Práticas Avançadas em Enfermagem no Reino Unido

Global Developments of
Advanced Practice Nursing
PAHO/WHOCC Brazil
Professor Melanie Rogers and Dr Daniela Lehwaldt

#NPAPN2021 www.npapn2021.com
Why do we need Advanced Practice Nurses?
Non communicable
diseases kill 41 million
people each year, 71%
of deaths globally
77% of NCD deaths
occur in low to middle
income countries
All NCDs are increasing
Cardio-Vascular
Diseases 17.9% million
deaths
Cancers 9.3 million
deaths
Respiratory Disease 4.1
million deaths
Diabetes 1.5 million
deaths
970 million people
have a Mental Health
or Substance Misuse
problem

Why do we need Advanced Practice Nurses?
Communicable Diseases
Over 1.8 billion people are infected with TB (1.2 million die
annually)
Over 37.7 million people live with HIV (680,000 die annually)
Over 1.5 million die of diarrhoea disease (half are children)
Over 4 million deaths from pneumonia
Over 4.3 million Covid-19 deaths

The Universal
Healthcare
Quest
Better health
Better health
outcomes
Better
access
Better patient
experience
Improved
efficiency

Global Health
Challenges
• All UN Members state they will try to achieve
Universal Health Coverage by 2030

Health is a
Human Right
It’s the
challenge set
before us

Universal Health Coverage and
the Sustainable Development
Goals.
• UHC and SDGs provide the overarching objectives
for global strategic planning.
• They are a clarion call for countries to:
• Strengthen their health systems
• Establish new models of care
• Build APN Capacity.
• Recognise that APN’s can provide health care in all
populations and settings.
• However, APN’s need to be allowed to use their
maximum scope of practice to meet health care
needs.

How APN’s can address the global challenges.
Leaders in a multidisciplinary team
 Innovative models of care
 Autonomous and adaptable
 Patient focused
 Organisation focused- collaboration/mentoring
 Create vision and empower/engage others
Care across the continuum
 Increased access to care
 Hospital to the community
 Quality to value
 Integrated care
Benefits
 Highly skilled and educated health
professional
 High quality care
 High patient satisfaction
 Career pathway for nursing
Shift focus to:
 Population health management, wellness and
addressing social determinants of health
 Prevention and the overall holistic health of
populations
 Making every opportunity count

What stops
APN’s
achieving
their full
potential?
Lack of role clarity
Lack of legislation
Lack of regulation
Lack of/or limited Education
Inadequate Funding
No job opportunities or progression
Medical or other health care resistance

International Council of Nurses (ICN): APN
Guidelines
Published in 2020
Objectives:
• To contribute to a common understanding of APN, including definitions
• To describe the pilars of APN
• To engage in international feedback
Development:
• ICN NP / APNN Team + ICN members
• Experts from 33 countries
• 130 National Nurses Associations
• < 2 years
Languages
• English
• French
• Spanish
10
https://www.icn.ch/system
/files/documents/2020-
04/ICN_APN%20Report_E
N_WEB.pdf

Definitions
• Roles covered in the
Guidelines
• Clinical Nurse Specialist
(CNS)
• Nurse Practitioner (NP)
11

Nurse Practitioner
Entry at Master’s level –
specific APN focus with at
least 500 hours of
supervised clinical practice
12

APN Pillars
Master’s
degree
at
entry
level
Education
Country
specific
regulations
which
underpin
APN
practice
Regulation
Practice
at
advanced
level
in
clinical
care
and
cure
Practice
13
• Educational preparation beyond that of
a generalist or specialised nurse
• Minimum requirement of a master’s
degree programme that has the
components required for APN and is
specific to APN practice.
• It is acknowledged that, for some
countries, the requirement of a
master’s degree may be an aspirational goal
as they strive to achieve this standard.
• Transitional programmes and bridging
courses can be defined to progress to
this standard.
• Authority to diagnose
• Authority to prescribe medications
• Authority to order diagnostic testing and
treatments
• Authority to refer patients to other services
and/or professionals
• Authority to admit and discharge patients
to hospitals and other services
• Officially recognised title(s) for nurses working
as APNs
• Legislation to confer and protect the title(s)
(e.g. Clinical Nurse Specialist, Nurse Practitioner)
• A designated role or level of nursing
that has its focus on the provision of
care, illness prevention and cure,
beyond the Scope of Practice of a
generalist or specialised nurse.
• Extended and broader range of
autonomy
(varies by country context and clinical
setting).
• Advanced assessment, judgement,
decision-making and diagnostic
reasoning skills.

Emerging
pillar
‘Research
’
APNs need:
• the ability to integrate research evidence
into their practice
• to generate knew knowledge relevant to
APN practice, profession and regulation
Network projects
14

• Led by the Core Steering Group
• We developed the first Global Academy of Research and Enterprise in
2020
• We have 5 Subgroups:
• Education
• Practice
• Research,
• Health Policy
• Students
The ICN NP/APN
Network was
launched in 2000.
International Council of Nurses
Nurse Practitioner/
Advanced Practice Nurse
Network
• Members in 121 countries

The ICN NP/APN Network is the first global group of professionals who work
collaboratively together to provide leadership and support in furthering the development
of Advanced Practice Nursing around the world.
The Network provides global leadership on Advanced Practice Nursing to strengthen health
systems and to assist in the development, recognition and implementation of APN roles.
The primary goal of the Network is to become an international resource for APNs and
interested others (e.g. policymakers, educators, regulators, health planners, researchers).
We provide relevant and timely information about practice, education, role development,
research, policy and regulatory developments.
We provide a forum for sharing and exchange of knowledge expertise and experience.
We support nurses and countries who are in the process of introducing or developing APN
roles and practice.
We provide access to international resources.

ICN NP/APN Network
• The Network has a proven track record of delivering successful programmes of
work, research, policy and regulation and connects individuals across the world.
• We continue to support the work of the International Council of Nurses. The
network has some of the most experienced clinicians in the world and as such we
harness this capability to influence global health policy under the auspices of the
ICN.
• We are harnessing the skills and abilities of our members to be a leading force for
change in the area of Advanced Practice Nursing
• We aim to support the strengthening of health systems through policies and
other products that support increasing the capacity and capability of Advanced
Practice Nurses.
• We are building the scientific body of knowledge to positively influence APN
development, practice, patient outcomes and strengthen health systems.

APN Network Mission
To empower, connect and
promote Advanced
Nurses globally through
networking, policy
development, advocacy,
leadership, education and
research.
Our Vision
To support the development
of APN who will promote
holistic, accessible, high
quality, evidence-based and
cost effective health care.
We are PASSIONATE
The Network membership is passionate about seeing APNs revolutionise healthcare by seeking to improve the health
and wellbeing of individuals and communities in our care.
We are COLLABORATIVE
We foster strong partnerships in order to work together to achieve positive and lasting relationships that
breakdown silos and support international solutions.
We are GLOBAL
The Network is a global community of Advanced Practice Nurses, APN educators, researchers, regulators,
leaders and interested parties.
We are EVIDENCE-BASED
We encourage the development of Evidence-Based Practice and work closely with members to develop
holistic approaches to all aspects related to APN.
We are RESEARCH & INNOVATION FOCUSED
We support, initiate and participate in research and innovation which adds to the international knowledge
base and which guides APN development including role clarity, understanding of key competencies, roles and
functions within health systems and health workforces.

Current
contributions to
Global Research
on NP/APN
Practice,
Education &
Regulation
Covid-19 study into APN emotional and spiritual wellbeing and
resilience
Global SWOT Analysis of APN practice, education and regulation
APN Competency mapping of 19 countries
Global APN survey study on practice, education and regulation
Anglo-Africa APN Coalition
An examination of Advanced Practice Nurses’ job satisfaction
internationally
Faculty mentoring project in Hungary
Survey of clinical education of APNs globally

Future
contributions to
Global Research
on NP/APN
Practice,
Education &
Regulation.
Covid-19 study into APN emotional and spiritual wellbeing and
resilience phase 2
Africa APN Coalition
Review of global APN research gaps
Global APN perceptions of Spirituality
Webinars on APN
Developing APN Education CPD standards
Updating global APN roles and country profiles

Keep in Touch
http://icn-apnetwork.org/
https://www.facebook.com/ICNGlobalAPN/
https://twitter.com/ICNGlobalAPN
New website coming Autumn 2021
Network Bulletins and Social Media

APN
Development
Two Case
Studies

APN Development in Ireland
Daniela Lehwaldt PhD MSc PGDipCHSE BNS RGN RNT SFHEA
Chair ICN NP / APN Network
President AFG International ofGerman Network APN & ANP
Academic Member IrishAssociationAdvanced Nurse and Midwife Practitioners
Academic Lead Nursing, Dublin City University, Ireland

APN Background /
concept IRELAND
How did the Advanced Practice Nursing (APN)
implementation process take place in your country?
• 1998: Commission on Nursing Report
• 1999: National Nurses’ Strike
• Introduction of clinical career pathways for nurses
• Staff Nurse, Clinical Nurse Specialist (CNS),
Advanced Nurse Practitioner (ANP)
• 2001: first accredited Advanced Nurse Practitioner
• Two levels of APN: NP & CNS
• 2002: Nurse education fully at university level
• Bachelor, Masters, PhD
• APN at Master’s level

What were
the main
challenges
faced during
the
implementati
on of APN or
are still
facing?
• Resistance to change in the
beginning
• Nursing! & Medicine
• APN pay scales
• Delayed introduction
• Prescriptive Authority
• Legislations introduced in 2007
• Currently lack of CNS title protection
at NMBI level
• Provided through Office of the Nursing
and Midwifery Services Director
(ONMSD)

Is there a definition for APN in
your country to support the
training of this professional, in
addition to the concept of the
International Council of Nurses
(ICN)?
Within Ireland APN is very well
regulated and supported
• Chief Nursing Officer + 4 Assistant
CNOs
• Nurses and Midwifery Board of
Ireland
https://www.nmbi.ie/NMBI/media/NMBI/Advanced-Practice-Nursing-Standards-and-Requirements-2017.pdf?ext=.pdf

What is the difference between an
Advanced Practice Nurse and generalist
nurses?
• APN practice in a dedicated role carrying out advanced nursing practice e.g. they
provide patient care beyond that of a generalist or specialist nurse (ICU, OP, etc.)
• CNS: provide expert clinical advice and care related to differentiated diagnoses
in specialised fields of practice along with a systems approach in practicing as
a member of the healthcare team.
• NP: integrate nursing and medical skills in order to assess, diagnose and
manage patients with undifferentiated and undiagnosed conditions.
And what is the difference between the Advanced Practice Nurse practice and the
medical professional practice?
• NPs provide care & cure
• Example: ICN Outreach Nurse – the difference lies in the level of decision making
• Focus is on providing timely, patient-focused care that is safe and efficient

Training/Curriculum
Structure
• Which interventions are required in the training/graduation process to
train a nurse for graduate programs in APN? – Masters in Science,
including 500 hrs of supervised practice to achieve clinical competencies
(clinical practicum)
• What competencies and skills should the Advanced Practice Nurse learn in
the training process? – Advanced A&P, pathophysiology, advanced
pharmacology, prescribing, interventions, history taking, physical
assessment, practice/service development initiatives, teaching staff,
patient education, health promotion, management & leadership, etc.
• What is the curricular structure of a master's degree for the training of
Advanced Practice Nurses? – 2 years part-time at MSc level
• What are the APN specialty areas in your country? – see profiles
https://www.lenus.ie/handle/10147/254676
https://www.lenus.ie/handle/10147/116392

Are there any requirements such as certification
or registration for granting the work permit? -
Yes
All nurses in Ireland are registered
with the Nursing Board of
Ireland NMBI.
NPs have a special
register: RANP
Also, Registered Nurse
Prescriber (RNP)

• Number of professionals and regulation and legislation of APN
• NPs ~ 2% of the nursing workforce, CNS?
• What are the requirements for Advanced Practice Nurses?
According to NMBI https://www.nmbi.ie/Registration/Add-New-Division/Advanced-
Practitioners/Registering-as-ANP-AMP
You must:
• Be a registered nurse or midwife with NMBI
• Be registered in the Prescribers division
• Hold a Master’s degree (or higher) in nursing/midwifery or a Master’s degree which is
degree which is relevant, or applicable, to the advanced field of practice. The
practice. The Master’s programme must be at Level 9 on the National Framework of
Framework of Qualifications (Quality & Qualifications Ireland), or
equivalent. Educational preparation must include at least three modular components
modular components pertaining to the relevant area of advanced practice, in addition
practice, in addition to clinical practicum.
• In recognition of services that span several patient/client groups and/or division(s) of
and/or division(s) of the Register, provide evidence of validated competencies
competencies relevant to the context of practice.
• How is the APN professional distributed/staying in your country?
• Practicing across the country

• How autonomous is the Advanced Practice Nurse?
• Regulated through Service Level Agreements
https://healthservice.hse.ie/filelibrary/onmsd/template-10-service-level-agreement-nursing.pdf
• For the performance of his/her activities to care for the individual, does the Advanced Practice Nurse
need the supervision of other health professionals? – During training, at least 500 hrs of supervised
practice to develop clinical competencies (clinical practicum)
• Supervision and assessment through an experienced ANP or medical consultant
• Is there a career path for Advanced Practice Nurses? – led by APNs
• How are these professionals paid? – see next slide

32
file:///C:/Users/lehwald/Desktop/International/Salary%20Scales%20at%20the%201st%20October%202020.pdf
NP
CNS
Annual
basic income
*without weekends
*without nights
*without overtime

APN Development in England
Professor Melanie Rogers
Advanced Practice Lead- University of Huddersfield
NationalTeaching Fellow Advanced Practice
Director ICN NP /APN Network Academy of Research and Enterprise
Advanced Nurse Practitioner Primary Care

APN
Background
England
Why did Advanced Practice Nursing develop in your
country?
• Changing needs of the population
• A shortage of medical provision
• Reduction in junior doctor hours
• A desire to advance nursing

APN Background England
How did the Advanced Practice Nursing (APN)
implementation process take place in your
country?
• 1970’s Clinical Nurse Specialist developments (not always advanced
level)
• 1988 Nurse Practitioner (Primary Care) development initially Diploma,
now MSc
• 2000 Nurse Practitioner (Secondary Care) development
• 2012 Royal College of Nursing- Advanced Nurse Practitioner Guidance
• 2008 National Health Service Advanced PracticeToolkit
• 2015Advanced Clinical Practitioners
• 2017Voluntary credentialing by the Royal College of Nurses
• 2017 Multi-Professional Framework for Advanced Clinical Practice in
England
• 2020Accreditation to the Centre ofAdvanced Practice started

What were the
main challenges
faced during the
implementation of
APN or are still
facing?
• Lack of title protection
• Lack of regulation
• Lack of role clarity
• Resistance to change (Medical and
Nursing)
• Organisational constraints
• Supplementary prescribing 2002
• Independent Prescribing 2006
• Inability to sign sick notes
• Lack of support

Is there a definition for
APN in your country to
support the training of
this professional, in
addition to the concept
of the International
Council of Nurses (ICN)?
• In 2012 a decision to move from the term Nurse
Practitioner to Advanced Nurse Practitioner was
made to identify the “advanced” nature of the
role which hoped to bring more clarity to the role
• Around 2015 a decision was made nationally to
move to the title Advanced Clinical Practitioner
• Health Education England (2017) state that
‘Advanced clinical practice is delivered by
experienced, registered health and care
practitioners. 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
encompasses the four pillars of clinical practice,
leadership and management, education and
research, with demonstration of core capabilities
and area specific 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.’

• Scope of Practice
• CriticalThinking
• Qualification
• Clinical Decision Making
• Autonomy and Accountability
• Work Environments
• Leadership
• Salary
• What is the difference between an
Advanced Practice Nurse and
generalist nurses?
• What is the difference between an Advanced
Practice Nurse and Doctors?
• Different philosophical focus- care and
cure
• Different educational structure
• Timeline to practice
• Different regulatory format
• Salary
• Career outlook

Training/Curriculu
m Structure
• Which interventions are required in the
training/graduation process to train a nurse for
graduate programs in APN?
• Masters in Science, now apprenticeships with 30 hours
supernumerary per week and a clinical educator
• What training strategies for APN are used in your
country?
• Pre apprenticeship minimum of 500 hours supervised
practice with a clinical educator
• What competencies and skills should the Advanced
Practice Nurse learn in the training process?
• Pathophysiology, clinical decision making, assessment,
history taking, physical examination and management,
leadership, research and education.
• What is the curricular structure of a master's degree
for the training of Advanced Practice Nurses?
• 3 years part-time at MSc level. Core Clinical
Competencies, Contemporary Advanced Practice,
Prescribing, Developing Advanced Practice (Speciality),
Dissertation and End Point National Assessment

What are the APN speciality areas in your country?
Primary
Care
Secondary
Care
Cancer
Care
Mental
Health
Emergency
Care
Critical
Care
Paediatrics

• Number of professionals and regulation and legislation of APN
• Growth of 8.2%
• What are the requirements for Advanced Practice Nurses?
You must:
• Be a registered nurse or allied health practitioner
• Be registered as a prescriber
• Hold a MSc Advanced Practice
• How is the APN professional distributed/staying in your country?
• Practicing across the country and in many specialities

• How autonomous is the Advanced Practice Nurse?
• Full autonomy Primary Care, Shared Secondary Care
• For the performance of his/her activities to care for the individual, does the Advanced
Practice Nurse need the supervision of other health professionals? – Clinical Educator
required throughout training
• Is there a career path for Advanced Practice Nurses? –Yes, organisations and Health
Education England
• How are these professionals paid? – Salaries start at grade 7 in training and grade 8 on
qualification

#NPAPN2021 www.npapn2021.com 43

My practice as an
Advanced Nurse
Practitioner
• I run a weekly clinic seeing between 15-20 patients
• I have 10 minutes to assess, diagnose and treat
• I see “All Comings”
• Presentations range from the simple to the complex
• A typical surgery will include contraception, mental health, infections, long term
conditions, accidents, headaches, cancer and serious pathologies
• I work holistically within a bio-psycho-social-spiritual approach

My Contact
Details:
Prof Melanie Rogers
m.rogers@hud.ac.uk
Dr Daniela Lehwaldt
daniela.lehwaldt@dcu.ie

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