Advanced Practice Nursing Roles, Regulation, Education, and Practice: A Global Study

Kathy J. Wheeler; Minna Miller; Joyce Pulcini; Deborah Gray; Elissa Ladd; Mary Kay Rayens

doi:10.5334/aogh.3698

Figures & Tables

Table 1

APN Role and Regulation Studies.

STUDY YEAR/S DATA COLLECTED/REPORTED	STUDY TITLE	INVITED PARTICIPANTS	KEY FINDINGS
Research Subgroup of the ICN NP/APNN [8] 1999–2000 collected 2001 reported	Survey Conducted at the ICN Centennial Conference in London	– ICN International Conference 1999 (London, England) – ICN NP/APNN Conference 2000 – ICN Nursing Association Members (120)	– 40 countries responded – education beyond that of a licensed or registered nurse in 33 countries, with education varied – only 26 countries reported education that led to a degree, diploma or certificate – education programs reported some kind of accreditation or approval process, though varied widely – some form of regulation reported in 13 of the countries
Roodbol [9] 2003–2004 collected 2004 reported	Survey Carried Out Prior to the 3^rd ICN INP/APNN Conference	– 3^rd ICN NP/APNN Conference (Gronigen, The Netherlands) – conference attendees	– over 60 countries reported either presence or interest in APN roles
Pulcini, Jelic, Gul & Loke [10] 2008 collected 2010 reported	An International Survey on Advanced Practice Nursing Education, Practice, and Regulation	– 174 key respondents and members of the ICN NP/APNN	– 32 responding countries – 13 titles identified for the NP/APN role – NP/APN education in 71% of 31 countries, with 50% recognizing master’s degree as prevalent credential – NP/APN role formally recognized in 23 countries, with 48% having licensure maintenance or renewal requirements – greatest support from domestic nursing organizations, individual nurses, and the government – greatest opposition from domestic physician organizations and individual physicians
Heale & Buckley [11] 2011 collected 2015 reported	An International Perspective of APN Regulation	– National Nursing Associations and global nursing health policy makers	– 30 responding countries with 26 reporting evidence of APN role – questions on regulation, education, scope of practice, opposition/barriers – significant variation in educational requirements, regulation, and scope of practice from country to country
Maier & Aiken [12] 2015 collected 2016 reported	Task Shifting from Physicians to Nurses in Primary Care in 39 Countries: A Cross-Country Comparative Study	– country experts suggested by group of international experts	– 39 responding countries with 27 reporting evidence of APN role via task shifting (England, Northern Ireland, Scotland, Wales all reporting separately) – 11 countries demonstrated significant task shifting, 16 countries demonstrated limited task shifting, 12 countries demonstrated no task shifting

Table 2

Country Responses Compared to Previous APN Studies.

PULCINI, JELIC, GUL & LOKE [10] NOTE*	HEALE & BUCKLEY [11] NOTE**	MAIER & AIKEN [12] NOTE***	CURRENT STUDY
	Angola
Argentina
Australia	Australia	Australia (1)	Australia
	Austria	Austria (3)
	Bahrain
		Belgium (2)
	Bolivia
Botswana	Botswana		Botswana
		Bulgaria (3)
Canada	Canada	Canada (1)	Canada
			Chile
China
		Croatia (2)
		Cyprus (2)
		Czech Republic (3)
		Denmark (2)
			Ecuador (role not established outside US agencies)
Ethiopia
		Estonia (2)
Figi
Finland	Finland	Finland (1)	Finland
France	France	France (3)	France
		Germany (3)	Germany
			Ghana
	Greece	Greece (3)
Grenada
Hong Kong
		Hungary (2)	Hungary
		Iceland (2)
India
	Iran
Republic of Ireland	Republic of Ireland	Republic of Ireland (1)	Republic of Ireland
			Israel
Italy	Italy	Italy (2)	Italy
Jamaica			Jamaica
Japan
			Kenya
		Latvia (2)
		Lithuania (2)
		Luxembourg (2)
	Malaysia
		Malta (2)
	Mongolia
Netherlands	Netherlands	Netherlands (1)	Netherlands
New Zealand	New Zealand	New Zealand (1)	New Zealand
Nigeria
		Norway (3)
Oman
Pakistan
	Poland	Poland (3)
Portugal		Portugal (2)	Portugal
		Romania (3)
Saudi Arabia/KSA
	Sierra Leone
Singapore			Singapore
		Slovakia (3)
		Slovenia (2)
	Spain	Spain (2)	Spain
South Africa
South Korea
		Sweden (2)
Switzerland	Switzerland
Taiwan	Taiwan
Tanzania			Tanzania
Thailand	Thailand
	Togo
		Turkey (3)
		Switzerland (3)
United Kingdom	United Kingdom	United Kingdom (1) England Northern Ireland Scotland Wales	United Kingdom England Northern Ireland Scotland Wales
United States	United States	United States (1)	United States

[i] * Unclear if participation in survey demonstrated presence of APN role.

** Role present in all countries, though significant variation in regulation and education.

*** Level of task shifting as follows: 1 = significant task shifting, 2 = limited task shifting, 3 = no task shifting.

Table 3

Education and Credentialing Definitions Provided in Survey for Items Needing Clarification.

TERM	DEFINITION AS PROVIDED IN SURVEY
Title protection	Title protection, as adapted from the American Nurses Association definition, refers to the restricted use of the title to only those individuals who have fulfilled the requirements for the licensure/recognition in each jurisdiction’s legislation/regulations/rules so as to protect the public against unethical, unscrupulous, and incompetent practitioners.
Certificate/certification	To clarify the difference between the meaning of “certificate” and the meaning of “certification” the following definitions are provided by the American Accreditation Board for Nursing Specialties: Certificate program refers to “an educational program that awards a certificate after completing the program.” Certification refers to “an earned credential that demonstrates the holder’s knowledge, skills and experience. It is awarded by a third party.” Generally the third party is non-governmental but, in some situations, could be a governmental agency.
Certification/recertification	Certification, as defined by the American Accreditation Board of Nursing Specialties, refers to “an earned credential that demonstrates the holder’s knowledge, skills and experience. It is awarded by a third party…” Generally the third party is non-governmental but, in some situations, could be a governmental entity. Conditions for certification usually involve experience, education and an exam. Conditions for recertification usually involve experience and continuing education, but may involve another exam. Certification is a formal recognition of an individual’s education, skills and practice AS OPPOSED to licensure/registration/endorsements, which is an individual’s formal authorization to practice.

Table 4

Country Respondents.

COUNTRY	N	PERCENT
Australia	5	1.54
Botswana	2	0.62
Canada	85	26.15
Chile	3	0.92
Ecuador (role not established outside US agencies)	1	0.31
Finland	4	1.23
France	4	1.23
Germany	3	0.92
Ghana	3	0.92
Hungary	1	0.31
Israel	1	0.31
Italy	1	0.31
Jamaica	1	0.31
Kenya	2	0.62
Netherlands	39	12.00
New Zealand	4	1.23
Portugal	3	0.92
Republic of Ireland	5	1.54
Singapore	3	0.92
Spain	10	3.08
Tanzania	1	0.31
United Kingdom England Northern Ireland Scotland Wales	41	12.62
United States	103	31.69

Table 5

Demographics of Survey Respondents.

PRACTICING NURSES	N	PERCENT*
Registered/Generalist Nurse	71	21.82
Hospitalist/Acute Care NP/APN	48	14.77
Specialty care specific to disease or illness NP/APN	50	15.38
Specialty care specific to an age group or population NP/APN	32	9.85
Family NP/APN	121	37.23
Geriatric/Gerontologic NP/APN	18	5.54
Paediatric NP/APN	17	5.23
Adult NP/APN	45	13.85
Adult Gerontologic NP/APN	7	2.15
Women’s Health NP/APN	12	3.69
Midwife	2	0.62
Community Health NP/APN	21	6.46
Mental Health NP/APN	17	5.23
CNS	22	6.77
Other	47	14.46
EDUCATORS	N	PERCENT
Registered/Generalist Nurse	18	11.69
NP/APN	65	42.21
Both of above	59	38.31
Other	12	7.79
ADMINISTRATORS	N	PERCENT
Nursing personnel	22	48.89
Non-nursing personnel	0	0
Both of above	23	51.11
RESEARCHERS	N	PERCENT
Nursing related	56	52.83
Non-nursing related	6	5.66
Both of above	44	41.51
OTHER ROLES	N	PERCENT
	73

[i] * Percentages do not add to 100% because respondents could select more than one answer.

Table 6

Education.

COUNTRY	N	FORMAL EDUCATION, NO. OF PROGRAMS	EDUCATION CREDENTIAL	TYPES OF EDUCATION FOR NPS/APNS*	PROGRAM DETAILS	STUDENT REQUIREMENT DETAILS
Australia	5	Yes, >10	Doctorate, master’s	a-m	2 yr. full time/3 yr. part time 300 dedicated clinical, 5000 hours before endorsement as NP Funding by government and/or student	Registration as RN/Generalist Nurse Academic degree Minimum 2 yrs. as RN in specified clinical field and2 yrs. of current advanced nursing practice in same clinicalfield
Botswana	2	Yes, <10	Master’s, baccalaureate, advanced diploma	a, d, f, g, j, k, l, m	2 yr. full time 500 clinical hours Funding by government and/or student	Registrationas a RN/Generalist Nurse Academic degree Minimum 2 yearsas RN/Generalist Nurse
Canada	85	Yes, >10	Doctorate, master’s, baccalaureate, certificate, advanced diploma	a-m, n (anaesthesia/anesthetist, neonatal, primary care)	Programlength varies according to school and degree Clinical hours varyaccording to school and degree Funding by government, private funding, and/or student	Registration as a RN/Generalist Nurse Academicdegree Minimum of 2 years as RN/Generalist Nurse
Chile	3	Yes, <5	Master’s	m, n (degree generic, considered = to MSN)	2 yr. full time 500–800 clinical hours Funding by student	Registration as a RN/Generalist Nurse Academic degree Minimum of 3 years as RN/Generalist Nurse
Ecuador (role not established outside US agencies)	1	No	N/A	N/A	N/A	N/A
Finland	4	Yes, <5	Master’s, certificate, advanced diploma	a, b, g, i, l, m	Program length varies according to school and degree Clinical hours vary according to school and degree Funding by government or employer	Registration as aRN/Generalist Nurse Academic degree Minimum of 3 years asRN/Generalist Nurse, more if they will be a prescriber
France	4	Yes, <5	Master’s, advanced diploma	b, e, k, l, n (oncology, nephrology)	Program length varies according to school and degree No response to clinical hours question Funding by government	Registration as a RN/Generalist Nurse Academic degree Minimumof 3–5 years as RN/Generalist Nurse, depending on schooland degree
Germany	3	Yes, <5	Doctorate, master’s, baccalaureate, no credential is granted	b, c, e, g, h, k, l, m	2–3 yr., depending on school and degree No response toclinical hours question Funding by government and/or student	Registration as a RN/Generalist Nurse Academic degree Minimum of 1–2 years as RN/Generalist Nurse, depending on school and degree
Ghana	3	Yes, <5	Baccalaureate, advanced diploma	a, f, g, l, m, n (general nurse practitioner)	2–3 yr. full time Noresponse to clinical hours question Funding by student	Registration as a RN/Generalist Nurse Academic degree Minimum of 3 years as RN/Generalist Nurse
Hungary	1	Yes, <5	Master’s	a, c, e, k, n (anesthesiology, perioperative)	18 mo. full time 1490 clinical hours No response to source of funding	Registration as a RN/Generalist Nurse Academic degree Minimum of 3 years as RN/Generalist Nurse
Israel	1	Yes, <5	Certificate	No response	No response	No response
Italy	1	Yes, <5	Doctorate, master’s	d, e, g,	2 yr. full time 500 clinical hours Funding by student	Registration as a RN/Generalist Nurse Academic degree
Jamaica	1	Yes, <5	Master’s	d, f, g, j, l, m	2–3 yr. full time No response to clinical hours question Funding by student	Registration as a RN/GeneralistNurse Academic degree Minimum of 2 years as RN/GeneralistNurse
Kenya	2	Yes, <10	Master’s	b, j, k	No response regarding program length, clinical hours or funding	Registration as aRN/Generalist Nurse Academic degree Minimum of 2 years asRN/Generalist Nurse
Netherlands	39	Yes, >10	Master’s, baccalaureate, certificate, advanced diploma	a-m, n (other: five APN types-acute, preventive, intensive, chronic and mental health. Soon only general healthcare and mental healthcare. GYN skills transferred to nurse specialists)	2 yr., though one program 3 yr. Unclear response to clinical hours question Funding by government, private funding, student and/or other	Registration as a RN/Generalist Nurse Academic degree Minimum of 2 years as RN, Generalist Nurse
New Zealand	4	Yes, <10	Doctorate, master’s, baccalaureate, certificate, advanced diploma	All except midwife. Midwives are not considered APNs.	2–5 yr. full time 300–500 clinicalhours Funding by government, private funding, and/or student	Registration as a RN/Generalist Nurse Academic degree Minimum of 4 years as RN/Generalist Nurse
Portugal	3	Yes (for clinical specialist, specialist nurse), <10	Master’s, certificate	a, d, f, i, j, k, l, m, n (rehabilitation)	18 mo. No response to clinical hours question No response to funding question	Registration as a RN/Generalist Nurse Academic degree
Republic of Ireland	5	Yes, <10	Master’s, advanced diploma	a-m	2 yr. FT 500 clinical hours + 100 hours prescribing question Funding bygovernment or other	Registration as a RN/Generalist Nurse Academic degree Minimum of 3 years as RN/Generalist Nurse
Singapore	3	Yes, <5	Master’s	a, b, c, d, e, f, g, h, i, k, l	2 yr. plus 1 yr. internship, under review to reduce to 18 mo. 800 clinical hours, increasing to 1200 in 2020, 12 mo. internship Funding bygovernment and/or other	Registration as a RN/Generalist Nurse Academic degree Minimum of 5 years as RN/Generalist Nurse
Spain	10	Yes, <5	Doctorate, master’s, certificate, advanced diploma	a, b, d, e, f, h, i, j, k, l, m, n (emergency nurse anesthetist)	2 yr. full time No response to clinical hours question Funding by government and/or student	Registration as a RN/Generalist Nurse Academic degree
Tanzania	1	Yes, <5	Doctorate, master’s	j, l,	2 yr. full time Noresponse to clinical hours question Funding by government and/orstudent	Registration as a RN/Generalist Nurse Academic degree Minimum of 1 years as RN/Generalist Nurse, though 3 preferred
United Kingdom	41	Yes, >20	Doctorate, master’s, baccalaureate, certificate, advanced diploma, no credential is granted, other (unspecified)	All & n (neonatal)	2–3 yr. full time 500–1000 clinical hours according to school and degree Funding by government, private funding, student and/or other	Registrationas a RN/Generalist Nurse Academic degree Minimum of 2–7years as RN/Generalist Nurse
United States	103	Yes, >20	Doctorate, master’s, baccalaureate, certificate, advanced diploma	a-m, n (nurse anesthetist)	18 mo. to 4 years depending on school and degree 500–1200 clinical hours according to school and degree Funding by government, private funding, student and/or other	Registration as aRN/Generalist Nurse Academic degree Number of years of experienceas RN/Generalist Nurse varies according to school and program

[i] Low response countries in shaded gray.

* a = Hospitalist/acute care NP/APN, b = specialty care specific to disease or illness NP/APN, c = specialty care specific to an age group or population NP/APN, d = family NP/APN, e = geriatric/gerontologic NP/APN, f = paediatric NP/APN, g = adult NP/APN, h = adult gerontologic NP/APN, i = women’s health NP/APN, j = midwife, k = community health NP/APN, l = mental health NP/APN, m = clinical nurse specialist, n = other.

Table 7

Regulation, Credentialing, and Certification.

COUNTRY	N	FORMAL RECOGNITION LEVEL	REGULATION LEVEL	REQUIREMENTS TO PRACTICE	RN/POST RN PRACTICE LEVEL	SPECIFIC REQUIREMENTS TO RENEW	REGULATORY MODEL
Australia	5	Government, hospital/health care agency, professional organizations	Federal, jurisdictional	Academic degree, approved education program, registration/licensure/endorsement by government agency	Post RN	Continuing education, portfolio, practice	Registration/licensure/endorsement at national level Tasmania has similar process as above
Botswana	2	Government, hospital/health care agency, professional organizations	Federal	Academic degree, approved education program, registration/licensure/endorsement by government agency	Post RN	Continuing education, portfolio, practice	Registration/licensure/endorsement at national level
Canada	85	Government, hospital/health care agency, professional organizations	Federal, jurisdictional	Academic degree, approved education program, registration/licensure/endorsement by government agency, certification by a non-governmental agency	Post RN*	Continuing education, portfolio, practice	Registration/licensure/endorsement at jurisdictional level Certification exam by independent agency
Chile	3	Role recognized but no formal government regulation, professional organizations in existence	N/A	Approved education program	RN/Post RN	N/A	Registration/licensure/endorsement at agency level
Ecuador (role not established outside US agencies)	1	N/A	N/A	N/A	N/A	N/A	N/A
Finland	4	Role recognized but no formal government regulation	N/A	Academic degree, approved education program	RN/Post RN	N/A	Registration/licensure/endorsement at agency level
France	4	Government, hospital/health care agency, professional organizations	Federal	Academic degree, approved education program	RN/Post RN	Portfolio	Registration/licensure/endorsement at national level
Germany	3	Role recognized but no formal government regulation, professional organizations in existence	N/A	Academic degree, approved education program	Post RN	N/A	Registration/licensure/endorsement at agency level
Ghana	3	Government, professional organizations	Jurisdictional	Academic degree, approved education program, registration/licensure/endorsement by government agency	RN/Post Rn	Continuing education, practice	Registration/licensure/endorsement at jurisdictional level
Hungary	1	Government, professional organizations	Federal	Academic degree, approved education program, registration/licensure/endorsement by government agency	Post RN	Continuing education, portfolio	Registration/licensure/endorsement at national level
Israel	1	Government, professional organizations	Federal	Academic degree, approved education program, registration/licensure/endorsement by a governmental agency, certification exam by a governmental agency	Post RN	N/A	Registration/licensure/endorsement at national level Certification exam
Italy	1	Role recognized but no formal government regulation	N/A	Academic degree	Post RN	N/A	Registration/licensure/endorsement at agency level
Jamaica	1	Role recognized but no formal government regulation	N/A	Approved education program	Post RN	Continuing education, practice	Registration/licensure/endorsement at agency level
Kenya	2	Role recognized but no formal government regulation, professional organizations in existence	N/A	Approved education program	RN	N/A	Registration/licensure/endorsement at agency level
Netherlands	39	Government, hospital or health care agency, professional organization	Federal	Academic degree, approved education program, registration/licensure/endorsement by a governmental agency	Post RN**	Continuing education, portfolio, practice	Registration/licensure/endorsement atnational level
New Zealand	4	Government, hospital or health care agency, professional organization	Federal, jurisdictional	Academic degree, approved education program, registration/licensure/endorsement by a governmental agency	RN/Post RN	Continuing education, portfolio, practice	Registration/licensure/endorsement at national level
Portugal	3	Government, hospital or health care agency, professional organization	Federal	Academic degree, approved education program, registration/licensure/endorsement by a governmental agency	RN/Post RN	N/A	Registration/licensure/endorsement at national level
Republic of Ireland	5	Government, hospital or health care agency, professional organization	Federal, jurisdictional	Academic degree, approved education program, registration/licensure/endorsement by a governmental agency	RN/Post RN	Continuing education, portfolio, practice	Registration/licensure/endorsement at national level
Singapore	3	Government, hospital or health care agency, professional organization	Federal	Academic degree, approved education program, registration/licensure/endorsement by a governmental agency	Post RN	Continuing education, practice	Registration/licensure/endorsement at national level
Spain	10	Role recognized but no formal government regulation	N/A	Academic degree, approved education program, registration/licensure/endorsement by a governmental agency, registration/licensure/endorsement by a non-governmental agency, sponsorship by a clinical agency	RN/Post RN	N/A	Registration/licensure/endorsement at agency level
Tanzania	1	Role recognized but no formal government regulation	N/A	Academic degree	Post RN	Continuing education	Registration/licensure/endorsement at agency level
United Kingdom	41	In infancy at government, hospital or health care agency, professional organization***	N/A	Academic degree, approved education program, registration/licensure/endorsement by a non-governmental agency***	RN/Post RN	Note***	Registration/licensure/endorsement at agencylevel Note***
United States	103	Government, hospital or health care agency, professional organization	Federal, jurisdictional	Academic degree, approved education program, registration/licensure/endorsement by government agency, certification examination by a non-governmental agency	Post RN****	Continuing education, portfolio, practice	Registration/licensure/endorsement at jurisdictional level Certification exam

[i] Low response in shaded gray.

*Some NPs were grandfathered to role without master’s degree but met other education/exam requirements. They tend to practice in remote areas.

**The APN, entitled Nurse Specialist, is issued a credential of qualification upon graduation from a professional program. Over the next five years the APN must demonstrate a specified level of practice, continuing education and a number of other professional activities. If the APN cannot provide proof of these activities the APN is struck from the Registry, losing the Nurse Specialist title. The title can be reestablished by entering an individual educational program with a licensed MANP program. At the conclusion of the program the credential is re-earned and the individual can register as Nurse Specialist with the Registration Commission.

***Government starting to place requirements on advanced nursing practice but in infancy. RCN offers a credentialing process, but it is not compulsory. Some groups campaigning for formal entry on the NHS. The Royal College of Emergency Medicine and the Faculty of Intensive Care Medicine both offer a credentialing process and associate membership.

****Some NPs were grandfathered to role before master’s was required. Now rare since most are retired or close to retirement.

Table 8

Regulatory Models: Advantages and Disadvantages.

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