlled substances. In Botswana, there is
legislation and as well as guidelines endorsing overall general nurse prescribing, but
none specically for nurse practitioners. Further, the prescriptive authority legisla-
tion and laws in place for nurses, have lacked clear guidance on prescribing, regula-
tion, or supervision.
Prescribing in the country is guided primarily by the Drugs and Related
Substances Act (1992) which allowed all nurses to prescribe according to their
training and the level of health service at which they work [26, 23] and the Nurses
and Midwives Act of 1995 [22] outlined medications that nurses and midwives may
prescribe, but it was silent on drugs that nurse specialists such as FNPs may pre-
scribe. The subsequent 2013 Medicine and Related Substance Act [27], stated that
the Minister of Health and Wellness in consultation with Director of Health Services
may authorize limited powers of additional prescription of medicines to nurses, but
offered no specic additions in legislation. This act did lead, however to the most
recent and specic prescribing guidance for nurses in the country, the Botswana
Essential Medicines List (BEML) [28]. The BEML 2016 is a guideline specically
for health care providers in government-run facilities and provided as follows: a list
of the medications, who can prescribe, and specic availability in various settings.
It stated that nurses can prescribe certain drugs at primary health care settings such
as clinics and health posts as stipulated by Drugs and Related Substances Act (1992)
[26]. It also outlined which types of drugs that can be prescribed by specic groups
of nurses at government facilities. These groupings included what can be prescribed
by general nurses and certain nurses with post-basic diplomas including midwives
and psychiatric mental health nurses, as well as additional medications nurse spe-
cialists with a master’s degree (including MNS prepared FNPs) can prescribe. This
document, however, is a guideline and only for government-run facilities. Also, the
vast majority of FNPs do not have master’s degree and are not licensed as nurse
specialists. Thus, many NPs in Botswana continue to prescribe medication to
patients as per their NP training but without clear legislative guidance or regulation.
A Typical Workday foraFamily Nurse Practitioner inBotswana
A typical day for a family nurse practitioner (FNP) in Botswana takes place most
commonly in an ambulatory setting, primarily public clinics often with overnight
capability, health posts, and outpatient departments of hospitals. This starts at 07:20
D. C. Gray et al.
231
hours by receiving night clientele report from the night nurses who are usually reg-
istered nurses, but occasionally may be one or two FNPs. The report includes patient
numbers, case reports of individuals, day-duty pharmacist information on any medi-
cations, out of stock and test reagents not in stock so that unavailable patient care
resources are known. The NP asks questions to get clarity related to night-shift
patient assessment and management and gives relevant information regarding as to
what could have been done in some patient encounters. Most times clinics are
staffed with one nurse practitioner and one registered nurse, and each assesses and
manages patients in consulting rooms. Stafng may include one physician, however
this is often only on an intermittent basis, i.e. once a week and sometimes as infre-
quently as once a month, particularly in rural areas. Patients are not usually sched-
uled and are seen in the consultation room on a rst come, rst served basis, or if
needed sooner as per emergent triage analysis.
In the ambulatory setting the FNP assesses and manages clients across the lifespan
for a wide range of acute and chronic conditions, also including preventive services and
occasionally ophthalmic and dental care. The FNP consults with their patient load, and
also receives referrals of complex patients from the RN.In more complex cases, the
FNP will assess the patient and refer to the physician if at clinic or when next on-site,
or to the regional hospital for specialty care. FNP management often includes rapid
tests as necessary, e.g. hemoglobin, malaria, pregnancy test, urinalysis, and insertion of
intravenous drip. FNPs also often dispense any needed medications. Patients usually
carry a notebook in which the FNP will document their care. Also, completion of a
clinic medical statistics record book of all conditions treated is a must. The FNP usu-
ally takes a 15-minute tea break between 10:00 and 11:00 hours if possible and a one-
hour lunch break at 12:45 hours. The afternoon session starts at 13:45 hours where the
process of consultation continues till 16:30 hours, in the case of an eight-hour clinic.
Most FNPs do not leave on time and work overtime hours with no additional pay,
because all patients seeking treatment at the clinic must be assessed that day. If it is a
24-hour clinic, the FNP gives a report to the night clinic staff, and the circle continues.
The Future oftheNurse Practitioner inBotswana: Challenges
andAdvancement
Although the FNP role started in Botswana in the 1980s, many aspects have been
slow to develop and formalizing the role remains in its early stages, in terms of
legislation and regulation of an advanced standardized educational pathway, licens-
ing, prescriptive authority, and scope of practice recognition. Efforts are under way
to remedy the gaps, but much still needs to be done.
Discrepancy between required educational levels for practice is one of several
issues that has hampered development of formal recognition for the NP role. Despite
the institution of the Nurse Specialist-FNP licensure, it is only available for master’s
prepared graduates. Further, the majority of FNP enrollment is still largely in the post-
basic RN diploma FNP program since specialist licensure is not required for FNP
employment. In addition to slowing progress toward role development, this
The Nurse Practitioner Role andPractice inBotswana
232
educational and regulatory inconsistency has led to a lack of recognition and misun-
derstanding of expectations for the role by regulators, health care administrators, and
the public, such that diploma FNP graduates have often been placed in generalist nurs-
ing roles in hospital settings. To remedy this, the Ministry of Health and Wellness
(MOHW) through Institute of Health Sciences (IHS) training unit is in the process of
upgrading FNP diploma holders to bachelor’s level and currently developing and tran-
sitioning the FNP diploma program to a bachelor’s program. Further, to encourage
nurses to upgrade their education, the MOHW (2022) released a proposed training
plan to the nursing community indicating that there would be sponsorship provided
for FNP students at the bachelor’s and master’s degree levels [29]. Finally, the School
of Nursing at the University of Botswana has for some time envisioned offering an
addition to their master’s program, specically through a distance online offering. A
hybrid program, partially online offering of the FNP master’s program was initiated in
January 2019 with the hope to transition and benet diploma FNPs and other working
registered nurses to more easily obtain advanced degrees [30].
Family nurse practitioners in Botswana currently do not have an organized bar-
gaining or advocacy body to speak for their specic needs, which in the past has
resulted in decisions sometimes being made without their input. However, the pro-
cess of establishing an FNP association has begun. The practitioners had been meet-
ing annually from 2017 to 2019 at a central point in the country to map the way
forward toward forming an FNP Association that would be under the Botswana
Nurses Union and providing an advocacy and bargaining role specic to the FNP
role. The FNP Association constitutional document was developed after 2019 and is
currently in the process of the registration. In July 2019, a formal task group had
been formed and assigned with specic FNP issues to discuss and with relevant
authorities; however COVID restrictions impacted the process. To continue work, an
online virtual platform has been created where issues pertaining to FNP practice are
discussed and consultations of FNP stakeholders and regulatory bodies have been
ongoing. Additionally, FNPs are working toward making a deliberate effort to “sell”
their role to get due recognition. There is limited documentation about FNP in
Botswana and a need for current studies on the practice is on demand with the MOHW.
Additionally, there has been some movement toward formalizing FNP regula-
tions in Botswana with regard to standards of practice and prescribing. The NMCB
has developed formal standards of practice for FNP Nurse Specialists. These stan-
dards of practice are in press and still to be gazetted and distributed. Additionally, in
February 2022, the NMCB tasked a committee to develop regulation on FNP private
practice, prescriptive authority, and other issues in anticipation of review and
changes to the Nurses and Midwifery Act enacted almost 30 years ago.
Conclusion
Since the initial development and integration of the role in Botswana almost 40
years ago, the NP has become a mainstay for provision of primary health care, espe-
cially in rural areas. Although still evolving with many challenges yet to be
D. C. Gray et al.
233
overcome, the role and its pathway for development remains an exemplar for other
countries in Africa and elsewhere seeking a guide to implement the NP role.
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D. C. Gray et al.
235
Nurse Practitioner Role inKenya
RachelWangariKimani andEuniceNdirangu-Mugo
Introduction
Nurses in Kenya constitute the largest health workforce and are essential in realiz-
ing the goal of universal health coverage and improving the quality of health ser-
vices, including promoting primary healthcare. Mortality and morbidity due to
infectious diseases remain high in sub-Saharan countries [1]. In addition, emerging
non-communicable diseases place an additional strain on health systems struggling
to meet the needs of an ever-expanding young population [2]. The increased popula-
tion and demand for managing complex and chronic diseases necessitate increased
health workforce requirements for such services [3]. The effective and greater use
of nurses in advanced practice is a potential measure to ensure universal access and
cost-effective and quality service delivery.
The nurse practitioner role has had a slow and steady growth in sub-Saharan
Africa (SSA) [4]. With the evolution of nursing practice and the emergence of nurse
specialists and advanced practice nursing (APN) roles in SSA, questions on the
potential of advanced practice and regulation of advanced practice emerged in
R. W. Kimani (*)
School of Nursing and Midwifery, Kenya, Nairobi, Kenya
Laboratory of Neurogenetics of Language, Rockefeller University, New York, NY, USA
e-mail: rachel.kimani@aku.edu
E. Ndirangu-Mugo
School of Nursing and Midwifery, Kenya, Nairobi, Kenya
e-mail: eunice.ndirangu@aku.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_17
236
Kenya. Though the APN programs have begun in Kenya, several contextual factors
may still constrain the scale-up of the APN role. These threats include a lack of
government and private stakeholders’ investment to implement the role, including a
lack of scheme of service, the institutionalization of the APN role, and a job- creation
strategy.
Masters’ programs in nursing were developed in the early 2000s, but APN is new
in Kenya. Historically, the Nursing Council of Kenya (NCK) regulated nursing cad-
res up to the bachelor’s degree level [5]. Therefore, if the APN’s role is to meet
International Council of Nurse (ICN) recommendations for autonomy and clinical
expertise, various regulatory and human resource structural challenges would need
to be solved. Otherwise, a lack of supportive regulation, education, and legislation
that formalizes the expanded roles of nurses threatens the sustainability of the
NP role.
Kenyan Context
Kenya is a lower-middle-income country with a population of over 53 million, of
which 75% resides in rural areas [6]. Though private and public access to healthcare
services is available, most people in rural areas rely on government-run services.
Kenya devolved its healthcare system from a centralized national model to counties
to equalize regional access to health services and the distribution of health resources
(WHO, [7]). The 47 county governments are responsible for service delivery,
including managing human resources. The national government is responsible for
health policy, regulation, and pre-service training [8].
Kenya has a high burden of communicable diseases and a rapid increase in non-
communicable diseases (NCD) and injuries [9]. Infections and maternal and neona-
tal deaths account for 54% of the total deaths. Between 2014 and 2020, NCD-related
deaths rose from 27 to 39%, and it is projected to surpass communicable diseases
by 2030 [1]. The major causes of NCDs include cardiovascular disease, cancer,
diabetes, and chronic lung diseases. The life expectancy is 69years for females and
64years for males, while the maternal mortality rate is estimated at 362 maternal
deaths per 100,000 births and 31 infant deaths per 1000 live births [6].
In Kenya, the healthcare workers’ (HCWs, i.e., doctors, clinical ofcers, nurses,
and midwives) ratio to the population remains below the WHO recommended stan-
dards. According to government reports, there are 13.8 HCWs per 10,000 persons
compared to the recommended 44.5 HCWs per 10,000 individuals [10].
Approximately 70% of nursing personnel are women and comprise 80% of the
health workforce in Kenya. There are 11.6 nurses per 10,000 people compared to
the recommended 30.5 per 10,000 [11]. A concerted effort has been made to scale
up the nursing workforce, which has led to a 41% increase in registered nurses, and
149% of bachelor’s qualied nurses between 2015 and 2020 [12]. Bachelor’s quali-
ed nurses make up 7.7% of nurses in Kenya and the numbers for master’s qualied
nurses to remain unreconciled since they are not part of the HCW surveil-
lance system.
R. W. Kimani and E. Ndirangu-Mugo
237
History ofNursing inKenya
The evolution of nursing in Kenya has been documented since the colonial period
when Kenya was a British colony [12]. Training programs in mission hospitals were
established to meet health service demands in major cities during the colonial
period. The rst registered nurses were trained in 1952. Kenya gained independence
in 1963, and it was not until 1982 that the rst Bachelor of Science in nursing pro-
gram was started [13]. The Master of Science in Nursing was rst approved in 2004
to train nurses for managerial and teaching roles [14]. Currently, training institu-
tions train nurses at Certicate, Diploma, Bachelor’s, Master’s, and Ph.D. levels.
The regulation of nursing is the responsibility of the Nursing Council of Kenya
(NCK). NCK also manages part of the Kenya Health Workforce Information System
(KHWIS), which contains data on pre-service education, training, registration, con-
tinuous professional education, and deployment of nurses and midwives [15]. In
addition, the NCK established the scope of practice, standards of education, and
practice. The NCK and the Commission for University Education have over the past
years been responsible for evaluating and approving nursing education programs at
the university level.
The Master of Science Advance Practice Nursing is a new program in Kenya
with two universities currently offering the program: Aga Khan University, Kenya,
and Masinde Muliro University. The Nursing Council of Kenya, the main regulatory
body for nurses, historically did not register and license above the bachelor’s level.
However, the recent push for universal health coverage and the evolution of advanced
practice in sub-Saharan Africa has led to a change of strategy to clarify roles and
create an APN scope of practice.
Drivers forNurse Practitioner Role
Nurses in Kenya practice at advanced levels regardless of their dened role, formal
graduate education, or licensure. One study found that nurses working in dispensa-
ries and health centers who were likely to have lower nursing qualications have
greater autonomy than higher qualied nurses working in teaching or referral hos-
pitals [14]. There is also a long history of nurses performing tasks beyond their
scope to ll clinical providers’ gaps. For example, there is evidence of nurses in
marginalized areas providing curative services, including prescribing drugs [16].
Further, after ve years of registration, nurses can apply to practice autonomously
using a private practice license from the NCK.Still, this autonomous nursing does
not meet the educational and competency criteria set forth by ICN for APNs.
The APN role has evolved in Africa in the last two decades. Evidence from
Western and Asian countries afrms that APNs are effective in health service deliv-
ery, and this has fostered collaboration and support from international organiza-
tions, including the ICN and WHO.An example of such a partnership is the
Improving Nursing Education and Practice in East Africa (INEPEA) project, a
European-funded project exploring the potential for APNs in Kenya [14]. Through
Nurse Practitioner Role inKenya
238
persistent advocacy in the region, structural barriers constraining the growth of the
APN role have been identied, and strategies gradually implemented.
Despite the growth of nursing education into bachelor’s and graduate levels,
clinical competencies are mismatched to the population’s needs [17]. During the
COVID-19 pandemic, for example, one study found that nurses lacked the knowl-
edge to care for special populations [18]. Similarly, a shortage of nurses specializing
in cardiology, forensics, emergency, oncology, mental health, and research has also
been reported [19, 20]. The urgent need for human resource development in clinical
areas has led the intergovernmental corporation to facilitate sharing of specialists as
a short-term strategy. However, a long-term strategy of strengthening and scaling up
clinical practice through the APN role is necessary.
Competency concerns include the gap between theory and practice and the lack
of clinical leadership. Most of the nursing workforce has certicate and diploma
qualications. Government data shows that 61% of the nursing workforce are
diploma-level registered nurses, 30% are certicate-level enrolled nurses, and 7.7%
have bachelor’s degrees [12]. It is unclear how many nurses have graduate degrees
since they are not included in human resources for health statistics. Bachelor’s and
graduate level nurses out-migrate to other countries or leave the “bedside” nursing
for teaching and managerial positions [14, 21].
Epidemiological changes such as an increase in non-communicable and chronic
diseases require specialized and advanced nurses to address complex and chronic
health problems. Approximately 39% of deaths in Kenya are attributed to non-
communicable diseases, with an estimated 13.8% mortality due to cardiovascular dis-
ease [9]. National surveys indicate the prevalence of hypertension at 24.5%, diabetes at
3.1%, and preventable cancers such as breast, cervical, and colorectal account for 8%
of overall national mortality [1]. Scaling up access to APNs with ICN-recommended
education, clinical, research, and leadership competencies would substantially reduce
these rates accelerating progress toward Sustainable Development Goals.
Kenya has had a chronic shortage of HCWs. The shortage of higher skilled
clinicians led to the formal creation and implementation of task-shifting as a stop-
gap measure. WHO released task-shifting guidelines to increase access to HIV
services, but its application was extrapolated into other health services. WHO
denes task- shifting as a “delegation whereby tasks are moved, where appropri-
ate, to less- specialized health workers” (WHO, [22]). The Kenya 2017–2030 Task
Sharing Policy and Guidelines were launched in 2017 to legitimize task-shifting
between health professions in Kenya. For instance, nurses in Kenya have been
initiating and maintaining most patients on HIV treatment without formal
acknowledgment for decades due to a lack of clinicians. The task-sharing policy
formalized the use of nurses in HIV services but also expanded the scope of nurses
working in primary care settings, for example, to prescribe and give intravenous
uids [23]. Though the policy attempted to use the existing health workforce by
shifting clinical tasks to “less highly trained workers,” it failed court challenges
due to restrictive scopes of practice [24]. As a result, there is a need to revise cur-
ricula and legislation collaboratively and create less restrictive scopes of practice,
including for nurses.
R. W. Kimani and E. Ndirangu-Mugo
239
Several government health initiatives have pushed the development of the
APN role in Kenya. For example, the Kenya Health Policy Framework,
2014–2030, and the Kenya Health Sector Strategic Plan support the achievement
of universal health coverage [25, 26]. Government priorities include reducing
infectious, non- communicable diseases, mental disorders, the burden of violence
and injuries, provisional primary healthcare, and strengthening health system
stakeholders. To improve the access and quality of health services, the govern-
ment has committed investments to improve service delivery and the capacity
and numbers of HCWs.
Despite most of the population living in rural areas, HCWs are disproportionally
distributed, with most services available in cities. In contrast, individuals living in
rural communities are forced to travel long distances to seek care. As part of the
commitment to devolution of services, health workforce strategies aim to attract and
retain HCWs with an appropriate skill mix and equitably distribute them to meet
universal health coverage (UHC) goals by 2030. APNs are not only a solution to the
provision of services in rural communities but can provide leadership and clinical
expertise that is needed to strengthen all levels of the health system in Kenya.
cCase Study: Developing an Advanced Practice Nursing Program in
Kenya Background: It is essential to develop context-specific advanced
practice nursing (APN) programs in Kenya. Aga Khan University
School of Nursing and Midwifery East Africa pioneered one of Kenya’s
first APN programs. The objective of the APN program in Kenya was to
create a master’s educational program for bachelor’s level registered
nurses to foster an expert knowledge base, complex decision- making
skills, and clinical competencies to provide adult care in line with
UHC goals.
Methods: Developing an APN program was guided by the ICN APN
recommendations, market analysis, stakeholders’ input, and regulatory
agencies in three interrelated phases.
Phase one: (Scoping and positioning) Included market analysis,
stakeholder engagement, literature review, and alums surveys. Market
analysis in Kenya showed a need for a master’s program aligned with
the APN framework to provide clinical leadership. A previous study by
East etal. showed that clinical officers might not necessitate the need
for APNs. However, engagement with stakeholders (students,
clinicians, regulators, and educators) affirmed the need for an APN
program.
Phase two (Detailed design). Learning outcomes express which
competencies learners will be expected to achieve and how they will
demonstrate that achievement at the end of a learning activity.
These outcomes were created by faculty during retreats and capacity-
building exercises with collaborators from the United Kingdom and
Australia. Feedback was also sought from NCK, the Commission for
Higher Education (CUE), and incorporated into the curriculum. Partner
Nurse Practitioner Role inKenya
240
universities’ external reviewers reviewed the final document before
implementation.
Phase three: (Regulation) The comprehensive curriculum document
was presented to the Aga Khan University council, Nursing Council of
Kenya, and CUE for approval. The APN -adult health program finally
received CUE approval in mid-2020. The APN- adult program at Aga
Khan University includes problem-based learning and supervised
clinical practice in collaboration with physicians.
Results: The designed MSN APN curriculum offers a clinical track
in adult health. The program was to start in the spring, 2020 Spring
semester but was delayed by the onset of the COVID-19 pandemic. The
first intake was in October 2020 with ten APN students. The program
was designed to be a work-study program with students having two full
days on campus for classes. The first group of graduates is expected to
graduate in February 2023.
Conclusions: This curriculum development strategic approach
demonstrates a congruent and logical step that allowed the development
of a new program that prepares nurses to take new roles as nurse
practitioners.
Adapted from presentations given at ICN NPAPN2021 and Sigma’s
31st VIRTUAL International Nursing Research Congress [5, 27]
Nurse Practitioner’s Scope ofPractice inKenya
In Kenya, the conceptualization of the APN role is ongoing (Table1). Currently,
there are no NPs formally registered to practice in Kenya. In 2022 the Nursing
Council of Kenya released the Scope of Practice for Advance Practice Nurse
Practitioners. The document describes APN educational requirements, training,
licensure, certication, and professional responsibilities [28]. Similar to the ICN
Table 1 Progress of advanced practice nursing in Kenya
Advanced practice nursing in Kenya
Title Nurse practitioner
Clinical Nurse Specialist
Dened by Nursing Council of Kenya
Scope of
practice
Autonomous Authority to prescribe
medication and treatment
Published by Nursing Council of Kenya
May 2022
Licensure Nursing Council of Kenya None
Accreditation Commissioner for University
Education/Nursing Council of
Kenya
1.Aga Khan University, Kenya
2.Masinde Muliro University
Education Master’s Program APN Dened by Nursing Council of Kenya
Advanced Practice Nursing Scope of
Practice
R. W. Kimani and E. Ndirangu-Mugo
241
guidance, the NCK recognizes two types of APNs (Nurse Practitioners (NP) and
Clinical Nurse Specialists (CNS)) [29]. However, the current scope of practice
applies to NPs, and the CNS scope is yet to be dened.
The NP scope of practice is in addition to the Bachelor of Science in Nursing
degree scope of practice. NPs have graduate degrees, clinical training, and autono-
mous authority to practice beyond a bachelor’s level registered nurse. The Kenya
APN-NP scope of practice denes APN as “a specialist nurse who has acquired,
through additional graduate education (minimum of a master’s degree), the expert
knowledge base, complex decision-making skills and clinical competencies for
Advanced Nursing Practice, the characteristics of which are shaped by the context
in which they are credentialed to practice.”
The NP scope of practice identies four competencies expected of NPs: educa-
tion, clinical practice, leadership, and research (Fig.1). NPs work autonomously
and collaboratively to assess, diagnose, treat, and manage patients in outpatient and
inpatient settings per existing clinical guidelines. As clinical leaders, NPs work in
multidisciplinary teams to develop and implement clinical guidelines and health
policies, manage resources, and review mortality and morbidity cases to improve
individual, family, and community health outcomes. They also provide educational
leadership by identifying, developing, and implementing nursing curricula and fos-
tering professional development for nurses and allied professions. Moreover, they
contribute knowledge by conducting research, analyzing, and disseminating nd-
ings to inform evidence-based care and advocacy.
Direct Clinical and Community
Prac!ce Research and evidence-based
prac!ce
Leadership,governanceand
collabora!ve prac!ce Educa!on
APN Character!s!cs
Graduate educa!on
Cer!fica!on
Clinicalprac!ce
-Professionaldevelopment
-Clinicalteaching, supervisionand
mentorship
-Clinicaleducationmonitoringand
evaluation
-Curriculumdevelopment
-Conduct research
-Dissemination
-Evidence-basedpractice
-Communitiesofpractice
research
-ICT in health research
-Implementation of policy
programsand guidelines
-Advocacy
-Stewardship and oversight of
resources
-Clinical leadership
-Prescription
-Diagnostics
-Inpatient admissionand management
-Preventativecare
-Mortality andmorbidity casereviews
-Multidisciplinarycollaboration
-Consultancy
Fig. 1 Nurse practitioner competencies in Kenya
Nurse Practitioner Role inKenya
242
Future ofNurse Practitioner Role inKenya
Nurse Practitioners have effectively improved health outcomes and substantially
reduced mortality and morbidity in other countries [30]. In Kenya, they have the
potential to improve stalled health outcomes such as maternal, child, and infant
mortality. In addition, NPs can be the key to the universal provision of care, which
is necessary to reduce the rising NCDs. To realize this potential, NPs must have suf-
cient knowledge, skills, and an enabling work environment. Moreover, for NPs to
provide quality care as reported internationally, they require a full scope of APN
competencies that meets international standards and be integrated into the
health system.
There have been signicant strides to advance the nurse practitioner role in
Kenya by approving two APN programs and launching a scope of practice. However,
it is unclear how and when the NCK plans to register and license NPs graduating
from approved programs. There has been no surveillance of master-level nurses or
licensures authorized for those NPs who completed approved programs outside the
country. It is, therefore, challenging to estimate the number of graduate-level nurses
who meet the competency required to practice as an NP in Kenya, as articulated in
the newly released NP scope of practice. It is also unclear how many NPs are prac-
ticing in Kenya under the private practice license offered to nurses with over ve
years of clinical experience. A private practice license gives nurses autonomy to
practice but does not meet the educational and competency criteria set forth by ICN
or NCK for APNs.
Given the lack of consensus on the role of bachelor’s level nursing in Kenya’s
health workforce, justifying the need for advanced practice education is bound to
remain a challenge. While progress has been made to develop APN educational
programs in line with the ICN APN guidelines in two universities, it is unclear how
unied requirements are and whether graduate NPs have the required competencies
to practice within the new scope of practice. Further, the faculty shortage has been
a persistent issue in training institutions in Kenya. Therefore, educating and recruit-
ing more multidisciplinary faculty to teach and supervise advanced practice stu-
dents is necessary to scale up nurse practitioners’ education quality.
The NP scope of practice is a big step in the right direction in institutionalizing
the NP role in Kenya. Ultimately, more needs to be done to get stakeholder buy-in
and incorporate APNs in health workforce strategies. With the devolution of health
services, the national and county governments need to be involved in understanding
the effectiveness of the NP role and investing resources in creating jobs and recruit-
ing and retaining APNs. NPs need recognition from regulators and county and
national leadership for this signicant investment to materialize. Additionally, to
accurately estimate and distribute APNs, exact numbers of service training, gradua-
tion, and licensure of APNs need to be integrated into the current Kenya Health
Workforce Information System surveillance by NCK.Furthermore, the ministry of
health needs to update workforce norms and standards to facilitate hiring APNs as
clinicians in health facilities. Discussions on the nancing and infrastructure of
human resources for health that includes APNs are also essential in establishing
R. W. Kimani and E. Ndirangu-Mugo
243
nancial commitment to create jobs and encouraging nurses to pursue a career in
clinical practice.
The quest to formalize NP’s prescriptive authority through Kenya’s medical and
pharmacy boards has yet to be implemented. Given previous task-shifting chal-
lenges during the Kenya Task Sharing Policy and Guidelines implementation,
engagement, and collaboration with allied stakeholders, especially those with
shared tasks, may mitigate the risk of judicial challenge [24].
Conclusion
Kenya is undergoing population and epidemiological changes that demand skilled
and competent clinical leadership. Nurses have been lling the clinician gaps in
marginalized settings without the requisite education, authority, or recognition.
Therefore, creating an educational pathway to advance nursing education, practice,
and regulation will enable nurses to practice to the extent of their skills and knowl-
edge. A substantial scale-up of APNs is needed to provide preventative services,
manage chronic diseases, and achieve the UHC goal. In the past year, signicant
achievements have been made to launch APN programs meeting ICN recommen-
dations and institutionalizing APNs by establishing the NP scope of practice.
However, more must be done to create a licensing pathway and increase employer
and stakeholder buy-in. The future role of the NP role will depend on the synchro-
nization of APN education to meet population demand, regulation, engagement of
stakeholders, and the incorporation of the APN role in health workforce schemes
of service.
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Nurse Practitioner Role inKenya
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The Nurse Practitioner Role inTanzania
JosephKilasaraTrinitas andJaneBlood-Siegfried
Introduction
Tanzania is a sovereign nation in Africa, also referred to as the United Republic of
Tanzania. The country is located just south of the equator, on the eastern coast of
Africa and occupies a total area of 945,087 square kilometers (364,900 square
miles). Tanzania’s population is estimated to be 60 million [1].
Background
The global health care system has always struggled with a shortage of health pro-
viders. Effective utilization of the health care workforce is paramount to ensuring
high-quality and cost-effective care delivery. The World Health Organization [2]
stated that 20 to 40% of the deciency in the health system is due to workforce inef-
ciency and weaknesses in health workforce governance. Across all countries,
about 50% of the health workforce are nurses. Nurses play a critical role in health
promotion, pediatrics, maternity, aging, and non-communicable diseases. They are
key to the achievement of universal health coverage and achieving Sustainable
Development Goals [3]: 3.1, 3.2, 3.3, 3.4, 3.6, 3.8, and 3.9 [4]. Nurses are more than
capable of meeting these needs with comparable health outcomes when compared
J. K. Trinitas
Faculty of Nursing, Kilimanjaro Christian Medical University College (KCMC),
Moshi, Tanzania
e-mail: joseph.kilasara@kcmcuco.ac.tz
J. Blood-Siegfried (*)
Nursing Duke University, School of Nursing., Durham, NC, USA
e-mail: blood002@duke.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_18
248
to physicians [5]. As the world struggles to increase the number of health care pro-
viders, the most critical action should be to integrate and optimize the contribution
of all health care professionals functioning at their full capacity.
Current Situation
Tanzania has made signicant progress in reducing infant mortality, malnutrition,
HIV, tuberculosis, and malaria. But like much of the world there is an escalation of
non-communicable diseases such as hypertension, diabetes, cancer, renal diseases,
and maternal and neonatal mortality. However, the biggest issues are equitable
access to health services, essential primary health care, and access to health cover-
age. These services remain elusive for millions of people, particularly in rural
areas [6].
Access to primary and specialty health care in Tanzania is often lacking due to
the limited number of trained clinicians who can provide appropriate services, espe-
cially in rural areas which dominate much of the country. Nurses in these areas
become the providers. Yet because of lack of educational programs, nurses continue
to function beyond their educational preparation and scope of practice, to meet the
health needs of the community [7].
The WHO 2008–2012 progress report on nursing and midwifery stressed the
necessity to develop specialized nursing and advanced practice nursing (APN)
roles with the core competencies to meet population health and health services
needs as a means to revitalize the primary health care systems [1]. They developed
the concepts of task-shifting and task-sharing to allow nurses to meet specic
needs: however, these programs are very individualized to cover limited diseases
and procedures and do not address the capabilities of nurses in advancing primary
health care. Many of these nurses have had to cross the boundaries of their own
education to fully meet the health needs in their communities, without adequate
educational preparation. Strengthening nursing practice through comprehensive
educational programs is a perfect strategy to promote access to primary health
services. Over the past years nurse leaders across Africa have begun to explore
ways to advance nursing practice by developing new nursing roles and educational
programs in their countries [8].
In Tanzania, and many other countries, the discussions about task-shifting have
delayed the creation of meaningful comprehensive educational programs. They
have not made signicant progress toward developing and implementing a reason-
able APN role. According to the government of Tanzania, one of the rst steps to
achieve the goal of health is to ensure access to health care workers with enough
resources and capacity to deliver quality care. Today these goals are not met, and the
situation is worse in rural areas. Due to the lack of professional health care workers
in Tanzania, especially in geographically remote areas, nursing staff perform duties
beyond their formal education level [7]. Health care worker shortages are largely
responsible for poor health outcomes in Tanzania, including increased maternal and
child mortality [9–11].
J. K. Trinitas and J. Blood-Siegfried
249
Nursing Practice
The Tanzania Nursing and Midwifery Act [12] denes nursing practice as the provi-
sion of care to help people promote, maintain, and recover their health, cope with
health issues, and achieve the best quality of life. Nurses are accountable for their
decisions and actions, and for ensuring their professional competence [13].
Tanzania’s nursing scope of practice gives nurses an independent and self- regulatory
mandate to prescribe medications, carry out minor surgical procedures, and perform
other complex tasks in the absence of a physician or medical doctor [13]. This act
was developed to favor the task-shifting policy that aims in addressing health work-
force shortage in rural areas, with very specic, but constrained needs. Task-shifting
has been successfully used in Tanzania to increase access to anti-retroviral therapy,
family planning, and the treatment of malaria and tuberculosis; but it does not
address the broader issues related to preventive and primary health care needs in the
country. It also does not take into consideration that nurses in Tanzania are profes-
sionals. The nurse practitioner role is not task-shifting; it is an advanced practice
specialization. As the largest group of health care professionals in the country,
nurses are one of the best resources for solving issues of health care access as
advanced practice nurses.
The International Council of Nurses [14] denes the advanced practice nurse as
follows:
A registered nurse who has acquired the expert knowledge base, complex decision-making
skills and clinical competencies for advanced practice, the characteristics of which are
shaped by the context and/or country in which he/she is credentialed. [15]
According to the Tanzania Nursing and Midwifery Council Scope of Practice docu-
ment (2014), an advanced nurse practitioner is “a registered nurse who has com-
pleted specic advanced nursing education and training in the diagnosis and
management of common as well as complex medical conditions” [13].
The Initiative
Kilimanjaro Christian Medical University College (KCMUCo) Faculty of Nursing
at Moshi, in northern Tanzania, has been working in partnership with Duke
University School of Nursing (DUSON), based in the United States, to develop a
Family Nurse Practitioner (FNP) program. This APN specialty is educated to deliver
primary and acute care for patients at all stages of life. The Family Nurse Practitioner
has been successfully providing comprehensive health care in the United States for
more than 50years. The program is intended to cover the shortages of physicians,
especially in rural areas, by allowing educated and competent nurses to assess, diag-
nose, and treat common illness in primary health care facilities.
To provide a baseline of need for Tanzania, a needs assessment (GAP analysis)
was conducted by KCMUCo faculty members and DUSON to assess the realities of
The Nurse Practitioner Role inTa n zani a
250
nursing in four rural regions of Tanzania. These data demonstrated several important
ndings. Tanzanian nurses, medical professionals, health care administrators, and
community members were all positive that an advanced nursing role would benet
Tanza nia . Nu rs es al so s ta te d th at t hey kn ew they wer e pr ac tic ing ab ove thei r ed uc a-
tional limitations but were compelled to take care of the patients when no other pro-
viders were available. They were caught in a moral dilemma and recognized they
needed more education. The nurses participating in the study represented all levels of
nursing, but the majority were either certicate or diploma level nurses. Only a few
had been trained by task-shifting programs. As such the majority of nurses
working in the rural areas are working beyond their level of education preparation
and are not covered by the legal authorities or regulatory bodies and sometimes
face legal implications when a patient has a negative outcome [7].
In 2015, in order to stimulate conversation about the Family Nurse Practitioner’s
role, a consensus-building conference was organized in Arusha, Tanzania. All
potential stakeholders were invited to attend: the Tanzanian Ministry of Health,
Tanzanian Nursing and Midwifery Council, Tanzanian Commission for Education,
representatives from the medical and nursing professional organizations, and from
Tanzanian schools of nursing. Following the conference, KCMUCo was given per-
mission by the Tanzanian Ministry of Health to start a pilot FNP program. The
Ministry of Education, Science, and Technology was also informed [16].
Since that time, the rst faculty member from KCMUCo has obtained a master’s
level degree as an FNP from the University of Botswana and is currently continuing
to teach students and practice at KCMUCo. The process of developing a program
has been slow but continues on. The Aga Khan University in Tanzania is expected
to launch the rst APN program. The curriculum is currently approved by the
Tanzania Commission for Universities (TCU) and the Ministry of Health (MoH).
The program will be offered at the master’s level and is expected to begin enrolling
nursing students in 2023. It is a signicant step forward for the country in terms of
implementing the APN role. The APN program will provide nurses with opportuni-
ties for career advancement and encourage continuing professional development,
which is critical given that nurses from developing countries frequently relocate to
developed countries in search of better pay and opportunities for advancement.
NP Educational Preparation
The fundamental level of nursing practice and access to an adequate level of nursing
education that exists in a country shapes the potential for introducing and develop-
ing Advanced Practice Nursing [15]. There is some disagreement over the level of
education necessary to practice as a family nurse practitioner; however, it is very
dependent on the needs of the country. Given the fact that the majority of nurses
residing in rural Tanzania hold a certicate or a diploma qualication, it would be
challenging to raise them to the master’s degree level. Therefore, the consensus
meeting agreed that nurses could be trained at the bachelor’s level with re- evaluation
of this decision over time [7]. It is reasonable that many Tanzanian nurses who are
J. K. Trinitas and J. Blood-Siegfried
251
currently diploma trained would be well prepared to practice as nurse practitioners
through advanced training at the bachelor’s level. Additionally, earning a bachelor’s
degree would signicantly aid in their career advancement and enable them to have
more nancial security. There is precedence for this decision. The FNP role was
successfully implemented in the United States, Botswana, and many other countries
as a certicate program, or at the bachelor’s level. These have evolved over time to
the standard master’s level preparation. Holding a diploma degree with an average
of B+ or a GPA of 3.5 and at least two years of experience and an RN license are
adequate prerequisites for admission to the nurse practitioner baccalaureate
program.
Tanzania faces a number of difculties in providing advanced training for rural
nurses. While they pursue further education, the majority must continue to work at
their health facilities. The lack of rural health care providers would only get worse
if these important players are removed from an already overburdened health system
to attend a university. Therefore, it is signicant to employ the distance learning
approach as an effective method to increase both the skills and the numbers of quali-
ed health care workers capable of meeting the health care needs of the Tanzanian
population. Educational institutions offering advanced training for nurse practitio-
ners should give preference to hiring nurses who are willing to live and work in rural
areas and assist them in staying in their communities throughout their educational
program by using distance-based teaching methods delivered via internet or cell
phone technology, supplemented by brief on-campus visits.
Challenges totheImplementation oftheAdvanced
Practice Nursing
The APN role implementation is complicated and needs signicant pre-planning to
effectively introduce the role and dene how it differs from that of other profession-
als. Eliminating the obstacles to APN practice is crucial to increase utilization of
these effective and efcient health care providers [17]. Despite all the progress that
has been accomplished in implementing the APN role in Tanzania, many barriers
still exist.
There is recognition of a greater role for nurses but a lack of regulation and title
protection for advanced nursing practice. This barrier exists at the organizational
level whereby the lack of human resource planning and standardized job descrip-
tions leads to the inability to practice within the full scope of the APN [18]. There is
a lack of understanding of the role of an APN and the benets it offers to the health
care of the nation. This imparts a resistance to change that engenders a lack of sup-
port for the role. Resolving these barriers involves complex advance planning for
introduction, mentoring, and taking into account the overlap between an APN and
other professions.
Sangster-Gormley etal. [18] assert that a lack of understanding and aware-
ness of the APN role may cause other professions to oppose adopting it.
Physicians often object to the role’s implementation because they believe that
The Nurse Practitioner Role inTa n zani a
252
APNs will take over some of their duties and roles as professionals [19].
Therefore, the physician community’s unfamiliarity about the APN is a key bar-
rier to implementing the role within any health care organization. Physicians
must be provided the opportunity to gain understanding about the APN’s func-
tion, scope of practice, and competences. This can be a slow and painstaking
process, and this challenge exists in Tanzania as well as in many other countries
around the world.
The primary element that restricts the APNs’ scope of practice is the absence of
a designated role and workplace. Since the APN position has not yet been estab-
lished in Tanzania’s primary health care system, distinct work positions for APNs
are not recognized and available in the clinical setting. Having a designated work-
place and role denition is crucial to facilitate communication and collaboration
with the health care team [20].
Although many nurses in Tanzania may be practicing in a task-shifting role, it is
not an advanced nursing practice. The task-shifting policy allows nurses to practice
beyond their extended roles without advanced practice licensing. Nurses are trained
and given certicates to handle one specic set of tasks but are not covered under
Tanzanian law.
Another large barrier is the education of this cadre of nurses. There is a signi-
cant absence of doctorally prepared faculty members capable of educating students
at the master’s level which delays the development of the APN role. External fund-
ing sources are difcult to obtain which will inhibit the number of educational pro-
grams available in Tanzania. The government should view this as an opportunity for
expanding and improving health care services toward promoting universal health
coverage (UHC).
Recommendation
One of the primary strategies for meeting Sustainable Developmental Goals (SDGs)
involves building local capacity in a culturally appropriate manner that increases the
acceptability and sustainability of new programs. The implementation of the nurse
practitioner role will help Tanzania advance toward achieving the SDGs by enhanc-
ing local access to qualied health care services that are compatible with their cul-
tural norms. The APN role will supplement the number of providers critical to
providing primary care in rural Tanzania.
The Tanzanian government has been working to improve its highly specialized
medical services in order to reach international standards. The scope and quality of
specialized and super-specialized services will be expanded in all zonal, special-
ized, and national hospitals. The goal is to eliminate the need to refer patients
abroad, while at the same time introducing medical tourism to Tanzania. The APN
would augment health care and provide an opportunity to allow more specialized
programs to be introduced and implemented.
To facilitate the operation of educational programs, a serious increase in the
number of competent and qualied faculty members will be needed to instruct this
J. K. Trinitas and J. Blood-Siegfried
253
new cadre of professional nurses. Programs need to be developed that will promote
and retain APNs in the rural areas where care is most needed as well as enhance
Tanzanians’ capacity to create programs that are specically tailored to Tanzania’s
health requirements.
Governmental support for the role and updated legislation by the Tanzanian
Nursing and Midwifery council (TNMC) to promote regulation and jobs for the new
nurses is critical. The 2014 TNMC Act [13] must be revisited to allow the expansion
of the current advanced practice nursing role, which includes title protection, role
clarity, educational ladder, supportive regulations, and payment policies. As a result,
more nurses will be encouraged to remain and practice in the rural settings to reduce
health care disparities. It will be an advantage for Tanzania to have another nursing
specialty which holds global recognition.
This growing workforce has become integral to sustaining health care needs,
especially in rural and underserved areas in many parts of the world. Although the
integration of APN roles into the skill mix of health care delivery is challenging,
the idea of strategic planning is fundamental to the development of roles and the
planning of the workforce. The protection of the public and of patients, as well as
the advancement of nursing professional standards, depends on the regulation of
APN roles [21]. In order to develop an APN that delivers high quality, safe, ef-
cient, and effective health services to patients and populations, it is crucial to
apply validated advanced nursing practice models and frameworks, establish clear
scope of practice standards, and embed interprofessional education. It is impor-
tant to note that the APN is fundamentally a nursing role, built on nursing princi-
ples aiming to provide the optimal capacity to enhance and maximize
comprehensive health care services. The APN is not seen as competing with other
health care providers, nor is the adoption of their domains seen as the essence of
APN practice.
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J. K. Trinitas and J. Blood-Siegfried
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The Evolution andFuture ofNurse
Practitioners inNew Zealand
SueAdams andJennyCarryer
Background
Aotearoa New Zealand (New Zealand) is located in the South Pacic Ocean and is
of similar geographic size to the United Kingdom and Japan. It consists of two main
islands, the North Island (Te-Ika-a-Maui), dominated by volcanic hills and moun-
tains; the South Island (Te Wai Pounamu), where the Southern Alps form a moun-
tainous backbone; and many smaller off-shore islands. The population of New
Zealand is just over ve million people, with 77% living on the warmer North
Island, and 16.3% living rurally. There are four main ethnic groups: Māori, the
Indigenous people of the land, or tāngata whenua (16.5%); European (70.2%);
Pacic (8.1%); and Asian (15.1%). Just over 27% are born overseas (StatsNZ, [1]).
New Zealand is a bicultural nation with the Treaty of Waitangi (Te Tiriti o Waitangi)
widely considered as the founding and constitutional document. While this docu-
ment guides the relationship between the Crown (in New Zealand) and Māori,
Treaty rights are often not explicitly stated in legislation and therefore not enforced
[2]. A recent Waitangi Tribunal inquiry (2019) highlighted breaches of Te Tiriti o
Waitangi in relation to Māori health and equity; funding for Māori health organiza-
tions; pay and conditions for the Māori workforce (particularly nursing and the
S. Adams (*)
School of Nursing, University of Auckland, Auckland, New Zealand
e-mail: s.adams@auckland.ac.nz
J. Carryer
School of Nursing, Massey University, Palmerston North, New Zealand
e-mail: j.b.carryer@massey.ac.nz
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_19
256
unregulated health workforce); and lack of career opportunities for Māori in the
health sector. Indigenous marginalization through colonial practices and racism has
resulted in grossly inequitable socio-economic and health outcomes, which persist,
for both Māori and Pacic peoples [3, 4].
The Introduction oftheNurse Practitioner Role inNew Zealand
In the late 1990s, a Ministerial Taskforce on Nursing [5] made recommendations to
the Ministry of Health to enable nursing to realize its full potential in its contribu-
tion to the health of New Zealanders. The imperative to develop advanced clinical
nursing roles, including nurse prescriber and nurse practitioner roles was central to
the report. Despite some early controversy, including between nursing professional
groups [6], consensus was reached with nursing leaders determining that Nurse
Practitioner would be a new scope of practice, regulated by the Nursing Council of
New Zealand (the Nursing Council) [7]. This move has been signicant for the pro-
tection of the NP role, allowing ongoing regulatory and legislative changes, leading
to a revised scope of practice in 2017 [8]. However, the implementation of the NP
role into practice settings has remained largely ad hoc, with no national workforce
policy directing NP integration.
The rst NP was registered in New Zealand over twenty years ago in 2001.
While the growth of the NP workforce was slow over the rst fteen years, gradual
acceptance of the role together with increased funding to train NPs has seen the
number of NPs double over the past four years to 630 NPs by March 2022 (Fig.1).
However, Māori and Pacic NPs are under-represented in the NP workforce, with
9% being Māori, 2% Pacic, and 79% European (Fig.2). Addressing workforce
inequity to promote health outcomes for Māori, and Pacic, is a necessary priority.
0
100
200
300
400
500
600
700
800
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Registered NPs
Year
Total number of NPs registered with NCNZ
through to end March 2023
Fig. 1 The growth of the NP workforce in New Zealand)
S. Adams and J. Carryer
257
0102030405060708 0
European/Pākehā
MELAA/Other
Asian
Pacific Peoples
Māori
Percentage
Ethnicity
NP numbers
Aotearoa NewZealand
popula"on
09
Fig. 2 The ethnicity of the NP workforce compared to the overall population of Aotearoa at the
end of February 2022. (Figure reproduced from [10, p.2], with permission)
Table 1 Nurse practitioner scope of practice in New Zealand
Nurse practitioners have advanced education, clinical training and the demonstrated
competence and legal authority to practise beyond the level of a registered nurse. Nurse
practitioners work autonomously and in collaborative teams with other health professionals to
promote health, prevent disease and improve access and population health outcomes for a
specic patient group or community.
Nurse practitioners manage episodes of care as the lead healthcare provider in partnership
with health consumers and their families/whānau (extended family). Nurse practitioners
combine advanced nursing knowledge and skills with diagnostic reasoning and therapeutic
knowledge to provide patient-centred healthcare services including the diagnosis and
management of health consumers with common and complex health conditions. They
provide a wide range of assessment and treatment interventions, ordering and interpreting
diagnostic and laboratory tests, prescribing medicines within their area of competence and
admitting and discharging from hospital and other healthcare services/settings. As clinical
leaders they work across healthcare settings and inuence health service delivery and the
wider profession.
NCNZ [8]
Scope ofNurse Practitioner Practice
The evolution of the role of NPs in New Zealand has been challenging, with multiple
changes required to legislation, regulation, and education [7]. The result of ongoing
advocacy and action has resulted in a broad and permissive scope of NP practice
(Table1). Nurse Practitioners are authorized prescribers, with access to the full New
Zealand prescribing formulary, governed by PHARMAC; are able to order a full
range of diagnostic tests; refer to specialists; and undertake procedures previously
reserved for medical doctors, such as certifying death and issuing sick and injury
certicates [8, 11]. Nurse Practitioners practice autonomously and independently
The Evolution andFuture ofNurse Practitioners inNew Zealand
258
(without protocol or supervision) and increasingly are establishing NP-led services
in the public and private sector to meet gaps in health service provision.
Nurse Practitioner Education
The function of the Nursing Council, under the Health Practitioners Competence
Assurance Act 2003, is to protect the health and safety of the public by setting
scopes of practice, qualication and competency requirements, and standards of
education to ensure regulated nurses are t to practise. To achieve registration, NPs
have to be experienced registered nurses with a clinical master’s degree in nursing
and have demonstrated the required advanced practice nursing competencies [12].
The NP educational pathway generally takes at least four years during which the
registered nurse is working clinically while undertaking part-time postgraduate
study. While eight tertiary education providers are accredited to deliver an NP pro-
gram, four universities produce 90% of all NPs. The nal year of the master’s pro-
gramme is an advanced practice practicum with academic course content during
which the NP trainees have 500hours of super-numerary supervised clinical prac-
tice (either from an NP or from a medical doctor). NP trainees are supported by NP
academic mentors and are required to complete case studies and objective struc-
tured clinical examinations (OSCEs). At the end of this nal practicum year, the NP
trainees are required to complete a portfolio demonstrating their NP competencies
[12]. The portfolio is then submitted to the Nursing Council and the NP trainees are
assessed by a panel of experienced NPs. As soon as NPs are registered, they can
begin practice as an NP.
Growing thePrimary Healthcare Nurse Practitioner Workforce
The original intent of the introduction of NPs into the health workforce was to
improve access to healthcare and promote health equity [13]. However, without
national strategy, NP positions were developed where the nurses themselves drove
the service development, and often within acute care settings. Implementing NPs in
the primary healthcare sector, dominated by physician privately owned businesses,
was problematic [14]. Approximately 60% of NPs in New Zealand work in clinical
settings broadly dened as primary healthcare, including general (family) practice
(roughly 40%), urgent care, aged residential care, community mental health and
addiction services, and local health or third sector providers serving priority, and
often underserved, communities [15]. Of these, approximately 14% work rurally.
Nurse practitioners in New Zealand are able to deliver comprehensive primary care
services. They can enrol patients, having their own caseload (or panel) and access
national and regional funding in the same way as general practitioners (family phy-
sicians). Consequently, NPs are lling signicant gaps in primary care provision in
both permanent positions in family practices and covering short-term general prac-
titioner vacancies.
S. Adams and J. Carryer
259
Positioning theNurse Practitioner Workforce fortheFuture
Within New Zealand, the visibility of the NP workforce is nally gaining national
attention [9]. In August 2022, the government committed to fund 100 training places
per year through a national consortium of up to six universities, representing a ve-
fold increase in the number of fully funded NP training places since 2016. As with
many countries, New Zealand is facing a severe health workforce crisis, which
intensied through COVID-19, though was in the making long before. General
practitioner vacancies have increased in the past two years, evidenced by advertise-
ments for NPs that far exceeds the available workforce. The 100 training places will
be inadequate by 2025 given the rising demand for NPs. Yet while this demand
grows, we argue that the NP profession is at a watershed moment in history. There
are decisions for the NP profession to make within a health system grappling with
its future structure and direction. Firstly, how will the NP profession position their
contribution to the health of the nation; and secondly, how will they inform health
policy to ensure their role is successfully integrated into practice, delivering health-
care that meets the health needs of local communities.
In July 2022, New Zealand embarked on health reforms [16] following the Health
and Disability System Review [17]. This followed decades of rhetoric within
national and regional health policy to prioritize health and social care, particularly
for Māori, to improve health outcomes. The Review stipulated the health system
must shift its focus towards primary healthcare and use co-designed locality
approaches to integrate health and social care services and improve healthcare
access and equity. The health reforms offer a considerable opportunity for the NP
workforce to work alongside local communities to design and deliver culturally safe
healthcare to prioritized population groups, including Māori, and Pacic, peoples;
people living with complex comorbidities; and others who are vulnerable and mar-
ginalized within society. It is in this space, where NPs work is grounded in a social
justice paradigm, that the greatest gains for population health can be achieved
[18–22].
The intent of the NP role in New Zealand as envisaged by nursing leadership
was to identify and meet health needs of local communities by delivering a cul-
turally safe model of healthcare that bridged biomedicine and nursing [7].
Within the primary healthcare sector, a diverse range of NP service delivery
models have evolved reective of the multiple organizational and business mod-
els in operation. Mainstream primary care is delivered by for-prot small busi-
ness and corporate entities, while trust or not-for-prot providers tend to deliver
services to underserved, rural or marginalized communities. It is the NPs who
practise outside of mainstream primary care who are most able to work innova-
tively and transformationally with community groups such as youth, gender
diverse, homeless, young mothers, isolated older adults, refugees, as well as
people living with social and health complexity, including mental health and
addiction issues. We have previously raised the importance of research that
focuses on the short- and long-term outcomes of such transformative care deliv-
ered by NPs [19].
The Evolution andFuture ofNurse Practitioners inNew Zealand
260
At the same time the shortage of general practitioners is leading to a pressing
demand for NPs to work within those mainstream practices under a funding and
care delivery model that is not always conducive to the best use of NPs’ skills
and philosophical approach to practice [20, 22]. The international evidence that
NPs deliver at least equivalent health outcomes to family physicians and often
superior health outcomes is compelling [23, 24]. The unique disciplinary knowl-
edge of nursing, Wood [22] argues, forms the basis of NP practice and the “qual-
ities that generate high levels of patient satisfaction and improve patient
outcomes, [are] a direct result of NP led care” (p.51). The challenge for New
Zealand, and likely other countries, is whether NPs will be subsumed within the
biomedical paradigm, working as substitutes for medical practitioners, or
whether they will hold true to the intentions of the NP role, to deliver meaning-
ful, culturally safe, and holistic care alongside careful diagnosis and prescribing
practices [25].
Nurse Practitioners asAgents ofTransformational Change
A critical next step for the NP profession in New Zealand to optimize their value
and contribution is to develop frameworks for the successful integration of NP
roles into primary healthcare settings. To date this has been ad hoc [14]. Barriers
and facilitators have been described internationally [26] and documented in New
Zealand [10, 14, 27], identifying multiple factors at play within complex settings.
Attention needs to be paid to role transition, professional autonomy, teamwork
and collegiality, professional development, funding and organizational systems
and processes. Additionally, NPs “advocate, inuence and manage innovative
changes to healthcare services to improve access, equity of outcomes, quality and
cost- effective healthcare for specic groups or populations” [28, p.5]. This core
competence of NP practice reects the expected leadership skills required of NPs
to work with local communities to deliver appropriate services. Given that more
and more NPs are registering each year, there is an imperative to ensure that a
range of mechanisms is in place locally and nationally to enable NPs to ourish
at work.
The NP role in New Zealand is at a tipping point where NPs are being recognized
as a potential signicant health workforce. The next phase of the evolution of the
NP role in New Zealand is to protect and nurture NPs as agents of transformation of
health service delivery, rather than being perceived as props in a struggling system
of care delivery. The biomedical model of care is not t for purpose in the face of
increasing prevalence of long-term conditions, escalating mental illness and addic-
tion, and the known close links between poor health and socio-economic determi-
nants. Nurse practitioners understand the complexity and interplay between health
and our social world. With their relational and enablement skills, knowledge of
local communities and combined nursing and medical skills, NPs are a critical
resource for transforming the way primary healthcare is delivered.
S. Adams and J. Carryer
261
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263
Transforming Healthcare: TheAustralian
Nurse Practitioner Role
ChristopherHelms andLeanneBoase
Introduction
Australia’s land mass is vast, with a population of approximately 26million spread
across eight states and territories. The population is primarily concentrated in large
metropolitan centers on the continent’s coastlines. However, 10% of Australians are
geographically isolated in outer regional and remote communities, which are sepa-
rated from metropolitan and inner regional centers by hundreds of kilometers of
aging highways and dirt roads [1]. Infrastructure supporting residents in these com-
munities is poor, with over one-third experiencing overcrowded housing, and 75%
of Australia without mobile phone or internet coverage [2]. These factors, and other
critical social determinants of health mean that access to healthcare is poor in
regional and remote areas, with a resulting mortality rate that is 1.5 times higher
than persons living in metropolitan areas [3].
cReconciliation and Acknowledgment of Country Australia is on a journey
toward reconciling our collective history, by acknowledging the wrongs
committed to Aboriginal and/or Torres Strait Islander persons and communities
since colonization. The adverse effects of past genocide, the destruction of
social and cultural structures, including local traditions upholding cultural
beliefs and connection to country, as well as the ongoing effects of
intergenerational trauma and racism on First Nations persons health and
C. Helms
Charles Darwin University, Casuarina, NT, Australia
e-mail: christopher.helms@cdu.edu.au
L. Boase (*)
Australian College of Nurse Practitioners, Melbourne, VIC, Australia
LaTrobe University, Bundoora, VIC, Australia
e-mail: Leanne.boase@acnp.org.au
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_20
264
wellbeing is a real and constant threat to Aboriginal and Torres Strait
Islander safety.
In an effort to address institutional racism and promote equity in Aboriginal
and Torres Strait Islander health outcomes, Australia’s health practitioner
regulator has embedded the requirement for Cultural Safety in health
practitioner legislation (Ahpra, 2022). This means that all nurses and midwives
are held professionally accountable in assuring Culturally Safe healthcare in
their practice and work environments.
Culturally Safe healthcare begins with understanding, respecting, and
reflecting upon differences. The health and wellbeing of Australia’s First
Nations peoples is indelibly linked to Australia’s land, seas, and skies. When
opening conferences, official ceremonies, or meetings, it is customary to
receive a Welcome to Country by an Indigenous elder. If you are a visitor to
Australia, and are speaking or presenting at one of these events, an
Acknowledgment of Country would be welcomed by Australia’s First Nations
peoples.
There are many ways to acknowledge country. An example acknowledgment
is provided below, and should be reflected upon and delivered with meaning:
I wish to acknowledge the traditional custodians of the lands upon
which we meet today. I pay respects to and acknowledge their continuing
culture, and their connection with land, sea, and sky. I pay respects to
those Elders and knowledge holders who may be with us today, as well
as those past and emerging. These are your lands and will always be.
Australia is home to many Aboriginal and Torres Strait Islander persons and
communities, who hold the histories, health traditions, and social practices of the
oldest continuous culture in the world. Australia’s First Nations peoples have
employed effective health and wellbeing practices for over 65,000 years. However,
since colonization in 1788, they have suffered from an increasing burden of disease
and ill-health that has been perpetuated by genocide, the destruction of social and
cultural structures, systemic racism, and the dispossession of lands with which they
hold a unique and enduring spiritual connection. These factors have resulted in
extraordinarily high morbidity and premature mortality, with Australia’s First
Nations peoples experiencing an age-standardized rate of death 1.7 times that of
non-Indigenous Australians [4].
The Australian Nurse Practitioner (NP) role began in the early 1990s, with nurs-
ing leaders identifying the untapped potential of the nursing profession to holisti-
cally address healthcare gaps in these, and many other marginalized populations
and contexts [5]. Since then, the role has matured considerably over the last three
decades. Like many other countries who have introduced the NP role into a system
traditionally governed through medical hegemony, the role has encountered barriers
C. Helms and L. Boase
265
to practice that are being systemically challenged by nursing leaders [6–9]. This
chapter describes the origins of the Australian NP role and current workforce demo-
graphics. It then provides an overview of how nursing views advanced practice in
Australia, and how it relates to the education and regulation of NPs. The funding
and legislative frameworks supporting the role are described, and this chapter con-
cludes with an overview of the future strategic direction of the role, with a discus-
sion on how the nursing profession is seeking to eliminate practice barriers to ensure
the NP workforce is working effectively, efciently, and to the top of their scope of
practice.
Origins oftheAustralian Nurse Practitioner Role
cNurse Practitioners as Disrupters Bower and Christensen [10] first described
the theory of disruptive innovation as applied to business, whereby a smaller
company (the disrupter) with relatively few resources can eventually challenge
a larger, well-established business (the sustaining incumbent) with
substantially greater resources.
This process is accomplished over time by the disrupter focusing its efforts
on products and services for a tightly defined market with lower profitability.
That market has been ignored by the incumbent, in favor of products that
sustain mainstream consumers, as well as more profitable markets. Eventually,
as the smaller business refines and improves its products and services, it
begins to expand its reach into the mainstream market with greater services.
Eventually the disrupter displaces the incumbent in the mainstream market as
consumers recognize the disrupter’s services and products as meeting their
needs. There are many examples of disruptive innovation in the industry, such
as those products developed by Netflix and Apple. Importantly, the process of
disruption takes time, and many attempts at disruption fail due to a lack of
strategic thinking and momentum.
The theory of disruptive innovation has been successfully applied to
healthcare and importantly, to nurse practitioners [11]. In the Australian
context, nurse practitioners could be viewed as disrupters, noting the sustainers
(medical practitioners) have recognized NPs working independently and to
their full scope of practice as threats, and have implemented strategies to
undermine, subsume, and control them. This is seen in the Australian context
and in other countries around the world. Unfortunately, the Australian medical
fraternity does not recognize that the intent of the NP role is not to replace or
substitute, but complement existing workforce capabilities. This lack of
foresight has meant that marginalized communities continue to struggle with
access to timely, effective, and efficient healthcare in the Australian context,
resulting in an unnecessarily high burden of disease and ill-health.
Transforming Healthcare: TheAustralian Nurse Practitioner Role
266
This section provides an overview of the historical development of the NP role in
Australia. It aligns this discussion with the theory of disruptive innovation [10]. We
do so because, although disruptive innovation was only rst discussed at a time
when the NP role was in its infancy in Australia, the concepts surrounding the the-
ory are ultimately responsible for the role’s initial successes and ongoing chal-
lenges. We feel that applying the theory of disruptive innovation to our learnings
would be helpful for other countries in the early stages of role legitimization and
development.
The historical origins of the NP role in Australia are well documented [12]. A
series of debates, working groups, and discussion papers led by the nursing profes-
sion culminated in governmental support to fund ten demonstration projects in the
state of New South Wales (NSW) in the early 1990s. The purpose of those projects
was to show the added value, safety, and ability of registered nurses (RN) to practice
in roles approximating that of the NP role, as described from the literature arising
from the United States and United Kingdom. The medical profession at large was
vociferously opposed to this body of work at the outset and had signicant concerns
over “nursing independence” and “doctor substitution.”
Those concerns ultimately inuenced the ways in which the demonstration proj-
ects were designed, studied, and reported, as well as how the role was operational-
ized during the rst ten years of its development in the Australian context. For
example, the medical profession did not want the evaluation design of the projects
to be randomized controlled trials (RCT) that compared NP versus medical practi-
tioner care, but favored projects having a descriptive study design, resulting in only
two of the project sites using RCT designs [6]. The trend of favoring descriptive
studies for NP models of care continued throughout the rst decade of role develop-
ment in Australia, and has been critiqued for their poor implementation delity [13],
which makes it difcult to identify and compare outcomes across differing models
of NP-directed care.
In addition, the projects were limited to marginalized communities and those
with poor access to care, including regional and remote communities, outreach
clinics for sex workers and homeless populations, and in discrete specialty areas
that were underserved or undervalued by the medical profession. The projects
allowed RNs working in advanced roles to “supplement” traditional medical roles
by allowing them to diagnose and treat a limited range of conditions. Practice
guidelines, as well as medication, diagnostic pathology, and imaging protocols
were used to support autonomous practice within a narrow area for discrete health
conditions, but not independent practice across a large range of conditions.
Guidelines and protocols mandated by legislation that directed NP care were quite
prescriptive and found to unnecessarily limit NPs from achieving their fullest
capabilities [14]; they took years to abolish and had the unintended consequence
of stunting the expansion of NPs from working beyond discrete specialty and
subspecialty areas during the rst decade of role implementation. These limita-
tions provided assurances to medical practitioners that nurses would have a lower
likelihood to serve as competitors (i.e., through substitution models) in the health-
care market. Overall, the NSW demonstration projects were successful in
C. Helms and L. Boase
267
demonstrating RN safety and ability to implement the NP role [15], which led to
other Australian states and territories developing similar projects that provided
comparable outcomes [16–18]. In 1998, NSW nurses gained legislative title pro-
tection for the NP role, which was a key milestone in legitimizing and advancing
the role in Australia. Soon after, legislation was changed to enable the autono-
mous prescribing of medicines and to practice independently. In 2000, the rst
two NPs were authorized to practice in a generalist remote context and in emer-
gency nursing. Other Australian states and territories followed with legislated title
protection, as well as changes to their medicines legislation in a disjointed and
incremental manner.
The statements published by the media from medical unions and professional
associations at the time of the demonstration projects bordered on hysteria. They
demonstrated a lack of respect for the nursing profession, voiced fears of siloed
approaches to healthcare, demonstrated medical non-collaboration, and frequently
bordered on slander. The use of media to perpetuate medical hegemony has contin-
ued today, and is continually problematic for the nursing profession who is repre-
sented in less than 2% of media articles relating to health and health policy [19].
This is slowly changing with the advent of social media, with greater numbers of
nurses engaging with the media, health consumers, politicians, and professional
bodies through various platforms. Interestingly, the voices of health consumers
were relatively absent during the rst decade of NP role development. This has
changed substantially, with greater recognition of the important role health consum-
ers play in advocating for NPs and their ability to support community health and
wellbeing.
The nursing profession quickly recognized that a professional body was required
for promotion and advocacy for the NP role, and for continuing education, coordi-
nation, and collaboration among early NP leaders. The Australian Nurse Practitioner
Association was established after amalgamation of separate state-based NP interest
groups in 2003, and became the Australian College of Nurse Practitioners (ACNP)
in 2009. Today, the ACNP has an increasing political and health policy footprint
with policymakers, health consumers, politicians, and health systems administrators
at a national level. It advocates for NPs working to their full scope of practice, so
that all Australians have access to high quality healthcare.
In summary, the Australian NP role is on a journey toward disruptive innovation.
It has its origins in, and has had its greatest impact through helping communities
that are marginalized or underserved by traditional medical models of care. NPs
began with tightly controlled and limited clinical scopes of practice that have
evolved over time to meet dynamic population needs, which is further described in
the following sections. This has allowed NPs to stay somewhat “under the radar” of
medicine, and allowed them to develop a growing identity as trusted and well-
regarded clinicians in the communities they serve. Health consumers are increas-
ingly advocating for the NP role, which has resulted in Australian NPs strategically
establishing themselves in mainstream primary healthcare. Nurse practitioners are
not yet disruptive innovators within Australian healthcare. With time, strategic
direction, growth, and perseverance, they will be.
Transforming Healthcare: TheAustralian Nurse Practitioner Role
268
Workforce
Since 2000 there has been a slow but steady growth of the NP workforce across all
Australian states and territories. As of 2022 there were approximately 2500 NPs
practicing in Australia, representing 0.01% of the total RN workforce [20]. Figure1
below provides an overview of the total numbers and distribution of NPs in each
jurisdiction, as well as their compound annual growth rate (CAGR) over a period of
ten years. Workforce growth rates through CAGR or other similar measures can be
used to draw inferences on the health of a growing NP workforce through time. One
expects the CAGR to increase with a newly established workforce, and decline and
stabilize as the NP workforce matures and saturates the market. Australia’s average
CAGR over its eight jurisdictions was 14% from 2010–2020. It is important to note
that some jurisdictions, such as the Northern Territory and Western Australia, have
smaller numbers of NPs that are distributed across large areas of land with relatively
small populations. These factors may overstate the relative CAGR when comparing
differing jurisdictions.
In comparison with New Zealand, which introduced the NP role at a similar time
to Australia and has comparable education and regulatory frameworks governing
entry to practice for NPs, the CAGR was 20% over nine years across the entire
country [21]. Available literature suggests jurisdictions with legislation and policies
that enable scope of practice using a right-touch regulatory approach [22, 23], with
roles supported by funding that enables clinical practice [24], as well as candidacy
and professional support programs (such as communities of practice [25] and well-
designed clinical placements for NP students [26]), promote NP workforce growth
and model of care expansion. Therefore, these are current and future strategic prior-
ity areas for Australian NP workforce development.
We
sternAustralia
Northern Territory
South Australia
Victoria
Australian CapitalTerritory
Tasmania
New SouthWales
Queensland
629total NPs
16%CAGRover10years
12 NPsper 100,000 pop.
557 totalNPs
14% CAGR over 10 years
7NPs per 100,000 pop.
59 totalNPs
10% CAGR over 10 year
s
13 NPsper 100,000
pop.
50 totalNPs
11%CAGR over 10 years
9NPs per 100,000 pop.
581 totalNPs
22% CAGR over 10 years
9NPs per100,000 pop.
194total NPs
13% CAGR over 10 years
11 NPsper 100,000 pop.
293 totalNPs
11% CAGR over 10 years
11 NPsper 100,000 pop.
35 totalNPs
15% CAGR over 10 years
14 NPsper 100,000 pop.
Fig. 1 Australian nurse practitioners—jurisdictional registrations (as of March 2022)
C. Helms and L. Boase
269
There are many factors that have inuenced workforce growth in Australia. Until
recently, there were no published logic models or national workforce strategies used
for developing and evaluating NP models of care. This has likely contributed to a
lack of strategic momentum in the development of the Australian NP workforce. In
addition, jurisdictions have implemented NP policy and legislation incrementally
and in a disjointed fashion, which has led to confusion about the capabilities of the
NP role among nurses, educators, health consumers, governments, and the broader
health professions. Unfortunately, compelling Australian research has also found
that nursing itself has, at times, undermined the NP role [27]. Fortunately, Australia’s
NP workforce has gained momentum over the past decade, as Australia’s nursing
leaders have unied in their understanding and appreciation of the NP role and its
value-add to broader health initiatives.
Impact ofFunding onWorkforce
Funding to enable clinical practice has played a signicant and lasting role in the
historical development of the NP workforce. Australia enjoys universal healthcare;
all eligible residents have access to comprehensive primary healthcare and hospital
services that are free of charge or subsidized by taxpayer funding. Traditionally,
NPs have worked for public sector health departments, where healthcare for eligible
residents is made freely available in hospitals and outpatient clinics run by state and
territory governments. Before 2010, almost all NPs worked in the public sector.
Today, approximately 72% of employed NPs work in the public sector, with the
remaining working in the private sector [28]. Concerningly, not all NPs working in
the public sector are employed in named positions due to various employer-related
factors. Such factors include the higher costs of employment, a lack of strategic
workforce planning, and an inability to fully realize the benets of the role due to
workplace-based restrictions arising from a system designed to enable medical
practitioners, as opposed to NPs. For example, many NPs working in the public sec-
tor are unable to prescribe medicines or request diagnostic examinations to their full
scope of practice due to poor local planning and unsupportive local policies. Recent
data published by the Australian Commonwealth indicates up to 28% of NPs are not
employed or working in named roles [29], and are therefore unable to practice to
their full potential and contribute to health system reform.
The private sector offers a slightly different picture. In 2010, funding reforms
were enacted by the Australian Commonwealth, which enabled patient subsidies for
the costs of NP-directed healthcare in the private primary healthcare sector [30].
Previously, health consumers or employers in the private sector paid the full costs of
NP-directed care, which limited growth in a market where care obtained from medi-
cal practitioners was oftentimes fully subsidized. As opposed to the public sector,
which is nancially supported by the states and territories, health consumers in the
private sector receive nancial subsidies from the Commonwealth and private insur-
ers. Limitations on these funding subsidies have been differentially applied to health
consumers choosing to seek care from an NP, where doctor-led care has access to a
Transforming Healthcare: TheAustralian Nurse Practitioner Role
270
much greater suite of subsidies for professional services, medicines, and diagnostic
imaging services [31]. This was a policy mechanism enacted in 2010 by the
Australian Commonwealth that was led by aggressive medical lobbying to regulate
NP clinical scope of practice and reduce the ability of the NP workforce to create a
competitive primary healthcare market. This policy decision has led to the unin-
tended consequence of some private sector NPs shifting their target markets away
from marginalized communities and populations to mainstream markets, who have
a greater ability to pay for the costs of NP-directed healthcare [32].
The 2010 funding reforms have been one of the key enablers for NP workforce
development in primary healthcare in the last decade. The costs of professional
attendances (including telehealth), prescribed medicines, requested examinations
(i.e., diagnostic imaging and pathology), and referrals to medical specialists are
partly subsidized through these changes. Generally, due to the competitive nature of
the private sector, NPs have fewer local policy restrictions governing their practice,
as employers are motivated to enable their workforce to work to their fullest abili-
ties in an efcient and effective manner. This has resulted in a growing exodus of
NPs from the public sector, where they are enabled to develop innovative models of
primary healthcare and demonstrate their value-add to the system. However, there
are substantial limitations to the subsidy of these services [24], which continues to
limit growth in the private primary healthcare sector due to ongoing NP concerns of
shifting healthcare costs to health consumers.
In addition, aggressive medical lobbying in 2010 resulted in the Commonwealth
government legislating the requirement for collaborative arrangements for NPs work-
ing in the private sector. Mandated collaborative arrangements do not restrict the abil-
ity of NPs to practice independently or restrict their scope of practice. However, they
are required for patient subsidies for NP-directed healthcare in the private primary
healthcare sector. The unintended consequences of this policy decision have disad-
vantaged health consumers and NPs alike, as some medical practitioners have chosen
not to collaborate with NPs at the sacrice of multidisciplinary patient-centered care,
have resulted in unnecessary duplication of care and care silos, have resulted in higher
out-of-pocket costs for health consumers choosing an NP as their healthcare provider,
and have blurred lines of medicolegal accountability [9, 33].
Scope ofPractice Considerations
In Australia, scope of practice is determined by the individual NP, their employer,
and legislation. Core practice activities unique to the NP role compared to other
advanced practice nurses in Australia include their ability to independently:
• assess, diagnose and treat patients;
• prescribe medicines;
• request and interpret diagnostic imaging;
• request and interpret diagnostic pathology; and
• refer to allied health and medical specialists for management.
C. Helms and L. Boase
271
Independent practice, as applied to the above core activities, is what differenti-
ates the NP role from other autonomous advanced practice nursing roles in Australia.
Funding for the above core activities impacts greatly upon the ability of NPs to
actualize their scopes of practice in both the public and private sectors. In the public
sector, NPs are limited in their ability to perform core activities required of their
roles due to local and jurisdictional policy mechanisms. In the private sector, NPs
are primarily limited by the scope of patient subsidies for NP-directed care versus
those available for doctor-directed care. NPs in the private sector frequently self-
impose limitations to their scope of practice due to concerns of unnecessarily shift-
ing healthcare costs to health consumers [34].
The discrete populations and areas in which Australian NPs have developed their
practice have resulted in a plethora of specialties. The Australian NP workforce
consists of over 50 different specialty and subspecialty areas [35], with the biggest
cohort working in hospital-based emergency and urgent care services. The second-
largest cohort are those NPs working in primary care contexts, and include many
who are working in aged care, mental health, and other generalist and specialist
areas of practice [28]. From the perspective of clinical learning and teaching, the
plethora of specialties has made the educational governance of NP students particu-
larly challenging, with students in the same specialty graduating from their NP pro-
grams with considerably different clinical scopes of practice and abilities [36]. It is
recognized the proliferation of differing specialty areas has contributed to issues of
health consumers, service providers, policymakers, and health practitioners not
understanding the true scope and capabilities of the NP role [37].
cThe Australian Nurse Practitioner Metaspecialties
• Primary healthcare
• Aging and palliative care
• Emergency and acute care
• Child and family healthcare
• Mental healthcare
• Chronic and complex care
These issues led to empirical research that developed the Australian metaspecial-
ties, which provide a framework for the development of NP students and their clini-
cal scopes of practice [38]. A metaspecialty “groups specialty and subspecialty
areas of NP clinical practice into broad population groups requiring similar knowl-
edge, skills and expertise” [39]. They are similar in concept to the USA NP popula-
tion foci in that they are used in a framework to describe clinical educational
requirements for NP students, but differ in the fact the metaspecialties are not meant
to be used in a mutually exclusive manner [40]. It is hoped as the metaspecialty
framework is implemented and further developed in education programs, it contrib-
utes to a consistent and reliable NP workforce whose scope of practice is able to
better evolve with dynamic health system needs.
Transforming Healthcare: TheAustralian Nurse Practitioner Role
272
Education andRegulation
Australian NPs are perhaps unique compared to other countries in that they are
required to demonstrate an advanced level of nursing practice before they are eli-
gible for entry into an NP education program. Advanced nursing practice in Australia
is dened by a level of practice, and is not determined by a title, employment status,
or remuneration [41]. A large body of empirical evidence has conrmed this con-
struct of advanced practice by adapting the Strong Model of Advanced Practice to
the Australian context [42–44]. A tool has been developed from this research, which
can be used by nurses, employers, and educationalists to assist in determining level
of practice and readiness for an NP education program [45].
Australian standards for NP educational programs were rst established in 2004
[46, 47]. Education programs are at the master’s degree level, and are externally
accredited using national standards regularly reviewed and published by the
Australian Nursing and Midwifery Accreditation Council [48]. Currently there are
13 approved NP programs of study that range from 18–36 months’ duration.
Eligibility for an NP education program includes the following:
• Current general registration as an RN
• A minimum of two years’ full-time experience (FTE) working as an RN in an
area of practice
• A minimum of two years’ FTE working at an advanced level in this same area of
practice
• A postgraduate qualication in a clinically relevant area
This means that most NP students hold a minimum of eight years’ education and
training before being allowed to enter an education program. Some feel these
requirements are onerous, and have contributed to the slow development of the
Australian NP workforce [49]. A review of the education and training of Australian
nurses was recently conducted by the Commonwealth and promises to change the
ways in which all Australian nurses are educated and trained [50]. This review and
other initiatives may have an impact on how NP education programs are delivered
into the future.
Once students have completed their NP education program and have accumu-
lated a minimum of three years’ advanced practice, they are eligible for endorse-
ment as an NP through the national nursing regulator. The Nursing and Midwifery
Board of Australia (NMBA) is the national regulator for nurses and midwives, and
publish standards, guidelines, and frameworks on the expected behaviors, actions,
and practices the public should expect from NPs to maintain a safe level of practice
[51–54]. Once the individual has received the NMBA’s endorsement, they are listed
on a public register, allowed to use the NP title, and are authorized to practice in all
Australian states and territories.
The NMBA does not regulate an individual NP’s clinical scope of practice. This
is primarily the responsibility of the individual, and is supported by employer
C. Helms and L. Boase
273
clinical governance, legislation, and/or credentialing frameworks [55]. Nurse prac-
titioners are authorized to independently perform all core activities required of their
roles through state and territory legislation. For example, they are authorized to
prescribe in all Australian jurisdictions, but are prohibited from prescribing specic
medicines reserved for medical specialists or for certain purposes. To illustrate, NPs
are currently unable to prescribe medicines used for medical termination of preg-
nancy, voluntary assisted dying, or prescribe oral isotretinoin for treatment- resistant
acne across all jurisdictions. Nurse practitioners can request most diagnostic imag-
ing tests, including those that expose to ionizing radiation, although nancial subsi-
dies for requested imaging examinations are limited.
Supplementary activities are regulated through legislation and include those that
NPs perform to reduce care duplication, enhance care provision, or complete an
episode of care. They relate to specic authorized activities, ofcial assessments, or
paperwork required for administrative purposes. For example, driver’s license med-
ical paperwork, workplace injury (capacity) and death certicates, and participation
in the voluntary assisted dying process are all examples of supplementary activities.
Nurse practitioners are currently unable to perform many important supplemental
activities across Australia, with only two jurisdictions allowing NP authorization of
workplace injury (capacity) certicates. Nurse practitioners are authorized to per-
form specic roles in the voluntary assisted dying process in some Australian juris-
dictions (Table1).
ACT NSW QLD VIC NT TAS WA SA
Example Core Activities
Prescribe Schedule 2, 3, 4, and 8 Medicines
-Medical Marijuana
-Medical Termination of Pregnancy
Request diagnostic imaging
Request diagnostic pathology
Example Supplemental Activities
Authorise absence from work certificates
Voluntary assisted dying N/A N/A
Authorise death certificates
Authorise driver’s license medicals
Authorise workplace injury (capacity) certificates ** ***
ACT: Australian Capital Territory; NSW: New South Wales; QLD: Queensland; VIC: Victoria; NT: Northern Territory; TAS:
Tasmania; WA: Western Australia; SA: South Australia
N/A: These territories currently do not have legislation permitting voluntary assisted dying
**: A certificate can only be issued for up to seven days.
***: A certificate can only be issued by emergency department NPs for up to seven days.
Work is currently underway to harmonize legislation across Australianjurisdictions, but this is a proces
s
complicated by resistance from medical bodies, political whim, and disjointed workforce strategies.
Table 1 Nurse practitioner state and territory scope of practice authorizations
N/A: These territories currently do not have legislation permitting voluntary assisted dying
ACT Australian Capital Territory; NSW New South Wales; QLD Queensland; VIC Victoria; NT
Northern Territory; TAS Tasmania; WA Western Australia; SA South Australia
**A certicate can only be issued for up to seven days
***A certicate can only be issued by emergency department NPs for up to seven days
Transforming Healthcare: TheAustralian Nurse Practitioner Role
274
Work is currently under way to harmonize legislation across Australian jurisdic-
tions, but this is a process complicated by resistance from medical bodies, political
whim, and disjointed workforce strategies.
The Future oftheAustralian Nurse Practitioner Workforce
To continue our journey toward disruptive innovation, and to fully enable the NP
role in Australia, strategic thinking and legislative reform are essential. Our strate-
gic priorities must address the expansion of funding models for NP-directed care,
harmonize prescribing legislation, address barriers arising from legislatively man-
dated collaborative arrangements, resolve issues relating to public and employer
understanding of the NP role, and enable supplemental activities required for the
efcient and effective use of the workforce. In addition, improvements to the clini-
cal education and training of NP students, as well as the development of a national
workforce evaluation dataset are important priorities for our strategic work.
A national review of government subsidies for health services provided by NPs
occurred in 2018. Recommendations for funding reform were supported by exten-
sive evidence [56], as well as a cost-benet analysis commissioned by the Australian
government [57]. Despite this evidence, and widespread nursing and health con-
sumer support for those recommendations, a taskforce overwhelmingly represented
by medicine provided unsubstantiated and unrealistic substitute recommendations.
This highlights the importance of nursing having a representative seat at the policy
table, or risk exclusion. This has served as a galvanizing moment for nursing, whose
various professional associations, bodies, and unions have united to push for more
meaningful workforce reform. In 2023, Australia is currently nalising its very rst
national strategic nursing and NP workforce plans, which aim to better train and
utilize the workforce, by enabling it to work to its fullest capabilities.
Unlike the USA, legislatively mandated collaborative arrangements in Australia
relate entirely to nancial subsidies for health consumers who obtain NP-directed
care in the private sector. They do not limit the ability of NPs to perform activities
required of their roles or work independently, nor do they directly restrict an NP’s
clinical scope of practice. They enable limited nancial subsidies for prescribed
medicines, requested diagnostic and screening examinations, and health services
provided by NPs. The legislative requirement for these arrangements is currently
being reviewed at a national level. Again, medicine is attempting to inuence the
outcome of proposed legislative reform relating to these arrangements, and seeks to
use them to further restrict and regulate NP clinical scope of practice. If medicine is
successful in its inuence, it will likely have an adverse impact on the growth of
innovative models of care in the private health sector and continue to serve as a
mechanism to shift costs of healthcare delivery away from the government to mar-
ginalized and disadvantaged populations.
Limitations to prescribing and supplemental activities could largely be addressed
in a similar manner to New Zealand. In 2018, New Zealand amended its various
health acts and regulations by replacing the term “medical practitioner” with “health
C. Helms and L. Boase
275
practitioner.” This enabled NPs to authorize, certify, and prescribe in much the same
way as medical practitioners. Undoubtedly this “right-touch” regulatory approach
would be the most efcient and effective way of improving access to care in
Australia. However, opposition to the NP role here would appear to make this
unlikely.
Conclusion
We are on a journey toward enhancing the clinical education of NP students and
normalizing the Australian NP role. We are not simply an addition to healthcare, but
as an essential part of an optimized multidisciplinary healthcare team. Australian
NPs are not a substitute for any other health practitioner, nor do we aim to be com-
petitors. However, in the interests of the marginalized and disadvantaged popula-
tions we serve, we intend to be disruptors and are here to stay.
The nursing profession comprises the largest cohort of regulated health practitio-
ners in Australia. We now speak with one voice in support of the NP role. There are
established and regulated pathways for clinically based nurses to fully utilize their
experience and education, and ultimately expand and extend their practice toward
an even more autonomous and independent role.
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C. Helms and L. Boase
279
The Nurse Practitioner (NP)
Role inSri Lanka
SujeewaDilhaniMaithreepala
andSriyaniPadmalathaKonara Mudiyanselage
Abbreviations
B.Sc. Bachelor of Sciences
ICN International Council of Nurses
ICU Intensive Care Unit
MOH Ministry of Health
NCD Noncommunicable Disease
NP Nurse Practitioner
NTS Nurses Training Schools
OT Operation Theatre
OOP Out-of-Pocket
PBS Post-Basic School of Nursing
S. D. Maithreepala
Department of Nursing, College of Medicine, National Cheng Kung University,
Tainan, Taiwan
Department of Nursing, Faculty of Allied Health Sciences, University of Peradeniya,
Peradeniya, Sri Lanka
e-mail: sujeemaithreepala@ahs.pdn.ac.lk
S. P. Konara Mudiyanselage (*)
Department of Nursing, College of Medicine, National Cheng Kung University,
Tainan, Taiwan
Operation Theatre Department, The National Hospital of Sri Lanka, Colombo, Sri Lanka
National Cheng Kung University, NCKU 1 University Road, Tainan, Taiwan
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_21
280
PBU Premature Baby Unit
PHNO Public Health Nursing Ofcer
PPE Personal Protective Equipment
RN Registered Nurse
SLNA Sri Lanka Nurses Association
UGC University Grants Commission
Introduction
Background toSri Lanka
Sri Lanka (Ceylon) is a beautiful island in the Indian Ocean with a land mass of
approximately 65,610 square km [1]. The political system and government are demo-
cratic [2]. It is considered a lower-middle-income country [3], and the estimated cur-
rent population is approximately 21million [4]. Women’s life expectancy is 78.6years,
and males’ is 72years [5]. The country possesses seven United Nations Educational,
Scientic and Cultural Organization (UNESCO) World Heritage sites [1].
Healthcare System inSri Lanka
The Sri Lankan health system consists of the state and private sectors. The main-
stream of services in the country, 95% of together with inpatient care and outpatient
care are provided by the state sector and 50% of total abulatoray care [6]. In addi-
tion, the state/public sector provides free health services for all Sri Lankans [3]. The
main administrative body for health is the Ministry of Health (MOH), and Indigenous
Medicine in Sri Lanka aims to provide comprehensive and effective health services
to the nation. Healthcare systems broadly address curative, preventive, and rehabili-
tative services [2] through a well-established system of networks through different
levels of hospitals from rural hospitals to tertiary care. In addition, community
health centers are located nationwide to facilitate access to care for most of the
population [7]. The MOH is not limited to provide health care; it also involves in
framing health policy and guidelines, developing and managing specialized medical
institutions, and purchasing all medical supplies in bulk through the Department of
Health Services [2]. Also they may includes educational training for healthcare pro-
fessionals for research and public health, including maternal and child health, com-
municable diseases, and etc. [8].
The private sector primarily offers ambulatory, some inpatient, and rehabilitative
care with different capacities of complexity. The private sector facilities are run and
nanced by out-of-pocket (OOP) payments by individuals or families, and a small
amount of private health insurance plans cooperate with employers. In recent years,
OOP expenditures have increased dramatically and stood at 51% of current health
expenditures [6].
S. D. Maithreepala and S. P. Konara Mudiyanselage
281
History ofMedicine andNursing inSri Lanka
Historical evidence shows that the Buddhist monks in the fth century performed
medicinal practices and had institutionalized training with hospitals called “Halls of
Care.” This was mainly to provide care to sick monks. Buddhism inuenced the
country’s ancient kings to establish hospitals for sick people, primarily to practice
and develop the traditional “Ayurveda” (traditional indigenous medicine). From 437
to 346B.C., there is some evidence of the existence of hospitals and maternity
homes for the community called “Sotti Shala and Sivica Shala” [9]. In 1505 Sri
Lanka was colonized by the Portuguese, providing evidence of the introduction to
Western medicine. This inuenced Sri Lanka’s healthcare system signicantly, and
Western medicine became the primary practice in the country under the state [2].
The effect of the undertaking of Western medicine in Sri Lanka inuenced the
establishment of institutionalized nursing education [10].
Developing Professionalism inNursing
andEducation Milestones
Sri Lanka obtained independence from British rule in 1948 [11]. The colonization
of the Portuguese (1505) and the British Ceylon period (1815–1948) resulted in the
initiation of traditional Western medicine, and it positively inuenced the establish-
ment of institutionalized nursing education [9]. Formal nursing education is essen-
tially hospital-based/clinical oriented that was initially spearheaded by an
apprenticeship modeled from the British nursing tradition. The rst nursing school
was established in 1939 as the School of Nursing in Colombo. This led to the devel-
opment and entrenchment of another 16 Nurses Training Schools (NTS) (NTS—
Anuradhapura, Ampara, Badulla, Batticaloa, Galle, Hambantota, Jaffna,
Jayawardanapura, Kalutara, Kandana, Kandy, Kurunegala, Matara, Mulleriyawa,
Ratnapura, Vavuniya) [10, 12]. These educational institutions provide 3-year
diploma-level nursing education. NTSs follow a national-level curriculum which
includes signicant subjects such as medical-surgical, psychiatric nursing, pediatric
nursing, and maternal nursing. Most diploma nurses will integrate into the govern-
ment healthcare system as they were attached to the Ministry of health based on
pre-registration for nursing [12]. In addition, the Post-Basic School of Nursing
(PBS) in Colombo further supports continuing nursing education in specialized
areas. It also provides training programs about teaching and supervision and man-
agement for qualied nurses [13].
Establishment ofUndergraduate Nursing Education
In 2005, the rst conventional university-based Bachelor of Sciences (B.Sc.)
(Honors) in Nursing program was established at the University of Sri
Jayewardenepura. This is a 4-year program for nursing undergraduates. The
The Nurse Practitioner (NP) Role inSri Lanka
282
selection criteria differ from the normal process of recruiting nurses from MOH.If
secondary school graduates want to apply for a government university nursing pro-
gram, they should follow the biology stream and meet the required Z-score values
[14] for university entrance. The selection is made through the University Grants
Commission under the Ministry of Higher Education. However, the nurses recruited
by MOH were based on a certain amount of Z-score value and an interview by
selected NTS.The B.Sc. nursing curriculum was enriched and advanced through
subject matter experts and other relevant stakeholders. Currently, ve conventional
universities offer the B.Sc. in Nursing: The University of Sri Jayewardenepura
(2005), the University of Peradeniya (2006), the University of Ruhuna (2008), the
University of Jaffna (2006), and the Eastern University (2006). The nursing faculty
may attach to the faculty of medicine, healthcare sciences, or the faculty of Allied
Health Sciences. One more degree-offering faculty started recently at the University
of Colombo has uniqueness as it is the only nursing faculty in Sri Lanka [12, 14]. In
addition to these six state universities that offer a 4-year undergraduate nursing
program, two other institutions offer B.Sc. (Honors) programs: Open University, Sri
Lanka, and the General Sir John Kotelawala Defense University [14]. Open
University is the rst institution, starting in 1994, which provides the B.Sc. Degree
for diploma-qualied government nurses to preserve their higher education [13]. In
addition to these universities, some private institutions offer B.Sc. in Nursing in Sri
Lanka. There needs to be a well-established policy or guideline to rank these differ-
ent systems-oriented graduates [14].
Recruitment andCredentials inNursing Sri Lanka
Formal nursing education and licensing as a Registered Nurse (RN) are essential
qualications to work in the state healthcare system. The Sri Lanka Nursing Council
is the formal body to provide credentials as a RN [14] and Registered Midwife
(RM). This is only offered for the nurses who obtained their diplomas or degrees
from government-sponsored institutions, and these nurses could be either NTS
diploma holders or B.Sc. graduates from conventional universities recognized by
the University Grants Commission (UGC). However, the B.Sc. graduates should
have completed a 6-month orientation and coordination course before being permit-
ted to work as a hospital staff nurse from NTS.They also need to obtain formal
appointment letters from the MOH since they were not pre-registered to the MOH,
Sri Lanka. Sri Lanka Nurses Association (SLNA) was established in 1943 to get
professional membership for nurses who work as RN.This council also advocates
enhancing professional nursing practice, nursing standards, and support for prevent-
ing ergonomics from improving nurses’ working conditions. It is also afliated with
the International Council of Nurses (ICN) [15].
However, recruitment and credential are different for nurses in private healthcare
settings. These nurses recruit and train by the employer based on their vocational
requirements, and there are no general standardized recruitment or credential crite-
ria for them. Still, they are not eligible for RN certicate from the Nursing Council
S. D. Maithreepala and S. P. Konara Mudiyanselage
283
in Sri Lanka. However, some accredited private hospitals have their own standard-
ized, individualized nurse practice with adiquate qualications. In addition, some
short-term specialized foreign pieces of training, such as wound care management,
ostomy care, bariatric surgery, bone marrow transplant, etc., are sponsored by pri-
vate healthcare institutions.
Nurse Practitioner Role inSri Lanka
The backbone of the Sri Lankan healthcare system is nurses. They play a signicant
role in curative, preventive, health promotive, and rehabilitative care in health in
both curative and community care settings. However, there is no dened role of a
Nurse Practitioner (NP) in the Sri Lankan healthcare setting. Most practicing nurses
in government healthcare contribute to direct patient care [16]. Nurses and mid-
wives who work in primary care settings consistently achieved good health indica-
tors in the past years. However, changing disease patterns and subsequent disease
burden signies the necessity of changes and modications in nursing education
and healthcare delivery [17]. MOH, combined with NTS and the Faculty of
Medicine, has conducted short-term specialized training for RN with more than
2–5years of experience, such as 6-month operation theatre (OT) training, intensive
care (ICU) training, premature baby care unit (PBU) training, midwifery training,
etc. Then they can register as a specialized training nurse such as midwifery nurses,
OT nurses, ICU nurses, etc. Furthermore, the MOH has introduced a promotion-
based training program conducted by PBS.Only RNs who have worked in govern-
ment hospitals for more than 5years can apply for these types of training to be nurse
managers (ward sisters), nurse educators (tutors), and public health nurse managers
(public health sisters). The total training period contains 18months of theory and
practice, including a 6-month midwifery course for female nurses and 6-month psy-
chiatric training for male nurses [9].
The higher education institutes of nursing, which provide bachelor’s in nursing
degrees, provide some courses like basic statistics, scientic writing, and research
methodology that are helpful for nurses to be competent in scientic research. In
addition, the rst and only master’s in a nursing program approved with the require-
ment of Sri Lanka Quality Framework (SLQF) guidelines is in progress. However,
no formal published evidence is available for this, as it was proposed and approved
during 2019–2020. This will be another turning point for Sri Lanka nurses to select
some specialized elds and contribute to the nurse practitioner concept in the
upcoming years.
In 2017, MOH recruited specialized nurses to the community healthcare centers
(wellness centers) around the country as public health nursing ofcers (PHNO).
Initially, 100 RNs with two government hospital experiences were enrolled as a
pilot project. These nurses have individualized rights to prescribe pain medications,
wound care, ostomy care, and noncommunicable disease (NCD) management [18].
In the future, these PHNOs will be community nurse practitioners. However, the
process will be postponed for the next 2years.
The Nurse Practitioner (NP) Role inSri Lanka
284
Challenges andIssues
Access to resources and standards of nursing services, lack of evidence-based prac-
tice, challenging nursing higher education during the pandemic, severe economic
breakdown, and poor access to information technology and digital health are some
challenges and issues in the Sri Lankan setting. Medical supplies, like personal
protective equipment (PPE), were scarce during the COVID-19 pandemic in Sri
Lanka. Like in many countries, there was signicant nurse burnout and turnover
rates which resulted in some recent issues and challenges in clinical practice. These
equally affected nursing students as they had poor access to the internet during their
participation in online classrooms. They lack of well-designed virtual reality or
simulation-based training which could have helped during the pandemic for their
clinical training. High technology-based teaching is a challenge for the future edu-
cation as Sri Lanka has been under severe economic collapse in 2021 and 2022. The
effect of this economic and political crisis is still in progress, recording a high ina-
tion rate. This also directly affects medical supplies and people’s health, as children
and adults are at high risk of malnutrition.
Evidence-based nursing is another big area for improvement. To improve patient
reported out come, nurses may need to learn and improve their research skills to
integrate decision-making into patient care and knowledge development in nursing
practice. International collaboration and guidance for standard nursing practice and
updated nursing education are other aspects that nurse educators and managers need
to address in Sri Lanka.
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287
Advanced Nursing Practice in the
Kingdom of Saudi Arabia
SiobhanRothwell
Introduction
The Kingdom of Saudi Arabia (KSA), founded in 1932, has a recorded history of
nursing which precedes this date by hundreds of years [1]. Rufaida Al-Asalmiya,
born around AD 620, was the daughter of a physician, is considered to be the rst
Islamic nurse, and was a companion to the Prophet Mohamed (PBUH) [2, 3]. She,
among other women, provided basic care and support during the Holy Wars and in
peace time, and was instrumental in the evolution of nursing care (Al-Osimy, cited
in [2]). This evolution included the founding of a nursing school to teach nursing
skills to other women, engagement in social care for those aficted with disease,
and particular commitment to the support of orphans and older persons. This noble
contribution to the sick, to healthcare, and to the education of women has been
largely forgotten and deserves mention in the discussion surrounding the global
evolution of nursing [3].
Saudi Arabia, situated on the Arabian Peninsula is the largest country in western
Asia, with a population of over 36million people [4]. A country that was nomadic
in nature has now become more settled since the discovery of oil in the 1930s [5].
Over 87% of the population is now urbanized and spans from the west of Eastern
Province to Mecca and Medina [5].
S. Rothwell (*)
Dublin City University, Dublin, Ireland
e-mail: siobhan.rothwell@dcu.ie
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_22
288
Nursing inSaudi Arabia
The global evolution of nursing, notably the advanced practice nurse (APN) role has
been in response to patient and healthcare needs [6]. The benets and challenges of
the role have been well documented since its inception, particularly centered around
the patriarchal nature of healthcare and medicine as well as barriers at the system
level [7–10]. Despite early pride in the profession in the time of Rufaida Al-Asalmiya,
nursing in KSA, in and of itself has struggled to have the profession viewed in a
positive light [11]. Respectability, or lack thereof, related to social and cultural fac-
tors, has meant it has been difcult to recruit and retain, particularly females, to the
profession of nursing [12, 13]. The heavy reliance on expatriate nurses has been
multifactorial, but primarily due to rapid expansion of the health services in KSA in
the 1980s and lack of local capacity or skill mix to support this effort [14].
A Royal Decree in 1992 introduced the concept of Saudization, a process to
increase the number of Saudi nationals into the workforce [1]. According to The
Statistical Yearbook, published by the Ministry of Health (MOH) in 2020, 43% of
the nursing population were Saudis, an increase of 6% since 2016. [15]. This illus-
trates some effort to increase the number of local nurses as the dependency on expa-
triate healthcare workers is tenuous given risks associated with international
relations, local disasters, and, as has been seen recently, global pandemics [16].
However, there is still concern regarding the Kingdom’s ability to increase the local
workforce within the healthcare system to meet the 2030 goals [17].
In recent years, shifts in cultural norms have begun to change the face of KSA.In
2016, the Kingdom published Vision 2030, a blueprint of strategic objectives which
aims to develop the country socially and economically with a specic focus on gov-
ernment accountability, transparency, and modernization [18]. Among a number of
strategic objectives, the health of the nation is considered paramount and emphasis
has been placed on enhancing hospital care as well as preventive medicine and the
development of the primary care sector [18]. There is an urgent need for further
investment in infrastructure, human resources, and technology, as well as medical
and nursing education to increase the number of Saudi graduates to achieve the
goals as outlined in Vision 2030 [19]. Improving access to healthcare services, a
catalyst for the evolution of advanced practice internationally, has been seen as an
opportunity to initiate the formal development of the APN role in the Kingdom
[20, 21].
Advanced Practice Nursing inSaudi Arabia
Madrean Schober [22] describes the impetus required to drive APN role develop-
ment which also needs to consider local context. This should include healthcare
needs, skill mix, workforce issues, the need to advance the profession, and improve
access to healthcare. These issues exist in KSA, and with a projected increase in
population, improvement in life expectancy, increases in chronic illness, and inad-
equate hospital capacity and primary healthcare facilities, the healthcare needs in
S. Rothwell
289
the Kingdom will continue to rise [19, 23, 24]. As in many other countries, physi-
cian shortages also exist [25]. However, given the issues with recruitment and reten-
tion of registered nurses, the question is asked whether now is the time to develop
the APN role [26]. Hibbert etal. [21] propounded the need for a culturally sensitive
APN model in line with international guidelines while acknowledging the need to
increase the number of highly trained graduate nurses. The issue of APN role per-
ception among the healthcare community and policy makers as an identied barrier
needs to be addressed, and given the variation in understanding and regulation of the
role, this could be a signicant challenge to overcome [27].
The provision of advanced nursing education is considered to be a conventional
starting point in the development of the APN role [22]. Master’s programs are con-
sidered the minimum level of education for advanced practice given the complexity
of the role with respect to decision-making, responsibility, and accountability [28].
In 2013 a collaborative relationship emerged between Dublin City University
(DCU), Ireland, and Princess Nourah bint Abdulrahman University (PNU) in
Riyadh, KSA.This collaboration saw the establishment of the rst master’s pro-
gram for advanced practice nursing in the Kingdom, delivered by DCU in PNU and
which commenced in 2017. Other universities in KSA started APN master’s-level
programs in 2022 while an advanced nursing practice diploma program has been
established by the Saudi Commission for Health Specialties (SCFHS) [29].
The ICN puts forward the need for country-specic regulatory mechanisms
which provide legislation and policies to support the authority required for the APN
role, including the protection of the title [28]. Currently there is no legal framework
in place in KSA [26]. Graduates of the DCU/PNU master’s program as well as
APNs who have graduated from universities overseas and work in advanced prac-
tice roles within their organizations, do so under local policy. This is not a new
concept in KSA, given that there is no nursing scope of practice for generalist nurses
[30]. The SCFHS regulates nurse classication and registration with respect to their
education, but their scope of practice is dictated by the organization within which
they work [30].
Currently, in KSA the advanced practice nurses and those undertaking the spe-
cic clinical component of their education are based in a variety of specialty areas
which include family care in primary healthcare clinics as well as in-hospital roles
in emergency care, oncology, organ transplantation, cardiology, bariatric surgery,
pre-operative clinics, colorectal, pelvic oor, pediatric care, and pain manage-
ment. The APNs work in collaboration with the multidisciplinary team and are
undertaking what is considered traditional roles of the advanced practice nurse
including advanced physical health assessments, clinical decision-making with
regard to treatment plans, diagnoses, health promotion, and patient and family
education. They also have privileges, such as ordering diagnostic investigations
such as blood tests and radiological tests and the prescription of medication which
vary in detail according to agreed local policies. While this is seen as a positive
step in role development at the organizational level, it is important to note that
there must be a move toward national regulations in KSA to facilitate the protec-
tion of the patient, the practitioner, and the organization [31–34]. KSA also lacks
Advanced Nursing Practice in the Kingdom of Saudi Arabia
290
an independent nursing regulatory body to oversee the practice and development
of the profession [26]. Currently the SCFHS is advised by a number of depart-
ments within the Commission—the Nursing Department, the Nursing Scientic
Council, and the Council of Professional Nursing Practice, all of whom report to
physicians [16, 35].
Next Steps
There is no internationally agreed upon starting point for initiating the APN role
[22]. However, once a start has been made, it is vital that all the necessary compo-
nents are addressed. With the increasing availability of APN programs in KSA, it is
now time to move to the next step in role development. There are over 160 graduates
from the DCU/PNU advanced practice program to date who await the advancement
of the APN initiative, and more graduates are expected. Robust undergraduate pro-
grams with access to specialty graduate programs is essential to grow the APN role
within the Kingdom [26, 36]. This will provide for the development of more career
pathways which can impact the public image of nursing and thereby contribute to
the retention of nurses once qualied [16]. There is a critical need for the creation
of legislative regulation including scope of practice, appropriate and standardized
education programs, protection of the APN title, credentialing and privileging, and
competency-based practice as undertaken internationally [28, 37–39]. Consideration
also needs to be given to appropriate remuneration by addressing how APNs should
be classied according to their advanced training and levels of responsibility within
the role [40]. Indeed, current online advertisements from companies in KSA look-
ing for ‘nurse practitioners’ offering low remuneration and vague job descriptions
lead to concern about how the role is perceived and who will ultimately benet. The
global experience has highlighted not only the benets of the APN role across
healthcare, but it has also provided a roadmap for the MOH and the SCFHS to
develop supportive legislative and regulatory processes to set professional stan-
dards, scopes of practice, and competencies which will contribute to the quality of
care as well as safeguards for the public and the practitioner [6, 28].
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Why Pakistan Needs Advanced Nurse
andAdvanced Midwife Practitioners
RafatJan, ArusaLakhani, AbeerMusaddique,
andYasminNadeemParpio
Background
Advanced Practitioner Nurses and Midwives are the registered nurses and midwives
with additional specialized experience and short-capacity-building trainings. They
are capable of examining, analyzing, diagnosing, admitting, and discharging
patients with undifferentiated health problems [1]. Globally, advanced nursing prac-
tice has arisen in response to the demand for enhanced services and results for
specied priority groups, increased access to treatment, shorter wait times, and cost
control in health care [2].
According to the International Council of Nursing, APNs are dened as “A reg-
istered nurse who has gained the skilled knowledge, tough decision-making skills
and clinical abilities for prolonged practice, the elements of which are designed by
the framework of the country in which they are granted for practice” [3].
In Pakistan, the rising demand for high-quality, expensive health care services
has placed a signicant burden on health care delivery regardless of level of treat-
ment. The brain drain of health care workers and scarcity of general nurses and
midwives are becoming more evident as the country is unable to offer adequate
remunerations to these professionals. Furthermore, having no formal title for serv-
ing their roles brings signicant impact on their incomes. A non-supportive regula-
tion for titles is also a major hindrance. The people, particularly women, children,
and the elderly in poor communities, believe that they need universal health cov-
erage [4].
Despite the fact, literature has shown that APNs have considerable impact on
health care quality and improvement in systems [4]. Pakistan’s health care system
R. Jan (*) · A. Lakhani · A. Musaddique · Y. N. Parpio
Aga Khan University, School of Nursing and Midwifery, Karachi, Pakistan
e-mail: rafat.jan@aku.edu; arusa.lakhani@aku.edu; abeer.musaddique@aku.edu;
yasmin.parpio@aku.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_23
294
places an extreme demand on APNs to create an effective system and address the
country’s health care needs. There are three primary reasons why Pakistan needs the
Advanced Nurse and Advanced Midwife Practitioners:
(a) Poverty, heavy population, and high number of vulnerable people
(b) Challenging physical geographies, from high mountains to vast deserts
(c) Natural and anthropogenic disasters
The brief descriptions of the aforementioned reasons are as follows:
Poverty, Heavy Population, andHigh Number
ofVulnerable Population
Poverty has been a common challenge for all countries, affecting the health depriva-
tions. The current population of Pakistan is230,674,750. About 100million people
are driven into extreme poverty each year because of out-of-pocket spending on
health. The World Bank (WB) estimates that poverty in Pakistan has increased from
4.4% to 5.4% in 2020, with over two million people having fallen below the poverty
line. Using the lower-middle-income poverty rate, the WB estimated that the
Pakistan’s poverty rate stood at 39.3% in 2020–21 and is expected to continue at
39.2% in 2021–22. Due to the heavy population, 40% of households in Pakistan [5]
experienced moderate to severe food insecurity, which inuences the global health
deprivation.
Despite global efforts, health inequalities remain widespread in developing
countries. In Pakistan, the maternal mortality rate (MMR) is 186 deaths per 100,000
live births, with around 251 fatalities per 100,000 live births due to pregnancy-
related complications, such as excessive bleeding after childbirth, infection, or
unsafe abortion [6]. Only 33% of women receive postnatal care within 6weeks of
childbirth. Similarly, the infant mortality rate (IMR) in Pakistan is exceptionally
high, at 60 per 100 live births [7]. In Pakistan, almost 40% of children are stunted
and 18% are wasted under 5years of age [8]. Furthermore, approximately 53,000
children die from diarrhea and 91,000 from pneumonia every year in Pakistan.
Given the prevalence and severity of health deprivation in Pakistan, a growing body
of literature has sought to explain the factors of health deprivations [9]. The epi-
demic interrupted health care and stretched countries’ health systems to their break-
ing point in 2020. The COVID-19 pandemic has the potential to stop two decades
of global progress toward Universal Health Coverage. Poverty and health care are
inextricably linked. Poor socioeconomic conditions (illiteracy, hunger, poor sanita-
tion, etc.) result in high mortality and morbidity, affecting people’s overall health.
As a result, there is a need for poverty-reduction strategies. The eastern Mediterranean
region has introduced the concepts of the community-based initiative Basic
Development Needs (BDN). Intersectional arrangements at the operational level
can be used to establish a connection with nursing. A nurse can thus be a part of the
BDN support team and can not only provide health and social services but also
R. Jan et al.
295
participate in the development of the community [10]. This has amplied the
urgency of accelerating efforts to develop robust and resilient health systems to
make progress toward Universal Health Coverage (UHC).
To achieve Universal Health Coverage (UHC) in low-income populations, coun-
tries must develop comprehensive action plans. Universal Health Coverage (UHC)
means that all individuals and communities have access to the health’s services
without risk of nancial hardships that includes the full range of essential and high-
quality health services, from health promotion to prevention, treatment, rehabilita-
tion, and palliative care throughout their lives. These services must be supplied by
competent and skilled health and care professionals with the right mix of abilities at
the institutional, outreach, and community levels, and they must be distributed,
receive adequate support, and have respectable jobs. The provision of these services
necessitates adequate and competent health and care professionals with an appropri-
ate skill mix at the facility, outreach, and community levels, who are equally dis-
persed, adequately supported, and have decent working conditions. By concentrating
on people’s needs and choices, a primary health care (PHC) approach can help
countries equitably maximize the level and distribution of health and well-being
(both as individuals and communities) [11]. The World Health Organization (WHO)
and the United Nations Children’s Fund (UNICEF) jointly documented a vision for
PHC in the twenty-rst century that combines three core components: multisector
policy and action; empowered people and communities; and primary care and
essential public health functions as the core of integrated health services [12]. By
combining these three components, PHC establishes the framework for the achieve-
ment of UHC and the health-related sustainable development goals (SDGs) [13].
Many poor countries provide good coverage of their territory with health facili-
ties but have limited access to services, because facilities lack the personnel required
to function normally.
There are numerous examples of developing countries that have a good network
of health care facilities yet limit access to treatments due to a shortage of staff for
the facilities to function properly [14]. Half of the world’s population lack access to
basic health services, including sexual and reproductive health care. Leaving no one
behind requires attention and action to the needs of women, adolescents, and the
most vulnerable and marginalized.
Challenging Geographies fromHigh Mountains
toSpread Deserts
Pakistan lies at the epicenter of a highly volatile geopolitical region, with multiple
decades of conict within the country and along its borders [15]. More than 90% of
the sevenmillion deaths in children under the age of ve occur in only 40 countries,
with most of the mortality occurring in a few South Asian countries. Health plan-
ners have been interested in geographic variation [16]. Pakistan, the world’s seventh
most populous country, has made economic development but is struggling to nd a
route to the SDGs. The health and population characteristics in the northern and
Why Pakistan Needs Advanced Nurse andAdvanced Midwife Practitioners
296
many challenging areas of Pakistan are high fertility, low life expectancy, a young
age structure, high maternal and child mortality, high incidence of infections and
communicable diseases, and a wide prevalence of malnutrition among children and
women. The country is unable to offer adequate health care providers toward the
challenging geographies and a demographic transition because of which it faces not
only the challenges of health care systems but also the increased burden of non-
communicable diseases [17–18]. A challenging geographical area creates difcul-
ties but provides an opportunity to gain experience by being creative, taking
initiative, and being resilient in addressing emergency cases. Nurses and midwives
have an integral role in providing high-quality health care, especially in the far-ung
regions where they may be the primary care provider in their community [19].
In addition to a lack of prioritization of care and signicantly limited resources
for sexual and reproductive health of adolescent girls and women, these challenging
geographies require nurse and midwife practitioners.
Natural andMan-Made Disasters
Natural disasters such as earthquakes, epidemics, and pandemics, and recent oods,
have affected 33million people, approx. 16million children, and resulted in an
estimated 1596 deaths (July to September 2022). During the recent ood disaster,
an estimated 4000 children, 650,000 pregnant women, and 73,000 births are
expected, while one million homes are damaged and the risk of gender-based vio-
lence increases [20–26]. The data is an estimate, whereas death, destruction, and
displacement are tragedies to the lives of women, young girls, and children in gen-
eral, and during disasters. Working as a nurse-midwife during various disasters
(earthquake, pandemic, ood) and leading teams from Kashmir’s earthquake to
COVID-19 pandemic to ood related disasters, many challenges were encountered
such as highly compromised sexual and reproductive health services and rights
(SRHR); severely lacking emergency obstetric services; gender-based violence and
sexual assault; missing of young girls and children from parents; lack of menstrual
hygiene and other physical hygiene; spread of malaria, Gastro-Intestinal diseases,
and other infections; stark deciency of nutrition supply for pregnant and breast-
feeding women and young girls; maldistribution of resources or storage of resources
by some powerful personalities; lack of inexistences of access to health care facili-
ties or health care in general, displacement trauma and exposure to harsh environ-
ment creating immense physical, emotional, and mental traumatic experiences; lack
of awareness about any policies regarding women and children, or priorities to deal
with during and post-disaster survivors.
A few studies to learn more about the calamities and their impacts, with the goal
of producing a standardized maternal health dataset for use in Pakistan and develop-
ing nations are required. There is lack of awareness about policies pertaining to
women and children, or priorities for dealing with victims during and after crises;
lack of access to health care facilities or health care in general; displacement trauma
R. Jan et al.
297
and exposure to harsh environment cause tremendous physical, emotional, and
mental traumatic experiences.
The study shows that the needs of Pakistani women, young girls, children, and
nurse-midwives (NMs) after disasters that population and health care providers
acknowledged the need to learn about the consequences of post-disaster survivors
as their own feelings and dilemmas that reveals the magnitude and effectiveness of
disasters [27]. However, they expressed lack of knowledge and abilities to manage
a burdensome task, questioned the health system in disaster, and reported disap-
pointment, grief, and powerlessness with the lack or absence of policies and effec-
tive disaster measures. Short-term volunteer and facility-introduced solutions
hindered nurse-midwives’ efforts to help themselves and survivors.
During the disaster, nurses and midwife practitioners used a variety of situation-
specic strategies, including (a) prioritizing care based on who needs emergency
obstetric care and who needs routine SRH services and who needs rights protection;
(b) attempting to remove or minimize vulnerability within the displacement or camp
location, such as providing privacy; preventing abuse; monitoring young girls, chil-
dren, and women (pregnant and breastfeeding women); (c) endorsing for the non-
separation of laboring women from their families, particularly from their husbands
and children; (d) helping children not to be separated from their parents; (e) assur-
ing safe care by NGOs or people known for child care to those who lost their par-
ents; (f) providing with team who would extend humble and respectful care; (g)
advocating for distribution of benets on an equal basis, particularly for women,
children, and young girls who are the most vulnerable in such circumstances; (h)
spending time with the team during emotional outbursts, crying, and emotional
trauma, and (i) resolving problems while advocating for patients and their families.
Some of the challenges are described in the literature [19–20], but post-disaster
trauma care remains unfold. All the above strategies would be impossible to imple-
ment without the assistance of advanced nurse and midwife practitioners.
The term “nurse practitioners” (also known as Advanced Practice Registered
Nurses) comprises four roles that encompass advanced practice nursing: nurse mid-
wives, nurse anesthetists, nurse practitioners, and clinical nurse specialists. Graduate
degrees are required for all four roles to qualify as a practitioner [28]. Nursing has
developed in Pakistan over the last 25years, whereas strong midwifery practitioner
models have existed for the last seven decades. Nursing begins with a 3-year
diploma and continues to undergraduate and graduate programs. The country estab-
lished a 2-year bachelor’s degree for nurses in the early 1990s, with a 3-year diploma
and a 1-year specialty diploma in any nursing discipline. Nursing leadership soon
realized the signicance and need for an internationally recognized 4-year under-
graduate program. The 4-year undergraduate degree was introduced in the country
in the late 1990s to improve patient care and career pathways in the profession. A
master’s degree and a doctorate in nursing were offered a decade ago to encourage
nurses to succeed in educational and clinical leadership and research. Today, nurses
in Pakistan aspire for the highest nursing degree in the profession. Similarly, mid-
wives are now obtaining undergraduate degrees, and this curriculum is now avail-
able through the university.
Why Pakistan Needs Advanced Nurse andAdvanced Midwife Practitioners
298
Prior to the country’s independence, Pakistan recognized midwifery as a profes-
sion in the early 1900s. In Pakistan, there are three types of midwives: nurse mid-
wives, registered nurses (RNs), and registered midwives (RM). Almost 90% of
registered nurses also have midwifery training. Another cadre is the community
midwife, who has completed 2years of midwifery practice and holds an RM desig-
nation. The nal cadre is that of a Lady Health Visitor (LHV), who completes
2years of studies at Public Health schools, including 1year of midwifery and 1year
of public health, and has a Lady Health Visitor designation and begins a private
maternity home or practices domiciliary midwifery. A 2-year undergraduate degree
known as post-RN Baccalaureate Studies in Midwifery already exists for registered
nurses. Aside from obstetricians, midwives are the best qualied health profession-
als to provide maternity and newborn care. The Pakistan Nursing Council (PNC) is
the governing organization for nurse education and licensure in Pakistan.
Admission criteria for nursing and midwifery
Field of study/degree program Duration Specialties/elds
Diploma in Nursing 3 years Registered Nurse (RN)
Diploma in Midwifery 1 year Registered Midwife (RM)
Diploma in Community Midwifery
(CMW)
2 years Registered Community
Midwife
Lady Health Visitors (LHVs) 2 years Registered LHV
Post-RN BSN
Bachelors after Post-RN
2 years
2 years
Registered Nurse (RN)
Direct Bachelor of Science in Nursing
(BScN)
4 years Registered Nurse
Master of Science in Nursing 2 years after BSN to
MSN
Add in License MSN
Doctoral Degree (PhD) 3 to 5 years Add in License PHD
Role ofNurses, LHVs, andMidwife Practitioners at Rural Health
Settings inPakistan
The Pakistani health care system is developing, and since the last few years it has
worked hard to enhance the quality of health care delivery and has implemented
numerous reforms [29].
The creation of Basic Health Units (BHUs) and Rural Health Centers (RHCs),
participation in the Millennium Development Goal (MDG) program, the introduc-
tion of Public-Private Partnership (PPP), and the development of vertical programs
are the key successes to Pakistan’s health system [30].
The state provides health care through a three-tiered system of primary, second-
ary, and tertiary level health facilities [31]. The majority of PHC facilities are fully
equipped with public health workers in Basic Health Units, which include Lady
Health Workers (LHWs), dispensers, midwives, and Lady Health Visitors (LHVs)
who are primarily responsible for health promotion, disease prevention, and pre-
referral treatment to the population in their catchment areas, particularly in
Pakistan’s rural areas. Secondary health services are given by tehsil hospitals and
R. Jan et al.
299
district hospitals, which are staffed with a small number of specialists doctors, med-
ical ofcers, and nurses, whereas tertiary care is provided by teaching hospitals.
The same three-tiered health delivery method is used in Pakistan’s Gilgit-
Baltistan region, though due to limited access, hard terrain, and harsh weather in
the region, health care human resources are a major constraint in providing health
services. Thus, an LHV/Registered Midwife working in health facilities or eld
health units, particularly for mothers and children, is the rst point of contact for
the people in this region. LHVs/RMs serve the community as practitioners by
offering pre-referral therapy and liaison with the region’s next level of care
facilities.
According to Pakistan Nursing Council (PNC), the midwives are responsible to
provide counselling and educating women, families, and the community about
health issues. She is able to keep an eye on the families’ social, psychological, and
physical health during the entire childbearing cycle. This makes them potential to
independently practice their key competencies while also assisting the commu-
nity [32].
Contribution ofLHV/Midwives/Nurse inImproving
theHealth Indicators
The supply of future health care to attain effective health care is a global challenge.
RMs and LHV RMs serve in a range of capacities in Pakistan’s public and private
health settings, including non-governmental organizations (NGOs) such as the Aga
Khan Health Service, Pakistan (AKHS, P), a leading non-prot, non-governmental,
and non-denominational community-based organization that provides quality
maternal and child health services throughout Pakistan. This NGO established the
LHV RM-led maternal and child health facilities in 1974 as a strategy to combat the
increasing rate of maternal and child moralities, particularly in Gilgit-Baltistan,
Chitral, and other rural areas of Pakistan. This has a signicant impact on reducing
maternal and child mortality. It was followed by the establishment of a comprehen-
sive community-based primary health program in which LHV midwives played a
key role as facility-based health professionals as well as in mobile teams in ensuring
the program’s success in accomplishing its goals. Midwives’ role to decreasing the
trend of mortalities is noteworthy, as IMR was 158/1000 live births in the baseline
survey and MMR was more than 500/100,000 live births, which were reduced to
19/1000 and 39/100,000, respectively, in the program survey population [33].
Why Pakistan Needs Advanced Nurse andAdvanced
Midwife Practitioners?
The function of the nurse has evolved over time in response to advancements in
knowledge of science and changes in health care needs [34]. Midwives, LHVs,
nurse-midwives (NM), and, more recently, community midwives (CMWs) have
Why Pakistan Needs Advanced Nurse andAdvanced Midwife Practitioners
300
traditionally provided community-based preventative and routine care to women
and children at a minimal cost. Prior to Universal Health Coverage (UHC), these
cadres were delivering care to poor residential areas, villages, and in challenging
environments. Throughout the crisis, they have always been the rst caregivers. The
inhabitants of many geographical mountainous/challenging region have received
care while no one is there, ranging from severe landslides in high mountains to
plains or deserts where walking is impossible during the summer due to heat.
Furthermore, they are the voice for women and children who cannot speak.
When childbearing women need relief with problems or referrals, they advocate for
their families. During COVID-19, when governments shut down all maternity and
child-led health care facilities, they were a major advocate; they reached out to these
groups and offered good antenatal, intranatal, and postnatal care, as well as contin-
ued breast feeding and vaccination [35].
These cadres also provided prophylactic health care, such as vaccinations, well-
baby and mother clinics, and the delivery of supplements for nourishment during
and after pregnancy. The introduction of APN into the health care context will
improve the outcome of health care delivery since APN improves the patient’s jour-
ney, helps to have better-informed patients, and facilitates patient-centered treat-
ment. APNs also promote communication between patients, patient’s families, and
multidisciplinary teams.
Gradually, Pakistan nurses and midwives are working with doctors and starting
from post-diploma program at preventative sites and the plan is to advance these
programs at Advanced Practitioners level. Currently, a group is working on post-
graduation of diabetic diploma in which both nurses and midwives will be trained.
Way Forward
In Pakistan, like many developing countries, nurses and midwives continue to battle
for recognized legal title with a dened scope of practice for advanced practice.
Competencies in the respective elds and legal approvals at national level are
required. Despite the fact, the nation acknowledges advanced practice and prescrip-
tion; it will always be challenged since it lacks legal standing.
The nurses and midwives have already proposed the revision in the act of the
regularity body, which has been sent to Parliament and the Senate for approval. The
Advanced Practitioner Registered Nurses (APRN) Consensus Model: License,
Accreditation, Certication, and Education (APRN Consensus Model) is a unied
model of regulation for the future of advanced practice nursing that is intended to
align the interrelationships between licensure, accreditation, certication, and edu-
cation (LACE). Adopting the Consensus model benets not only the nursing profes-
sion, but also patients and existing and prospective APRNs. It denes advanced
nursing practice, describes a suggested regulatory approach, and designates
advanced-practice titles. Once this is accomplished, nurses and midwives will have
ofcial authorization to use the title with denitions and scope of practice [36].
R. Jan et al.
301
One of the challenges in a poor country is providing good health care. As a result,
integrating advanced nurses and midwives into health care setting to improve access
and availability of care is appealing and advantageous which will improve health
care delivery outcomes. With the addition of this cadre to the system, communica-
tion among patients, family members, and health care providers would strengthen.
APNs and APMs can also work in Pakistan’s remote and hilly areas, where morbid-
ity and mortality rates remain high due to a lack of doctors. In a nutshell, the scope
of APNs is expanding, and they will be a signicant resource to the current health
care delivery system.
They can also serve as mentors for new nurses in managing cases on their own.
Recognizing their importance in our context would necessitate signicant advocacy
and support from political and regulatory bodies.
Conict of Interest
Nothing to Declare.
Source of Finding:
Not Applicable.
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The Future forInternational NP Role
Development
MadreanSchober
Introduction
International enthusiasm and global emergence of Nurse Practitioners (NPs) has
seen trend-setting growth over the past ve decades. In turn, the result is increased
visibility of the NP.The increased prominence of this nursing role places the evolv-
ing concept of the NP at a turning point. A look to the future implies a need to
strengthen an understanding of the role and practice level of these nurses. The future
looks bright for increased development; however, there is a need to provide clarity
and guidance to the public, key stakeholders, healthcare planners, and other health-
care professionals in order to establish sustainable initiatives. Forging the NP role,
especially when there are no role models present, offers exciting options for innova-
tive practice in every domain where healthcare services are provided, while also
highlighting issues that require debate and discussion. Enthusiasm and motivation
for the NP concept, however, are not enough. Key healthcare decision makers will
ideally need to develop a strategical approach for optimal inclusion of NPs in order
for these nurses to practice to their full potential.
While noting a bright outlook for NPs worldwide, this chapter explores critical
challenges to consider for the future. Key issues to identify when coordinating,
rening, planning, or launching an NP initiative are proposed. In addition, the
chapter emphasizes the need for effective global leadership and ongoing research
to continue to support and demonstrate the value of NPs in diverse healthcare
settings.
M. Schober (*)
Schober Global Healthcare Consulting, New York, NY, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_24
304
Foundations fortheFuture ofNurse Practitioners
Key components of the NP role should be found wherever nursing exists and pro-
vide the foundation for clinical practice. The ICN Guidelines on Advanced Practice
Nursing 2020 includes a denition of the NP that is necessarily broad, given the
necessity to take into consideration variations in healthcare systems, regulatory
mechanisms, and nursing education in individual countries (Refer to Chap. 2 for the
ICN NP denition). The following foundational assumptions provide points for dis-
cussion in the development of a sustainable future for NPs. All NPs
• Are practitioners of nursing, providing safe and competent patient care
• Have a foundation in generalist nursing education
• Have roles which require formal advanced education beyond the preparation of
a generalist nurse
• Have roles with increased levels of competency that are measurable
• Have competencies which address the ethical, legal, caregiving, and professional
development of the advanced practice role
• Have competencies and a professional standard which are periodically reviewed
for maintaining currency in practice
• Are inuenced by the global, social, political, economic, and technological
milieu. (Adapted from [1, p.11])
The ICN ofcial position emphasizes that:
The degree of judgement and accountability increases between the preparation of nurse
generalists and that of the APN [which includes the NP]. This added breadth and depth of
practice is achieved through additional education and experience in clinical practice; how-
ever, the core does not change and it remains the context of nursing. [1, p.9]
The professional status of nursing and its ability to introduce a new level of prac-
tice will inuence the launching of a successful NP initiative. The prominence and
maturity of nursing can be assessed by the presence of other nursing specialties,
levels of nursing education, policies specic to nurses, and the extent of nursing
research.
Forging theNurse Practitioner Concept
Identifying foundational assumptions for the NP, when looking to the future, offers
a basis for promoting discussion and debate for ongoing development. The extent of
nursing practice and access to a level of nursing education that exists in a country
shapes the potential for future development and progression of the NP concept. In
addition, the following questions require consideration when rening a view for the
future [2, p.5]:
M. Schober
305
• What is the nurses’ perspective of advancement and NP practice?
• What does advancement or professional progression for nursing mean within the
country context?
• Is there a career structure for promotion that would support the integration of NPs?
• Is there an identied position for the NP within the healthcare system with a
welldened job description and scope of practice along with a career pathway
commensurate to the NP qualications and capabilities?
• Are the key components of NP practice acknowledged and addressed?
International organizations such as the World Health Organization (WHO) and
the International Council of Nurses (ICN) repeatedly stress that nursing is an essen-
tial part of healthcare services worldwide and endorse the benets of the delivery of
healthcare services by NPs and other APNs [3, 4]. This international attention is
encouraging, however, it is up to the profession to take up the challenges and
develop pathways that are relevant to NP practice and commensurate to countries’
healthcare needs.
Critical Challenges
Nurse practitioners are emerging as a valued healthcare professional with immense
possibilities for the future. To fulll this potential, there are critical challenges that
require attention. As NPs emerge globally, they often venture into situations that are
uncharted and, at times, hostile. In order to fulll future prospects, it is suggested
that the following critical challenges lie ahead: (1) integrating NPs into healthcare
workforce planning that includes capacity building; (2) international consensus-
building around NP professional identity, and (3) ongoing research.
Integrating NPs into theHealthcare Workforce
As healthcare planners, policymakers, and administrators face the escalating chal-
lenges of providing cost-effective, accessible healthcare services, they are pursuing
options that are less reliant on the hospital sector, with increased attention to PHC
in community settings. If the NP is to be a permanent and sustainable part of the
healthcare workforce for the future, it is imperative that human resource develop-
ment takes account of the place and position of the NP in the healthcare spectrum
and skill-mix planning. The critical challenge for NPs is to begin to understand and
contribute to frameworks and strategies that take account of the potential services
that an NP brings to healthcare.
Activism and advocacy are necessary on the part of the NP to promote the role
and create sustained working partnerships with policy and healthcare decision mak-
ers for effectively integrating NPs within the healthcare workforce. It seems at times
The Future forInternational NP Role Development
306
that there is a desire to move more quickly or to avoid slow and halting progress in
advancing the NP concept; however, it is notable that progress depends on the abil-
ity of informed individuals and organizations to identify strategic goals. Nurses in
advanced levels of practice, such as NPs, are in an ideal position to participate in
reshaping healthcare strategies and strategical communication. Theoretical frame-
works and toolkits can provide guidance in developing a strategic approach along
with increased participation of NP representatives [5–9].
Integral to this challenge is capacity building that emphasizes a continuing pro-
cess of strengthening NP abilities not only to perform core clinical functions but to
solve problems by dening and achieving objectives, while understanding and deal-
ing with developmental needs [10]. It could mean collaboration between countries
or organizations within a country to share information and provide an effective lob-
bying voice based on a deliberate process of building and maintaining momentum
in support of an NP presence. It is imperative that NPs, nursing leaders, and key
stakeholders pay attention to culture, values, and power relations that inuence
organizations and individuals to effectively impact the policy and regulatory envi-
ronment. Eventually, successful engagement in capacity building should increase
the range of people, organizations, and groups with knowledge, skill, and con-
dence to identify issues that are problematic and act on solutions. This challenge
asks the nursing profession to be both innovative and practical in engaging in activi-
ties that increase the capacities of healthcare systems and the profession to ensure a
bright future for NPs [5].
International Consensus-Building Around Professional Identity
oftheNP: Terminology, Definition, Scope ofPractice, Core
Competencies, andEducation
As a distinctive and new healthcare professional in the healthcare workforce, the NP
is increasingly called upon to portray a clear image of this aspect of professional
nursing as it is depicted at an advanced level of practice. There is a need to focus on
aspects specic to NP practice rather than continually comparing NP practice to
medical care. Lack of role clarity or an ambiguous understanding of the role dis-
tracts from the signicance and value the NP brings to the provision of healthcare
services [11, 12]. For the future, NP representatives and leaders will continue to be
called upon to provide a clear prole of the NP concept and its signicant position
in the healthcare workforce. A look to the future implies a need to strengthen the
focus on understanding the role or level of practice associated with the NP in order
to establish a distinct and understandable professional identity.
Even though discussion and disagreement are necessary in seeking a consensus
supportive of the NP concept, ultimately there must be agreement on the key issues
of denition, education, scope of practice, and credentialing. These topics are criti-
cal to the continued existence and growth of NPs [11]. The core denition of NPs is
M. Schober
307
a concept that applies to nurses who provide direct clinical care to diverse popula-
tions. As a result, the NP role and level of practice require expanded clinical skills
and decision-making based on advanced education requiring a different level of
regulation and credentialing. Unrealized potential for NPs can be linked to a lack of
clarity in role denition [12] and absence of a professional standard with supportive
policies. Global leadership needs to act in concert to promote clarity and consis-
tency in a collective approach to meet the complex aspects of this challenge as the
international NP trend progresses.
It is not surprising that as the NP concept spreads from countries where the role
and level of practice is well established to countries with less experience of the NP,
inconsistencies and differences begin to emerge and are noted to be important.
These differences require consideration and discussion; however, they are incom-
patible to systematic and consistent development of the NP internationally.
Differences and inconsistencies are handicaps in a world where globalization is
taking place within a context of greater mobility of healthcare professionals. The
challenge is to identify effective means that promote the continual building and
updating of international agreement around core topics central to NP practice. The
ability to achieve consensus speaks directly to the aspiration that NPs have a national
and global identity that allows consumers and other healthcare professionals to
identify who NPs are and for the public to know and trust the services they offer.
Refining Descriptive Terminology
Appropriate use of descriptive terminology is fundamental as NPs strive to accu-
rately portray and rene their professional identity [12, 13]. As this nursing role has
developed, literature has repeatedly reported uncertainty, confusion, and ambiguity
in describing the NP [12–14]. This vagueness and lack of clarity has led to a level
of misunderstanding as to who this nurse is. In addition, terms such as “mini-doc,”
“midlevel provider,” “non-physician provider,” and “physician extender,” along
with reference to “task shifting” from doctors to nurses do not accurately depict the
unique role and scope of practice of an NP.Authors, consultants, and researchers
who refer to and use this kind of terminology do a disservice to establishing clarity
on behalf of the professional identity of NPs.
In an effort to provide a benchmark for international dialogue and encourage
consensus building, ICN offers guidance in Guidelines on Advanced Practice
Nursing 2020 [1, 13]. The concept of consensus building based on accurate and
appropriate terminology is essential. It is acknowledged that nursing practice and
NP role development is sensitive to country context and even differences in inter-
pretations within a nation or region. The concept of consensus building for NP ter-
minology worldwide may seem difcult, however; the ability to offer effective
dialogue and mechanisms that encourage periodic updating in the use of terminol-
ogy can more accurately depict an international focus associated with the NP role
and level of practice. A continued approach to some level of consensus related to NP
terminology is imperative for the future.
The Future forInternational NP Role Development
308
Research: Defining theGaps andFinding theEvidence
A key challenge facing the future development and presence of NPs is the need to
continue to demonstrate the value of these advanced practice nurses. As a unique
and new professional in diverse healthcare settings, the NP is increasingly being
called upon to portray a clear image of professional nursing as exhibited in this role
and level of practice. Not only is evidence and data benecial, but there is also a
need to focus on aspects of clinical care specic to NP practice instead of continu-
ally comparing NP practice to medical care. Clinical outcomes need to be speci-
cally attributed to the NP presence in order to enhance the accuracy of the research
that is conducted [15]. All too often the value and impact of NPs is invisible in
medically driven healthcare systems that lack NP sensitive indicators [2, 15, 16]. In
the future, conrming the value of the NP in distinct healthcare settings will require
specic and accurate appraisal of the settings in which they practice. Readily avail-
able evidence will continue to be a valuable resource as key stakeholders, healthcare
decision makers, managers, administrators, and other healthcare professionals
request information clarifying the NP role and associated clinical outcomes.
In addition, NPs need to increasingly participate in the research processes [15–
17]. They will also be called upon to assess the quality of evidence demonstrated in
research studies and translate ndings into practice. If NPs of the future are required
to include research as a role component in practice, they will be expected to under-
stand and implement the evidence. Healthcare systems and employers need to
acknowledge the legitimacy of this aspect of the NP role and take into consideration
planning for suitable resources, time to participate in research processes and estab-
lish recognition that research is a valued component of the NP role.
Even though international literature substantiates data supportive of the NP con-
cept, evidence continues to mainly originate from developed countries and nations
that have a longer history of success with NP roles. Future research describing the
growing presence of new NP initiatives will not only document clinical outcomes
but has the potential for comparing differences and similarities in development and
implementation as countries increasingly seek to identify strategies for integrating
NPs into the healthcare workforce.
Refer to chapters “The NP as a Contributor to Research” and “NP Outcomes
Evaluation” for further discussion of the NP as a participant in research processes.
Conclusion
Contemporary geopolitical circumstances and societal needs, together with comor-
bidities of illness and aging populations, can seem daunting when seeking to achieve
solutions to enhance healthcare services worldwide. The World Health Organization,
in its 2030 Agenda for Sustainable Development Goals, seeks an era of universal
healthcare where we take a long-term, patient-centered view. This perspective pro-
motes a view of illness prevention and health promotion as well as cure that neces-
sitates consideration of new delivery models for healthcare services. Realigning the
M. Schober
309
perspective of provision of healthcare services requires a shift away from traditional
positions and responsibilities of healthcare professionals to focus on innovative and
transformational models of care. A component of this viewpoint requires more
responsive prototypes of care that includes strengthening the nursing profession.
Nurse practitioners are seen as one option that can add value and strengthen
healthcare systems. However, global leaders and the nursing professional must
recognize critical challenges in order to pursue and develop strategies for action.
This chapter portrays a view of the future for NPs and identies challenges that
will continue to need attention as these nurses carve a fundamental position as
vital healthcare professionals in diverse settings. The future ahead rests on meet-
ing a complex set of needs and environmental factors. The more urgent the demand
for access to healthcare services, the more likely NPs will be considered as a solu-
tion to enhancing health care. Barriers such as lack of role clarity, lack of leader-
ship and regulatory restrictions contribute to a more slowly evolving process of
acceptance.
The point of origin for the spark that starts the cascade of change may differ. It
may be the inspired individual nurse with a vision of how nurse-managed services
can improve care; or a physician administrator who understands that collaborative
models of care may make better use of different healthcare professionals. An orga-
nization or healthcare facility looking to enhance the quality of health care can initi-
ate changes to introduce a skill mix of professionals that include NPs. A consumer
with experience of care by NPs in another facility or country can stimulate discus-
sion on the possibility of a similar service in their community. Nurses searching for
career pathways that enable them to expand their professional and clinical skills and
be recognized for this can be the catalyst for conversation that leads to recognition
and implementation of NPs.
Country narratives in Chap. 2 and additional chapters in this book provide exam-
ples of numerous international and intercountry collaborative efforts that have
shaped the present-day landscape for NPs. A view of prospects for the future of NPs
suggests that sharing of clinical experiences, regulatory prociency, and research
will strengthen the ongoing interest in the NP concept.
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17. Harris AL, Flanagan JM, Jones DA.Advanced practice registered nurses: accomplishments,
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M. Schober
Part III
The Role of the Nurse Anesthetist
313
Challenges toGlobal Access
toAnesthesia andSurgical Care
RichardHenker andMaiTaki
Abbreviation
CN Certied Nurse
CNS Clinical Nurse Specialist
COVID-19 Coronavirus Disease of 2019
CT Scan Computerized Tomography scan
DALY Disability Adjusted Life Year
G4 Global Alliance for Surgical, Obstetric, Trauma and Anaesthesia Care
ICN International Council of Nurses
IFNA International Federation of Nurse Anesthetists
IOM Institute of Medicine
LMIC Low- and Middle-Income Countries
MOH Ministry of Health
NSOANP National Surgery Obstetric Anesthesia and Nursing Plan
NSOAPs National Surgery Obstetric and Anesthesia Plan
SAO Surgeon, Obstetrician and Anesthesiologist
SDG United Nations Sustainable Development Goals 2030
SOTA Surgical, Obstetric, Trauma and Anesthesia Care
TNSMI Training system for Nurses to perform Specic Medical Interventions
UHC Universal Health Coverage
R. Henker (*)
Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh,
Pittsburgh, PA, USA
e-mail: rhe001@pitt.edu
M. Taki
Division of Nursing Practice, Department of Nursing, Acute Care Nursing,
Nishikyushu University, Kanzaki, Japan
e-mail: takima@nishikyu-u.ac.jp
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_25
314
UN United Nations
UNITAR United Nations Institute for Training and Research
WFSA World Federation of Societies of Anesthesiologists
WHA World Health Assembly
WHO World Health Organization
WPRO Western Pacic Ofce of the World Health Organization
Overview ofAccess toAnesthesia andSurgical Care
Access to anesthesia and surgical care is often overlooked as a component of global
health. It is estimated that 5.3billion people do not have access to safe, affordable
surgical and anesthesia care [1]. Farmer and Kim [2] described surgery as the
“neglected stepchild of global health.” Craig McClain described global anesthesia as
the “invisible friend” of the neglected stepchild of global health [3]. Common condi-
tions such as hernias, fractures, obstructed labor, appendicitis require treatment with
surgical and anesthesia care. It was estimated that 16.9million or 32.9% of all deaths
are due to lack of anesthesia and surgical care [4]. Access to surgical and anesthesia
care has lagged compared to other areas of global health [5]. In 2019, Dr. Tedros
Director-General of the World Health Organization stated, “No country can achieve
Universal Health Coverage unless its people have access to safe, timely, and afford-
able surgical services…It’s therefore vital that countries invest in surgery.” In a pub-
lication from the WHO in 2017 [6], it was estimated that one third of the global burden
of disease requires surgical, obstetric, or anesthesia care. Of the 313million surgical
cases performed each year, only 6.5% of surgical cases are performed in low- and
middle-income countries (LMICs) [7]. If patients can access surgical care a quarter of
them and their families will incur nancial catastrophe [5]. The World Bank has esti-
mated that 77.2million disability-adjusted-life-years (DALY) could be prevented
with surgical care [8]. The Lancet Commission on Global Surgery has proposed a
goal that 80% of the world population have access to surgical care by 2030 [5].
Access to surgical care requires not only additional surgeons, nurses, techni-
cians, and other support staff but anesthesia providers, including nurse anesthetists
that can increase access to anesthesia services and surgical care. Nurse anesthetists
and other non-anesthesiologist healthcare providers are the most predominant anes-
thesia providers in countries with the lowest anesthesia provider density [9].
Countries in Africa and Southeast Asia are most likely to have less than ve anes-
thesia providers per 100,000 of the population [9]. Nurse anesthetists are often cited
as the answer to the lack of access to surgical care [10–13].
How is Access toSurgical andAnesthesia Care Defined?
Access to surgical care has been dened by Alkire etal [1] as timeliness, surgical
capacity, safety, and affordability.
R. Henker and M. Taki
315
Timeliness is dened by Meara etal. [5] as the ability to reach a facility in two
hours to provide access to surgical care. Bellwether procedures that require urgent
attention within two hours include caesarean delivery, laparotomy, and treatment of
open fractures. The Western Pacic Region Ofce of WHO reported that in most
countries in the WPRO region, less than 80% of the population has timely access to
surgical care [14].
Surgical volume is dened as the number of procedures conducted by a country
[5]. In the Western Pacic Region, there is considerable disparity between the high-
income countries and LMICs. The number of surgeries performed in Australia in
2016 was reported to be 10,156 per 100,000 of the population. In the Solomon
Islands, the number of surgeries performed in 2016 was 868 per 100,000. Watters
etal. [15] state that a smaller number of procedures is related to greater complica-
tion rate in LMICs due to limitations in equipment, supplies, and personnel. The
Lancet Commission on Global Surgery recommends a minimum of 5000 cases per
100,000 of the population to improve life expectancy and maternal mortality [5]
Safety in anesthesia and surgical care has improved considerably in high income
countries, but still lags in LMICs. In a study done by the Global Surgery Collaborative
[16], the mortality rate for ASA 3 (an anesthesia risk factor classication) patients
requiring emergency abdominal surgery was 7.2% for high income countries, 17.7%
for middle income countries, and 19.1% for low-income countries. Mortality rate
was reported as 3.1% in a study of non-cardiac surgery patients in Southern Africa
[17]. In a meta-analysis [18] of surgical mortality in LMICs, the mortality rate
ranged from 0.1% for appendectomies, cholecystectomies, and caesarean sections
to 20%–27% for head injury-related surgeries and typhoid intestinal perforation.
Interventions used to improve safety and perioperative outcomes have included the
development and implementation of guidelines such as the International Council of
Nurses Guidelines on Advanced Practice Nursing: Nurse Anesthetists [19], the
WHO World Federation of Societies of Anesthesiology (WFSA) International
Standards for a Safe Practice of Anesthesia [20], and the WHO Safe Surgery
Checklist [21].
Financial catastrophe It has been estimated that 33million people will have
nancial catastrophe from out-of-pocket expenses due to disease process that
requires surgical care [22]. Hamid etal. [23] projected that 3.4% of households
were moved into poverty due to healthcare expenditures. Disease processes that
were most likely to cause catastrophic healthcare expenditures included cholecys-
tectomy, mental health disorders, kidney disease, cancer, and appendectomy. In a
study done by Ferraras etal. [24], not only was the impact of the direct costs of
neurosurgical procedures reported but the authors also discussed the costs incurred
with transportation, care giver expenses, and lost income due to unemployment of
patients and care givers. Out-of-pocket costs for surgical procedures require an
immediate outlay to cover expenses that leads to higher burdens on impoverished
patients and families. Recommendations from authors based on these ndings
included increased awareness for policymakers of the out-of-pocket expenses not
only for direct costs of surgical care but indirect costs.
Challenges toGlobal Access toAnesthesia andSurgical Care
316
Policy Initiatives toPromote Access toAnesthesia
andSurgical Care
WHO, United Nations, International Council of Nursing, International Federation
of Nurse Anesthetists, G4 Alliance, and other groups have been involved in policy
initiates that focus on improving access to anesthesia and surgical care.
WHO Global Initiative forEmergency andEssential Surgical
Care (GIEESC)
In 2005, the WHO established the GIEESC.The focus of GIEESC was to “…share
knowledge, advise policy formation and develop educational resources to reduce
the burden of death and disability from conditions that could be treated through
surgery” [25]. The rst meeting of the GIEESC was held in Switzerland in 2006 and
the most recent meeting of the group was held in Bangkok in 2020. Objectives of
the meeting in Bangkok included follow-up on the progress of implementation of
WHA resolution 68.15in the Southeast Asian and Western Pacic regions, and dis-
cussion of the development of NSOAPs in LMICs.
WHO: Safe Surgery Saves Lives
In 2007, WHO initiated a 19-item safe surgery checklist program to decrease the
number of surgical deaths around the world. It was estimated that 39% of adverse
events took place in the operating theatre and many could be averted [26]. The ini-
tiation of the checklist was reported to reduce the number of complications per 100
patients from 27.3 to 16.7 and hospital mortality from 1.5% to 0.8% [27]. Although
surgeons and staff often dislike the delay in using the checklist [20], the implemen-
tation of “time outs” has decreased perioperative morbidity and mortality worldwide.
Institute ofMedicine: TheFuture ofNursing Leading Change,
Advancing Health
In 2010, the Institute of Medicine (IOM) published The Future of Nursing Leading
Change, Advancing Health [28]. The Robert Woods Johnson Foundation and the
IOM, under the guidance of Donna Shalala, developed a landmark initiative that
was designed to position the nursing profession into a leadership role in a rapidly
changing healthcare environment. The recommendations from the IOM [28] were:
1. Nurses should practice to the full extent of their education, and training.
2. Nurses should achieve higher levels of education and training through an
improved education system that promotes seamless academic progression.
R. Henker and M. Taki
317
3. Nurses should be full partners, with physicians and other health professional, in
redesigning health care in the United States.
4. Effective workforce planning and policy making requires better data collection
and an improved information infrastructure [28].
Although this report was intended for nurses in the USA, this initiative has been
cited by many leaders around the world to expand scope of practice for nurses and
improve access to health care, including anesthesia care.
Sustainable Development Goals (SDGs)
The sustainable development goals were introduced in 2015 and adopted by the
United Nations member states. The 17 SDGs focus on ending poverty and other
deprivations. Meeting the SDGs is expected to improve health, education, equality
and promote economic growth [29]. Recent challenges to meeting the SDGs include
the COVID-19 pandemic and climate change. These challenges have affected avail-
ability of food, health, education, environment, peace, and security.
World Health Assembly Resolution 68.15 Strengthening
Emergency andEssential Surgical Care andAnaesthesia
asaComponent ofUniversal Health Coverage
In 2015, the World Health Assembly approved resolution WHA 68.15, a policy
initiative to advance global surgical care. The resolution provided recommenda-
tions on providing an increase in the most cost-effective surgical procedures,
increasing surgical capacity, and creation of National Surgical, Obstetric, and
Anesthesia Plans (NSOAP). Since the passage of the resolution of the WHA
68.15in 2015, NSOAPs have been initiated in Zambia, Ethiopia, Tanzania,
Nepal, and Pakistan [25]. In Nigeria, nursing was added to their NSOAP, there-
fore the plan for strengthening surgical care is the national surgery, obstetric,
anesthesia and nursing plan (NSOANP). Seyi-Olajide etal. [30], state that
“…quality nursing care is required for safe surgery and that improvements in
surgical outcomes are difcult to achieve without strengthening nursing care.”
Components of the NSOAP strategy as provided in the UNITAR NSOAP Manual
2020 [21] include:
• Service delivery
• Infrastructure, products, and technology
• Workforce
• Information management
• Financing
• Governance
Challenges toGlobal Access toAnesthesia andSurgical Care
318
United Nations Resolution Adopted by theGeneral Assembly
2019, Universal Health Coverage: Moving Together toBuild
aHealthier World
In 2019, United Nations passed an updated version of the Universal Health Care
resolution that, for the rst time, included surgical care. In section 35 on page 6 of
the resolution, it states:
Scale up effort to address the growing burden of injuries and deaths, including those related
to road trafc accidents and drowning, through preventive measures as well as strengthen-
ing trauma and emergency care systems, including essential surgery capacities, as an
essential part of integrated health-care delivery.
Another document published by the United Nations Institute for Training and
Research (UNITAR) is the National Surgical Obstetric and Anaesthesia Planning
Manual 2020 [22]. This document provides a blueprint for countries to develop and
implement NSOAPs. Sections of the manual include: “Developing a case for
Prioritizing and Planning SOA Care” and “The SOA Planning Process” [22]. The
NSOAP manual was developed with the Global Surgery Foundation and the Harvard
Medical School Program in Global Surgery and Social Change [22].
Action Framework forSafe andAffordable Surgery intheWestern
Pacific Region (2021–2030)
The Western Pacic Region Ofce (WPRO) of the WHO published the Action
Framework for Safe and Affordable Surgery in the Western Pacic Region
(2021–2030) [14]. Rationale provided for the safe surgery initiative was lack of
access to surgical care within two hours for Bellwether procedures such as caesar-
ean section, laparotomy, and treatment of open fractures. Mortality after surgery
was cited as 1in 100 [14]. Suggestions to improve access to surgical care included
areas such as expanding the workforce, medications, equipment, infrastructure, and
data management [14]. Of note, nurses are often referred to as non-physician health
care workers. In Section 2.3 of the report, Skilled Workforce, there is little discus-
sion about the importance of “non-physician” providers in the plan even though
nurse anesthetists have been providing many of the anesthetics in the WPRO region.
A goal of 20/100,000 surgeons, anesthesiologists and obstetricians has been set, but
there was no goal for the number of nurses, nurse anesthetists, midwives, or nurse
practitioners indicated in the document [14].
Scope ofPractice
Developing and implementing standards of care for anesthesia providers has been
suggested as a strategy to provide the highest level of anesthesia care [19]. The
International Council of Nursing, in conjunction with the International Federation
R. Henker and M. Taki
319
of Nurse Anesthetists (IFNA), published guidelines to “…support stakeholders to
develop policies, frameworks and strategies support of Nurse Anesthetists.” (page8)
[30]. The guidelines are used to contribute to education, regulations, and scope of
practice for nurse anesthetists around the world. IFNA standards are to be used to
conrm scope of practice in countries that are developing their own scope of prac-
tice [31]. The ICN Guidelines include content to support implementation or growth
of nurse anesthetist practice:
• Introduction
– Background of the Nurse Anesthetist
– History of Nurse Anesthesia
– Practice Settings
– Need for Nurse Anesthetists
• Description of Nurse Anesthetists
• Nurse Anesthetist’s Scope of Practice
• Education for the Nurse Anesthetist
– Prerequisites for entry into a Nurse Anesthetist education program
– Post-graduate education requirements for the Nurse Anesthetist
– Program length
– Accreditation or recognition of Nurse Anesthetist educational programs
• Establishing a Professional Standard for the Nurse Anesthetist
– Certication, credentialing, and regulation of the Nurse Anesthetist
– Title protection for the Nurse Anesthetist
– Experience, Lifelong Learning/Continuous Professional Development
– Increase awareness and clarication of the role of Nurse Anesthetist
• Nurse Anesthetists’ contributions to healthcare services
• Safe Practice of Anesthesia
– Systematic reviews
– Research evidence
– Summary of ndings on safe nurse anesthetist practice
The World Federation of Societies of Anesthesiology and WHO published
updated International Standards Safe Practice of Anesthesia in 2018 [19]. The
components of the standards include (1) professional aspects; (2) facilities and
equipment; (3) medications and intravenous uids; (4) monitoring; and (5) the
conduct of anesthesia. Although standards were categorized as highly recom-
mended, recommended, and suggested, there was no grading of evidence to sup-
port the standards. The Lancet Commission on Global Surgery recommendation
of 20 surgeons, anesthesiologists, and obstetricians per 100,000 of the population
was highly recommended in the standards document [19]. The number of nurse
anesthetists was not included in the standards although it was highly recom-
mended that anesthesiologists provide all anesthesia care and supervise other
anesthesia providers [19]. Given the workforce shortage in many LMICs, nurse
anesthetists have been cited as the solution to increasing access to anesthesia and
surgical care [10–13].
Challenges toGlobal Access toAnesthesia andSurgical Care
320
Factors Delaying Access toAnesthesia andSurgical Care
Delays in access to anesthesia care and surgical care include not only infrastructure,
service delivery, workforce, equipment, supplies, nancing, information systems but
challenges with travel, cultural beliefs, poor education, and low awareness of ser-
vices available [5]. The Lancet Commission on Global Surgery categorizes delays in
receiving care using the 3-delay framework. The rst delay is due to education, cul-
tural beliefs, or lack of awareness of availability of care by patients and families. The
second delay is due to lack of hospitals in the area. Delayed access to hospitals can
include few travel options for patients, or travel cost may exceed resources of patients
and families. The third delay occurs when the patient can travel to a hospital that may
lack comprehensive surgical or anesthesia care. Contributing barriers for families
include limited access to the Internet and literacy. Literacy rates in LMICs are less
than high income countries and access to the Internet is often limited, contributing to
lack of awareness of where to access to health care. In Laos, a low- middle- income
country, word of mouth is often used between families to gain knowledge regarding
access to care.
Infrastructure forHospitals inLMICs
In high-income countries, infrastructure is often assumed to be available to support
hospitals, but in LMICs, basic resources such as electricity and water are not always
accessible. In a study reported by Kushner etal. [32], from 132 facilities in eight
LMICs in 2010, water was not available in 23% of facilities. Electricity was not
available in 11% of facilities, and sometimes available in 53% of facilities. Oxygen
was never available in 46% of facilities, sometimes available in 33% of facilities,
and always available in 21% of facilities. Anesthesia machines were never available
in 45% of facilities, sometimes available in 23% of facilities, and always available
in 32%. Although this study was published in 2010, assumptions regarding basic
resources such as water and electricity need to be considered when developing sys-
tems for anesthesia and surgical care.
An area that is always overlooked for support of the sophisticated equipment for
providing surgical care is the biomedical technician support. Many organizations
have donated the highest level of equipment to locations in LMICs only to have the
equipment relegated to the “medical device graveyard” due to lack of a skilled tech-
nician to keep the machine running. There are biomedical device companies that
take into consideration the lack of infrastructure to provide surgical care. Gas
machines by these companies do not require oxygen or electricity and little mainte-
nance that can provide general anesthesia in austere environments [33].
R. Henker and M. Taki
321
Financing toImprove Access toAnesthesia andSurgical Care
Financing to provide adequate access to anesthesia and surgical care in LMICs by
2030 was reported to be $300 to $420 billion [34]. Current funding for surgical care
in LMICs is typically a low priority [34]. Potential funding sources for surgical care
include governments, philanthropic bodies, non-governmental organizations, and
the private sector. Other options are insurance and out of pocket funds. Budgets for
governments in LMICs are often tight, and increasing funding for surgical and anes-
thesia care is a challenge. Sonderman etal. [35] suggest that an increase in funding
efforts should use a corporate social responsibility approach. This approach would
show a company’s social concerns and benet to society [35]. Innovative strategies
to fund access to surgery and anesthesia care are required to meet the goal of 80%
of the world population to have access to surgical care by 2030.
Blood Supply forSurgery
Blood transfusion services are a critical part of surgical and anesthesia care. Groups
most affected by a limited blood supply in LMICs are children under 5 years age
with anemia, and women during pregnancy and delivery [35]. Barnes etal. [36]
found that 50 of 71 hospitals in LMICs that responded to a survey had hospital
blood transfusion services. Of those that had blood transfusion services, 77% col-
lected blood for transfusion. Only 23% of transfusion services in LMICs were
dependent upon a centralized blood supply similar to blood transfusion services in
high income countries. Barriers for blood transfusion services in LMICs include
lack of infrastructure, low public participation, shortage of a skilled workforce, lack
of access to educational programs, and a dearth of sustainable nancial models [37].
Imaging Services toImprove Surgical Care
Imaging services, including ultrasound, X-rays, and computerized tomography
scans, are needed to diagnose, monitor, or treat disease processes [37]. Imaging is
particularly important for care of the patients with cancer. Surgery has been reported
to be responsible for 60% of cancer cures or control of cancer [5]. The number of
radiologists has been reported to be on average 1.9/million in low-income countries,
22.3/million in low-middle-income countries, and 97.9/million in high income
countries [36]. The number of CT scanners in LMICs has been reported to be 1 for
every million of the population compared to 40 for every million of the population
in high income countries [38]. Imaging services are an essential component of sur-
gical care.
Challenges toGlobal Access toAnesthesia andSurgical Care
322
Travel asaBarrier toSurgical Care
Access to surgical care is also related to travel availability to hospitals by patients
and families. Meara and colleagues [5] reported that the median distance traveled
for surgical care was greater than 25km in LMICs and less than 10km for high
income countries [5]. Many patients and families in rural LMICs do not have a
vehicle and need to pay for transportation to a hospital. It should be noted that road
conditions affect patients and families’ abilities to travel. Weather conditions such
as monsoons and treacherous roads extend travel time. Direct costs for the surgery
and hospital stay are often reported, but nancial hardship for transportation is often
not conveyed.
Culture asaBarrier toSurgical Care
Understanding of culture is vital to improving health care in LMICs. Ideally, tradi-
tional medicine is incorporated into the care provided by nurses and physicians in
the hospital setting, but traditional medicine sometimes delays access to surgical
care. In Lao Peoples Democratic Republic (PDR), Hmong families that reside in
mountainous rural areas will rst see a Shaman to protect the sick from spirits often
by sacricing animals. Due to the use of traditional care and challenges with travel,
few Hmong patients from rural areas are seen within the 2-hour limit for Bellwether
procedures. Once in the hospital, ethnic groups such as the Hmong, may be appre-
hensive of the care provided by clinicians of other ethnic groups. Hmong believe
that the spirit leaves a patient during anesthesia and families will ask to help regain
the spirit at the entrance to the operating theatre. The best method to work with
Hmong families is a nurse anesthetist that is Hmong and understands the culture and
can speak the language with patients and families.
Anesthesia Workforce
Workforce for surgery and anesthesia care includes surgeons, anesthesiologists,
nurse anesthetists, obstetricians, nurses, pathologists, radiologists, laboratory tech-
nicians, rehabilitation specialists, biomedical technicians, and engineers [5]. A
threshold for specialist surgical workforce of 20/100,000 population or more has
been suggested by the Lancet Commission on Global Surgery to improve outcomes
[5]. The specialist surgical workforce includes surgeons, obstetricians, and anesthe-
siologists, often referred to as SAO density. The WFSA has recommended 5 anes-
thesia providers/100,000 of the population to improve access to anesthesia care and
patient outcomes [9]. In addition to surgeons and anesthetists, the Lancet
Commission on Global Surgery highlighted the importance of healthcare providers
at health centers and rst level hospitals to refer patients to a hospital that can pro-
vide Bellwether procedures [5].
R. Henker and M. Taki
323
Comparison ofAnesthesia Workforce inHigh-Income andLMICs
The anesthesia workforce consists of nurses, physicians, medical assistants, and
others that provide anesthetics in LMICs. The World Federation of Societies of
Anesthesiology and the International Federation of Nurse Anesthetists continue to
assess the anesthesia workforce in countries around the world. In a study con-
ducted by the WFSA and reported by Kempthorne etal. [9], 153 of 197 countries
responded to a survey of the anesthesia provider workforce. Of those countries, 70
had less than ve anesthesia providers per 100,000 of the population. This included
nurse anesthetists, anesthesiologists, and other healthcare workers providing anes-
thesia. The areas of the world that were more likely to have low numbers of anes-
thesia providers was Africa and Southeast Asia [9]. See Table1 from Kempthorne
to compare the number of physician anesthesia providers by World Bank Country
Category.
The nurse anesthetist workforce is often included in the group labeled as non-
physician anesthesia providers in reports from WFSA.The number of non- physician
anesthesia providers overall in countries in Africa is 10,706 and the number of anes-
thesiologists is 3713 for 910,172,000 of the population in Africa. The ratio of anes-
thesia providers to population in Africa is 1.58/100,000. In the Western Pacic
Region, the number of physician anesthesia providers is 5935 and non-physician
anesthesia providers is 209 for a regional population of 249,959,773. The ratio of
anesthesia providers to population is 2.46/100,000in the Western Pacic Region.
This compares with high income countries such as Japan with 12,208 physicians
providing anesthesia and an unknown number of nurse anesthetists for a ratio of
9.64 anesthesia providers per100,000 of the population. The number of anesthesia
providers in the United States is 67,000 physicians and over 57,000 nurse anesthe-
tists. The anesthesia provider ratio is 20.82/100,000 of the population. The number
of nurse anesthetists in some of the WFSA reports were underrepresented, but the
IFNA is collaborating with WFSA in assessing the workforce to provide a more
accurate indication of anesthesia providers.
Table 1 Kempthorne etal. (September 2017)
World Bank
country
category
Number of
countries Population
Total physician
anesthesia
providers
Physician anesthesia
providers per 100,000 of
the population
High Income 45 1,162,625,644 208,813 17.96
Upper-Middle
Income
40 2,550,539,869 175,739 6.89
Lower-Middle
Income
42 2,860,308,239 50,942 1.78
Low Income 26 594,671,000 1102 0.19
The WFSA Global Anesthesia Workforce Survey, Anesthesia & Analgesia, Volume 125, Number
3, 981–90. Reprinted with permission
Challenges toGlobal Access toAnesthesia andSurgical Care
324
Nurse Anesthetists inRural Areas inLMICs
The number of anesthesia providers is known to be low in LMICs, but the number
of anesthesia providers in rural areas of LMICS is even less [10]. There is wide sup-
port for the development of nurse anesthesia programs to increase anesthesia care
and access to surgery in these rural areas [11, 12]. In Kenya, the number of anesthe-
siologists is 0.44/100,000 and only 20% of the surgical need is met in eastern sub-
Saharan Africa. Umutesi etal. [10] evaluated the impact of Kenyan registered nurse
anesthetists on access to surgical care in nine hospitals. Kenyan nurse anesthetists
were used to increase the anesthesia provider density by 43% in three of the nine
hospitals. The increased access to anesthesia care almost doubled the number of
surgical cases performed in the hospitals where nurse anesthetists were utilized
[10]. To meet the WFSA goal of 5 anesthesia providers per 100,000 of the popula-
tion in LMICs, education of more nurse anesthetists around the world is needed
[10–13].
Recommendations toIncrease theAnesthesia Work Force
inLMICs
In response to the low number of anesthesia providers in LMICs, recommendations
have been provided to reach the 5 anesthesia providers per 100,000 of the popula-
tion [11]. Federspiel etal. [39] suggested task shifting as strategy to meet goals for
surgical and anesthesia care. Task shifting is dened by WHO as “…the name now
given to a process whereby specic tasks are moved, where appropriate, to health
workers with shorter training and fewer qualications.” [39]. In the review by
Federspiel etal. [39], nurse anesthetists were practicing in 111 countries. Expanding
nurse anesthetist practice was suggested to increase access to anesthesia care. The
WFSA suggested a Global Anesthesia Training Framework for physician and non-
physician anesthesia providers to increase the number of anesthesia providers [11].
Other recommendations from WFSA included improving the quality and safety of
care. Recommendations from the Lancet Commission on Global Surgery also sug-
gested increasing the number of non-physician anesthesia providers [5]. In addition,
Meara etal. [5] suggested that non-government organizations that engage in medi-
cal missions coordinate activities with the ministry of health and include an educa-
tion component for local surgical teams [5]. The ICN guidelines for nurse anesthetist
practice recommend expanding education of nurse anesthetists to increase access to
anesthesia and surgical care to prevent disability and save lives [31].
R. Henker and M. Taki
325
Access toSurgery andAnesthesia Care inaHigh-Income
Country: Japan
In Japan, a shortage of surgeons and anesthesiologists was identied as a problem
in 2004 due to the uneven distribution of physicians by region. In response, an advi-
sory body to the Minister of Health, Labor and Welfare discussed the development
of the role of “anesthesiology nurses” like those in other countries [40]. Since this
advisory report was provided to the Ministry of Health, Labor and Welfare, the
development of anesthesiology nurses and other highly specialized nurses has
accelerated.
Barriers to access surgical care were reported in a survey conducted by the Japan
Surgical Society in 2016. Factors that decreased access to surgical care included: (1)
outsourcing of anesthesia services due to difculties in hiring anesthesiologists at
their facilities; (2) rising compensation for outsourced anesthesiologists; (3) inabil-
ity to handle emergency surgeries; and (4) an increase in patient waiting time for
surgery due to lack of anesthesia care [40]. In response, the importance of multidis-
ciplinary collaboration, including advanced practice nurses, has been cited.
The annual number of anesthesia cases and surgeries in Japan in FY2020
exceeded 17.38million [41]. The number of surgeons in FY 2020 was 13,211 and
anesthesiologists 10,277 [40]. If the number of surgeries is simply converted to the
number of physicians, one surgeon is responsible for ve surgeries per day, and one
anesthesiologist is responsible for eight anesthesia cases per day. Assuming it takes
more than one hour from the time a patient enters the operating room to the time he
or she leaves, it is calculated that a surgeon must perform more than ve surgeries
per day and an anesthesiologist must perform more than eight surgeries per day.
Note that although the Japanese Society of Anesthesiologists has adopted the prin-
ciple of “one anesthesiologist per surgery” in which all anesthesia is performed by
an anesthesiologist, in practice, anesthesia is often provided by a member of the
surgical team.
In Japan, in 1995, graduate education for Certied Nurse Specialists (CNS) was
started. In 2010, Certied Nurse (CN) training of Peri-Anesthesia Nurses began
and, in 2015, the Training System for Nurses to perform Specic Medical
Interventions (TNSMI) was launched. In 2019, training in intraoperative anesthesia
management began, and highly specialized nurses called “Japanese APNs” were
able to manage anesthesia under the direction of doctors [42]. In 2022, the total
number of nurses in Japan was 1.29million, with 2733 CNSs, 21,847 CNs, and
2887 TNSMI graduates. In addition, the number of nurses who have completed
educational courses in intraoperative anesthesia management has increased to 554,
indicating that the Japanese nursing system is moving toward greater access to anes-
thesia care due to the implementation of these nursing specialty programs.
Challenges toGlobal Access toAnesthesia andSurgical Care
326
Table 2 The Global Alliance for Surgery, Obstetric, Trauma and Anesthesia Care (The G4
Alliance) provided the following indicators for evaluation of SOTA care [44]
Domain Clinical area Indicator
Access Surgical system Access to timely essential surgery
Trauma care Estimated proportion of seriously injured patients transported
by ambulance
Trauma and
obstetrics
National whole blood donation rate
Obstetrics C-section rate
Anesthesia Proportion of operating theatres with pulse oximetry
Ratio of anesthetists to surgeons
Quality Surgical system Surgical volume
Trauma care Inpatient mortality rate
Obstetrics Maternal mortality ratio
Neonatal mortality
Anesthesia Postoperative mortality rate on operative day
Financial Surgical System Protection against impoverishing expenditure
Protection against catastrophic expenditure
Indicators ofAccess toSurgery andAnesthesia Care inLMICs
Progress for access to anesthesia and surgical care can only be determined if there
are indicators measured to evaluate the effectiveness of implementation of policies
related to NSOAPs and expansion of the anesthesia workforce. Indicators of access
to surgery that have been provided by the Lancet Commission on Global Surgery
include (Table2):
• Geographical access to a hospital providing Bellwether procedures within
two hours
• Surgical, anaesthetic, and obstetric provider density
• Total operative volume
• In-hospital postoperative mortality
• Impoverishing cost burden
• Catastrophic cost burden
For a recent example of the use of these indicators in Colombia, please see the
publication by Hanna etal. [43].
Next Steps toImprove Access toAnesthesia andSurgical Care
Improving access to anesthesia and surgical care will require implementation of
policy initiatives (e.g., NSOAPs), building the workforce, nancial support for
infrastructure, equipment, and supplies. Implementation of indicators to measure
progress is essential to determine actions that are successful in improving access to
anesthesia and surgical care. The Lancet Commission on Global Surgery suggested
R. Henker and M. Taki
327
action in the following areas to meet the goal of 80% of the world population having
access to anesthesia and surgical care by 2030 [5].
• Infrastructure
• Workforce
• Service delivery
• Financing
• Information management
See the Lancet Commission on Global Surgery for a more detailed description of
actions needed to meet the goal for access to surgical care in 2030.
The role for nurse anesthetists as we work on meeting this goal is to advocate for
policies to improve access to anesthesia care. We need to promote nancing of
global anesthesia by governments, corporations, and individual donations. As a pro-
fession, we need to contribute to the development of the nurse anesthetist workforce
in LMICs. There are excellent models from programs developed in Kenya and other
countries around world. Expanding the global nurse anesthetist workforce is one of
the answers to increasing access to surgical care to decrease disability and save lives.
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Challenges toGlobal Access toAnesthesia andSurgical Care
331
The International Federation ofNurse
Anesthetists: Past, Present, andFuture
PascalRod
cAbbreviated Key Terms
AANA American Association of Nurse Anesthetists
ANP Advanced Nursing Practice
APAP Approval Process for Anesthesia Programs
APN Advanced Practice Nurse
CQAIE Center for Quality Assurance in International
Education
EBA European Board of Anaesthesia
EFN European Federation of Nurses
ESAIC European Societies of Anaesthesia and
Intensive care
ESNO European Specialists Nurses Organization
EU European Union
G4 Alliance Global Alliance for Surgical, Obstetric, Trauma
and Anesthesia care
GIEESC Global Initiative for Emergency and Essential
Surgical Care
ICN International Council of Nurses
IFNA International Federation of Nurse Anesthetists
IHF International Hospital Federation
LIC Low Income Country ( World Bank Classification)
MIC Middle Income Country (World Bank
Classification)
P. Rod (*)
Executive Ofce, International Federation of Nurse Anesthetists, Mantes la Jolie, France
e-mail: p.rod@ifna.site
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_26
332
NSOAP National Surgery, Obstetric and Anesthesia care
SOTA Surgical, Obstetric, Trauma and Anesthesia care
WCNA World Congress for Nurse Anesthetists
WFSA World Federation of Societies of Anesthesiologists
WHA World Health Assembly
WHO World Health Organization
Genesis
When, in 1978, Mr. Hermi Löhnert, a nurse anesthetist from Switzerland, heard
through his surgeon that there were also nurse anesthetists in the USA, he was sur-
prised that Switzerland was not the only country in the world with nurse anesthetists
[1]. He had just been elected as the rst president of the recently founded associa-
tion of Nurse Anesthetists in the German-speaking part of Switzerland. In his quest
for further information, he found an issue of the American Association of Nurse
Anesthetists (AANA) magazine in a library, where he read more about their prac-
tice. He decided to participate to their continuing education annual meeting in
Detroit, Michigan and was nancially supported by his surgeons to attend. There,
Mr. Löhnert met another foreign nurse anesthetist from Denmark, and enjoyed the
very well-organized professional American organization with more than 22,000
members and a strong Continuing Education system. After interesting discussions
with the Executive Director, Mr. John Garde, and the President, Mr. Ron Caulk, it
was decided to establish a close relationship. Mr. Löhnert attended more meetings
after this one and, several years later, he proposed to the AANA organization of a
rst International Symposium for nurse anesthetists. This project became a reality
in 1985in Lucerne, Switzerland where 250 participants attended from 13 countries.
The Nurse Anesthesia specialty was denitely not as secluded and unique as some
thought. This rst international event was the starting point of an international coop-
eration. A second global meeting was in 1988in Amsterdam, The Netherlands,
organized by the Dutch association of nurse anesthetists. At the second symposium,
a meeting was held with representatives of different countries to work on the estab-
lishment of an international Organization for nurse anesthetists. After a few addi-
tional meetings, in June 1989, representatives from 11 countries met in Teufen,
Switzerland to sign the charter and launch the International Federation of Nurse
Anesthetists (IFNA).
Foundation Steps
During preliminary discussions, many topics were discussed and each country was
promoting its own model of education, practice, and regulation. There was no har-
monization. and differences were based on historical developments in each country.
Since the very beginning, anesthesia was controlled by surgeons and early providers
were nuns, nurses, or students long before physicians became involved. There is no
P. Rod
333
medical anesthesia specialty before the late 1950s, especially in Europe, were the
Poliomyelitis pandemic has been one of the reasons for having more non-surgeon
physicians involved in needs for intensive care and ventilatory care. The medical
specialty in anesthesia-intensive care is still combined in most of the countries in
the world. At the same time, nurses remained the natural anesthesia providers for
surgery procedures, receiving an adequate additional training and/or education. It
was certainly one of the rst special training in nursing beyond the general care,
even if it took time for recognizing it. Based on this, charter association members of
the IFNA went on discussions with their own historical background and educational
evolution. In many countries, the anesthesia medical specialty was more and more
developed and an increasing number of physicians inuenced the reorganization of
anesthesia services, with nurses slowly losing some of their autonomy. In 1989, at
the time of foundation of the IFNA, many associations were referring to political
ghts for maintaining their specialty in front of medical inuence for limiting more
and more their competencies. Many were also referring to the duality in their roles
as both Nurse and Anesthetist with the quest for existing between nursing bodies
looking at them as technicians and medical bodies trying to limit them to executive
tasks. Each national experience for maintaining their existence has inuenced many
of the discussions. Rapidly, nevertheless, common objectives could be dened. The
wording Nurse Anesthetist was chosen as generic title for dening the role of nurses
involved in anesthesia care whatever their ofcial recognition could be. The ofcial
title was varying in different countries, but on working site, it was the most com-
monly used denomination. The draft bylaws were very inspired by the ICN ones, as
it was the only recognized International Organization for nurses in existence.
Because most differences in status, recognition, education, and practice were more
dependent on each country’s regulations, it was decided to have national association
membership, one per country, instead of individual ones. The choice for being a
federation was then the most rational. Each country’s association, whatever their
number of active members, has the same voice, considering that the model of educa-
tion and practice is more important than the number of practitioners for interna-
tional purposes. The association member has to be the most representative of the
nurse anesthetists in the country, and it can be an independent body, or a branch of
a larger group or organization. The most important is to be autonomous in one’s
decisions and not dependant on a board that won’t have any nurse anesthetist. In
1989, there were very few countries recognizing nursing practice beyond the gen-
eral care, and advanced practice concept was not widespread, especially in Europe.
In some countries, there were nursing specialties recognized, but corresponding to
areas of practice more than advanced roles. It was a common point of agreement
between the IFNA charter members that there was a gap between the ofcial recog-
nition of education and practice of nurse anesthetists and their actual scope of prac-
tice. The nursing bodies were mainly focusing on only technical skills of nurse
anesthetists, ignoring what was considered as medical tasks. The physician anesthe-
tists on their side, despite a close collaboration on working sites, were denying the
autonomy of nurse anesthetists during ofcial discussions to avoid the risk of confu-
sion of roles. This is still a remaining positioning from anesthesiologists. This
The International Federation ofNurse Anesthetists: Past, Present, andFuture
334
ambiguous situation in re nurse anesthetists’ recognition has inuenced nurse anes-
thesia development in different countries. Some associations had to organize them-
selves separately from Nurses’ main organizations, because they were denied their
specic nursing practice and considered as doing medical tasks. In the same time,
there was an absolute need for anesthesia continuing education for maintaining and
updating competencies what nurse anesthetists had to organize by themselves. It is
the reason why the rst purpose of the international collaboration was about con-
tinuing education. In some other countries, the question of the level of education for
nurse anesthetists was raised and the minimum entry requirement was to have
achieved a secondary level of education in order to assimilate essential notions of
physics, chemistry as well as advanced physiology, anatomy, and pharmacology
knowledge. In countries where general care nursing was still organized at secondary
level, it couldn’t match with the demanded level for entering a nurse anesthesia
program. It is the reason why in countries with low nursing level of education, the
nurse anesthesia programs were open to non nurses, but for students with a high
level of education without nursing background. They were then neither listed nor
recognized as nurse specialists, but as High Health Technicians, even if in their cur-
riculum, nursing competencies were included and taught, adding by the way a lon-
ger time of training. These professionals were then organized separately from
nursing bodies. All these aspects went on the table at the time of discussions on
bylaws for the IFNA.It was nevertheless decided to privilege the nurse anesthesia
prole with an additional training and/or education beyond a basic level of nursing
education. On June 10, 1989, 11 charter country member associations of nurse anes-
thetists were planting the seed of the International Federation of Nurse Anesthetists
(IFNA) [1]: Austria, Federal Republic of Germany, Finland, France, Iceland,
Norway, South Korea, Sweden, Switzerland, the United States of America, and
Former Yugoslavia.
In the described context, the following aims and objectives were dened into
bylaws [1, 2].
cArticle II: Philosophy The International Federation of Nurse Anesthetists
is an international organization of nationally registered nurses with
special formal and/or actively pursuing a formal education in nurse
anesthesia. The members of this professional organization are dedicated
to the precept that its members are committed to the advancement of
educational standards and practices, which will advance the art and
science of anesthesiology and thereby support and enhance quality
patient care.
Article III: Purpose
The purpose of the IFNA is to promote assistance in the development
of strong national nurse anesthesia associations.
Article IV: Objectives
1. To promote cooperation between nurse anesthetists internationally.
2. To develop and promote educational standards in the eld of nurse
anesthesia.
P. Rod
335
3. To develop and promote standards of practice in the eld of nurse
anesthesia.
4. To provide opportunities for continuing education in anesthesia.
5. To assist nurse anesthetists’ associations to improve the standards of
nurse anesthesia and the competence of nurse anesthetists.
6. To promote the recognition of nurse anesthesia.
7. To establish and maintain effective cooperation between nurse anesthe-
tists, anesthesiologists, and other members of the medical profession,
the nursing profession, hospitals, and agencies representing a commu-
nity of interest in nurse anesthesia.
These objectives have been the permanent direction line for the IFNA until today.
International Standards [1, 3]
One of the rst objectives has been to work on international standards, rst of educa-
tion, then standards of practice for nurse anesthetists. An Education and Practice
Committee was appointed with experts from different country members. In 1990, the
Educational Standards for nurse anesthetists were established. The rst important
point was to dene entry criteria based on basic nursing education.The only interna-
tional reference for nursing basic education was the one dened by European Council,
a larger European collaborative political organization enclosing the European Union.
Nursing education was dened with duration of 36 months. Most of the country mem-
bers had in their own country, before entering the nurse anesthesia program, a request
for a nursing experience of at least one year, preferably in critical care, in order to have
students with acquired competencies in this area of care. This nursing experience was
then included as entry requirement into the standards of education. We then agreed on
a list of skills, competencies, and knowledge to be taught and required for practicing
as nurse anethetists. These rst standards of Education were published in 1990. A year
later Standards of Practice were dened, with a code of Ethics. In 1997, Mrs. Marjorie
Peace Lennn, founding President of the Center for Quality Assurance in International
Education, stated that the IFNA was the rst healthcare Professional international
organization to have dened international standards of Education and Practice. The
membership grew up very soon with many applications from Europe, but also from
Africa, bringing a very different working experience and specic requests. It was then
requested to develop some recommendations for safe practice of anesthesia for which
we develop Monitoring Guidelines that become very soon Monitoring standards. The
rst standards have been revised and updated in 2012. The Education committee and
the Practice Committee worked together for revising them. A new concept of presen-
tation was decided by using the CanMeds model for health care professionals. The
concept is to have the professional included in a multidisciplinary team approach with
its own competencies and expertise. Draft standards were shared with the ICN and the
revision was adopted in 2012 with ICN temporary endorsement. An improvement of
levels of education was requested and the Standards were nally updated in 2016in
their current version.
The International Federation ofNurse Anesthetists: Past, Present, andFuture
336
International Study [4]: About Global Nurse
Anesthesia Workforce
In 1990, Maura McAuliffe, a nurse anesthetist from USA, a PhD candidate at the
University of Texas, was challenged by her doctoral professor of International
Healthcare Policy, Dr. Beverly Henry, to develop a program of research with a
global impact. Maura Mc Auliffe knew that nurse anesthetists were providing the
majority of anesthetics in the USA and wondered if it could be the case more glob-
ally. The IFNA was just founded and at least county members were reporting about
their own anesthesia practice. McAuliffe was introduced to WHO Chief Scientist
Dr. Miriam Hirseld in 1991 and proposed to do global research about anesthesia
provided by nurses globally. The WHO accepted to endorse the research and assist
in contacting authorities in all countries in the world. The AANA sponsored the
research and the IFNA appointed McAuliffe as its Researcher. The study was
developed in three phases. The rst phase was designed for identifying countries in
which nurses were providing anesthesia. Ofcial reporting stated that nurses were
providing anesthesia in more than 107 countries out of 200 countries contacted.
Phase 2 was focused on scope of practice and education of nurses providing anes-
thesia, and phase 3in 1999 was verifying data and evolution during the ve years
of the study. This study brought evidence that anesthesia services in the world were
mainly provided by nurses, even if it was claimed being a physician’s task. It was
the rst documented global research about nursing contribution to anesthesia
worldwide [4].
Continuing Professional Development
One of the other objectives of the IFNA is to provide opportunities for continuing
Education, and the IFNA organized a World Congress for Nurse Anesthetists, rst
every three years, and now every four years, expecting to have regional events orga-
nized in the period between congresses.
In order to assist our country members and help other non-members, we devel-
oped different educational program curricula for Certicate, bachelor’s, and mas-
ter’s levels that can serve as models for starting formal nurse anesthesia educational
programs. More recently, we developed an Approval Process for Anesthesia
Programs (APAP) [5] assessing existing programs of education with three levels of
approval, depending on how much they are matching the IFNA standards criteria,
partially or in full.
International Relationship andCollaboration
To be recognized as the international voice for nurse anesthetists, it was important
to establish close relationship with main international organizations involved in
development of nursing care and anesthesia services worldwide.
P. Rod
337
International Council ofNurses (ICN)
The IFNA was, since the beginning, in contact with the International Council of
Nurses (ICN) [1], in order to develop a close collaboration and relationship. Criteria
for being recognized as an ICN Afliate member were quite strict at the beginning,
and the geographical requirements for having members in at least ve of seven ICN
regions couldn’t be met in early years. We have nevertheless established a non-stop
close relationship, rst recognized as an ofcial resource group for nurse anesthesia
specialty in 1996, and then, in 1997, being nally the second specialist nursing
international organization introduced as Afliate member. IFNA Standards of
Education and Practice have been regularly shared with the ICN, and the IFNA
participates in the APN network and events. In 2020, a collaborative work between
the ICN and IFNA experts has developed Guidelines on Advanced Practice Nursing
dedicated to Nurse Anesthetists, published in 2021 by the ICN [6].
World Health Organization (WHO)
The rst contact with WHO was in 1990 with the last chief Nursing Scientist, Dr.
Miriam Hirscheld for introducing the IFNA as new global nursing organization of
anesthesia providers. The WHO did not anymore recognize any new organization as
a collaborative body and we were told that Anesthesia was represented by the World
Federation of Societies of Anesthesiologists (WFSA). Unfortunately, after Dr.
Hirscheld, Dr.; Jean Yan was until 2009 the last representative of Nurse at high
level within the WHO, and when she left, the direct contact became difcult for
nurses’ organizations even for the ICN.We could participate as individual members
to the Global Initiative for Emergency and Essential Surgical Care (GIEESC) meet-
ings, and be involved in the nal development of the WHO Check list program.
Since Dr. Elisabeth Iro became the New Chief Nursing Ofcer, we could have
closer appointments. One important initiative to which we have participated was to
lobby for the World Health Assembly resolution that was passed in 2015
“Strengthening Emergency and Essential Surgical Care and Anesthesia as a
Component of Universal Health Coverage” [7]. We could participate in many
meetings organized by the WHO before in collaboration with Anesthesiologists and
Surgeons. Surgical, Obstetric, Trauma and Anesthesia (SOTA) care have to be
developed in different countries and National Surgical, Obstetric, Trauma, and
Anaesthesia Programs (NSOAP) are in progress. All care providers, including non-
Physicians, have to be incorporated into the workforce and service developments.
World Federation ofSocieties ofAnesthesiologists (WFSA)
The World Federation of Societies of Anesthesiologists [8], is the recognized voice
for anesthesia services at the WHO, but representing only physicians. It took time to
establish a close contact and to have a rst meeting together. The rst meeting of the
The International Federation ofNurse Anesthetists: Past, Present, andFuture
338
two boards was in 1997, but it emphasized on disagreements upon recognition of
mutual competencies. Anesthesiologists wanted to promote that anesthesia is a phy-
sician’s task, which we couldn’t agree with as it is not reecting the global actual
situation. It was nevertheless decided to look at possible collaboration missions con-
cerning anesthesia providers’education and patient safety. The relationship became
easier after 2000 thanks to common participations to GIEESC initiatives for the
Surgical Check List and further developments around the 2015 WHA resolution.
There is evidence that such target cannot be reached without considering the non-
physician anesthesia providers, Nurse Anesthetists being the main representatives.
The two Boards are now meeting regularly and we collaborate in different initiatives
about Patient Safety, Global Anesthesia Workforce, and other key indicators.
European Specialist Nurses Organization (ESNO)
The European Specialist Nurses Organization (ESNO) [9] is a European organiza-
tion gathering different nursing specialties. In European Union, only General care
nursing is regulated for education and practice. All nursing practice beyond general
care is not recognized despite many specialties existing. In 1995, the IFNA went in
contact with different organizations representing Nursing at European level for pro-
moting the nurse anesthesia specialty. Nursing specialties at this time, even at
national levels, were not very well recognized. Many nursing bodies were consider-
ing specialties either as a practice of nursing in a specic area of care without any
advanced competencies, or as nurses with technical skills. For this reason, many
specialties were already organized as transnational associations inside larger
Europe. National associations of nurses created the European Federation of Nurses
(EFN), formerly called Permanent Council of Nurses, and proposed to different
specialists’ groups to collaborate rst as a networking. Many EFN members were
looking at specialists’ groups as a fragmentation of the Nursing profession, while
these were seeking at being recognized in their specic competencies beyond gen-
eral care. After a few years of collaboration, specialists couldn’t participate any-
more as a network and were asked to integrate with the EFN without any decisional
voice, as a consequence, specialists founded their own separate entity called the
ESNO.The IFNA has been a leader during all the process since rst contacts. The
ESNO is more and more recognized as a valuable partner with EU authorities. The
ESNO represents nurses in the European Medicine Agency Health Professional
Working Group. The ESNO is active in promoting the recognition of specialists
nurses and furthermore as advanced nursing practitioners.
European Societies ofAnesthesiologists andIntensive Care
(ESAIC) andEuropean Board ofAnesthesiology (EBA)
The Anesthesia physician specialty is represented in Europe by two entities very
linked, the ESA gathering, different national societies of anesthesiologists and the
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EBAofcial branch of anesthesiologists, into the European Medical Specialties
organization. The IFNA came in contact with these two groups at a moment when
anesthesiologists, because of their shortage, wanted to delegate deep sedation for
endoscopy acts to Gastro Enterologists, who would themselves delegate it to
endoscopy nurses. It has been the perfect opportunity for the IFNA to remind that
there were already nurses educated and trained for providing safe sedation and
anesthesia, which they were perfectly aware of. The threat of competitive function
was blinding them, but they recognized the inappropriate aspect of the proposal
and withdrew it. For avoiding such unsafe decision, it was proposed to create a
tripartite Liaison Committee with two representatives from each physician orga-
nization and four representatives from the IFNA.The committee worked well for
a few years and the IFNA could present two proles for Nurse anesthetists at the
European level, depending on the duration and content of educational programs.
One model was referring to advanced roles and autonomy as existing in some
European countries (Denmark, Iceland, France, Luxembourg, Norway, Sweden,
Switzerland, The Netherlands) the second one was for shorter educational pro-
grams and limited assisting roles for nurses. Anesthesiologists wanted to promote
the second model in priority before introducing the most advanced one. For IFNA
representatives, both models corresponding to actual situation in Europe had to be
presented at the same time. This situation creates a standby in the relationship that
is very much depending on countries’ representation into the two physician
boards. At the same time, the IFNA appointed a nurse Anesthetist into the ESA
Patient Safety committee who is very active and appreciated by committee part-
ners. The ESA has recently changed its name to European Societies of Anesthesia
and Intensive Care (ESAIC) as the Anesthesia Medical Specialty in Europe is
including Intensive Care into the practice that represents the longer part of the
curriculum.
G4 Alliance forSurgical, Obstetric, Trauma andAnaesthesia Care
Associations of Surgeons, Anesthesiologists, and Non Governmental Organizations
having surgical missions in Africa after discussions started in GIEESC meetings
founded this new organization. The aim is to gather different professions for improv-
ing surgical services worldwide according to the WHA 2015 resolution [7].
The G4 Alliance [10] is committed to achieving universal access to safe surgical,
obstetric, trauma, and anaesthesia (SOTA) care for all. The IFNA is an active mem-
ber of this New Alliance and the voice for non-physician anesthesia providers who
are essential in SOTA care for the target regions.
IFNA Achievements
The IFNA has now 43 members from all over the world, including two members as
associate members, who don’t have ofcial nursing background.
The International Federation ofNurse Anesthetists: Past, Present, andFuture
340
cIFNA Country Members Associations [2]
America:
Jamaica and United states of America
Africa:
Benin, Burundi, Côte d’Ivoire, Democratic Republic of Congo,
Ethiopia, Ghana, Kenya, Liberia, Morocco, Nigeria, Rwanda, Sierra
Leone, Tunisia (associate), and Uganda
Asia:
Australia, Cambodia, Indonesia, Japan, South Korea, and Taiwan
Europe
Austria, Bosnia I Herzegovina, Croatia, Denmark, Finland, France,
Germany, Greece, Hungary, Iceland, Luxembourg, The Netherlands,
Norway, Poland, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey
(associate), and the United Kingdom.
IFNA Standards [3] have been widely accepted by each country member associa-
tion and wider and serve as reference for Nurse Anesthesia education and practice.
Standards could be developed thanks to the Education Committee and the Practice
Committee composed of experts in nurse anesthesia education and practice with a
fair geographical representation. Standards have been developed, reviewed, and
updated by these committees before being adopted by Country members associa-
tions. An Approval Process for Anesthesia Programs (APAP) [5] has been also
developed in order to assess different existing programs of education. As programs
can have different duration, contents, and required levels of practice after certica-
tion, there are three categories of approval: Registration, Recognition, and
Accreditation. While Accreditation level recognizes that the Educational Program is
meeting all IFNA standards criteria, the two others depend on partial achievement
of criteria. There are 36 programs awarded, 13 at Accreditation levels. The IFNA
organizes a World Congress for Nurse Anesthetists [11] every 2–4 years in order to
bring opportunities for sharing different experience and providing continuing pro-
fessional development [12]. Regional events are also organized.
An IFNA Foundation for Research and Education [13] is also available, award-
ing grants for different projects that could have an international interest for nurse
anesthesia developments. Applications can be uploaded from the IFNA website. It
concerns research and educational projects, including student and faculty exchange
programs.
The IFNA provides support to associations seeking to have the nurse anesthesia
education and practice recognized by their national or regional authorities. The
IFNA can assist in development of formal programs of education as replacement of
on-site training. There are also opportunities for supporting programs that want to
move from school to university, from certicate and bachelor’s levels to mas-
ter’s ones.
The IFNA has recently reviewed the bylaws and has updated them in accordance
with new denitions and objectives: The new denition of Nurse Anesthetist is the
one dened into the ICN Guidelines for advanced nursing practice nurse anesthe-
tists [6]:
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cArticle VII: Definition of Nurse Anesthetist A Nurse Anesthetist is an
Advanced Practice Nurse who has the knowledge, skills, and
competencies to provide individualized care in anesthesia, pain
management, and related anesthesia services to patients across the
lifespan, whose health status may range from healthy through all levels
of acuity, including immediate, severe, or life threatening illnesses
or injury.
There is also one objective that has been added into updated Bylaws [6, 14] for
being in accordance with the WHA resolution [7]:
cTo improve access to safe anesthesia care and universal health
worldwide.
Global Leadership
Historically, the rst anesthesia providers [1] were surgeons’ assistants, generally the
nun or nurse immediately close by. Nurses have then been involved in anesthesia
since the real beginning and even more than 150 years after the rst anesthesia expe-
rience; they are still representing a large part of the global anesthesia workforce.
There is evidence that in rural areas and or remote settings, nurse anesthetists are the
only educated anesthesia providers available. Nurse anesthesia has been a model for
development of advanced nursing practice [1], demonstrating that nurses educated
beyond the level of general care can provide safe advanced care to the population.
Recognized as advanced practice nursing specialty, nurse anesthetists have always
maintained their autonomy in practice with advanced competencies for assessment,
interpretation of monitoring data, clinical signs and decisions in corrective actions
for maintaining safe anesthesia. Their advanced knowledge in anatomy, physiology,
pathophysiology, and pharmacology is recognized even if regulation can limit their
scope of practice. Many polemics are raised because of this dual positioning, as
nurse and anesthetist, that doesn’t match with a traditional vision making difference
between care and cure. The IFNA tries to erase this narrow vision and promotes a
collaborative approach for optimizing the quality of care to the population, taking in
consideration actual advanced competencies. The synergy is more efcient than
opposition, and it takes time to move lines and barriers. The IFNA in this objective
supports all actions toward politicians, health deciders, and other healthcare profes-
sionals with the aim of improving anesthesia services worldwide and everywhere.
Conclusion
Since 1989, when the IFNA was founded, many objectives have been achieved. The
IFNA is the recognized international voice for Nurse Anesthesia and wider for all
non-physician anesthesia providers. Even if, historically, nurses were the rst
The International Federation ofNurse Anesthetists: Past, Present, andFuture
342
anesthesia providers in many countries, it took years to have this international rec-
ognition, rst as a nursing specialty, and furthermore as an Advanced Practice
Nursing. There is still a lot to do and needs for developing nurse anesthesia pro-
grams of education in order to participate in improvement of access to safe anesthe-
sia services everywhere.
References
1. International Federation of Nurse Anesthetists (2021) The Global Voice for Nurse Anesthetists,
International Federation of Nurse Anesthetists (1989–2021).
2. International Federation of Nurse Anesthetists, country members. https://ifna.site/about- ifna/
accessed 8 September 2022.
3. International federation of Nurse anesthetists, International Standards, https://ifna.site/app/
uploads/2017/06/IFNA- Booklet- HD.pdf accessed 8 September 2022.
4. McAuliffe MS, Henry B.Countries where anesthesia is administered by nurses. AANA J. 1996
Oct;64(5):469–79. PMID: 9124030
5. International Federation of Nurse anesthetists., https://ifna.site/ifna- accreditation- program/
approval- process- for- nurse- anesthesia- programs/ accessed 8 September 2022.
6. ICN (2021) Guidelines on advanced practice nursing; nurse anesthesia. https://www.icn.ch/sys-
tem/les/2021- 07/ICN_Nurse- Anaesthetist- Report_EN_WEB.pdf accessed 2 August 2022.
7. World Health Assembly (2015) Resolution 68.15. strengthening emergency and essential sur-
gical care and anesthesia as a component of universal health coverage. https://apps.who.int/gb/
ebwha/pdf_les/WHA68/A68_R15- en.pdf accessed 8 September 2022.
8. World Federation of Societies of Anesthesiologists. https://wfsahq.org accessed 8
September 2022.
9. European Specialist Nurses Organisation. https://www.esno.org
10. G4 Alliance for Surgical, Obstetric, Trauma and Anaesthesia care. https://www.theg4alliance.
org accessed 8 September 2022.
11. World Congress for Nurse Anesthetists. https://ifna.site/etusivu/congresses/ accessed 8
September 2022.
12. International Federation of Nurse Anesthetists. https://ifna.site/etusivu/practice/cpd/ accessed
8 September 2022.
13. IFNA Education and Reasearch Foundation https://ifna.site/ifna- education- research-
foundation/ accessed 8 September 2022.
14. IFNA Mission, Vision,Objectives http://ifna.site/app/uploads/2015/06/Bylaws- May- 2022-
Update.pdf accessed 8 September 2022.
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Global Development ofNurse
Anesthesia Education
fromMid- Nineteenth Century into
Today’s Advanced Nursing Practice
MarianneRiesen, JaapHoekman, andKarinBjörkelund
Introduction
There is scarce documentation of early nurse anesthesia practice and education in
most member countries of IFNA, except in the USA.With the advent of anesthesia,
starting in the mid-nineteenth century, nurse anesthesia education developed from
on-the-job training into a profession with a systematic, formalized, tertiary educa-
tion as it is today. Nurse anesthesia at its beginning was not a specialty but part of
nursing education [1]. Most nursing textbooks at the end of the nineteenth and
beginning of the twentieth centuries were written by surgeons and included anesthe-
sia [2]. Responsibility and documentation of anesthesia were with the surgeons,
while administering was delegated to nurses. They obviously received training in
nursing schools and on the job. The change into formalized postgraduate education
began in the mid-twentieth century.
M. Riesen (*)
Former IFNA APAP Manager, Schaffhausen, Switzerland
J. Hoekman
Former IFNA President, Ie, The Netherlands
K. Björkelund
Former Chair IFNA Education Committee, Lund University, Lund, Sweden
e-mail: Karin.bjorkman_bjorkelund@med.lu.se
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_27
344
Nurse Anesthesia fromtheMid-Nineteenth
totheMid-Twentieth Century
Fundamental changes toward modern science-based medicine at the beginning of
the nineteenth century required professional nursing [1]. Up to this time, the care for
patients was in the hands of lay people whose job was to alleviate suffering, and
preparing patients for their death. The new doctors realized very quickly that their
art was due to fail if the patients were not professionally cared for. Nursing was
intended to become a signicant healing tool of modern medicine. Many nurses up
to then came from religious institutions and were convent sisters or deaconesses [2].
Born out of the caritas, nursing developed continuously as medicine developed.
Soon the rst nursing textbooks appeared. Most of them were written by surgeons.
Besides anatomy, physiology, and pharmacology, the major part contained the
desired traits nurses had to exhibit. Patriarchal structures represented the image
society had of women and especially of nurses. Von Roten, in her controversial book
“Frauen im Laufgitter” (women in a playpen), explains that this spirit was sup-
ported partly by society and partly by the nurses themselves [3]. Private life was
normed toward the characteristics of convent sisters. This moral stand was very
welcome to justify low payment, long working hours, and maximum dedication.
The treatment of the sick was an opportunity for sacrice for nurses, and a gold
mine for the doctors. Unfortunately, it had a negative impact on other predominantly
female professions.
Despite Nightingale’s effort to put nursing education into the hands of women
[1], early nursing schools in Europe, founded in the late nineteenth and early twen-
tieth centuries, were directed by doctors, mostly surgeons [2]. The new schools
were focused completely on medical requirements. The main topics were anatomy,
physiology, internal medicine, infectious diseases, surgery, psychiatry, ethics, and
anesthesia, which was inherent in nursing education at this time.
According to Franklin, the teaching and learning methods in health care at the
time followed more or less Billroth’s (1829–1894) work called Teaching and
Learning the Medical Sciences in German Universities [4]. The book was the major
inspiration for Abraham Flexner’s recommendations to educate health professionals
in the USA in 1910. The emphasis was put on the acquisition of core competencies
such as biomedical topics at the expense of a more comprehensive understanding of
social and community health problems.
After the rst anesthesia in Oct. 1846in Boston, the news travelled very quickly
to Europe and other parts of the globe [5]. In Germany, France, Switzerland, Austria,
Finland, Sweden, Norway, Denmark, and Iceland, and indeed most European coun-
tries, for approximately one hundred years—from the mid nineteenth to the mid
twentieth century—the “drip nurse” was part of every image showing surgeries. The
nurse who personally initiated the inhalation anesthesia and carefully monitored the
condition of the patient is a ubiquitous gure at the head of the operating table on
contemporary photographs. Nonetheless, today she has disappeared from collec-
tive memory.
The anesthetizing nurse. (In: [6] Hodel A. (1927) pg. 14)
M. Riesen et al.
345
An early German text book on anesthesia, published in 1954, did not mention
nurse anesthetists at all in the overview of the history of anesthesia [7]. Atzl and
Artner brought the work utensils of the early nurses to light [8]. They have system-
atically analyzed the stock of nursing objects in museums and other collections in
the German-speaking area. Among those objects were the chloroform and ether
drip-bottles used by nurses.
German-speaking nursing textbooks from the late nineteenth and early twentieth
centuries emphasized how “responsible” the work of “chloroforming” was and
stated furthermore that it could only be learned through “lots of practice under the
supervision of a doctor” [6, 9–12]. All authors were surgeons except Angelina
Hodel [6]. She was a Swiss convent sister and led a nursing school at the time. In all
textbooks, the central idea of nursing is dened as observing the patient, which
formed the key of nursing training [5]. Observing the patient has continued to be
central to this day. The brief statement on “chloroforming” shows that the nurses
received training.
According to Tenedios etal., a major factor supporting the development of the
nurse anesthesia profession was the reluctance of physicians in the late nineteenth
century to engage in the practice of anesthesia [13]. At the turn of the twentieth
century, anesthesia did not seem challenging, interesting, or nancially lucrative,
especially in the United States. Few medical practitioners could make a living of it
(particularly outside large cities). A shortage of suitable anesthesiologists and the
reluctance of physicians to provide anesthetics in the second half of the nineteenth
century encouraged nurses to take on this role in a large number of countries.
During the period between 1915–1930, modern anesthesiology slowly began to
develop. As in other countries, nurses played an important role in anesthesia at an
early age in Sweden as well, which can be illustrated by the following quote from the
Swedish surgeon Petrén (1920) “To be able to fulll these tasks well, the narcotist
(anesthetist, author’s note) requires not only reliability, conscientiousness and calm-
ness but also a great deal of anesthesia experience …. it is certainly safer to be anaes-
thetized by an anaesthetizing nurse than, for example, by a professor of surgery” [14].
Global Development of Nurse Anesthesia Education from Mid-Nineteenth Century…
346
In most European countries, anesthesia remained completely within nursing
until about the 1950s. The anesthesia part of the early nursing textbooks contained
exact methods of dropping ether, what to prepare, how to maintain an airway, tech-
nology to be used, and how to observe the vital signs of the patients [10]. Later ones
also included the application of chloroform [12]. Schleich began to mix ether and
chloroform in the 1890s because he observed that patients felt better afterward [15].
Nausea and vomiting were the same, but not as long as with ether alone. There was
also less saliva and less postoperative bronchitis. The mixture was called Billroth
mixture, and it contained chloroform–ether–alcohol in a 1:1:3 ratio.
We certainly can appreciate the skills and knowledge of those nurses when read-
ing about Theodor Billroth’s achievements as an example [4]. Billroth was one of
the greatest pioneering surgeons. His most famous achievement was a partial gas-
trectomy in 1881 for cancer of the stomach. Several aspects make this outstanding,
the technical side of the operation was achieved in an era with limited anesthesia
(only chloroform and ether), the absence of intravenous support, the inability to
administer blood transfusions, and the lack of antibiotics to ght infection.
Anesthesia practice developed and those nurses developed their skills and knowl-
edge with it. According to Schloffer, a surgeon in Prague, one of the early anesthesia
machines such as the Roth–Draeger, produced in 1910, was commonly in use in
1923 [16]. Those nurses clearly had the technical skills and knowledge to handle an
anesthesia apparatus that had already components which are still in use today.
Roth-Draeger 1910 (In: [17] Draegerwerk: History of Anaesthesia at Draeger
(1996) page 18)
M. Riesen et al.
347
A Brief Historical Overview ofNurse Anesthesia inSome Selected
IFNA’s Member Countries
The IFNA is the authoritative voice for nurse anesthetists, supporting and enhancing
quality anesthesia care worldwide [18]. IFNA comprises 43 member countries.
France has a long history in nurse anesthesia [19]. Anesthesia was also the respon-
sibility of the surgeons and they considered nurses as more efcient and better
trained in providing it than, e.g., medical students. The rst ofcial course in France
was developed in 1948 at the Ecole de Médecine, Paris and it was accessible for
doctors and nurses. It lasted a few months. The rst formal course for nurses and
midwives began in 1950. The history and development toward modern nurse anes-
thesia in European countries is similar in Sweden, Norway, Denmark, Iceland, the
Netherlands, and Switzerland.
Little is known about the early years of anesthesia in IFNA’s African member
countries. Benin, Burundi, the Rep. of Congo, and Tunisia, which were Belgian or
French colonies, have a history of French or Belgian surgeons and nurses providing
early anesthesia from the respective countries [20–23].
In 1850, six copies of the Dutch edition of Schlesinger’s German book on ether
anesthesia, were translated by the ofcial translators of the Tokugawa Shogunate,
Japan [24]. Dutch physicians brought chloroform to Japan and it was used in the
Inland Wars. After 1869, Japanese medicine came under German inuence. Regional
anesthesia was dominant over general anesthesia. It was not until 1950, when Meyer
Sakland from the USA conveyed modern knowledge of anesthesia, making general
anesthesia popular. There have been no non-medical anesthesia professionals in
Japan, but the debate has started regarding its potential introduction into Japanese
operating theaters. Nurse anesthetists predated physician anesthetists in the United
States as anesthesia providers by a number of years. After returning from her anes-
thesia studies in Heidelberg (Germany), Agnes McGee established, in 1909, the rst
school of nurse anesthesia, a six-month course at St. Vincent’s Hospital, Portland,
USA.This rst school of anesthesia in the world was often attended by future physi-
cian anesthetists as well. The propagation, development, and expansion of the nurse
anesthesia profession received new impetus when the USA entered WWI in Europe.
Over 1000 nurse anesthetists were deployed to Britain and France. While in Europe,
those nurse anesthetists often risked their lives on the front, winning the admiration
of the most celebrated surgeons and medical practitioners in the medical world.
In Cambodia, formal nurse anesthesia education started in 1991 [25]. It was initi-
ated by the Ministry of Health together with Médecins Sans Frontières, France.
Unfortunately, the education of nurse anesthetists in Cambodia is suffering from
funding problems. The courses do not take place regularly. Currently, there are
plans to redevelop the education and change it into a bachelor program.
We have no record of early history of nurse anesthesia in Indonesia. Like in many
African countries, the Indonesian nurse anesthetists are the major and, in remote
parts, the sole providers of anesthesia today [26].
Nurse anesthesia in South Korea has its roots in the aftermath of the Korean War.
There were few anesthesiologists in the country [27]. The American Sister Margaret
Global Development of Nurse Anesthesia Education from Mid-Nineteenth Century…
348
Kollmer recognized in 1964 a serious lack of anesthesia providers in the country. In
1969, she implemented a training program in hospitals which was based on the
American model. It lasted 18months. Kollmer promoted nurse anesthesia in South
Korea for 29years. Unfortunately, the number of programs declined sharply. Today,
only one University is offering a graduate degree. It produces only ten graduates per
year, which is very little for a country with 51 million citizens.
In Taiwan surgeons and medical doctors administered anesthesia, but they were
replaced by anesthesia nurses and anesthesiologists [28]. The year 1958 was the
beginning of nurse anesthesia education and, in 1959, the rst nurse anesthetists
performed at the Taipei Veteran General Hospital.
In Australia and many countries of the British Empire, anesthesia arrived early
[24]. Like in Great Britain, it became a medical discipline from a very early time.
Other than in the USA or continental Europe, it enjoyed a high recognition and
professionalism. Anesthesiologists and surgeons stood as equals and perspectives
for jobs were good. The issue of non-medical anesthesia providers never came up.
There were and are high quality assistants in anesthesia, but more within sub-
branches of the discipline, such as acute pain management, pre-operative assess-
ment, hyperbaric and diving medicine, etc.
The Beginning andDevelopment ofFormal Nurse Anesthesia
Education inSelected IFNA Member Countries fromthe1950s
Till Date
Transformation into anAssisting Role inAnesthesia
The practice of anesthesia began to change signicantly in the 1950s, with the intro-
duction of endotracheal intubation [5]. The advent of this, together with new tech-
nologies, triggered the handover of anesthesia from the nurse to the doctor in some
countries. In Germany and Great Britain, for example, the delivery of anesthetics
became a “medical task.” While handling the objects during inhalation, anesthesia
was seen as a simple technique that could be performed by women; the new techni-
cal skills of endotracheal intubation, including complex apparatuses, could only be
expected of men. This view was shared by doctors as well as the organization of
nurses. The actual expertise that those nurses brought to the job as nurse anesthe-
tists, namely, the systematic observation of the patient, was addressed neither by the
doctors nor by the nurses who participated in this debate. By 1918in Britain and
1953in Germany, surgeons were arguing that nurses were not competent to handle
technology such as endotracheal intubation—so anesthesiology was removed from
their domain of practice.
As in Germany, Great Britain, and many countries of the British Empire, in
Austria, where the rst anesthesiologists began work in 1952, nurse anesthetists and
anesthesiologists worked in cooperation [29]. Over the years, nurse anesthetists
were slowly replaced by anesthesiologists and they found themselves in an assis-
tant’s role. This happened despite a course that was held in the 1960s in Vienna and
M. Riesen et al.
349
Innsbruck. The Austrian Association of General Nurses was not interested in sup-
porting nurse anesthesia. There were various efforts to keep it alive, but, in 1997, a
new law downgraded the role of those nurses denitely to that of an assistant. The
history is similar in Spain, where specialist nurses work under direct supervision (an
anesthesiologist is present at all times), on the one hand, and also cover the periop-
erative domain such as preoperative assessment, post-op recovery, and pain man-
agement [30]. In the beginning of the twentieth century, nurses provided anesthesia
in Finland [31]. In the early 1950s, a Finnish nursing teacher went to the USA in
order to learn more about anesthesia. In the following years (1952/1953 and
1956/1957) the rst nurse anesthesia courses started in Finland. In 1963, a formal
nurse anesthesia education was introduced in Helsinki followed by another in Oulu
(1968). However, in the 1990s, as the basic nursing education changed from a col-
lege degree to a university applied-sciences diploma, the nurse anesthesia education
was replaced by a course in perioperative care included in the nursing program [32].
Hence, the Finnish education differs from the other Nordic countries with its place-
ment in the basic nursing education. The subject is very general, aiming toward
perioperative nursing, and it is very short, taking a total of 20weeks. After the
transformation in education, the profession of the Finnish nurse anesthetist expired.
Anesthesia is administered together with an anesthesiologist. The Finnish
Association of Nurse Anesthetists (FANA), established in 1963, has worked hard to
re-establish a two-year specialist education program with an integration between
anesthesia, intensive care, and pain nursing, leading to a diploma [31]. Although
there is yet no recognized education program by the Finnish government, an infor-
mal special anesthesia program of 30 credits started in 2015 at the Lahti University.
Development into Today’s Nurse Anesthesia Role
While the scope of practice transformed into assisting the anesthesiologist in some
countries, in many others, nurse anesthesia developed and transformed together
with the development of modern anesthesia. McAuliffe & Henry, in the mid-1990s,
found out that nurses administered anesthesia in 106 countries providing anesthesia
in 77% of rural areas of the world and in 75% of urban areas [33]. Fifty-seven per-
cent were required to have anesthesiologists supervise their work. That means 43%
were still working independently at the time of the study. In the remaining coun-
tries, all had formal education, but some had to leave their countries to become
educated.
In Europe, we nd a variety of education schemes for nurse anesthetists despite
the Bologna declaration that was supposed to harmonize education throughout the
continent [34]. The construction of the European Union (EU) does allow for such
differences though. The EU is a unique global example of real integration of dif-
ferent states, a reality that includes 450 million people living in 27 countries. The
unique feature of the EU is that although the Member States all remain sovereign
and independent states, they have decided to pool some of their “sovereignty” in
areas where it makes sense to work together [35]. This explains the differences in
Global Development of Nurse Anesthesia Education from Mid-Nineteenth Century…
350
education and scopes of nurse anesthesia practice that can be found among European
nations. Today, Cabrera & Zabalegui state that there is still a lack of harmonization
of master’s degree programs in Europe and clinical nursing positions for Advanced
Practice Nurses (APN) vary among and within countries, making difcult the
mobility and collaboration among APN in Europe [36]. The higher qualied nurse’s
work is mainly in clinical settings as managers, and in higher education institutions
and universities, as professors, teachers, and researchers. Generally, healthcare poli-
cymakers in Europe recognize the advanced role and higher qualication of these
professional nurses, but there is a lack of legal regulation frameworks to support
their autonomy in the healthcare system.
In May 1950, the World Health Organization (WHO) founded the Anesthesiology
Centre Copenhagen [37]. Leading anesthesiologists from the UK, Sweden, and the
USA were employed to teach a one-year course in anesthesia. Some early European
anesthesiologists were educated in the specialty at the center. Björn Ibsen, a pioneer
in anesthesiology and intensive care, introduced a completely new form of treat-
ment for polio patients [38]. He performed a tracheotomy to allow overpressure
ventilation which became the practice in anesthesia as well. Due to Ibsen’s method,
the mortality of these patients decreased from 87% to 26%. The many hundreds of
students, nurses, and doctors who manually ventilated and cared for the patients
displayed true courage of the rst degree. Seven decades later, we see a striking
parallel to the Covid-19 pandemic [39]. We have seen more patients than ventila-
tors, understaffed hospitals, and a snowballing pandemic.
When talking to colleagues during the 14th IFNA World Congress for Nurse
Anesthetists in Sibenik, Croatia (2022), two authors of this chapter, JH and MR,
found out that many nurse anesthetists of all participating countries were moved to
intensive care units in order to help with the care and ventilation of the large number
of Covid-19 patients. The aftermath was still palpable at the congress because many
operations in most countries were postponed and the catching up is still going on. It
also had a signicant impact on the clinical education of nurse anesthesia students.
Experienced nurse anesthetists were busy ventilating Covid-19 patients on intensive
care units and therefore not available to clinically supervise and educate students.
Scandinavian Countries
In many countries, anesthesiologists took a pragmatic view about nurse anesthetists.
At the time, there were only very few anesthesiologists and to rely only on them
would have severely limited patient’s access to surgery. Therefore, they saw a neces-
sity to train the nurses in modern anesthesia techniques.
According to Ibsen, doctors and nurses had to be specially trained to precisely
observe and maintain the patient’s vital functions [40]. He came to the conclusion
that the education of nurses was not sufcient for the task, and local courses for
nurses in anesthesia were introduced in 1957. In 1977, the rst national curriculum
for nurse anesthesia education was established in Denmark and then revised twice
in 1997 and 2017 [37], controlled by the Danish Government and specied in hours
for all the different subjects and practice hours [32]. The program, comprising two
years of full-time studies (theory 13% and practice 87%), is established at a hospital
M. Riesen et al.
351
level. Course participants are employed by the hospital, while the theoretical educa-
tion is handled by educational leaders attached to education departments in the dif-
ferent regions. The program is free for the students who receive a salary during the
whole education. Danish nurse anesthetists work independently or under delegated
responsibility as well as in teams with anesthesiologists [37].
Between the 1930s and the 1950s, in Sweden’s nurse anesthesia administration,
ether was the main anesthetic agent in use [41]. The rst anesthesia textbook
appeared already in 1958, written by Matts Halldin [42]. As the number of anesthe-
siologists were few, the nurse anesthetists had to take on the responsibility for anes-
thesia [43]. Nurses in the 1950s and the 1960s who chose to stay in nurse anesthesia
could, after one year of anesthetic experience, attend to a 5-month course containing
theory and practice at the National Institute of Higher Education in Stockholm or
Gothenburg. The rst course was held in Gothenburg in 1954 and it included anat-
omy, physiology, pharmacology, and anesthesiology. The lectures were mainly
given by anesthesiologists. The course also consisted of a written essay and anes-
thetic practice. At this time, the Swedish Association of Nurse Anesthetists, later
including Intensive Care Nurses, was established [41]. In 1966, the education for
registered nurses was changed from 3.5years, including specialization, to 2.5years
with a following education program of 1year in a special eld [44]. Before entering
a specialization program, students had to have at least oneyear of practice as a reg-
istered nurse. The nurse anesthesia programs were organized at the Local
Government County Council schools. The curriculum directives, formulated by the
Swedish Government, were already very detailed, containing roughly 450 lectures
and lessons (about 12weeks) in subjects such as advanced anatomy and physiology,
microbiology, pharmacology, anesthesiology, organization theory, and staff man-
agement. Practical training was 32weeks (1280hours) in general and special anes-
thesia care, operating room, emergency or intensive care. Nurse anesthesia programs
were transformed into university-based education in the 1970s, followed by an
academic-based program in 1997, directed by universities under the regulation of
the Swedish Government and the Swedish National Agency for Higher Education
[41]. In 2007, Swedish Higher Education adopted the Bologna Process and the spe-
cialist programs are since then a professional degree at advanced level, including a
one-year master’s; “Postgraduate Diploma in Specialist Nursing-Anesthesia Care”
and a “Degree of Master of Medical Science (60 credits); Major in Nursing” [45].
The degree is a protected professional title since 2001 by the Swedish Parliament
and the National Board of Health and Welfare. Eligibility requirement for entering
a nurse specialist program is, since the beginning of 2000, a bachelor’s degree in
Nursing, consisting of 180 credit points. Since the mid-1990s, the Swedish
university- based education system for registered nurses has been adapted to further
academic levels, implying the continuation into a doctoral degree in Nursing Science
of fouryears. Swedish nurse anesthetists work independently, as well as in teams
with anesthesiologists, under their own responsibility. The program, offered by 15
universities, is free for the students.
The Norwegian education was placed at hospital level for many years with the
rst formal one-year nurse anesthetist training starting in Bergen around 1960 [46].
Global Development of Nurse Anesthesia Education from Mid-Nineteenth Century…
352
A three-month “supplement nurse anesthetist course” began in 1964 and nally, in
1976, after hard work by the National Association of Nurse Anesthetists (ALNSF),
the Norwegian Anesthesiologists and local authorities approved the national train-
ing curriculum. Although the education plan never received an ofcial approval by
the National Government of Health and the National Ofce of Nursing, it was in use
until 1998. The year after, the Norwegian Government decided that all higher edu-
cation should take place at universities or university colleges and no longer at the
hospitals. A national framework establishing national standards for nurse anesthe-
tist’s education stated that nurses, after obtaining their nursing degree (bachelor
level), had to work for at least twoyears as a registered nurse before starting the
18months of anesthesia training. The program consisted of theory and practice,
50%, respectively. The national framework was revised in 2005 with minor adjust-
ments implemented. Today, most of the universities and university colleges have
established a master’s program for nurse anesthetists lasting twoyears.
In Iceland, the rst registered nurse anesthetist started practicing in 1962 [47].
She was educated in Uppsala, Sweden. Several nurses followed her path over the
years and were educated either in Sweden or Denmark. From 1968 until 1976, two
main hospitals in Reykjavik were responsible for nurse anesthesia training. In 1976,
nurse anesthesia was formally recognized by the Ministry of Health. In 1976, an
ofcial program was established and it lasted for two years. That program was
active until 1990, when the University of Iceland took over and terminated it. It took
eight years until the next diploma course started again. It was a two-year program
and the entry requirement was a bachelor’s degree in Nursing. From 2003, nurse
anesthesia is at master’s level. It was offered every year. Since 2017, two programs
are running simultaneously to meet the demand for future recruitments.
Selected Continental European Countries
In France, the Ministry of Health proposed the creation of a certicate for anesthe-
sia assistants [19]. The opposition of the anesthesiologists was erce, but the
Ministry of Health delivered it in April 1960. The course was accessible for nurses
holding a state diploma. It lasted 18months. The year 1972 saw an update of the
curriculum, entry, and selection requirements. The course was increased to two
years and was available for nurses and midwives. In the 1980s, 20 civil and three
military nurse anesthesia programs were in operation. The teamwork of anesthesi-
ologists and nurse anesthetists became the norm. Since 1991, nurse anesthetist is a
protected title in France. Due to the adoption of the Bologna process, higher educa-
tion had to change. The current nurse anesthesia education has been adapted to
university requirements. It was re-organized into 120 European Credit Transfer
System (ETCS), containing research and clinical and theoretical training at mas-
ter’s level.
Hossli, the rst anesthesiologist at the University Hospital of Zurich, Switzerland,
began the rst nurse anesthesia training in 1952in an attic room of the hospital [48].
The training was informal and hospital based (online communication with R Jenni,
June 2012). Very soon a formal training scheme was started together with other
Swiss University hospitals. Teaching and learning material were put together by
M. Riesen et al.
353
several anesthesiologists involved in educating future nurse anesthetists. It was not
before 1983 that the rst Nurse Anesthesia textbook in Switzerland was published
by Hossli and Jenni, leading nurse anesthetist at Zurich University Hospital [49].
The qualication was eventually recognized by the Swiss Nursing Association after
some negotiations. In 1970, the rst nurse anesthetist formally graduated. The
course lasted and still lasts two years. In 2000, the new basis and regulation for a
postgraduate diploma in nurse anesthesia was a decree of the Federal Department of
Economics, Education and Research. The 2-year post-diploma course is based on a
national educational framework which is to be used by all nurse anesthesia schools
of the country. Entry into a program requires a nursing diploma and at least one year
practice in a preferably acute setting. Students are employed by a hospital which is
associated with a nurse anesthesia program. The school has to be approved by the
government. The education consists of roughly 30% theory and 70% practice. It
ends with a state diploma and the title is protected. Swiss nurse anesthetists work
under indirect supervision and in teams with the anesthesiologists who can delegate
an anesthesia to them. One anesthesiologist can serve 2–3 operating theatres, staffed
by nurse anesthetists, at the same time.
In the Netherlands Professor Keuskamp produced the rst anesthesia textbook
somewhere around 1970, followed by a second print in 1976 [50]. In 1978, part two
was printed with the title, “Practical application” [51]. Remarkably, both books
were written with the subtitle “Handbook for nurses and clinical assistants.” Like in
Switzerland, informal training was started in the Netherlands years before it became
formal. Only large hospitals did have one or more permanent anesthesiologists [52].
Smaller hospitals used anesthesiologists that travelled between them. It was com-
mon that anesthesia was administered by nurse anesthetists. At the beginning, those
providers were educated by colleagues, surgeons, and, if available, anesthesiolo-
gists. This informal training was mostly organized by the hospitals. During the
1970s, the trainings were evaluated and the National Hospital Association (NZR)
organized a more national training which was not regulated by the government
though. The Dutch law at that time prohibited any other than a physician to do medi-
cal interventions, including anesthesia. Nurses were only allowed to do what sur-
geons or anesthesiologists allowed them to do. The increasing number of
anesthesiologists led to an unpopularity among nurses to work in the operating
room because of low payment and loss of independence. The education centers
were starting to admit people with backgrounds other than nursing to administer
anesthesia. It was illegal. Nonetheless the government allowed it because of the
shortages of nurses and the increasing healthcare costs. Finally, the law was changed
allowing non-nurses into the courses despite protests by all advisors, nurses, and
anesthesiologists. The only body agreeing was the hospital association of anesthe-
tists (Letter to the Members of the NVAM from the formal president MH Bakkers.
Nov. 1987). This policy did not change anything. There is still a shortage and the
costs are even higher. Thanks to the lobbying of the Dutch Nurse Anesthetist
Association (NVAM) to keep the Dutch nursing competencies in the curriculum,
there are still nurse anesthetists. More than 60% of them are nurses and this is
increasing because of an initiative from the universities and the NVAM.A new
Global Development of Nurse Anesthesia Education from Mid-Nineteenth Century…
354
education program was started in 2012 that included a full nursing education pro-
gram combined with the anesthesia diploma.
Africa andAsia
In all African IFNA member countries, formal nurse anesthesia education started
between the 1970s and the 1990s and some even later [53]. In most countries, nurse
anesthesia education is formalized. Kelly (1994) did an international study of edu-
cational programs for nurses who provided anesthesia [54]. Sixteen African coun-
tries responded stating that qualied nurses were admitted to anesthesia programs
which were lasting between 6 and 27months. The anesthetic skills identied were:
Pre-anesthetic assessment, induction, maintenance and termination of anesthesia,
spinal and epidural blocks as well as emergency service, respiratory care, and post-
operative recovery. In many African countries, nurse anesthetists or other well-
educated non-physician anesthesia practitioners (NPAPs) are the major providers
and, in some countries, like, e.g., Liberia, the sole providers [55]. In Ethiopia, the
rst program goes back to 1974 [56]. Currently Ethiopia sees 19 nurse anesthesia
programs, and their graduates provide 95% of all anesthesia in the country. In 1976,
a new policy of higher education was implemented in Tunisia [23]. The goal was to
provide the country with NPAPs that had a shorter and more inexpensive education.
A University Degree was started to educate anesthesia high technicians. They began
to replace anesthesia nurses in 1979. This program does not admit nurses. Tunisia is
an associate member of IFNA due to this fact. The course ends after three years with
a bachelor degree. Kenya sees a lack of anesthesia services especially in remoter
areas [57]. Eventually a competency-based curriculum was established covering
general anesthesia, sedation, and regional anesthesia. Competency-based education
allows students to gain a lot of experience and to gradually learn to apply the theory
in practice.
In Indonesia, nurse anesthetists enjoy the autonomy to provide anesthesia [26].
Services also include: analgesia services in the operating room and outside, periop-
erative services, pain management (chronic and acute), emergency services, cardiac
and pulmonary resuscitation, and emergency services. There is formal education
and the practitioners have to be licensed. Like in many African countries, they are
the major providers of anesthesia services. The districts are responsible for their
education. In the beginning, there was no description of the scope of practice, but in
2010, the national Nurse Anesthesia Association developed standards in coopera-
tion with the Health Human Resources Development and Empowerment Agency of
the Ministry of Health. This claried the scope of practice in the country and the
education was matched to the standards. South Korea runs just one University based
program, but a current analysis demonstrated a great need for Nurse Anesthetists
[27]. The current professionals work under supervision of the anesthesiologists. In
Taiwan, data of the national health insurance in 1995 revealed that every anesthesi-
ologist provided at least four anesthetics at the same time [58]. This highlighted the
role of nurse anesthetists. In 2006, the Ministry of Health recognized that too few
anesthesiologists were educated and, therefore, a robust nurse anesthesia training
scheme was needed. For this reason, the national association developed standards.
M. Riesen et al.
355
The association also advocated for the recognition and the value of the contribution
of nurse anesthetists. In Taiwan, they can provide or assist in all types of anesthesia
under the indirect supervision of a physician, not just an anesthesiologist. The
national association is dedicated to safe patient care through a multilayered process
of developing a national nurse anesthesia certication exam. The written exam was
implemented in Dec. 2020 and the oral one in March 2021. In Japan, in 2010, a
private organization called Japanese Society of Peri-Anesthesia Care (JSPAC), con-
sisting of nurses, anesthesiologists, surgeons, and joint medical volunteers, was
established [28]. A training scheme was started in 2015 called Training System for
Nurses to Perform Specic Medical Interventions (SMIS). Although the Japanese
Society of Anesthesiologists (JSA) refused SMIS previously in 2019, they agreed to
the implementation of specic actions related to anesthesia. Examples of such
actions are airway management, mechanical ventilation, administration of medica-
tions for circulation, and postoperative pain management.
Harmonizing Nurse Anesthesia Education Worldwide by Using
Global Standards
Safe anesthesia and surgical care are not available when needed for 5 billion of the
world’s 7 billion people [59]. According to a survey the World Federation of
Societies of Anesthesiologist (WSFA) in 2017, major deciencies in the specialist
surgical workforce in many parts of the world were found. Results showed that
nurse anesthetists and NPAPs working in less well-resourced countries were highly
likely to provide direct anesthesia care, either supervised or independently, account-
ing for a large proportion of the anesthesia workforce in many countries with lim-
ited resources, mainly in Africa and Southeast Asia. The nurse anesthetists and
NPAP workforce turned out to be a heterogeneous group, ranging from highly
trained nurse anesthesia providers, highly qualied NPAPs to health workers with
very brief on-the-job training. These practitioners play a vital part of the global
workforce, especially in low- and middle-income countries (LMICs). A marked
increase in training of anesthesiologists, nurse anesthetists, and NPAPs will need to
occur if we are to have any hope of achieving safe anesthesia for all by 2030.
IFNA was well aware of those differences in education early in its history [60].
These differences are not specic to any continent or country. The scope of practice
though is very similar in most IFNA member countries, independent of the respec-
tive educational concepts. One of the rst goals after its charter in 1989 was to
develop professional standards. It was recognized that education was important to
support practice and enhance patient safety worldwide. The rst Education and
Practice Standards and Code of Ethics were adopted between 1990 and 1992. The
standards were revised in 1996 and 1999, and Monitoring Guidelines were added.
From 2010–2016, all standards underwent a major revision meeting requirements
for safe anesthesia care and advancement of the profession worldwide [61]. The
standards were adapted to professional roles, providing a professional framework
for nurse anesthesia to practice, monitoring, and education [60].
Global Development of Nurse Anesthesia Education from Mid-Nineteenth Century…
356
Of the various frameworks, IFNA has adopted and adapted the Canadian Medical
Education Directives for Specialists (CanMEDS) role model [62]. Permission was
obtained from the Royal College of Physicians and surgeons of Canada in
May 2012*.
*The signed permission letter can be found under Appendix B page 507in [60]
Ouelette SM, Horton BJ, Rowles JS.The Global Voice for Nurse Anesthesia:
International Federation of Nurse Anesthetists (1989–2021).
The 2016 standards were validated by Herion etal. [63]. The study shows a
rigorous psychometric approach applying factor analysis to provide evidence of
construct validity of the CanMEDS roles and the IFNA standards of practice for
nurse anesthetists. It provides evidence that the IFNA standards 2016 are a valu-
able international framework to dene national standards for nurse
anesthetists.
The International Council of Nurses (ICN) issued Guidelines on Nurse
Anesthetists in 2021 [64]. This commitment is to ensure that by 2030, ve bil-
lion people will have safe and affordable access to surgical and anesthesia care
around the world. The ICN is committed to supporting this ambitious but essen-
tial goal. The aim of these guidelines is to provide clarity on nurse anesthesia
practice and to ensure that, as a result, the role continues to develop to support
safe and affordable anesthetic care to people across the world. The guidelines
also contain the latest version of the IFNA standards (2016) (as an Appendix 1
page 33–38).
M. Riesen et al.
357
Competency-Based Education (CBE)
Competence and competency should be used only as they are primarily dened in
the Oxford Dictionary of English: “The ability to do something successfully” [65].
The goal of the competency-based approach is ensuring that nurse anesthesia edu-
cation worldwide was preparing students to be safe practitioners. The Lancet
Commission report had identied a series of reforms of education aiming at the
acquisition of competencies responsive to local needs but connected globally, which
include a culture of critical enquiry and the effective use of information technolo-
gies [66]. Reforms should also trigger a renewal of professionalism. Medical and
other healthcare education institutions are entrusted with preparing a professional
workforce that is capable of and committed to providing reliably safe, timely, effec-
tive, efcient, equitable, and patient-centered care [67]. Meanwhile the need for
health professionals to master competencies in domains that extend well beyond
those that can be tested with a high-stakes multiple-choice- exam is widely accepted.
Not only a body of knowledge must be mastered but also the ability to apply that
knowledge into service to others, act as professionals, work effectively in teams,
communicate compassionately with patients and respectfully with colleagues, col-
laborate to improve systems of care, and engage in critical reection and lifelong
learning. The CanMEDS was the chosen model because it covers those domains.
The primary intent of competency-based education (CBE) is supposed to provide
transparency, so that the profession and the public can be condent that a training
program is producing competent professionals who are equipped with the knowl-
edge and skills for practice [68]. As clinical educators implement competency
frameworks into assessment programs, they must make competencies concrete so
that they may be clearly assessed [69]. Supervisors and trainees need to know which
educational targets are important to attain, and they must know what, specically,
will be assessed. The development of Entrustable Professional Activities (EPA) is
an important step toward a veriable practical training. EPAs are those professional
activities that together constitute the mass of critical elements that operationally
dene a profession.
IFNA’s Anesthesia Program Approval Process (APAP)
The International Federation of Nurse Anesthetists is improving anesthesia patient
care through a voluntary Anesthesia Program Approval Process (APAP) for schools
and programs [70]. It is the result of a coordinated effort by anesthesia leaders from
many nations to implement a voluntary quality improvement system for education.
These leaders rmly believe that meeting international education standards is an
important way to improve anesthesia, pain management, and resuscitative care to
patients worldwide. As national governments, education ministers, and heads of
education institutions work to decrease shortages of healthcare workers, they would
Global Development of Nurse Anesthesia Education from Mid-Nineteenth Century…
358
benet from considering the value offered by quality improvement systems sup-
ported by professional organizations. When education programs are measured
against standards developed by experts in a profession, policymakers can be assured
that the programs have met certain standards of quality. They can also be condent
that graduates of approved programs are appropriately trained healthcare workers
for their citizens.
Benefits ofAPAP
Adopted in 2010, the IFNA APAP was the rst international system for accredita-
tion of advanced practice nursing programs [71]. It was based on the education
standards that were supported by IFNA’s country members. In addition to human-
itarian concerns for the world’s citizens, anesthesia program directors have identi-
ed other benets of being an APAP program. These are international recognition
demonstrating congruency with the mission of the anesthesia program, feedback
from anesthesia colleagues with different cultural and ethnic backgrounds, con-
tact with program ofcials of other countries which are a source of potential col-
laborative research, and a chance for student and faculty exchanges. Last but not
least, the use of international standards, which allows graduates to claim that their
program is recognized by a global nurse anesthesia organization afliated by the
International Council of Nurses (ICN). The programs are promoted by announc-
ing that they received an award for complying with international standards of
education, thereby increasing the recognition by anesthesia organizations
worldwide.
Development ofAPAP
Work began in 2006–2007, when the members of the IFNA Education Committee
with Maura McAuliffe as chair drafted student and faculty pilot evaluation forms
that were tested on four nurse anesthesia programs [71]. Faculty from Sweden, the
Netherlands, Switzerland, and the USA completed the forms, after which the mem-
bers of the Education Committee analyzed the results. Following McAuliffe’s res-
ignation was Betty Horton. She had held, among many other important positions, a
position as director of the Council on Accreditation (COA) in the USA and brought
with her extensive experience on the subject of accreditation. During her rst
Education Committee meeting in Tunis 2008, many questions had to be answered
and solutions had to be found to deal with the differences between non-physician
anesthesia programs around the globe. Some programs admitted only nurses, some
non-nurses, or a mixture of both. Further, anesthesia education globally ranged
from non-existent to highly developed courses of study. There were differences in
faculty qualication, wide variation of student populations, and varying levels of
resources.
M. Riesen et al.
359
Categories ofApproval
Those differences in anesthesia education were already obvious in the description of
the development into today’s Nurse Anesthesia role (paragraph 3.2). To deal with
this reality, a philosophy for APAP was written to serve as a foundation for all poli-
cies and procedures that had to be developed [72]. It reads: “The International
Federation of Nurse Anesthetists (IFNA) believes that it is possible to improve the
health and welfare of humanity by promoting international educational standards
for non-physician anesthesia programs. Based on this belief and for the purposes of
program approval, it is the policy of IFNA to approve programs that admit students
who are nurses or who are educated in another scientic area which prepares stu-
dents to succeed in their anesthesia education. Although IFNA strongly supports a
nursing background for admission, it also believes in an approval process that rec-
ognizes the differences that currently exist in the educational preparation of health
professionals worldwide that have contributed to nurses and non-nurses being
enrolled in anesthesia programs. IFNA believes that an inclusive process provides
the greatest opportunity to improve anesthesia care to patients now and in the future”
[72, page 1]. To assure access to all programs, it was decided that an applying pro-
gram did not need to be in a country that was an IFNA member [71].
According to the July 2008 Education Committee meeting minutes, three catego-
ries were drafted using the APAP philosophy as a guide [71]. The three categories
would be Registration, Recognition, and Accreditation. Programs in all categories
have to renew the registration/recognition/accreditation every ve years.
Registration (Level 1). IFNA Level 1 “Registration” would require the sub-
mission of an application for Registration pledging by the anesthesia program to
meet the IFNA Educational Standards to the best of its ability [71]. The program’s
curriculum would be posted on IFNA’s website with a statement that IFNA had not
approved the curriculum, but it was being posted for information only. The website
would note that the program had committed to meeting the IFNA Educational
Standards to the best of its ability.
Recognition (Level 2). IFNA Level 2 “Recognition” would require the submis-
sion of an application for recognition pledging by the anesthesia program to meet
the IFNA Educational Standards to the best of its ability [71]. The program would
also be required to submit its curriculum and related material for review by the
IFNA Education Committee. The information would be audited to determine if it
met the IFNA Educational Standards. Following the auditing process, the program’s
curriculum would be posted on IFNA’s website with a statement that IFNA had
reviewed the curriculum and determined it substantially met IFNA’s Educational
Standards determined by an audit of written program materials. Programs that admit
non-nurses but meet the IFNA standards substantially can apply for this category.
Accreditation (Level 3). IFNA Level 3 “Accreditation” offers two pathways:
IFNA Level 3 Accreditation requiring the submission of a pledge by the anesthe-
sia program to meet the IFNA Educational Standards [71]. The program would also
be required to submit its curriculum and related material in a written Self- study for
Global Development of Nurse Anesthesia Education from Mid-Nineteenth Century…
360
review by the IFNA Education Committee. The information would also be evaluated
by an on-site team of visitors to determine if it met the IFNA Educational Standards.
Following the accreditation process, the program’s curriculum would be posted on
IFNA’s website with a statement that IFNA had reviewed the curriculum, reviewed a
self-study, conducted an on-site visit to the program, and determined the program
substantially met the IFNA Educational Standards. The website would note that the
program had substantially met the IFNA Educational Standards as determined by a
full review of the program, including a written self -study and on- site review.
The second option is Deemed Accreditation, introduced in 2017 [ 71]. Programs
approved through this pathway must verify that they have met the ofcial govern-
mental or non-governmental standards for nurse anesthesia education. The program
also has to prove that those standards are equivalent or exceed IFNA’s Education
Standards. A nurse anesthesia program with Deemed Accreditation status will have
all the privileges of an accredited program. Level 3 Accreditation is only accessible
for programs that admit nurses only.
Eligibility
It is proposed that programs admitting nurses, non-nurses and both types of students
would be eligible for approval [71]. This recognizes the differences that currently
exist among students enrolled in anesthesia programs in various countries. The ulti-
mate goal of offering an approval process for all types of anesthesia programs is to
improve anesthesia patient care by encouraging programs to use IFNA’s Educational
Standards, irrespective of available local resources. IFNA could also obtain infor-
mation of all types of non-physician anesthesia education around the globe. All
programs would be encouraged to improve patient care through a commitment to
the Educational Standards. A recommendation was made that for approval admis-
sion requirements must include an education in nursing or another scientic back-
ground that prepares students to succeed in their anesthesia program.
The implementation of APAP began in 2010 and IFNA started to accept applica-
tions in June 2010 [71]. All categories of approval are free except Level3
Accreditation. The on-site visit has to be covered by the applying program. This
presented a problem for many. IFNA decided to fully support four nurse anesthesia
programs by providing a grant.
Till date, IFNA has awarded Registration to 5, Recognition to 17, and
Accreditation to 12 programs [73].
Conclusion
While nurse anesthetists in the USA became independent very early, this was not
the case in many other parts of the world. In many European countries, e.g., anes-
thesia was part of nursing education. The nurses in Europe administered anesthesia,
M. Riesen et al.
361
but it was documented as the responsibility of the surgeons, hence the scarce evi-
dence. Nurse anesthesia, therefore, remained invisible for a long time. Still, anes-
thesia practice developed and those nurses developed their skills and knowledge
with it. From about the mid-twentieth century, in most IFNA member countries,
nurse anesthesia was no longer part of the nursing education, but emerged into a
postgraduate specialty.
Its importance is shown in many low-income countries where nurse anesthetists
are the major or even sole providers of anesthesia due to a severe lack of physician
anesthetists. These practitioners play a vital part in the global workforce. To con-
sider the differences in education among IFNA member countries, a competency-
based educational framework was chosen (CanMEDS). It is ensuring that not only
a body of knowledge is mastered but also the ability to apply that knowledge into
service to others.
The International Federation of Nurse Anesthetists is improving anesthesia
patient care through a voluntary Anesthesia Program Approval Process (APAP) for
schools and programs. Meeting international education standards is an important
way to improve anesthesia, pain management, and resuscitative care to patients
worldwide. National governments, education ministers, and heads of education
institutions’ work to decrease shortages of healthcare workers would benet from
considering the value offered by quality improvement systems supported by profes-
sional organizations. When education programs are measured against standards
developed by experts in a profession, policymakers can be assured that the pro-
grams have met certain standards of quality. They can also be condent that gradu-
ates of approved programs are appropriately trained healthcare workers for their
citizens.
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367
Nurse Anesthesia Recognition: Practice
Challenges, Credentialing, andTitle
Protection
SandraMareeOuellette andSusanSmithCaulk
Nurses on the global stage have assumed advanced practice roles for many years.
Their history of quality service speaks to organization at the national and global
levels, educational advancement and credentialing such as licensure, certication,
and recertication. Practice challenges in the early 1900s, predominantly from phy-
sicians determined to make anesthesia an all-medical specialty, never ended. Since
the roles and practice of the nurse anesthetist overlap with that of physician anesthe-
tists, these challenges are not unexpected. While these professionals have different
educational backgrounds, they share similar practice standards. AANA was founded
in 1931 when legal challenges in the United States against nurse anesthetists by
medicine was too much for individuals to address alone [1]. Lessons learned over
the next 58years positioned leaders in AANA, along with those from ten other
nations, to globalize the nurse anesthesia profession in 1989 by founding the
International Federation of Nurse Anesthetist.
This chapter begins with a discussion of the evolution, credentialing, and recog-
nition of the American nurse anesthetist. It highlights the global impact of the
International Federation of Nurse Anesthetists on international education and prac-
tice standards and quality assurance in nurse anesthesia educational programs and
its support for member countries seeking licensure, titles, and title protection, lead-
ing to recognition at the national level. Key workforce studies with attention to
credentialing are briey summarized and guidelines for advanced practice for the
nurse anesthetist, developed by the International Council of Nurses and International
Federation of Nurse Anesthetists are highlighted. It closes with a discussion of the
bond between national and international organizations, quality in delivery of anes-
thesia and protection and safety for the patients and future steps for the global nurse
anesthesia specialty.
S. M. Ouellette · S. S. Caulk (*)
American Association of Nurse Anesthetists, Cleveland, OH, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_28
368
The Evolution andCredentialing oftheAmerican
Nurse Anesthetist
Nurses have administered anesthesia in the United States since the Civil War of
1861–1865. In her autobiography, Catherine Lawrence spoke of administering
anesthesia in the Second Battle of Bull Run in 1862. She administered chloroform
to union soldiers on the battleeld and performed other lifesaving interventions on
wounded soldiers such as suturing, tying bleeding arteries and giving resuscitation
medications. Chloroform was the anesthetic of choice during that time because it
was easily inhaled, acted quickly, and was believed to be more efcient than ether
[2]. At the time Miss Lawrence administered anesthesia, it was relatively new.
William Morton, an American dental surgeon, had made history at the Ether Dome
at Massachusetts General Hospital on October 16, 1846, when he gave the rst
public demonstration of ether anesthesia during surgery [3]. In her autobiography,
Catherine Lawrence stated, “I rejoice that the time has arrived that our American
nurses are being trained for positions so important. A skilled nurse is as important
as a skilled physician. Life has too often been sacriced by both professions” [2].
This pioneer was undoubtedly among the earliest of advanced practice nurses in the
United States and the rst recorded nurse to administer anesthesia in the
United States.
While Catherine Lawrence was the rst recorded nurse in the United States to
administer anesthesia, Catholic nuns played an important role in training nurses and
nurse anesthesia specialists. The earliest recorded nurse to specialize in anesthesia
in the United States was Sister Mary Bernard who lived from 1860 until 1924 [4].
In the early 1900s, a shortage of trained anesthesia personnel and focus at home on
the Great Depression and World War I set the stage for expansion of training and use
of nurses to administer anesthesia. Success of these specialized nurses in anesthesia,
support by surgeons, and excellence in administering anesthesia was soon to result
in challenges by the medical community who viewed anesthesia as the practice of
medicine. That belief by physicians has been unaltered over the years and led to
many battles regarding the role of the nurse anesthetist in the United States.
Major Legal Challenges Against Nurse Anesthetists
intheUnited States
Between 1911 and 1933, there were three major legal challenges against the nurse
anesthetist in the United States. The rst challenge to the right of the nurse to
administer anesthesia occurred in 1911 when a physician, Francis McMechan,
brought opposition of nurse’s anesthesia practice to the Ohio Medical Board. In
1916, the Ohio State Attorney General ruled that only a physician could administer
anesthesia, which prompted the closure of the rst program for training nurse anes-
thetists at Lakeside Hospital in Cleveland, Ohio. In 1917, supporters of nurse anes-
thetist lobbied the Ohio legislature to create an exemption within the Medical
Practice Act for nurses, who were appropriately educated and under physician
S. M. Ouellette and S. S. Caulk
369
supervision, to administer anesthesia and it passed. Lakeside Hospital School of
Nurse Anesthetists reopened in 1917 [5].
A second major challenge for nurse anesthetists occurred in 1917 (Frank vs.
South) when the Louisville Society of Anesthetists suggested to the Kentucky
Attorney General that only people with medical knowledge and training should
administer anesthesia. Louis Frank, a Louisville surgeon, and Margaret Hateld, a
nurse anesthetist, led suit against the Kentucky Medical Society and won at the
appellate level. It was determined that Margaret Hateld was not engaged in the
practice of medicine when she administered anesthesia [6].
In 1934, Dagmar Nelson was charged by a physician William Vane Charmer-
Francis with practicing medicine and violating the California Medical Practice Act
by administering anesthesia without a license. The case went all the way to the
Supreme Court of California and Dagmar Nelson was given favorable ruling at each
level of the case. In favor of Nelson was a legal opinion that prescribing of an anes-
thetic was in the province of medicine and dentistry. Administering an anesthetic
without prescribing did not constitute the practice of either medicine or dentistry.
Thus, the California Supreme Court afrmed the superior court ndings and, in this
ruling, conrmed the legality of nurse anesthesia practice [7, 8, 9].
While these major legal challenges against nurse anesthetist ended favorably, it
indicated how vulnerable an individual was compared to the strength that could be
found in an organization regarding protection of practice rights. This realization led
to the formation of the National Association of Nurse Anesthetists (NANA) in 1931.
In 1939, the name was changed to the American Association of Nurse
Anesthetists (AANA).
Formation oftheNational Association ofNurse Anesthetists
Agatha Hodgins founded the National Association of Nurse Anesthetists (NANA)
on June 17, 1931, in Cleveland, Ohio. Early after founding, leaders were focused on
standardization of education and practice for nurse anesthetists believing that
through this mechanism, quality of care and patient safety would be enhanced and
practice would be protected [10]. Helen Lamb, Mother of Nurse Anesthesia
Education and Chairman of the AANA Education Committee, spearheaded the
effort to set accreditation standards for nurse anesthesia schools through their
implementation in 1952. Accreditation of nurse anesthesia educational programs
began in 1952 and in 1955. The US Department of Health, Education, and Welfare
recognized the AANA as the accrediting agency for schools of anesthesia [11]. On
June 4, 1945, the AANA administered its rst qualifying or certication examina-
tion. Standards for Nurse Anesthesia Practice were adopted in 1974. Licensure as a
registered nurse is required to administer anesthesia in the USA and certication of
the individual has been promoted since 1945 [12]. In 1956, the credential Certied
Registered Nurse Anesthetist or CRNA was adopted.
In 1975, changes in criteria for recognition of accrediting agencies by the US
Ofce of Education and a formal challenge from the American Society of
Nurse Anesthesia Recognition: Practice Challenges, Credentialing, andTitle Protection
370
Anesthesiology (ASA) regarding AANA’s right to accredit nurse anesthesia educa-
tional programs led to the creation of autonomous councils to provide accreditation
of programs and certication of individuals. In August 1971, the US Ofce of
Education, Health, and Welfare issued a letter to AANA asking why they should be
retained as a nationally recognized accrediting agency citing three deciencies. At
the time, this federal agency was tightening up on enforcement of criteria and
many agencies received such letters. Additionally, in 1973, the Ofce of Education
called a meeting between the ASA and AANA to explore ways for anesthesiolo-
gists to become more involved in the accreditation process of nurse anesthesia
educational programs. The following year, three letters of complaint against
AANA’s accreditation were led with the US Ofce of Education by ASA [13].
In August 1974, the US Ofce of Education Health Education and Welfare
released a change in criteria for accreditation agencies, which was a threat to nurse
anesthetists’ role in accreditation and certication. There was clearly increasing
evidence of challenges by certain anesthesiologists in relation to AANA’s authority
and capability in the accreditation of nurse anesthesia educational programs and
certication of graduates of those programs [14].
The predominant issue appeared to be who would control the education and
practice of nurse anesthetists and whether nurse anesthetists should be prepared to
function independent of anesthesiologists. Recognizing how critical this challenge
was to practice and how important compliance with criteria from the US Ofce of
Education had become, members of the AANA voted at the business meeting to
transfer credentialing functions from the AANA to councils. The Council on
Certication and Council on Accreditation of Nurse Anesthesia Educational
Programs were created and the credentialing functions of the AANA was trans-
ferred to these autonomous councils [15].
Continuous professional development has long been a goal for members of the
AANA.In 1969, members approved voluntary continuing education and, in 1978,
members passed a resolution requiring mandatory continuing education. A pro-
posed by-law amendment that led to organizational restructuring of the association
and formation of the Council on Recertication (COR) occurred. This change of-
cially separated AANA membership from the nurse anesthesia certication and
recertication processes and ofcially separated AANA membership from certica-
tion and recertication processes. The member could now be certied and use the
CRNA designation without being a member of AANA [16].
In 2007, the Council on Certication and Council on Recertication became the
National Board of Certication Recertication of Nurse Anesthetists. In 2011, a
controversial new continuing education program and process, known as Continuous
Professional Certication (CPC), was introduced. While this program underwent
multiple changes since inception, it remains the path to continuous certication
today. Now continuous certication is the rule and the process must be renewed
every 4years. All CRNAs must be registered as an RN in the state where they prac-
tice and in compliance with NBCRNA’s CPC to work in the United States. Table1
lists educational and credentialing milestones associated with the evolution of the
S. M. Ouellette and S. S. Caulk
371
Table 1 Evolutional and Credentialing Milestone for The American Association of Nurse
Anesthetists
1931 National Association of Nurse Anesthetists (NANA) was founded by Agatha Hodgins.
The name was changed to the American Association of Nurse Anesthetists (AANA) in
1939 and recently changed to the American Association of Nurse Anesthesiology.
1945 The rst national certication examination was administered by the AANA.
1955 The US Department of Health Education and Welfare recognized AANA as the
accrediting agency for schools of anesthesia.
1956 The credential Certied Registered Nurse Anesthetist (CRNA) was adopted by
AANA.Recently, an alternative credential recognized is Certied Registered Nurse
Anesthesiologist.
1969 AANA members approved voluntary continuing education and certicates for
Continued Professional Excellence were awarded to members who met eligibility
requirements.
1971 The rst bachelor’s degree program in nurse anesthesia began at Mount Marty College
Yankton, SD.
1975 The American Society of Anesthesiology formally challenged the AANA’s right to
accredit nurse anesthesia programs. This challenge, coupled with changes in criteria for
recognition by the US Department of Education, prompted AANA to develop alternative
credentials entities.
• The Council on Certication of Nurse Anesthetist and Council on Accreditation of Nurse
Anesthesia Educational Programs were created and credentialing functions of the AANA
were transferred to these autonomous councils.
• The Council on Practice was created and its name was changed to the Council on Public
Interest in 1988.
1978 The membership of AANA approved mandatory continuing education and the Council
on Recertication of Nurse Anesthetists was established.
1978 The rst master of science degree in nurse anesthesia education was granted from
Kaiser Permanente Nurse Anesthesia Clinical Program by California State University.
1985 The Council on Accreditation of Nurse anesthesia Programs received recognition from
the Council on Postsecondary Accreditation.
1987 The Council on Certication of Nurse Anesthetists conducted its rst Professional
Practice Analysis.
1998 The Council on Accreditation required that all programs be at the graduate level,
awarding at least a master’s degree by October 1, 1998.
2007 The AANA Board of Directors approved a mandate for the doctoral degree for entry
into practice by 2025.
2007 The Council on Certication and Council on Recertication were separately
incorporated and became the National Board of Certication and Recertication of
Nurse Anesthetists (NBCRNA).
2011 The new continuing education program and process developed by the NBCRNA, known
as Continuous Professional Certication (CPC), was announced.
2022 All 130 nurse anesthesia graduate programs at the master’s level successfully
transitioned to award doctoral degrees for entry into practice.
nurse anesthesia specialty with emphasis on the educational focus [17]. It was
reported in September 2022, all 130 Council on Accreditation (COA) nurse anesthe-
sia programs have successfully transitioned to award doctoral degrees for entry into
practice. In addition, there are 12 new programs in capability review in 2021–2022
and may open in the near future [18].
Nurse Anesthesia Recognition: Practice Challenges, Credentialing, andTitle Protection
372
The AANA has a long history of challenges and victories throughout its exis-
tence and will celebrate its 100th Anniversary in 2031. Lessons learned on this
rocky journey and knowledge of AANA history prepared American CRNAs for a
pivotal role in the globalization of the profession through formation of the
International Federation of Nurse Anesthetists. Much has been accomplished since
the founding of the International Federation of Nurse Anesthetists on June 10, 1989.
Much more needs to be done, especially with recognition and credentialing of nurse
anesthetists and global solution to anesthesia and surgery for all.
The Global Voice ofNurse Anesthesia: TheInternational
Federation ofNurse Anesthetists
In 1978, nurse anesthetists from Switzerland and Denmark, Hermi Lohnert and
Jan Frandsen, attended the AANA Annual meeting in Detroit, Michigan. Hermi
had learned of a “point system” for continuing professional development for
American nurse anesthetists and saw an opportunity for international collabora-
tion. Relationships formed and the seed was planted then for international col-
laboration among nurse anesthetists. The rst International Symposium for Nurse
Anesthetists was held in Lucerne, Switzerland in 1985 and the second Symposium
for Nurse Anesthetists was held in Amsterdam, the Netherlands in 1988. While
each country member was most interested in defending its own turf in those early
years, it was appreciated there was more that united us than divided us. The
International Federation of Nurse Anesthetists (IFNA) was founded on June 10,
1989, in Teufen, Switzerland. Hermi Lohnert from Switzerland is the recognized
founder of IFNA.IFNA was founded by 11 national organizations from the fol-
lowing countries: Austria, Finland, France, Germany, Iceland, Norway, Slovenia,
South Korea, Sweden, Switzerland, and the United States. Each country is repre-
sented by one individual and these representatives, collectively known as the
Council of National Representatives (CNR), are the governing body of IFNA
[19]. Today, 43 member countries belong to the International Federation of Nurse
Anesthetists.
Now That WeAre Organized, What Do WeDo?
During the rst year of IFNA’s existence, the Education Committee was formed.
This committee nalized the educational standards for nurse anesthetists in 1990
and they were adopted by the CNR.The decision to develop the educational stan-
dards was intended to address the IFNA objectives based on the fact that the edu-
cational standards worldwide were very diverse. In succeeding years, the
committee kept up its pace by developing international standards of practice
which were adopted in 1991, a code of ethics adopted in 1992, and monitoring
guidelines adopted in 1994. The monitoring guidelines were changed to monitor-
ing standards in 2002. In 1997, IFNA leaders learned from representatives from
S. M. Ouellette and S. S. Caulk
373
the Center for Quality Assurance in International Education (CQAIE) that IFNA
was the only international nursing organization to adopt such standards [20]. All
standards underwent major, comprehensive revisions in 2016 and are unchanged
since that time [21].
Leaders of IFNA in the early years were leaders in their national organizations,
had challenges at home as to education and practice, and believed a priority for the
young federation should be education. Due to the vast diversity in quality of nurse
anesthesia education around the world and in some countries, lack of educational
opportunity, education was a priority. At the fth World Congress for Nurse
Anesthetists held in Vienna, Austria, in 1997, the keynote address was delivered by
Dr. Marjorie Peace Lenn, Executive Director, Center for Quality Assurance in
International Education, Washington, DC, USA.A recognized leader in global
quality assurance in higher education, IFNA leaders listened carefully to her blue-
print for globalization of the nurse anesthesia profession [21]. Her guidance through
action steps for establishing a national or regional profession and a global profes-
sion and continued consultation was very helpful for IFNA in its infancy. Tables 2
and 3 list action steps for establishing a national and global profession. Early IFNA
leaders were pleased to see they were moving in the right direction and many of
these steps had been accomplished by IFNA.One link was missing and not com-
pleted until 2010 [22, 23].
The one missing link in the Lenn blueprint for globalization of the profession
was development of a quality assurance process for nurse anesthesia education
and professional development programs. The IFNA Education Committee,
under the guidance of Dr. Betty Horton, began this work and, in 2010, the
Anesthesia Program Approval Process (APAP) was developed and adopted by
IFNA [24].
The goals of IFNA’s Approval Process for Anesthesia Programs (APAP) are to
encourage programs to comply with IFNA’s Educational Standards for preparing
nurse anesthetists through an approval process that takes culture differences into
Table 2 Action steps for establishing a national or regional profession
1. Come to an agreement among nurse anesthetists within a country or region as to what
common standards will dene the profession.
2. Organize a regional or national association, if one does not exist.
3. Establish regional educational programs for nurse anesthetists.
4. Assure that the standards for the profession t into a national system of quality assurance for
education and a system of competency assurance for professional practice.
Table 3 Action steps for establishing a global profession
1. Act as an international witness to the need for professional standards in nurse anesthesia.
2. Interact effectively with appropriate regional and international organizations.
3. Act as a liaison to other globalizing professions.
4. Consider earlier, rather than later, developing a quality assurance process for nurse
anesthesia education and professional development programs.
5. Monitor and record its own progress through research, publications, and international
forums.
Nurse Anesthesia Recognition: Practice Challenges, Credentialing, andTitle Protection
374
consideration. A second goal is to improve the health and welfare of humanity by
promoting international educational standards [24, 25].
APAP, launched in 2010, was the rst international system for accreditation of
advanced practice nursing programs. It was also the only system that provided an
avenue for advanced practice nursing programs to earn accreditation for meeting
validated international standards [26]. Please refer to Chap. 30 in this book for a
comprehensive discussion of APAP.
Credentialing andtheQuality Imperative
Core values of the IFNA and endorsement by its component national members
forming the federation include processes that advance the art and science of nurse
anesthesia and enhance quality anesthesia worldwide. Six of the nine IFNA objec-
tives speak directly to this goal: develop and promote educational standards in the
eld of nurse anesthesia; recognize eligible anesthesia educational programs
through IFNA’s Anesthesia Program Approval Process (APAP); develop and pro-
mote standards of practice in the eld of anesthesia and anesthesia care; provide
opportunities for continuing education in anesthesia; assist nurse anesthetists’ asso-
ciations to improve the standards of nurse anesthesia and anesthesia care [27].
Credentialing is a term applied to the processes used to designate that a program
or individual has met established standards by an agent, governmental or nongov-
ernmental, recognized to carry out this task. Licensure, registration, accreditation,
certication is used to describe different credentialing processes. Credentials are
marks of quality and guide employers and consumers of health care as to what to
expect from a credentialed professional.
The IFNA Educational, Practice, and Ethical Standards stand as international
witness for globalization of the profession in both preparation and practice [27].
Member countries of IFNA may have national standards, but these are not in con-
ict with IFNA standards. Likewise, quality assurance in nurse anesthesia educa-
tional programs through IFNA’s APAP program is voluntary and may or may not
have national programs’ participation.
As far as individual recognition of the nurse anesthetist through licensure and
other credentialing processes is concerned, it is recognized that each member coun-
try of IFNA exists in its own political and legal environment, and direction offered
by IFNA must take these elements into consideration. Professional titles of nurse
anesthetists globally, requirements for such titles and title protection are best man-
aged at the country level. Most organizations require practitioners to have creden-
tials before using a title. Once a person successfully passes an entry level
examination, for example, they demonstrate they possess knowledge, skills, and
abilities to obtain a professional title.
A trend today is the recognition that a person can’t be certied for life. With the
complexity of an ever-changing science and practice of anesthesia, lifelong learning
and recertication or continuous professional certication is critical. The criteria for
lifelong learning are often formulated by a national association continuing
S. M. Ouellette and S. S. Caulk
375
education committee and an entity responsible for recertication is appointed to
recertify individuals periodically based upon criteria established by the national
committee. In the USA, recertication, now continued professional certication
(CPC), is mandatory. A CRNA in the USA must hold an RN license in the state
where they work, graduate from a nurse anesthesia program accredited by the
Council on Accreditation of Nurse Anesthesia educational Programs, pass an entry-
level certication examination, and be in compliance currently with the continuing
education program as dened by NBCRNA.Since 1986, federal reimbursement is
tied to these credentialing steps, and noncompliance with professional mandates
interferes with the individual’s right to work.
Regulation oftheGlobal Nurse Anesthesia Workforce
The history of the American nurse anesthetists, an advanced practice nurse, is
among the oldest and best documented in the world. Leaders of IFNA recognized
very early that regulation of the global workforce must be explored. What was found
in those early studies indicated great diversity in regulation, recognition, and prac-
tice in the global community.
During the IFNA World Congress III, in 1991, held in Oslo, Norway, Dr. Joyce
Kelly (USA) participated in a spontaneous gathering of nurse anesthesia educators
from 13 countries. They were eager to share knowledge and promote better educa-
tion for all nurse anesthesia students. During the gathering, participants realized
little was known about the education of nurse anesthetists globally and decided a
survey was needed to collect as much information as possible about programs. Dr.
Kelly volunteered to develop the survey and then collected information on nurse
anesthesia programs in 50 countries. The results of this work were published and
was believed to be the rst international research published on the education of
nurse anesthetists [28].
In 1990, IFNA President Ronald Caulk and Vice President Hermi Lohnert went
to Geneva, Switzerland, to meet with the ICN Executive Director and with represen-
tatives of the World Health Organization (WHO). At WHO, IFNA leaders met with
Mrs. Matsumoto who recognized and worked with non-governmental organization
(NGO) of WHO.It was soon learned that being formally recognized as an NGO
would not only be time-consuming it would also require working with the ofce
informally for a period of several years. Mrs. Matsumoto suggested that Mr. Caulk
and Mr. Lohnert meet with Dr. Miriam Hirschfeld, Chief Nursing Scientist, Division
of Health Manpower Development. The outcome of that meeting proved to be a
challenge.
Neither Dr. Hirshfeld nor the WHO seemed to know anything of the role of the
nurse anesthetist in providing anesthesia services worldwide. She wanted to know
why nurses should be administering anesthesia when there was a worldwide short-
age of nurses and abundance of physicians. She went on to ask why a technician
couldn’t give anesthesia and asked IFNA representatives to provide her the informa-
tion in writing about the role of the nurse anesthetist [29].
Nurse Anesthesia Recognition: Practice Challenges, Credentialing, andTitle Protection
376
During this time, the IFNA was approached by an American nurse anesthetist,
Maura S McAuliffe, who was planning her requirements for her doctorate. She was
interested in doing a study of nurse anesthesia internationally and IFNA was in need
of such a study. Dr. Hirschfeld was denitely supportive of the study and proposed
that though WHO could not endorse the study, due to lack of funds, they would
agree to collaborate in the study. The IFNA appointed Maura McAuliffe Ofcial
Nurse Anesthesia Researcher for the IFNA in 1992, and began to seek funding for
the study. Since this was to be an ongoing study, it would not be McAuliffe’s doc-
toral project, but she agreed to do the study [30]. The Council on Recertication,
AANA, agreed to fund the study and soon thereafter, researchers received word that
WHO agreed to endorse the research.
Members of IFNA were discovering that in many countries, anesthesia provided
by nurses was not a well-known fact. This comprehensive study entitled Nurse
Anesthesia Worldwide: Practice Education and Regulation, by Drs. Maura
McAuliffe and Beverly Henry, provided much information regarding the role of
nurses in anesthesia worldwide. This work was divided into three Phases and was
done between 1992–1997. Respondents from 107 countries (55% all WHO world
member states) reported that nurses gave anesthesia in their counties, nine countries
reported that nurses assist in giving anesthesia, and in 18 countries, the evidence
was inconclusive. It was also reported that as much as 77% of anesthesia in urban
areas and 75% of anesthetics in rural areas were administered by nurses [31].
Of interest to this discussion, McAuliffe and Henry included in their research 17
items about the regulatory and legislative issues that affect nurses who provide
anesthesia care. The research question asked was what are the licensing, certica-
tion, and recertication requirements of nurses who provide anesthesia care? Most
(93%) of the respondents reported that there were such requirements in their coun-
tries, but most reported (66.4%) that they do not have to be renewed. Likewise, most
respondents (78.4%) reported that a special license or certication was required to
practice as a nurse anesthetist. When asked if the licenses have to be renewed, most
(74%) said no.
When asked if there were special licenses or certication requirements for anes-
thesia assistants, most (82.5%) reported there were not. When asked if there are
special licenses or certication requirements for non-nurse, non-physician anesthe-
tists, most reported there were not. Most respondents (92.6%) reported that there are
special license or certication for physician anesthetists.
Most of the respondents (74.1%) reported there are hospital rules or regulation in
their country that recognized nurse anesthesia practice. When asked if there were
hospital rules or regulation that restrict practice, 50% stated yes. When asked if
there are governmental regulations that guided anesthesia practice by nurses, most
(59.3%) reported yes, but more respondents (74.1%) stated it was the hospital regu-
lations that guide the practice of nurse anesthesia. When asked what changes, if any,
would improve the anesthesia practice of nurses, the most frequent response was
improved access to continuing education followed by governmental recognition of
nurse anesthesia practice. In regards to governmental regulation, a frequent response
was the need for more supportive legislation and a need for government protection
S. M. Ouellette and S. S. Caulk
377
because of unfair tactics used by physician anesthetists to control all of anesthesia
practice. An additional nding was that although nurses play a vital role in anesthe-
sia delivery worldwide, their contributions often go unrecognized by their govern-
ments [31, 32, 33].
The IFNA Practice Committee was formed in November 2010, and its rst
committee meeting was held in Ljubjana, Slovenia. Both the Education Committee
and Practice Committee of IFNA are critical in achieving global goals of
IFNA.Revised objectives for the Practice Committee are listed on Table4 [34].
Pertinent to this discussion is the global survey which denes the scope and prac-
tice of nurse anesthetists and other non-physician providers in member countries
and credentials necessary to practice and the regulatory body responsible for the
credentialing.
The Practice Committee conducted a global survey in 2011–2012 and
2012–2014. A revised survey was developed in 2016 and trialed among new IFNA
country representatives. Satised with the updated survey, the Practice Committee
pushed for new country representatives to complete the survey and existing repre-
sentatives to update the data so results would be available for publication in 2020.
When comparing data from the 2012 survey and 2022 results, an increase in gov-
ernment recognition and licensure was noted. It was also noted that terminology
used to describe non-physician providers of anesthesia by the majority (70%) of
respondents was nurse anesthetist or anesthesia/anesthetic nurse. Others were
described as anesthesia ofcer, anesthesia technician, anesthesiologist assistant,
anesthesia assistant, registered clinical ofcer anesthetist, or non-physician anes-
thetist [35].
IFNA is governed by the Council of National Representatives or CNR.Each
member country has one representative and an annual country report is submitted
every two years. Recent country reports bear witness to the information reported by
the IFNA Practice Committee [36]. Among the countries represented in IFNA,
diversity remains as to education, practice, recognition, and credentialing. A com-
mon thread uniting the group, however, is support of IFNA Standards and quality
assurance in educational preparation of nurse anesthetists and other non-physician
anesthesia providers through the Anesthesia Program Approval Process (APAP). A
strong desire to be recognized for the quality work provided in their country is a
stimulus by member countries for governmental or regulatory identication, titles,
and title protection. While member countries are at different places on the
Table 4 Objectives for the IFNA Practice Committee
1. Dene the scope and practice of nurse anesthetists and other non-physician providers in
member and nonmember countries.
2. Identify credentials necessary to practice as a nurse anesthetist in various countries; identify
regulatory body responsible for credentialing.
3. Provide a model and effective strategies for continuing profession development.
4. Review, update, improve IFNA standards.
5. Cooperate with the IFNA Education Committee.
6. Recommend speakers and topics to the IFNA Congress Planning Committee.
Nurse Anesthesia Recognition: Practice Challenges, Credentialing, andTitle Protection
378
continuum with this goal, the need is strong and dedication of country leaders is
unwavering. The IFNA stands ready to support and advise member countries as they
work to achieve long overdue recognition as a credentialed anesthesia
professional.
International Council ofNurses andInternational Federation
ofNurse Anesthetists
Release Guidelines forNurse Anesthetists
In 2015, the World Health Assembly adopted a resolution intended to strengthen
emergency and essential surgical care and anesthesia as a component of universal
health coverage. This was the rst-time governments worldwide acknowledged and
recognized surgery and anesthesia as key components of universal health care. ICN
is committed to these goals and supported development of Guidelines for Advanced
Practice Nursing for Nurse Anesthetists in collaboration with the International
Federation of Nurse Anesthetists. The guidelines were intended to provide guidance
of the development of the nurse anesthetists for professional organizations health-
care providers, regulators, policymakers, and the public for maintaining and improv-
ing quality and safety in anesthesia care. The professional role of nurse anesthetists
as advanced practice nurses is identied in these guidelines [37].
In support of credentialing for the nurse anesthetist, the ICN guidelines state
credentialing is an essential function to support the practice of the nurse anesthetist.
Credentialing is used to recognize the skills and expertise of nurses who are work-
ing in an advanced practice role in anesthesia and demonstrates to the public and
healthcare system of a professional standard for practice in nurse anesthesia [37].
The credentialing process for nurse anesthetist should be led by a nationally
recognized organization, should be reviewed periodically, and must be clear and
transparent. Advanced practice nurses, including nurse anesthetists must continue
to maintain licensure by a regulatory body responsible for oversight of practice and
patient safety. Regulation authorizes a legal scope of practice for the professional
and legal use of a title which designates nurses working at an advanced practice
nurse level in anesthesia. Title protection for the nurse anesthetist should be a
requirement for the regulatory and credentialing process [37].
Next Steps forIFNA
While IFNA has advanced markedly since its beginning in 1989, there is still much
work to be done. While some member countries may not be positioned at this time
to comply with all aspects of the guidelines for nurse anesthetists developed by ICN
and IFNA, work should continue at the national level to make this a reality in the
future. In addition, IFNA must be that resourceful and supportive partner that assists
all member countries achieve these goals. That can be done by the collective
S. M. Ouellette and S. S. Caulk
379
experience, victories, and failures, of member countries as they steadfastly work
toward licensure, titles, and title and practice protection through national regulatory
agencies. While there may be differences among countries as to processes and pro-
grams, the work is not done until all advanced practice nurse anesthetists have
proper recognition for the role they play in safe, quality anesthesia services in their
country.
Summary
The evolution of national nurse anesthesia associations, such as AANA began as a
result of constant challenges regarding the right of the nurse anesthetist to adminis-
ter anesthesia. Strength that was found in organizations overcame these challenges
through development of high standards for education and practice, advancement in
educational credentials, and development of credentialing mechanisms and titles
that are now required to practice.
The global voice of nurse anesthetists in the IFNA. Since its beginning, it has
worked tirelessly to elevate the quality of anesthesia in all countries through devel-
opment of educational and practice standards, steps to globalize the profession, and
quality assurance in nurse anesthesia educational programs. Requirements to prac-
tice rests with the country, but can be guided by IFNA.It is at the country level,
supported by the national nurse anesthesia association, that practice requirements
such as licensure and titles will be created and protected. It is at this level the global
organization, along with the national organization, reaches the individual nurse
anesthetist and assists them to stay current with ever-changing trends in education
and practice. The individual is then best positioned to serve the public through qual-
ity, safe care for all populations, and be recognized as a major contributor in deliv-
ery of anesthesia worldwide.
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1997;77(3):267–70.
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in 96 countries. AANAJ 66: pg 273–286.
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Nurse Anesthesia Recognition: Practice Challenges, Credentialing, andTitle Protection
383
Universal Health Coverage andNurse
Anesthetists
JanetA.Dewan andAaronK.Sonah
Abbreviations
CESCR United Nations Committee on Economic Social and Cultural Rights
CRNA Certied Registered Nurse Anesthetist
DCP3 World Bank Disease Control Priorities 3; Essential Surgery
G4 Global Alliance for Surgical, Obstetric, Trauma and Anaesthesia Care
ICESCR International Covenant on Economic Social and Cultural Rights
ICN International Council of Nurses
CV-19 SARS Corona Virus 2 (Covid 19)
IFNA International Federation of Nurse Anesthetists
LIC Low-Income Country as dened by World Bank
LCoGS Lancet Commission on Global Surgery
MOH Ministry of Health
NGO Non-Governmental Organization
NSOAP National Surgery Obstetric and Anesthesia Plan
SDG United Nations Sustainable Development Goals 2030
SOTA Surgical, Obstetric, Trauma and Anesthesia Care
UHC Universal Health Coverage
J. A. Dewan (*)
Northeastern University, Bouve College of Health Science, School of Nursing,
Boston, MA, USA
e-mail: J.Dewan@northeastern.edu
A. K. Sonah
Phebe Ester Bacon College of Health Science Nurse Anesthesia Program, Gbarnga, Liberia
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_29
384
UN United Nations
US United States of America
WHA World Health Assembly
WB World Bank
WFSA World Federation of Societies of Anesthesiologists
WHO World Health Organization (OMS)
Universal Health Coverage means that all people have access to the health services they need,
when and where they need them, without nancial hardship. It includes the full range of essential
health services… WHO [1]
Background
World leaders committed to achieve Universal Health Coverage (UHC) benchmarks
by 2030 as a core health and wellness component of the United Nations (UN)
Sustainable Development Goals (SDGs). In 2015, along with the publication of
SDGs, the World Health Assembly (WHA), governing body of the World Health
Organization (WHO), acknowledged the central role of surgery and anesthesia in
achieving health equity when they published Resolution 68.15, “Strengthening emer-
gency and essential surgical care and anesthesia as a component of Universal Health
Coverage.” With the promulgation of this resolution, all 194 WHO member states are
expected to develop National Health Plans (NHP) for sustainable health system devel-
opment that includes surgery, obstetrics, and anesthesia service [1–3]. The nurse anes-
thetist role serves as a fundamental component for assuring any health system can
provide the security that people can access the surgery they need, when it is needed.
Surgery has been called the “neglected stepchild of global health” [4], but the
essential anesthesia contribution to global surgery is a veiled missing link [5]. WHO
recognition that access to essential and emergency surgery is a component of primary
care, and therefore UHC requirement, opens a sustainable development policy win-
dow for both surgery and nurse anesthesia. The availability of safe surgery is globally
unbalanced with more than half of the world’s population, over 5 billion people, lack-
ing access that meets UHC standards [6]. The magnitude of surgical complication and
mortality rates along with the adverse results when people are denied surgical cures,
make it a public health concern. Although many factors contribute to providing surgi-
cal service that meets UHC benchmarks, safe anesthesia care is always requisite. It
follows that supporting development and retention of a well-educated, competent, and
skilled anesthesia workforce needs to be a component of any NHP.Nurse anesthetists
are experienced, professional nurses who have completed additional anesthesia spe-
cialty education. Nurses deliver anesthesia all over the globe in high and low income
health systems [7, 8]. In some Low-Income Countries (LIC), nurses provide anesthe-
sia coverage for almost all surgeries [9]. This makes nurse anesthetists an important
component of any nation’s plan to meet UHC benchmarks and realize the universal
right to health. Their presence underpins a system’s potential to provide the security
that people can access the surgery they need when they need it.
J. A. Dewan and A. K. Sonah
385
Anesthesia andSurgery Human Resources
In 2015, the Lancet Commission on Global Surgery (LCoGS) put forward the argu-
ment that access to surgical care and meeting benchmarks for UHC established in
the SDGs, were interrelated and interdependent. The global disparity in access to
quality surgical services is associated with the unbalanced distribution of skilled
health workers, including anesthetists. The LCoGS offered evidence by collecting,
citing, and interpreting data and solutions by setting global benchmarks for surgical
services [10]. The Commission estimated that if benchmarks for skilled personnel
and other surgery targets are reached, access to needed surgical care would be raised
to a target minimum 80% of people everywhere by 2030 [6]. In resolution 68.15, the
WHA identied key points urging health systems to assure that the surgical and
anesthesia workforce “attains and retains” staff possessing practice appropriate core
competencies [11], but left it to States to strategize the solutions to accomplish this.
Validated global competency-based standards exist for nurse anesthesia education
and practice. These can be applied to any context and outline the knowledge and
prociency required for nurse anesthesia practice [12]. (See Chaps. 30, 31).
As systems strive to realize UHC, they can measure compliance using accepted
yardsticks. One assessable benchmark is the number of providers for surgery,
obstetrics, and anesthesia. The LCoGS suggested a conservative standard of at min-
imum 20 skilled surgical, anesthetic, and obstetrical personnel per 100,000 popula-
tion available by 2030 and used evidence to link this and other targets to sustainable
development. This ratio should be met everywhere not concentrated to urban or
better-resourced areas [6]. The British Medical Journal and the World Federation of
Societies of Anesthesiologists (WFSA) each proposed anesthesia-specic quotas of
4 or 5 skilled anesthesia providers per 100,000 population [13, 14].
Although medical associations stress the need to increase physician specialist
anesthesiologist numbersto reach benchmarks, they also recognize that in most
systems, both high income and developing settings, educated and credentialed nurse
anesthetists represent a sizable percentage of skilled anesthesia providers [9, 13].
Presently, in some developing systems in LICs, ratios for any skilled anesthesia
provider are well below the 5:100,000 population threshold designated to minimally
meet benchmarks. In Liberia, for example, in 2021, despite MOH commitment to
developing the anesthesia workforce, physician anesthesiologist density was
reported at 0.02 per 100,000 and the nurse anesthetist density at 1.56 per 100,000
[9]. For any system with a critically low number of skilled anesthesia providers,
guaranteeing access to the surgical component of UHC is impossible.
Some MOHs recognized the effect insufcient skilled anesthesia providers can
have on a system’s ability to meet UHC surgery benchmarks based upon the LCoGS
and WFSA indicators. A few MOHs have supported specically designated targets
for improving the quality and quantity of the nurse anesthesia workforce in their
NHPs. As health policymakers develop strategies to meet SDG benchmarks, includ-
ing UHC, they recognize the signicant role specialty trained advanced practice
nurses play [15–17].
Universal Health Coverage andNurse Anesthetists
386
Nurse anesthetists build on their education and experience as professional nurses
to view the care they deliver as a part of total patient care, not limited to intraopera-
tive period. Their competency-based specialty knowledge and skills prepare them to
support health systems beyond the operating room, optimizing patients’ conditions
before surgery and relieving pain and suffering postoperatively. Their nursing back-
grounds make them uniquely qualied to provide additional adjuvant services.
During the ongoing CV-19 pandemic, nurse anesthetists and student nurse anesthe-
tists, who are already qualied nurses, played key roles caring for patients with
respiratory compromise. To function in the emergency room, and respiratory care
areas, nurse anesthetists draw on their foundation nursing training to apply their
specialty skills to interprofessional, often life-sustaining, patient care wherever it is
needed [18]. With grounding in nursing fundamentals and practice experience,
nurse anesthetists are well positioned to play a signicant role in the realization of
UHC.Their presence makes any health facility better able to nimbly adjust to pro-
vide the services that assure access to care when it is needed.
Universal Health Coverage andtheUniversal Right toHealth
To operationalize UHC takes more than resolutions and good intentions and is
linked to progressively realizing the universal right to health. The SDG framers
knew that meeting targets required action in numerous domains and could not be
accomplished overnight. Right to health is not a new idea, nor simply a humanitar-
ian aspiration, it is a component of international human rights law enshrined in
national and international constitutions and statutes as well as professional ethics
codes. Human rights can serve as a legal and moral base for health policy decisions.
The modern concept trajectory of the right to health progressed from seventeenth
century Enlightenment philosophers to the post-World War II Universal Declaration
of Human Rights, to the legally enforceable United Nations International Covenant
of Economic, Social and Cultural Rights (ICESCR), ratied in 1976. Article 12 of
the ICESCR articulates measures for the right to health “the States parties to this
covenant recognize the rights of everyone to the enjoyment of the highest attainable
standard of physical and mental health.” This does not mean everyone will be
healthy, it does direct that everyone enjoys the opportunity to attain that “highest …
standard” of health. This denition surely includes timely access to safe essential
and emergency surgery and anesthesia for conditions such as Caesarian section,
laparotomy, cancer, fractures, neonatal and trauma care, etc.
Knowing surgical care is available supports mental as well as physical health
when citizens are reassured that they can access the care they need when they need
it. Signicantly, health is a positive, foundation right essential for the opportunity to
enjoy other rights, such as the right to life, security, education, work, and develop-
ment. Positive rights, for example, the right to health or education, require contribu-
tion and impose a shared accountable duty to respect, protect, and fulll on States
and others. The formal human rights paradigm is a base on which to draw the role
nurse anesthetists play in progressing toward rights based UHC [19, 20].
J. A. Dewan and A. K. Sonah
387
Nurse Anesthetists Fulfill theRequired Elements ofHuman
Rights-Based UHC
Nurse anesthetists are health system actors whose roles meet the criteria set forth for
measuring compliance with right to health, SDG 3, and the securing of UHC.General
Comment 14 of the ICESCR describes the characteristics required of any system to
meet right to health accountability criteria. Compliance means a health system’s
essential services contain interrelated and indispensable elements. It must be avail-
able, accessible, acceptable and of adequate quality [19, 20]. When viewed through
a human rights lens, UHC presents a unifying, measurable standard with moral,
legal, and functional signicance. Nurse anesthetists contribute to its realization in
all the mandated characteristic domains. The elements for which health systems are
held accountable are broadly dened in ICESCR and its Comments and can be
extrapolated to surgical and anesthesia services and care delivered by nurse anesthe-
tists specically [20].
SDG number 3 emphasizes that promoting health and well-being is essential
for development. In target 8 of SDG 3, it explicitly names UHC as a dened
marker for measuring SDG achievement. UHC means that people can access the
health care they need when they need it without excessive expense. The specic
benchmark for essential and emergency surgical access is that everyone can
reach a facility that will provide the care they need within 2hours at a cost they
can afford. This means the facilities are open and they are staffed with personnel
possessing the appropriate skills as well as the pharmaceuticals and equipment to
perform procedures such as Caesarian section, appendectomy, trauma, and other
essential and emergency surgeries without discrimination or incurring nancial
hardship. Very few, including high income systems, completely satisfy this UHC
requirement. Often the rate- limiting step in surgical care delivery in developing
systems, once the facility is reached, is the availability of a skilled anesthesia
provider [5, 6]. Nurse anesthetists’ roles reect all the essential characteristics.
Human rights elements supply elegant core arguments for investing in nurse
anesthetists.
Available
How do nurse anesthetists’ contributions achieve essential health system human
rights characteristics needed to realize UHC? General Comment 14 of ICESCR
gives the broad descriptors for the characteristics that determine essential criteria.
The rst mandated characteristic is that care is available. To meet the requirement
to make health care available, health facilities must be open and staffed with enough
appropriately skilled personnel [20]. For even basic surgical services, this would
mean a trained anesthesia provider, such as a nurse anesthetist, is present and has
the tools needed to deliver care.
Besides being critical to conducting emergency and essential surgery, nurse
anesthetists contribute to making other aspects of UHC available. They deliver
Universal Health Coverage andNurse Anesthetists
388
emergency airway and resuscitation care throughout health facilities. Their nursing
and anesthesia expertise also makes them skilled at techniques of analgesia man-
agement for surgical and non-surgical conditions, relieving pain and suffering.
Nurse anesthetists possess the technical prociency and knowledge that make them
a resource for any health system when needs arise. For example, their skill pro-
ciency and knowledge of asepsis and disease transmission positioned them to render
life-sustaining airway management outside of the operating theater when the nor-
mal function of health systems was disrupted by the CV-19 pandemic [18]. Nurse
anesthetists are central to a health system’s ability to deliver surgical care, as well as
emergency and pain management care, that meets UHC benchmarks to assure care
is available when needed.
Accessible
Nurse anesthetists contribute to achieving the second interrelated human rights ele-
ment, making health care accessible without discrimination. This goes beyond mak-
ing care at health facilities theoretically available. It means all can use the facilities
without impediments, including economic hardship [20]. Even in wealthy systems,
nurse anesthetists are the primary, at times the only, anesthesia provider in rural or
underserved areas. Their presence, often as members of the community, makes care
accessible at the community level. They enable accessible surgical and emergency
care to the underserved or remote. Recent evidence from Kenya shows that having
a cadre of well-trained nurse anesthetists increases productivity and prot at district
hospitals, enabling access to surgical care where it might not have been avail-
able [21].
Being accessible also means that patients can understand the care they need and
their options. Accessible care affords patients autonomous decision-making based
on information they can understand. Nurse anesthetists contribute to making health
system care accessible by using their nursing communication skills in patient
examinations, interviews, planning, explaining procedures, and obtaining patient
consent for care. The information they impart can remove barriers and help people
make informed decisions about accessing appropriate care. Nurse anesthetists may
also triage patients and refer them to higher acuity facilities or may consult with
specialists to optimize patient conditions for safe care, extending access. Nurse
anesthetists support the required accessibility element to provide care without
impediments.
Acceptable
Nurse anesthetists provide acceptable, skilled anesthesia care compliant with UHC
benchmarks. Acceptable health care means more than high quality medical care per
se. It means that the care available also meets ethical, moral, and legal standards of
non-discrimination and shows respect for patient rights [20]. Nurse anesthetists
J. A. Dewan and A. K. Sonah
389
staff facilities in major cities and in rural centers. They care for patients across the
lifespan in all states of health without discrimination. Nurse anesthetists frequently
are the primary or only providers in remote areas in developing and developed
health systems [5]. When there are insufcient skilled anesthesia providers, essen-
tial and even emergency surgery is triaged or may not be available at all. Groups
may experience de facto discrimination, since it is generally the marginalized who
suffer the disparity. When facilities in underserved areas are staffed with enough
nurse anesthetists and other surgical specialists, it is less likely there will be dispar-
ity in care delivery or services.
Acceptable care displays an integral moral component. It respects patient
needs, preferences, and values. Nursing and nurse anesthesia professional codes
encompass acceptable care in their ethics standards. The ICN and IFNA codes of
ethics explicitly instruct nurses to respect human rights, autonomy, and to practice
without discrimination. Complying with professional ethics is expected and inte-
gral behavior for a nurse anesthetist [12, 22]. Nurse anesthetists contribute to the
acceptability characteristic both by their presence in low resource areas and by the
nature of their professional and ethical nursing practice. When all facilities are
staffed with nurse anesthetists, they can deliver acceptable care that advances
toward UHC targets.
Adequate Quality
For a health system to function at a level of adequate quality, a sufcient number of
competent, appropriately trained, and distributed health workers must be available
to staff well supplied facilities [19, 20]. Anesthesia is somewhat unique because
safe, high quality anesthesia care is rarely recognized. It can be hidden; surgery
patients may be unaware of what the anesthetist does and there are generally no
anesthesia cures to record; whereas unsafe or decient anesthesia care is vividly
identied because it can result in tragic outcomes. Although this leaves quality
assessment difcult to measure, professional credentialing systems can reassure
that uniform standards are being met.
Regulation of practice and education provides an accepted quality model for
professionals and is the customary standard for the nursing profession. In virtu-
ally all systems, nursing licensure to practice is granted by a formal entity such as
a Board of Nursing or MOH that sets entry and continuing licensure requirements.
Nurse anesthetists, as advanced nursing practice specialists, often must meet addi-
tional advanced practice regulatory standards for their credentials above basic
nursing requirements. These may involve additional continuing education or com-
petency testing (see Chap. 31). Validated IFNA standards for nurse anesthesia
education and practice apply as guides with context adjustments. In 2021, the ICN
promulgated globally applicable Guidelines for the Advanced Practice of Nursing
in Anesthesia. These important, vetted guides reassure that there is a global stan-
dard that national regulating bodies can use as a point of reference for adequate
quality [12, 23].
Universal Health Coverage andNurse Anesthetists
390
Although our focus is on the human resources that meet adequate quality crite-
ria, nurse anesthetists also need support, including appropriately skilled interprofes-
sional personnel, equipment, and pharmaceuticals to deliver adequate quality care.
The IFNA, WFSA, and ICN guidelines incorporate monitoring and other adjuncts
as components of practice recommendations [12, 13, 23]. Core competencies pro-
moted in nurse anesthesia education include developing leadership, scholarship,
and advocacy strategies that underlie tactics to support high quality patient-focused
care. Aspects of professional nurse anesthesia practice extend beyond service in the
operating room to the very essence of healthcare structure. When nurse anesthetists
lend their advocacy voices to enlighten policymakers about their practice and the
quality measures safe anesthesia requires, it can help make essential health care
available to all when and where they need it. In addition to integrating high quality
clinical standards, core nurse anesthesia competencies of advocacy, leadership, and
scholarship impact the delivery of adequate quality care throughout health systems
(Table1).
Table 1 Nurse anesthetists respect, protect, and fulll required human rights elements for UHC
Essential surgery and
anesthesia must be
Examples of the contributions of nurse anesthetists supporting
human rights foundation for UHC
Available Staff facilities to deliver anesthesia for surgical procedures.
Provide emergency airway/respiratory management.
Participate in resuscitations and emergency interventions.
Use skills and knowledge to alleviate pain and suffering.
Render specialized care in emergencies, such as the pandemic.
Nurse anesthesia is a global profession and keep health facilities
open and functioning.
Accessible Staff facilities in remote areas.
Enlighten patients preoperatively.
Guide and refer patients for specialized care.
Foster community security by their presence.
Provide the security thatcare will be availablewhen it is needed
Provide cost-effective care that supports health systems.
Acceptable Support human rights and autonomy.
Preserve non-discrimination.
Relieve pain and suffering.
Promote specialty care throughout the health system.
Provide care across the lifespan when needed.
Practice in underserved areas.
Nurse anesthetists are cost-effective.
Adequate quality Competency-based education forms the global entry criteria for
practice.
Licensure assures oversight and professional tness to practice.
International professional standards underlie practice.
Continuing education upgrades skills and knowledge.
Professional competencies include advocacy to support broad
health system improvements.
J. A. Dewan and A. K. Sonah
391
UHC Benchmarks
Setting and documenting progress toward measurable targets can make legal, moral,
scholarly, and political indicators pragmatically applicable. Nurse anesthetists con-
tribute to achieving all the human rights-based required elemental characteristics
that underlie UHC, and their presence impacts a system’s ability to meet bench-
marks. Health facilities need skilled anesthesia providers to assure access to emer-
gency and essential surgery will be available within two hours. Nurse anesthetists
ll this role. After being on the sidelines of global health, surgical care is now rec-
ognized as a fundamental component of primary care and essential to the achieve-
ment of UHC.Most researchers have set the essential and emergency surgery target
that 80% of people everywhere have access to needed surgical care within two hours
by 2030 [6, 24]. Presently, with well over half of the globe’s people lacking access,
there is considerable work to be done.
An important aspect of measuring achievement toward globally relevant goals is
setting and recording progress toward measurablebenchmarks. To reach the 80% of
population coverage within the 2-hour target for surgery, a strategicdevelopment
anddistribution plan for surgical and anesthesia personnel is needed. The number of
nurse anesthetists, who represent a major fraction of skilled anesthesia practitioners
in many systems, is a measure of progress toward the target of a minimum of 4 or 5
skilled anesthesia personnel per 100,000 population. Collecting data on anesthesia
coverage calculated to secure the target for access within 2hours or less for the care
they need, when and where they need it, can quantify progress toward this bench-
mark [13, 14]. Although the main specialty contribution of nurse anesthetists is their
role as anesthesia provider for the surgical components of UHC, their specialized
nursing skills expand the scope of their potential contributions to UHC.They are
integral to the provision of available, accessible, acceptable care of adequate qual-
ity carethat meets criteria for thehuman rights-based foundation for SDG number
3 UHC.Nurse anesthetists contribute in many spheres as health systems strive to
meet UHC surgical access goals. Without nurse anesthetists’ contributions, many
objectives and targets for UHC will be difcult to achieve.
Scope oftheImpact
UHC is an explicit SDG 3 health and well-being target to which UN member states
committed when they accepted the UN development goals in 2015. UHC is strategic
to health equity. It is integral to realizing most, if not all, the other health and well-
being targets that contribute to health and security [25]. Meeting surgery, anesthe-
sia, and obstetric targets for quality, quantity, and access is an important component
ofactualizing UHC.UHC is an inclusive concept that can help form policy strategy
toward many other health SDG 3 targets such as improving maternal and child mor-
tality statistics, diminishing road trafc accident mortality, and disaster risk
Universal Health Coverage andNurse Anesthetists
392
reduction. This requires that evidence-based Surgical, Obstetric, Anesthesia, and
Trauma (SOTA) targets, as described by the G4 Alliance, are met. Among others,
these include access times and sufcient skilled personnel [6, 24].
Health serves as a foundation for achieving other goals, so meeting SDG 3 health
and well-being targets underlies achieving other SDGs, for instance, education,
gender equity, economic growth, security, and community strength. Training more
skilled health workers requires long term commitment and will not happen over-
night, even with the best NHPs. It helps to recognize that for ICESCR human rights
interventions, by denition, fulllment requirements can be progressive, never
regressing, and leaving no one behind [20].
Nurse anesthetists clearly canplay a strategic rolein advancing UHC as it relates
to essential and emergency surgery access. Their role beyond the operating theater
is not as readily apparent or easily calculated. In the WHO 2021 report on progress
toward UHC, some indicators slipped from pre-pandemic levels. This was speci-
cally apparent in surgical indicators. In low and high income systems, surgeries
were curtailed, clinics were closed, and the delay to care increased during quaran-
tineimposed by pandemic restrictions [26].
In the 2021 UN UHC report, 36% of countries reported disruptions in care dur-
ing the pandemic and world economic downturn. Primary care, including surgery
and emergency services, was impacted signicantly, disrupting previous advances
in access [26]. Nurse anesthetists contributed to pandemic care even as systems
struggled to function. In addition to assuring emergency surgeries could be accessed
despite pandemic restrictions and risks, in many systems, nurse anesthetists were
deployed to care for patients needing acute respiratory care. They continued to sup-
port elements of UHC even when not delivering anesthesia for surgeries [18, 27].
The data-driven 2021 UHC report highlights the underinvestment in skilled human
resources for health, leaving little room for adapting to drastic changes in health
system demands. Despite the critical contributions of nurse anesthetists toward
keeping care available in 2020–2021, the main reason given for disruptions in pri-
mary care, including surgery, was insufcient staff, highlighting the need for sys-
tems to invest in human resources for “normal” times in orderto be prepared for
emergencies [24, 26].
Nurse Anesthetists, UHC, andHealth Governance
When care is universally available, accessible, acceptable and of adequate quality,
no one is left outand the universal right to health is realized. Attention to surgery
and anesthesia as components of primary care essential to meeting UHC targets
gained momentum after 2015. With ofcial recognition of the role global surgery
and anesthesia play in UHC and development, a window of opportunity for policy
priorities opened. All 194 WHO member states committed to set priorities for
improving surgical access as a component of UHC.That year also saw the publica-
tion of the comprehensive LCoGS report setting goals for global surgery 2030 and
associated meeting those goals with sustainable development. The rst volume of
J. A. Dewan and A. K. Sonah
393
the third edition of the World Bank (WB) Disease Control Priorities; Essential
Surgery (DCP3), along with WHA Resolution 68.15 and the promulgation of the
UN SDGs that include UHC, rounded out a series of widely distributed and inuen-
tial publications supporting the intrinsic role of surgery in primary care and
UHC.The dissemination of all of these gave direction and imperative for govern-
ments to focus on developing surgery and anesthesia, including anesthesia person-
nel, as part of NHPs [1–3, 6, 26, 28]. Expert and evidence-based arguments
demonstrated that investing in surgery and anesthesia can serve as a foundation for
achieving other SDGs such as health security and poverty reduction. They demon-
strated that investing in surgery makes sense for the health of people and economies
[6, 21]. Some NHPs included National Surgery Obstetric and Anesthesia Plans
(NSOAPs) as discrete sections of their NHP [15, 28, 30]. Guided by the LCoGS,
primary plan targets should include access to essential surgery and development of
specialist surgical workforce, including anesthesia providers [17]. Some plans spe-
cically include measurable achievement benchmarks for the skilled anesthesia
workforce, including the investment in training to increase the quality and quantity
of nurse anesthetists [15, 29].
No discussion of meeting UHC targets is complete without referencing another
essential attribute to accessible and acceptable care, affordability. In HIC systems,
where high costs and catastrophic expense are threats to realization of UHC, surgi-
cal services may be physically available, but may not be accessible or acceptable
because the care incurs impoverishing costs for patients, families, and communities.
Nurse anesthetists have been shown to be cost-effective, highly skilled anesthesia
providers and often staff remote or less frequently utilized facilities, even in the
wealthiest systems. Providing surgical anesthesia care and emergency coverage
where it might be unavailable without them, makes rural nurse anesthetists impor-
tant to the feasibility of actualizing UHC [29, 31]. In developing systems, evidence
shows that stafng district centers with trained nurse anesthetists increases the
availability of surgical services [21]. Utilizing nurse anesthetists makes sense from
the system-wide economic vantage since it takes less time and expense to train them
than it does physicians, they are educated to be full-service practitioners who are
already professional nurses, and usually their salaries are lower than other anesthe-
sia providers [30]. In rural areas, they are essential to making surgical care avail-
able. Because they are frequently community members themselves, they contribute
to healthy communities and well-being, letting citizens know high quality care will
be there when needed. The words of one rural Certied Registered Nurse Anesthetist
(CRNA) in the US captured the composite requirements of UHC when he described
his practice; “CRNAs give high-quality, safe anesthesia, we’re cost-effective, and
we’re there to give the right care at the right time” [33].
In developing systems, specialty trained physician anesthesiologists are in short
supply. There has been some investment in training more of them. To secure spe-
cialty anesthesia training, physicians are often forced to leave the country support-
ing them, possibly for years. During foreign training time, they are a loss to the local
system and getting formal instruction in another country can incursignicant cost
[32]. For their training, nurse anesthesia students, in contrast, are generally
Universal Health Coverage andNurse Anesthetists
394
educated in their home system under the direction of nurse anesthetist educators and
preceptors. They are licensed nurses before they start anesthesia training and con-
tinue to provide care as student anesthetists in the domestic health system. Investment
in improving the quantity and quality of nurse anesthetists by committing to support
their specialty training and retention in NSOAPs sustains both short- and long-term
UHC goals toward providing health care when and where it is needed.
Nurse Anesthesia Advocacy Model toAdvance UHC
Nurse anesthetists play a signicant global role in assuring that UHC benchmarks
are reached. They are important providers in wealthy and lessdeveloped systems.
They provide the safe anesthesia that can increase surgical capacity and access to
surgery and emergency care. Human resources for global surgery are severely de-
cient in many systems [6, 34]. Although all skilled surgical practitioners, surgeons,
anesthetists, obstetricians and nurses are needed, the lack of skilled anesthetists is
often the rate-limiting factor for developing a sustainable program of surgery in
LICs [5]. When enough anesthetists are available, they support the development of
surgical services as MOHs incorporate surgery as primary care and a component of
SDG #3 and UHC.States and their funding sources are key to supporting the nurse
anesthesia profession and integrating the crucial role anesthetists play in achieving
UHC and other SDGs. The bottom line is when skilled anesthesia providers are not
available, people do not have access to the surgical care they require. Nurse anesthe-
tists can do more than deliver safe anesthetics to support realization of UHC by
advocating and educating to show policy-makers and donors their central role in
meeting sustainable health and wellness goals and reaching UHC benchmarks.
When NSOAPs support the development of the skilled nurse anesthesia work-
force, they are following a compelling paradigm built upon an internationally
accepted legal, moral, and scholarship foundation (Fig.1). International human
rights law and, specically, the ICESCR universal right to health, provide the legal
and philosophical base for the imperative to improve surgical and anesthesia service
to assure access to the “highest attainable standard of … health and well-being…”
[20]. Global governing bodies, the UN, the WHO, and the WHA, gave form to the
human rights template when they linked access to surgery to UHC and sustainable
development [1–3]. International nursing and anesthetist associations, ICN and
IFNA, have promulgated global guidance for the profession, while the LCoGS sup-
plied evidence-based solutions, including human resource benchmarks for global
surgery [6, 10, 24]. At the local level, MOHs and other health system governing
bodies who design the NSOAPs interpret the global moral and legal foundations
along with professional guidance into their local context to actualize UHC.Their
mandate is to guarantee that everyone can access the surgical care they need within
2hours [25, 29]. Prioritizing development of the skilled nurse anesthesia workforce
is a key part of any plan aiming to meet surgical targets for UHC.
Global IFNA standards and ICN Advanced Practice of Nurse Anesthesia
Guidelines model their recommendations on education and practice criteria that
J. A. Dewan and A. K. Sonah
395
Fig. 1 Legal, moral, and scholarship trajectory supporting global nurse anesthesia contribu-
tions to UHC
develop professionals whose role extends to interrelated competencies that include
advocate, communicator, educator, manager, scholar, and leader and expand the
nurse anesthetist’s core role as anesthesia expert [12, 23]. Nurse anesthetists, edu-
cated to these global professional standards, can advocate to impact NSOAPs.
Policymakers need guidance from clinical experts using their advocacy, communi-
cator, and scholarship skills, when deciding on health system investment priorities
that support UHC and health equity. There is a critical shortage of both physician
and nurse anesthesia providers in many developing systems, leaving a large decit
in the minimum population ratios that can assure progress toward UHC and access
to that unrealized, for many, right to the “highest attainable standard of …
health…” [20].
At the same time, most wealthy systems, referencing their own benchmarks, also
claim they have shortages of anesthetists. Despite the well-documented needs, sur-
gery and anesthesia remain underfunded by any standard both in foreign aid ear-
marks, NGO funding, and MOH distributions. What funding is realized is not well
aligned with LIC surgical deciencies [35, 36]. Donors rarely contribute to
anesthesia- specic programs despite demonstrated need for the specialty.
Recommendations include allocating health funding to train and retain a sufciently
Universal Health Coverage andNurse Anesthetists
396
skilled anesthesia workforce that includes nurse anesthetists, while also, educating
funders to needs and solutions [6, 13, 14, 36, 37]. Professional nurse anesthetists
can raise their visibility and show the value of their profession when they engage in
advocacy in the public and private sectors.
Nurse anesthetists comprise a global professional community with a potentially
large scope of inuence. Advanced practice nurse responsibilities play an expand-
ing role in health systems. ICN recognized nurse anesthesia as a global advanced
practice nursing specialty when they focused their rst published advanced practice
guidelines on nurse anesthesia. They acknowledged that some of the ICN guide-
lines, including entry level masters education for all advanced practice nurses, may
be “aspirational” for nurse anesthesia in some countries at this time, but can still
inspire health system short- and long-term strategic goals [23]. Along with the
SDGs and LCoGS measures, the ICN global guidelines can give MOHs policy
direction for building and sustaining the nurse anesthesia profession in any health
system context. When international standards are reected locally, UHC, including
universal access to essential and emergency surgery and skilled anesthesia care, can
support health equity and security. When everyone has access to the health care they
need and can afford it, the universal right to the “highest attainable standard of
physical and mental health …” can be realized.
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Nurse Anesthetists inAction
JackieS.Rowles andChristopheDebout
Abbreviations
APN Advanced practice nurse
APRN Advanced practice registered nurse
CRNA Certied Registered Nurse Anesthetist
CV-19 SARS coronavirus 2 (COVID-19)
HVO Health Volunteers Overseas
ICN International Council of Nurses
IFNA International Federation of Nurse Anesthetists
IOM Institute of Medicine
LCoGS Lancet Commission on Global Surgery
LIC Low-Income Country as dened by the World Bank
LMIC Low- and Low Middle-Income Country as dened by the World Bank
MOH Ministry of Health
NA Nurse anesthetist
PAP Physician anesthesia provider
SDG Sustainable Development Goals
UHC Universal healthcare
UN United Nations
US United States of America
J. S. Rowles (*)
Harris College of Nursing and Health Sciences, School of Nurse Anesthesia, Texas Christian
University, Fort Worth, TX, USA
International Federation of Nurse Anesthetists, St. Gallen, Switzerland
C. Debout
IFITS, Neuilly-sur-Marne, France
Sciences Po Paris/Institut Droit et Santé-Université Paris Cité, Inserm, Paris, France
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. L. Thomas, J. S. Rowles (eds.), Nurse Practitioners and Nurse Anesthetists:
The Evolution of the Global Roles, Advanced Practice in Nursing,
https://doi.org/10.1007/978-3-031-20762-4_30
400
WFSA World Federation of Societies of Anesthesiologists
WHO World Health Organization (OMS)
WWI World War I
WWII World War II
Introduction
The role of nurses in the provision of anesthesia was recognized in the mid-
nineteenth century when Catholic nuns provided anesthesia for wounded soldiers
during the US civil war [1]. Surgeons were key in advancing the nurse anesthetist
role as they sought qualied and dedicated practitioners to provide vigilant care for
their patients during surgery. Today, nurse anesthetists administer anesthesia, pain
management, and anesthesia-related services within each World Health Organization
region while serving to increase access to high-quality, timely anesthesia care and
surgical services.
History
Use of nitrous oxide was reported in the early to mid-eighteenth century but mostly
as a means of social entertainment, although there was some discussion of its poten-
tial use in pain relief [1]. Ether was employed as an anesthetic in the mid-nineteenth
century and forever more changed the landscape of global surgery and anesthesia.
Equipped with a means to manage patient’s consciousness, pain, and screams, a
growth in the number of surgeries quickly followed. Poor mortality rates necessi-
tated a role entirely dedicated to administering and managing the anesthetic. The
role of the anesthetist was not considered a very favorable one. In fact, it was seen
as a low-paying, subordinate role, which nonetheless required a high degree of
intelligence to manage the patients in an optimal status for the surgeons to be suc-
cessful [1]. Physicians and medical students were more interested in observing the
surgery than the patient’s physiologic status resulting in a high degree of mortality.
Women were the main caretakers and especially in times of war. It then makes sense
that the rst nurse anesthetists (NAs) were often Catholic nuns caring for wounded
soldiers. In turn, these Catholic hospital sisters began more formalized education of
lay nurses as NAs. Nursing textbooks in 1893 included content in anesthesia [1].
Historical records from the late 1800s report nuns educating NAs in the United
States, Africa, and Europe. Documentation of nurses administering anesthesia also
evidences nurse anesthesia’s practice quickly spreading to areas of Africa, Europe,
and the Middle East [1–3].
The International Federation of Nurse Anesthetists published a history book in
2021 entitled “The Global Voice for Nurse Anesthetists: The International Federation
of Nurse Anesthetists (1989–2001).” This book provided an in-depth look at the his-
tory of nurse anesthetists’ practice in 42 of their 43 country members and was the
J. S. Rowles and C. Debout
401
rst global documentation detailing international nurse anesthesia practice country
by country. Additional research has since been completed, and this chapter details
nurse anesthesia practice by the World Health Organization regions: Africa, the
Americas, South-East Asia, Europe, Eastern Mediterranean, and the Western
Pacic.
An unpublished 2018 survey by the International Federation of Nurse Anesthetists
reported more than 18 titles used to describe a nurse anesthetist. Survey results
revealed the most utilized and recognized title: nurse anesthetist [4]. In healthcare,
a title is used to describe one’s position or identify their work. Regardless of the
educational background or title, the practice of any anesthesia provider must meet a
common standard of care. Standards of care are developed in a multitude of ways,
most commonly within regulatory bodies, national or state law, professional organi-
zations, and expert panels, and are based on best scientic research evidence. Scope
of practice encompasses the arena of knowledge and skills necessary to meet and
provide the appropriate standard of care for a given specialty, healthcare role, or
title. Governing bodies determine the scope of practice based on education, training,
skills, and competencies.
Research into Global Nurse Anesthesia Practice
Maura McAuliffe is a CRNA from the United States who served as an ofcial
IFNA researcher. She, with colleague Beverly Henry, conducted a 3-year study
identifying countries where anesthesia was provided by nurses. McAuliffe trav-
eled to Geneva, Switzerland, to work more closely with the ICN leaders and the
World Health Organization (WHO) on her research. The American Association of
Nurse Anesthetists Council on Recertication of Nurse Anesthetists funded the
research. The research was endorsed by the WHO.Phase 1 surveys demonstrated
nurses providing anesthesia in 107 of the then 200 countries in the world.
Moreover, this research proved that nurses were anesthesia providers in all three
country levels of economic development as well as in all WHO regions. In 1992,
Phase 2 surveys were deployed, which identied not only the countries in which
nurse anesthetists were administering anesthesia but which types of anesthesia
were being performed [5]. McAuliffe summarizes the results of the phase research
by stating:
In essence, what the data revealed was that nurse anesthetists from countries in all regions
of the world and all level of development were performing all the critical tasks of anesthesia
services, some working with physicians and others working without them.—
(McAuliffe, 1992)
The third phase of research was a 5-year follow-up survey sent to all who
responded in Phase 2. The goal was to validate prior survey ndings and to deter-
mine if any changes had occurred in education, practice, and regulation of nurse
anesthesia practice. Results of this survey reported that few changes had occurred
over the prior 5-year period [5].
Nurse Anesthetists inAction
402
International Guidelines
The International Council of Nurses (ICN) asked the IFNA to serve as the content
expert in the development of advanced practice nursing guidelines for the nurse
anesthetist. A task force was formed in December of 2019 to accomplish this goal.
These would be the third set of guidelines developed within advanced practice nurs-
ing roles, with the nurse practitioner and the clinical nurse specialist having already
been completed. The need for the nurse anesthetist to help increase access to sur-
gery and universal health has been documented for years. Unfortunately, the role
remains somewhat of a mystery entangled in political debate in many countries.
Development of practice guidelines is key to increase the knowledge of government
decision makers, regulators, and the public in terms of the benet and contributions
of the nurse anesthetist. In the foreword of the NA guidelines, ICN President Annette
Kennedy and CEO Howard Catton not only strongly articulated the purpose of
guideline development but also addressed the issue of politics (emphasis added):
The aim of these guidelines is to provide clarity on Nurse Anesthetists practice and to
ensure that, as a result, the role continues to develop to support safe and affordable anes-
thetic care to people across the world. It is our hope that through the development of these
guidelines, some of the barriers and walls that have hindered Nurse Anesthetists can be
broken down. We are convinced that Nurse Anesthetists are one of the solutions to mak-
ing UHC for surgical and anesthetics services a reality.
It is acknowledged that for some countries, the requirements outlined in this guidance
paper may be aspirational. There are numerous mechanisms and strategies that can be
implemented as part of a bridging process to achieve this standard. Nursing and the Nurse
Anesthetists role will continue to evolve. This guidance paper seeks to provide the best cur-
rently available evidence to support and optimise this role moving forward.—[6]
These comprehensive guidelines address all aspects of the advanced practice
nurse anesthetist role: historical role development, role denition, education, regu-
lation/titling, scope of practice, professional standards, and document contributions
to care. These guidelines are available via the ICN website.
ICN denes an advanced practice nurse:
Advanced Practice Nurse (APN)
An Advanced Practice Nurse (APN) is a generalist or specialised nurse who has
acquired, through additional graduate education (minimum of a master’s degree),
the expert knowledge base, complex decision-making skills and clinical competen-
cies for Advanced Nursing Practice, the characteristics of which are shaped by the
context in which they are credentialed to practice [7].
The ICN-IFNA task force denes the nurse anesthetist (NA):
A Nurse Anesthetist is an Advanced Practice Nurse who has the knowledge,
skills, and competencies to provide individualised care in anesthesia, pain manage-
ment, and related anesthesia services to patients across the lifespan, whose health
status may range from healthy through all levels of acuity, including immediate,
severe, or life-threatening illnesses or injury [6].
Recognition and scope of practice vary greatly on the international level. Often
this is due to a misunderstanding or lack of understanding of who the NA is, what
J. S. Rowles and C. Debout
403
care NAs actually provide in practice, where NAs administer services (location or
practice settings), and what benets the role brings to a country in advancing the
health of its population. Current advocacy efforts are ongoing in multiple countries
for recognition of the NA role at the APN level, title protection, educational advance-
ments, and continuing education/continuous professional program development.
These efforts are not limited to the NA role but are common to all APN roles.
Dissemination of the ICN Guidelines is key to proper recognition, implementation,
and progression of the role. These guidelines should serve as a catalyst for appropri-
ate scope of practice setting for NAs in many countries as well as criteria for role
expansion (see Appendix 1: Nurse Anesthetists’ Scope of Practice).
The 160+ year history of the nurse anesthetist has resulted in many contributions
to health that remain largely unknown to the public as well as to many other health-
care professionals and regulators (see Appendix 2: Examples of NA Contributions
to Healthcare Services).
Role ofProfessional Organizations
The adoption, at national level, of an anesthesia practice model results from many
inuencing factors. These models are rooted in the history of the healthcare system
and are dependent on the existing structure of healthcare professions in each coun-
try [8]. When anesthesia was introduced in the second part of the nineteenth century,
nuns and nurses were frequently chosen by surgeons to provide anesthesia to
patients. Before World War II, in many countries, anesthesia was not considered as
a part of medical practice. Providing anesthesia to patients was not considered an
attractive activity for physicians who did not like to be seen as subservient to the
surgeon nor did they nd anesthesia practice lucrative enough.
During and after World War II, many innovations were introduced in the practice
of anesthesia. These changes, combined with the inuence of the British model
which considers the practice of anesthesia as an exclusive medical domain, attracted
physicians to this eld of practice. Thus, in many countries, the anesthesia provider
model was reconsidered at the request of this emerging physician’s group. Two
professions were usually directly concerned by this debate: the medical profession,
the newcomer in the eld, and the nursing profession whose practitioners’ expertise
was recognized and highly valued by surgeons. Medical and nursing professional
organizations were actively involved in these debates in attempts to ensure a favor-
able decision. Their opinions about the model to be used were frequently different
as well as the evidence they use to support their vision [8].
Is the practice of anesthesia to be considered in the nursing eld, in the medical
eld, or in both? Is patient safety jeopardized if the anesthesia provider is a nurse
even when he/she is adequately prepared to serve in this role? These types of
questions were frequently explored in debates and, of course, the two professional
groups give different answers to them. Tensions arose and, in some countries,
such as the United States, the decision of judges was part of the decision
process [8].
Nurse Anesthetists inAction
404
Discussions and tensions were frequently observed within these two professions.
For example, in medicine, at the end of the 1940s, surgeons and physicians did not
always share the same vision about the ideal anesthesia provision model. Surgeons
were leaders in this eld. On the other hand, emerging anesthesiologists were seek-
ing to be fully considered as a medical specialist, a status which is associated to
higher prestige in the medical profession and better salaries.
In nursing, the introduction of nurse anesthetists was frequently questioned by
other nurses and by their professional organizations. The question “Is the practice
of anesthesia part of nursing?” was raised in many countries when this new eld
of nursing practice was introduced. There were countries in which the nursing
profession rejected this eld of practice which led to the introduction of techni-
cians without any nursing background. In other countries, NAs had sometimes to
establish their own professional association to defend their role when they
observed indifference or rejection in their national nursing organization. These
types of debate have also occurred more recently within the global nursing profes-
sion when APNs’ role was introduced in countries where NAs were already in
place. The advanced nature of NA’s practice was then examined and was some-
times a source of controversy. The ICN is the authoritative body for global nursing
and nursing recognition. Development and publication of the ICN APN guidelines
for the NA should validate the recognition of the role at the advanced prac-
tice level.
Debates about the typology of anesthesia providers sometimes ended by the
adoption of a third option: introducing an anesthesiologist assistant or a technician
to help the PAP.Hospital administrators were also frequently concerned by this
debate and sometimes have made the nal decision about the anesthesia provision
model that will be used in organizations they manage. More globally, the healthcare
system structure and reimbursement scheme also had inuence on the model
adopted [8].
Throughout the world, countries answered to these questions differently leading
to the adoption of various models:
• PA P a lo n e, w i th t h e su p po r t of a n o n an e st h es i a pr ov i de r w ho c a n be t h e th e at r e nu r se
• PAP with an assistant AA who is not a nurse
• PAP with NA with various levels of supervision
• NA alone
• Mixed models of providers (team approach) based on the health status of the
patient or on the risks associated with the procedure [8]
The implementation and use of these models can vary when manpower shortages
occur. In many countries, the medical profession obtained a monopoly of anesthesia
provision, yet the number of PAPs was not, and is not yet today, sufcient to respond
to the needs of the population. Further, it is often difcult to attract and retain PAPs
in hospitals located in rural areas. In these situations, the access to surgery is often
compromised and at times non-prepared professionals had to administer anesthesia
to patients affecting the safety of care.
J. S. Rowles and C. Debout
405
Models of anesthesia provision can also evolve, and professional associations
certainly have inuence in the models utilized. More recently, due to the adoption
by the United Nations and the WHO of Sustainable Development Goals (SDG) and
the necessity to introduce universal health coverage (UHC) to achieve these out-
comes, countries have re-examined their models to improve surgical access.
Nonmedical anesthesia providers, frequently nurses, have been identied as addi-
tional anesthesia providers in countries where previously only physicians were con-
sidered qualied to administer anesthesia [8]. Enlarging the number of anesthesia
providers gives better access to the population to surgery or any other procedure
requiring anesthesia, including effective pain management during childbirth or
other advanced pain processes. With proper educational preparation, nurse anesthe-
tists are well qualied and competent to administer anesthesia and anesthesia-
related services, enhancing access to effective and safe anesthesia for patients.
Further, even though nurse anesthetists are typically higher paid than their general-
ist nursing colleagues, their salaries are lower than those of PAPs. Cost reductions
can result from a change in anesthesia practice models [8]. Unfortunately, conse-
quences of healthcare economics sometimes create tension between physicians,
nurses, and their respective organizations. Physicians may worry about losing
money, especially when solo practice authority is given to nurse anesthetists allow-
ing them to work directly with surgeons or dentists and receive direct nancial pay-
ments. Optimal care of patients and provision of anesthesia care require respect and
collaboration between the medical and nursing disciplines.
Validation ofPractice
Due to the overlap of anesthesia between medical and nursing practice, NAs have
faced numerous political challenges to practice including legal battles declaring
anesthesia as the practice of medicine. In 1936, this controversy was put to rest.
Chalmers-Francis v Nelson (1936) was a California, USA, lawsuit which chal-
lenged the legal basis for nurses to practice anesthesia. The court found for the
defense, stating that the discipline of medicine did not have exclusivity to the
knowledge of anesthetic administration. The court ruled that if a nurse provided
anesthesia, the nurse was practicing nursing [1, 2].
Current political challenges often claim that there is a difference between the
quality of care provided by an NA and that of a physician. Fortunately, there is
evidence to support high-quality care provided by NAs. In fact, quality studies date
back to the very beginning of the role development. Alice Magaw (1860–1928)
served as a personal anesthetist to surgeons Drs. Charles and William Mayo who
dubbed her the “Mother of Anesthesia.” Magaw was so skilled in the administra-
tion of open-drop ether that she soon was a draw for nursing and medical practitio-
ners to observe her technique. Further, in 1899, Magaw was the rst to publish
quality studies on nurse anesthesia practice and did so in a medical journal [9]. She
had multiple publications from 1900 to 1906 that highlighted her personal anes-
thetic practice and experience. Magaw’s 1906 publication reported over 14,000
Nurse Anesthetists inAction
406
personally administered open-drop ether anesthetics for surgical anesthesia with-
out one death [10]. For a nurse to have published in a medical journal during this
time in history is extraordinary, and she has been called a model for evidenced-
based practice [11].
Numerous studies have demonstrated that NAs administer safe anesthesia care
without statistically signicant difference in patient outcome. In 2008, Dulisse and
Cromwell published a research article in the well-respected US Health Affairs jour-
nal. This study researched anesthesia care provided by Certied Registered Nurse
Anesthetists in 14 states that had removed Medicare physician supervision require-
ments (opt-out states). National patient safety data was analyzed in the 14 opt-out
states versus non-opt-out states. The results reported similar complication rates in
care provided by CRNAs and physician anesthesiologists [12].
Cochrane reviews are internationally known as a high-quality, evidence-based
source of information. Their reviews are recorded in the Cochrane Database of
Systematic Reviews, a part of the Cochrane Library. A 2014 Cochrane review was
conducted with the goal of determining if nurse anesthetists were as safe and effec-
tive in providing anesthesia in comparison to physician anesthetists. The authors of
the published review concluded: “No denitive statement can be made about the
possible superiority of one type of anaesthesia care over another. The complexity of
perioperative care, the low intrinsic rate of complications relating directly to anaes-
thesia, and the potential confounding effects within the studies reviewed, all of
which were non-randomized, make it impossible to provide a denitive answer to
the review question” [13].
The case for nurse anesthetists as a solution for high-quality anesthesia man-
power needs was further strengthened by a 2018 Lancet report. This report
“Mortality due to low-quality health systems in the universal health coverage era: a
systematic analysis of amenable deaths in 137 countries” was eye-opening and
revealed a problem heretofore unidentied. Efforts to increase universal healthcare
have long centered on access to care. This report uncovered that deaths in LICs due
to low-quality care were actually greater than deaths from non-utilization of health-
care services [14]. The obvious questions are how and why. The most logical answer
can only be explained as inadequate education, training, skills, and competencies of
those providing care.
Task Shifting Is Not Task Sharing
Use of the term “task shifting” began in 2007 when the World Health Organization
(WHO) identied and reported a persistent shortage of healthcare workers. The goal
was to nd a way to increase the number of trained providers to improve access to
care. There was particular concern about the need to increase care in sub-Saharan
Africa where the HIV/AIDS prevalence was epidemic. Following the UN Special
Session on HIV/AIDS, the WHO introduced a plan entitled “Treat, Train, Retrain”
J. S. Rowles and C. Debout
407
or TTR [15]. This plan was primarily designed to address the increased require-
ments for healthcare to HIV/AIDS patients. Additionally, the WHO developed
guidelines on task shifting, which was dened as appropriately moving specic
designated tasks to new or other healthcare workers who had less training and quali-
cations. Over the years, the term task shifting has been applied in many instances
to movement of skills and/or care from physicians to nonphysician providers. Scope
of practice for disciplines evolves and grows. The term task shifting does not apply
to nurse anesthetists. As covered in previous chapters, the discipline of anesthesia
developed as a practice of nursing and of medicine. The key point is that nurse anes-
thetists have been providing care for over 160 years. From the very beginning, NAs
have been educated and trained to provide anesthesia care and related services. The
provision of anesthesia care and services by a NA is not task shifting. In fact, there
have been publications with physician anesthesiologist authors who speak about
“task sharing” [16]. Task sharing more appropriately describes the interrelated and
advancing practices of many healthcare disciplines.
Nurse Anesthetists Rise totheOccasion: CV-19
COVID-19 turned the world upside down throughout every nation and every area of
healthcare. Anesthesia providers were one of those at the very front of the front lines
in both emergent and extended care delivery. Each patient encounter put the NA in
a direct line of risk. Nurse anesthetists were particularly an important part of care
delivery as they stepped outside of operating suites and were deployed to numerous
areas to provide care. No matter where the geographical location, NAs were found
to be working on house intubation teams, providing critical care nursing skills in
intensive care units, turning recovery rooms and operating rooms into critical care
units, serving as respiratory consultants in intensive care units, and working in
emergency rooms, COVID testing, and immunization centers. The abilities of NAs
to provide high-level, safe, and competent care across a wide range of care further
demonstrates the value and skill set of this advanced practice role—the only anes-
thesia provider who possesses the experience and skill set to provide expert care
across this range of patient care needs.
Nurse Anesthetists inAction: Practice Summaries by
theWHO Regions
The very heart of the nurse anesthesia profession lies in practice. The desire to care
and advocate for patients at a time of extreme stress, fear, and an inability to advo-
cate for themselves fuels the motivation, protectiveness, and satisfaction found
within the heart and soul of a nurse anesthetist. The patient is the center of our
universe.
Nurse Anesthetists inAction
408
Africa
Africa is the second largest continent in the world, consisting of 54 countries within
6 African Union regions. Forty-seven countries are included in the WHO Africa
Region with the remaining countries assigned within the Eastern Mediterranean
region. According to the United Nations, the estimated population of Africa in July
2021 was 1.37 billion [17]. The World Federation of Societies of Anaesthesiologists
(WFSA) 2017 manpower survey reported that the goal for physician anesthesia pro-
viders (PAPs) is a minimum of 5:100,000 population for all countries [18]. The
Africa Region is one of the regions with the greatest need for anesthetists, as
reected in the 2017 WFSA manpower survey. Thirty-six countries reported less
than 5:100,000, with a range of 0–16.18 (South Africa); however, these numbers
included nonphysician providers [18]. An updated survey is currently under review
by the WFSA Global Anesthesia Workforce Survey Committee, which includes two
members of the IFNA leadership. The study data is unpublished, but countries not
included in our chapter research but those that have reported NAs in their anesthesia
workforce will be included in chapter tables so there is an optimal view of NA prac-
tice. It is hopeful that the current data will better represent the number of nurse
anesthetists working globally (Tables 1 and 2).
Table 1 Countries with
included region research
Countries included in region research
Benin
Burundi
Cameroon
Democratic Republic of Congo
Ethiopia
Ghana
Kenya
Liberia
Nigeria
Rwanda
Sierra Leone
Uganda
Table 2 Countries not
included in region research
but that report NAs
in WFSA workforce
surveys, 2015 or current
[18, 19]
Algeria Mali
Burkina Faso Mauritania
Central African Republic Mauritius
Chad Mozambique
Ivory Coast Niger
Eritrea Senegal
Gabon Swaziland
Gambia Tanzania
Lesotho Togo
Madagascar Zambia
Malawi Zimbabwe
J. S. Rowles and C. Debout
409
According to research conducted by Rowles and Meeusen [20], historical knowl-
edge of the NA in the African region is rst reported in 1939 when nurse anesthe-
tists from Ghana were recruited to serve in WWII.Most nurses were recruited and
trained by physicians who needed them to care for their surgical patients. Nigeria
and Tunisia report nurses administering anesthesia in the 1950s, while Burundi
nurse anesthetists began working in their country by 1959. Morocco and the
Democratic Republic of Congo have documented nurse anesthetists working in the
early to mid-1960s. In Uganda, anesthesia assistants began working in 1971, but
questions of quality care led their country to improve the role to those with health-
care experience, and a formal role for nurse anesthetists emerged in 1984. Ethiopian
nurse anesthetists began practicing in 1970, while Liberia and Benin started in
1975. Kenya and Rwanda recognized nurse anesthetists in 1990, and Sierra Leone
formally recognized nurse anesthetists in 2001. Nurse anesthetists working in
Cameroon have forged a recent relationship with the Association of Cameroon
Nurse Anesthetists in the United States. A US group of Cameroonian student anes-
thetists and CRNAs traveled to Cameroon in December 2021 to provide ACLS edu-
cation and airway skill training. More than 150 nurse anesthetists attended the
event, which is expected to be repeated yearly.
Education/Scope ofPractice/Challenges
Due to the lack of anesthesia manpower in Africa, and particularly the lack of physi-
cian anesthesia specialists, NA’s practice is mostly free of political inuence and
thus NAs practice to the full scope of their education and training (general anesthe-
sia, epidural and spinal anesthesia, peripheral nerve blocks). Full scope of practice
allows the public access to essential and emergent anesthesia care and surgical ser-
vices. Educational programs vary from on-the-job training to bachelor’s degrees
and to a master’s degree under development at the Phebe School of Nurse Anesthesia
in Liberia (Table3).
Regulation
Regulation of nurses is not a common or consistent framework across the African
region. In fact, in 2016, the WHO Regional Ofce for Africa published the Regional
Professional Regulatory Framework for Nursing and Midwifery in an attempt to
standardize regulatory structure and context within the region [21]. They looked to
the ICN to dene nursing, nursing function, and practice. Thus, the 2021 publica-
tion of the ICN advanced practice guidelines for the nurse anesthetist should now
serve as the basis for NA education, recognition, and scope of practice setting for all
governments and regulatory bodies. Not surprisingly, there are not enough nurse
Table 3 https://ifna.site/ifna- accreditation- program/
Africa Region Educational Programs Accredited by the IFNA
Bongolo Hospital Nurse Anesthesia Training Program, Libreville, Gabon
Phebe Nurse Anesthesia Program, Suakoko Bong County, Liberia
Nurse Anesthetists inAction
410
anesthesia educational programs in Africa to meet the continent’s demands for anes-
thesia providers. Further, Africa faces challenges that most do not. A lack of consis-
tent electricity, Wi-Fi, medications, equipment, and clean water makes even the
most qualied provider to struggle to provide optimal patient care.
Positive Outcomes andChallenges
According to the research by Rowles and Meeusen [20], the numbers of nurse anes-
thetists within Africa far exceed the numbers of physician anesthetists. The IFNA
has 13 country members within the African Union and contacts in several other
nonmember countries. IFNA Standards of Education and Practice have been shared
across the continent from one nurse anesthetist to another. The nurse anesthesia
education program at Kijabe Hospital in Nairobi, Kenya, has trained over 100 nurse
anesthetists. Many have moved to serve rural hospitals in Kenya and other East
African countries, allowing them the ability to provide much-needed surgical ser-
vices for their local communities. An article published in 2019 assessed Kijabe
graduates who were sent to work in nine rural hospitals within Kenya. The article
validated these nurse anesthetists’ contributions in lessening the country’s anesthe-
sia manpower gap, increasing access to surgery, and positively impacting the eco-
nomic stability of the hospitals in which they provided services [2, 22]. This program
serves as a model for other countries who are seeking to ll gaps in anesthesia care,
increase access to surgical services, and positively inuence health.
The Americas
The WHO region of the Americas consists of 35 countries plus multiple territories
within North, Central, and South America and the Caribbean with a region popula-
tion of over 1.014 billion [23]. The WFSA 2017 workforce survey reported that the
goal for physician anesthesia providers is a minimum of 5:100,000 population for
all countries. The 2017 survey results for the Americas report an overall density of
PAPs of 12.43:100,000. The density data ranges from a low of 0.74in Haiti to a high
of 20.82in the United States [18] (Tables 4 and 5).
Historical knowledge of the NA in this region dates to the beginning of the US
Civil War in 1861, where nurses were providing anesthesia to injured soldiers on the
battleeld. The most recognized and advanced level of NA practice lies within the
United States, whereas of September 22, 2022, CRNAs currently number 57,834
with 9418 student registered nurse anesthetists [24]. The United States recognizes
four advanced practice nursing specialties: Certied Registered Nurse Anesthetists,
Table 4 Countries with
included chapter data
Countries included in region research
Jamaica
Puerto Rico
United States
J. S. Rowles and C. Debout
411
Nurse Midwives, Nurse Practitioners, and Clinical Nurse Specialists. The practice
of anesthesia in the United States included both nurses and physicians from the
start. As the practice advanced, the medical community brought forth numerous
legal challenges concerning nurses administering anesthesia, stating that it is a med-
ical practice. None were successful and today, when a nurse administers an anes-
thetic, it is recognized as the practice of nursing. When a physician administers an
anesthetic, it is the practice of medicine.
In the United States, nurse anesthetists are the oldest of the advanced practice
nursing roles. Alice Magaw (previously mentioned in the section “Task Shifting Is
Not Task Sharing”) and Agatha Hodgins (1877–1945) were early pioneers in nurse
anesthesia and catalysts for expansion of the role within the United States and
Europe. Hodgins also was the founder and rst president of the national organiza-
tion of nurse anesthetists, which is now known as the American Association of
Nurse Anesthesiology. CRNAs are educated to, and enjoy, a full-scope practice in
the United States where they may work as members of an anesthesiology team or in
a solo practice setting. The federal government and insurers recognize the advanced
practice role of the CRNA and allow for direct billing and payment for CRNA anes-
thesia, pain management, and anesthesia-related services. The CRNA may work in
any location anesthesia is administered. Most often, this is a hospital, ambulatory
surgery center, endoscopy center, pain management clinic, and physician ofce.
Scope of practice is at the highest level of nursing diagnosis and includes all types
of anesthetic administration including neuraxial and regional blockade. CRNAs are
trained and procient in the use of ultrasound-guided blocks. CRNA Fellowship
Programs include Advanced Pain Management, Acute Pain Management, and
Pediatric Anesthesia.
Practice in the United States is regulated by certication requirements
(NBCRNA), licensure by state boards of nursing, federal law, state law, and the
facility in which the CRNA works. Practice regulations may vary from state to state
and even by facilities within a state. CRNAs are the primary providers of anesthesia
care in the US military and in 80% of rural America [ ]. The CRNA is educated
and prepared to practice to the highest levels of anesthesia care, offering high-
quality, safe anesthesia care to the public.
25
Canada was reportedly evaluating the use of nurse anesthetists at the national
level in 1994 with the documentation of a formalized program of education for
nurses in anesthesia [ ]. The education and practice of nurse anesthetists in Canada 26
Table 5 Countries not
included in region research
but that report NAs in WFSA
workforce survey, 2015 or
current [ , ]1918
Countries not included in this region research reporting
NAs in WFSA workforce surveys (2015 or current) [ , ]
Belize
El Salvador
Guyana
Honduras
Nicaragua
Paraguay
1918
Nurse Anesthetists inAction
412
were opposed by anesthesiologists, and this opposition has continued for decades.
Currently, there are efforts to title the Nurse Anesthetist in Canada and to begin
educational programs. A large backlog in surgeries ensued during COVID and con-
tinues. US CRNAs have served as consultants over the last 2 years in the efforts to
formally recognize, license, and begin education of the nurse anesthetist in two of
the Canadian provinces.
Puerto Rico is home to four nurse anesthesia programs, two of which are accred-
ited by the COA in the United States. These programs have moved from a master’s
degree to a doctoral degree. Scope of practice is inclusive of general anesthesia,
spinal anesthesia, and upper/lower extremity blocks. Currently, there are 135 RNAs
and 35 CRNAs (USA certied) and 60 physician anesthesiologists administering
anesthesia in Puerto Rico [27].
There is little documentation concerning NA practice in Central America. Nurse
anesthetists were identied as receiving education and administering anesthesia
within Mexico and the central American countries of Honduras, Nicaragua, and
Panama in 1994 [26]. Mexico was once a member of the IFNA.An AANA Journal
article in 2017 reported that an NA school opened in Belize in 2014 with the help of
HVO and that 60% of the anesthetics in 2012 were provided by NAs [28].
Current data is sparse for the Caribbean apart from Jamaica. The history of the
Jamaica NAs is found within the 2021 IFNA History book: The Global Voice for
Nurse Anesthesia: International Federation of Nurse Anesthetists (1989–2021). A
nurse from Jamaica attended a US nurse anesthesia program in 1956. Upon comple-
tion, she returned to Jamaica to work and was the catalyst for development of the
NA role in her country. Formalized NA education began in 1976 with the aid of the
MOH.Further, a Jamaican collaboration with the Government of Cuba in 1980
resulted in the education of RNs as NAs who returned to Jamaica. The Jamaica
School of Nurse Anesthesia began in 1981 through collaborative efforts of the
MOH, University of West Indies, and the Advanced Nursing Education Unit [20].
This school was known to have educated many of the NAs who work in other
Caribbean countries including Belize, Cayman, Costa Rica, Dominica, Grenada,
Montserrat, St. Lucia, and St. Vincent [5]. The educational program in Jamaica is
now at a master’s degree level and has incorporated education in pain management
and regional anesthesia [20]. While there is little known about the overall practice
of NAs in the Caribbean today, NAs from Jamaica and the British Virgin Islands
regularly attend annual meetings of the American Association of Nurse
Anesthesiology.
A lack of key contacts in South American has inhibited data collection on NA
numbers of scope of practice. Data collected in 1994 by Joyce Kelly demonstrated
NA practice in Chile, Columbia, Guyana, and Peru. Additionally, Kelly reported
that HVO had assisted with the development of a nurse anesthesia school in Guyana
[26]. A 2016 online article in the Kaieteur News entitled “Bitter complaints of
Nurse-Anaesthetists” speaks about an education program that began in 2008 and
challenges with governmental contracts for employment in regions of Guyana vali-
dating NA practice of Guyana [29].
J. S. Rowles and C. Debout
413
Table 6 https://ifna.site/ifna- accreditation- program/
Region of the Americas Educational Programs Accredited by the IFNA
University of Tennessee Health
Science Center, College of Nursing, Nurse Anesthesia Concentration, Memphis, Tennessee,
USA
Mount Marty College Graduate Program in Nurse Anesthesiology, Sioux Falls, South Dakota,
USA
Western Carolina University
Nurse Anesthesia Program, Asheville, North Carolina, USA
Puerto Rico School of Nurse Anesthetists, Puerto Rico
University of Alabama at Birmingham Nurse Anesthesia Program, Birmingham, Alabama,
USA
Wake Forest School of Medicine Nurse Anesthesia Program, Winston-Salem, North Carolina,
USA
Goldfarb School of Nursing at Barnes-Jewish College Nurse Anesthesia Program, St. Louis,
Missouri, USA
Virginia Commonwealth University, Nurse Anesthesia Program, Richmond, Virginia, USA
Northeastern University Nurse Anesthesia Program, Boston, Massachusetts, USA
Louisiana State University Health Sciences Center (LSUHSC) School of Nursing Nurse
Anesthesia, Louisiana, USA
University of Cincinnati, College of Nursing, Ohio, USA
Education/Scope ofPractice/Challenges
NA education in the Americas ranges from certicate, bachelor, and master to doc-
toral level degrees. The scope of practice for an NA also has a large breadth, ranging
from full scope to limitations that are most often neuraxial anesthesia (spinal/epi-
dural) and peripheral nerve blockade. Reportedly, scope of practice is often inu-
enced by the medical community (Table6).
Regulation
All countries with the Americas have regulatory bodies who determine practice pro-
tocols and rules. These regulations are put into effect from the MoH, other govern-
mental agencies, and state agencies such as the State Boards of Nursing in the
United States.
NAs in Jamaica work in a supervised team model, and there is current movement
for registration of NAs along with the other APRNs [20].
In the United States, nurse anesthesia educational programs must be accredited
by the Council on Accreditation for Nurse Anesthesia Educational Programs (COA).
Further, these programs are now required to confer a doctoral degree. To practice