Trends in APN practice engage in the change

GLOBAL TRENDS AND ISSUES IN APN
PRACTICE: ENGAGE IN THE CHANGE
DEENA A. NARDI, PHD, PMHCNS-BC, FAAN⁎ AND RENEAU DIALLO, MS, CNM†
The advanced practice nursing (APN) movement represents a global vision with similar issues
facing APNs across dissimilar countries, disparate political structures, and diverse cultures. As
APNs work toward independent practice, they face external challenges from medicine and
internal barriers within the domain of nursing. This paper presents reflections on the major
practice issues raised at the 7th International Nurse Practitioner/Advanced Practice Nursing
Network Conference, a subgroup of the International Council on Nursing (ICN), in London in
August, 2012. Major issues addressed at the conference included independent practice, barriers
to practice, educational standards, and the APN role in research and evidence-based practice.
APNs are best placed to provide and direct an advanced level of quality healthcare. APNs must
develop consensus models and present as a more unified force in the quest for independent
practice. (Index words: Advanced practice; Barriers to practice; Independent practice; Policy;
Educational standards; Entry into practice: global nursing) J Prof Nurs 30:228–232, 2014.
© 2014 Elsevier Inc. All rights reserved.
ADVANCED PRACTICE NURSING (APN) represen-
tatives from thirty one different countries con-
verged in London for three days in August 2012 to
examine global issues and trends in advanced practice,
health care, and health care policy and politics. The event
was the 7th International Nurse Practitioner/Advanced
Practice Nursing Network Conference, a subgroup of the
International Council on Nursing (ICN). ICN was
founded in 1899 as a federation of national nursing
associations, now numbering 130, and representing more
than 13 million nurses globally (About ICN, 2011). Its
goals are to advance nursing professionally, and to ensure
sound health policies and quality nursing care for all.
Approximately 400 delegates shared cutting edge knowl-
edge and updates from their roles as primary care
providers, clinicians, researchers, educators, and consul-
tants at the three day conference. APNs from the USA
were well represented at the conference, with presenters
from such institutions as the University of St Francis
Joliet and Rush University Medical Center and University
College of Nursing, the Mayo Clinic, Yale, Johns Hopkins,
George Washington, Indiana University, Washington
State, Columbia and Duke Universities.
What became apparent early on was that regardless of
the political, cultural, economic and physical contexts of
health care in Europe, the Americas, Asia, Australia, Africa
and the Middle East, APNs were increasingly recognized as
primary healthcare providers for all peoples, regardless of
income, social status or background (Smolowitz &
Reinisch, 2012). This is especially true for the vulnerable,
the voiceless, and those experiencing gaps in access,
treatment and follow-up of care. For, as Dr. Peter Carter,
CEO of the Royal College of Nursing, said in his welcoming
speech, "Florence Nightingale said nursing is the art and
science of the possible…and we do it in many countries by
filling in gaps. This is related to the way we look at health…
by looking at the whole person." Looking at the whole
person is central to our practice, as our profession
continues to dramatically evolve into one recognized for
its central role in healthcare at all levels.
The sessions were designed to bring leading edge
knowledge and updates from APNs around the world to
answer the question, “How then do APNs genuinely
engage with the whole person?” Answers to that question
were pervasive throughout the conference proceedings,
and can be briefly summarized in take-aways from the
conference that are presented below. The intent of this
paper is to raise the awareness of our peers about the
shared issues that APNs around the globe value as
pertinent to their practice, the health of their patients,
and to the profession at large.
⁎Professor and Director, DNP Program, University of St. Francis,
Joliet, IL.
†Director of Compliance and Medical Services, Beloved Community
Family Wellness Center, Chicago, IL.
Address correspondence to Dr. Nardi: Professor and Director, DNP
Program, Leach College of Nursing, University of St. Francis, 500
Wilcox St., Joliet, IL 60417. E-mail: makremer@ameritech.net
8755-7223
228 Journal of Professional Nursing, Vol 30, No. 3 (May/June), 2014: pp 228–232228
© 2014 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.profnurs.2013.09.010

Independent Practice
The concept of nurses practicing in advanced roles is
not new or restricted to the U.S. As early as the 1940s,
the U.S. and China recognized the practice of certified
nurse-midwives and certified registered nurse anesthe-
tists (Sheer & Wong, 2008; Weiland, 2008). In the U.S.,
the role of the nurse practitioner evolved in the 1960s in
response to the shortage of physicians and limits to
access to healthcare (Philips, 2012).
There is global consensus among APNs, however, that
barriers to independent practice prevent them from
performing to the fullest extent of their education,
certification, practice experience, titling, and regulation.
One such barrier is the continued effort by the medical
profession to control nursing practice (Weiland, 2008).
For instance, the U.S. Academy of Family Physicians has
just published its position paper, Ensuring a Quality,
Physician-led Team for Every Patient (Leawood, 2012),
asserting that advanced practice nurses should be
supervised by physicians in order to ensure safe health
care, that physicians are the leaders of healthcare teams,
and that physicians are the sole natural directors of
medical homes (Leawood, 2012). This policy would keep
APNs as supervised employees of physician group
practices, further restricting APN independent practice
as the primary healthcare providers they are prepared to
be, creating another layer of healthcare bureaucracy and
even longer waits and further delays in access to care.
This reluctance by regulatory bodies to recognize the
independent practice competencies of APNs internation-
ally was a major finding of the Education and Practice
subgroup of the International Nurse Network (INP/
APNN) survey focused on APN education in 2008.
These results are being used by the group as they continue
to identify patterns and gaps in APN regulation worldwide
(Buckley & Heale, 2012). APNs from Queensland,
Australia to the UK, to Botswana, and elsewhere,
identified the challenges ahead for APNs in their countries
in meeting the needs of global populations without the
necessary recognition of NP roles and regulatory mech-
anisms that support independent practice (Lewis, 2012:
Brook & Rushford, 2012; and Pilani et al., 2012).
APNs must be aware, however, of barriers to
independent practice that exist within the domain of
nursing itself. In the U.S., these barriers include the
refusal of nursing organizations such as the American
Nurses Association to move directly to end the three
paths to educational entry into nursing practice without
further delay; the reluctance of the state members of the
National Council of State Boards of Nursing to push for
changing academic preparation for taking the NCLEX
exams for RN licensing to just the BSN degree; and the
American Nurses Credentialing Centers (ANCC) move in
2000 to split RN specialty certifications into two levels—
specialty certification for ASN degreed RNs, and the
board certifications for BSN degreed RNs. The distinction
between “certified” and “board certified” are lost on our
patients and other members of the healthcare team,
including other nurses, and this addition of yet another
level of certification for RN practice further confuses our
educational preparation and competency levels.
Diverse educational preparation and overlapping role
responsibilities produce lack of clarity among stake-
holders and consumers and can compromise the APN
move toward full independent practice (Duffield, Gardner,
Chang, & Catling-Paul, 2009). This lack of clarity and lack
of standardization of APN practice, especially concern-
ing prescribing, is also cited as a major factor in
producing uneven patient outcomes in the UK, where
APN prescribing is, like the U.S, not nationally regulated
(Brook & Rushford, 2012).
Prescribing Practices
Prescribing competency is another area of concern
globally, as there is little information about the prescribing
patterns, barriers to prescribing, or knowledge gaps of
APNs who could prescribe as a regulatory part of their APN
role. As noted by an APN from the UK, many APNs who
could prescribe choose not to prescribe, but little is known
about the reasons for not using this regulated competency
as part of full patient care. (Baileff & Latter, 2012).
The need for unencumbered prescribing privileges for
qualified APNs in the US. is critical. Full APN practice
includes assessment and interpretation of all diagnostic
testing, developing diagnosis through critical reasoning,
and prescribing treatment regimens, including medica-
tions. Barriers to full APN practice, however, including the
prescribing of medications and treatments, are prevalent
throughout the globe, as exemplified by presenters from
Singapore (Lim, Chew, & Chua, 2012), and the Netherlands
(Maten-Speksnijder, Meurs, Grypdonck, Pool, & van Staa,
2012). These barriers include similar regulatory and scope of
practice supervisory restrictions, for instance, in all but
nineteen of the 50 states and District of Columbia in the U.S.,
that prevent APNs from practicing to the full extent of their
education, practice experience and licensing (Scott &
Lindsey, 2011).
Overcoming barriers to obtaining unencumbered
prescribing privileges is crucial to the delivery of full,
holistic healthcare. Prescribing restrictions on qualified
APNs present further challenges to the World Health
Organization’s (WHO, 1988) goal of improving access to
quality healthcare for the many that are locked out due to
poverty, global conflict, and lack of qualified providers.
Marsden, Shaw and Raynel studied the roles and effects of
policy on the evolving practice roles of APNs in the UK
and New Zealand. They discovered that healthcare needs
and policies of their countries largely dictate the
development of APN roles. They conclude that the
drivers of the APN role in their countries include a “lack
of experienced doctors and an unmanageable rise in
healthcare demand” (Marsden, Shaw, & Raynel, 2012,
p. 51). Similar factors drive the evolution of the APN role
in the U.S., but we contend that this unmanageable
healthcare demand can be managed by removal of
barriers to prescribing privileges for qualified APNs in
the U.S., so they can provide the full complement of
229GLOBAL TRENDS IN APN PRACTICE

healthcare services to their patients instead of referring to
other providers. Patients should not have to make
multiple appointments to different providers to receive
adequate diagnostic, medication and follow up treatment
for most of their healthcare needs These multiple
providers for the same diagnosis drive up healthcare
costs and use up patient and provider time and space.
Educational Standards
Presentations, focus groups and keynote speeches
focused on the goal of high quality graduate nursing
education for APNs, which is patient centered and
evidence- based. This education should be grounded in
universal standards, yet must be related to the healthcare
needs, culture, and social frameworks of each region.
From a global perspective, there is inconsistency in basic
and advanced levels of nurse education, and inconsis-
tency in how clinical practice is provided and supervised.
Economically developing countries have more limited
resources and a need to prepare health care professionals
in an accelerated manner (Pulcini, Jelic, Gul, & Loke,
2009). Mandating the BSN degree for entry into practice
and a masters degree for APN practice can impact
underserved nations in parts of Africa, Asia and Latin
America, all but crippling some nurses' hopes of attaining
a licensed nurse or even APN level of practice. But this
inconsistency in education and practice preparation is
also evident in countries with more economic and
educational resources, such as the U.S., where entry
into basic practice continues to exist on three levels, and
graduates of diploma, ASN and BSN degree program
continue to take the same NCLEX licensing exams to
practice as an RN.
The American Nurses Association first resolved that
“ANA continue to work toward baccalaureate education
as the educational foundation for professional nursing
practice” in 1964, then reaffirmed this resolution in 1991
and again in 2000 (ANA Reaffirms Commitment, 2000,
para. 5). Although this commitment seems to be
reaffirmed each decade by the ANA, there is a lack of
genuine political movement by this organization and all
of its subsidiaries and affiliates over the last half century
to realize this goal, if it is truly an organizational goal.
Although sufficient evidence demonstrates the critical
need for more highly educated nurses at the basic and
advanced level for better patient health outcomes, (IOM
(Institute of Medicine), 2011), nursing leadership has
backed away from requiring the BSN degree as the one
entry level of professional nursing practice.
One recent example of this reluctance to act on its
commitment and maintain the status quo is evidenced in
the new Joint Statement on Academic Progression for
Nursing Students and Graduates, co- authored by a
coalition of nursing organizations from four year and two
year degree institutions. It states that "despite the large
number of current RNs, more qualified nurses must be
prepared by programs offered by community colleges and
four year institutions" (Joint Statement on Academic
Progression for Nursing Students & Graduates, 2012,
para 1). This joint statement affirms the support for
continued lifelong education for all nurses, but at the
same time, it validates continuing this education at the
community college level, which is a growing anachro-
nism for all other health care professions.
APN Research
Nursing research is evolving, and has simultaneously
widened its targets and sharpened its focus on the
outcomes of health care design, delivery and education.
APN scholars are contributing to knowledge creation,
application and analysis. What is not fully understood or
agreed on, however, is the role of the APN in the research
process, and what sort of academic preparation truly
prepares APNs for this role. Questions about the best use
of DNPs, MSNs and nursing PHDs at the conference
centered on how best to prepare APNs academically and
experientially for a lead role in this process. Agreement
was reached at one of the general sessions of the
conference on the need for all APNs to use critical
analysis skills to critique, select and incorporate pub-
lished clinical evidence to improve health care delivery
practices. The debate continues, however, about the
effectiveness or usefulness of traditional biostatistics,
evidence based practice, literature review, or advanced
research courses in preparing APNs to do just that.
In addition, the need is critical to fund, conduct, use,
and disseminate research on outcomes of APN roles and
practice to the general public, to healthcare providers,
and especially to policy makers who influence regulation
of APN practice. Although there is a great deal of research
already on the safety and effectiveness of APN practice as
first line providers of quality healthcare, it is still
unknown if policy makers are aware of this research
and its implications. Physicians are still expressing
difficulty understanding the differences between RN
and APN roles, especially as it concerns the Clinical
Nurse Specialist (Carter, Dobbins et al., 2012. Concur-
rently, nursing is clearly experiencing difficulty in
crafting evidence-based messages about APN competen-
cies to policy makers (Carter, Lavis, & MacDonald-
Rencz, 2012) as well as to these same physicians, who are
invested in protecting their medical autonomy. Nursing
outcome researchers need to focus on tailoring their
implications and recommendations to healthcare policy
makers. They also need to directly disseminate their
findings on APN practice to nursing policy makers, who
can use them to tailor messages about APN roles and
practice to targeted groups, such as policy makers and
our physician colleagues, to inform them about the APN
role as fully qualified healthcare provider.
Conclusion
Throughout the deliberations, networking, and plans for
information sharing, it became apparent that the global
vision the conference proposed was surely becoming a
global reality. APNs must develop consensus models and
present as a more unified force in the quest for
independent practice. Although territorial battles
230 NARDI AND DIALLO

among health care provider disciplines can temporarily
obstruct the trajectory of advanced nursing practice, the
vision shared at the conference was clear and enthusias-
tically welcomed by those present. It is one of healthcare
providers best placed to provide and direct an advanced
level of quality healthcare. And that healthcare provider,
regardless of geographic or political location, is the
advanced practice nurse, a provider who recognizes that
all peoples have a right to receive a level of healthcare that
helps them maintain their best quality of life.
Much work remains to be done, however, to bring the
APN to the table as a fully recognized healthcare provider
competent to provide and evaluate patient health out-
comes of their role as full providers of healthcare within
their domain of practice, unfettered by unsupported,
unreasonable regulatory restrictions.
The role of the APN in directing and providing
healthcare is still evolving worldwide. Barriers to full
practice such as titling, multiple practice entries and
education levels, and restrictive practice polices advocat-
ed by the medical profession continue to exist. While the
possibilities of overcoming these barriers will be realized
in just a matter of time in more economically developed
countries, other countries are fraught with educational
and economic challenges that further confound the
process. Obtaining a consensus for licensing, accredita-
tion, certification and education (Consensus Model for
APRN Regulation, 2008) appears to be one strategy that
could propel positive change in nursing and healthcare
regulation legislation in the U.S. The adoption of similar
strategies may be useful in advancing APNs toward full
practice worldwide.
Another initiative to standardize and accept basic
educational preparation for nurses worldwide that is
gaining global acceptance is the Bologna Process. The
Bologna Process, or Accord, was established in 1998, and
is steadily growing in acceptance, with 47 European
countries currently as signatories. Its purpose is to make
academic degrees and quality assurance standards more
comparable and compatible throughout Europe. This is
being achieved through the development of a system of
easily interpreted and comparable degrees, a system of
granting three cycles of academic degrees (undergradu-
ate, graduate, and doctoral degrees), and using a system
of credits to promote widespread student mobility. It
allows for academic exchange of comparable credits and
degrees among the signatories. Its Tuning Process is used
to develop templates for learning outcomes and compe-
tencies that can be used in baccalaureate, masters, and
doctoral nursing programs. Its long term goal is to form a
more unified profession, and develop a higher education
process that will facilitate work migration for graduate
nurses across Europe (Adelman, 2009).
This paper began with the question, “How then do
APNs genuinely engage with the whole person?”To fully
engage with the whole person, the APN must be
unfettered by unreasonable and unsupported restrictions
on their diagnostic, treatment, and prescriptive compe-
tencies. The presentations from the APNs around the
globe at this conference clearly reflected some unified
answers from a very heterogeneous group. APN practice
is needed to increase access to quality healthcare and
improve healthcare outcomes. But the profession still is
struggling with barriers to full practice, few educational
standards, misunderstandings and assumptions about
the APN role, political naiveté, and lack of a strong
voice in healthcare policy decisions, Organizations such
as the INP-APNN can be instrumental in serving as a
voice for APNs internationally. When APNs can
successfully resolve the barriers within our profession,
we will be better prepared to overcome our external
challenges.
References
About ICN. Available: http://www.icn.ch/about-icn/about-icn/.
Adelman, C. (2009). The Bologna process for U.S. eyes: Re-
learning higher education in the age of convergence. http://
www.ihep.org/assets/files/EYESFINAL.pdf.
ANA Reaffirms Commitment to BSN for Entry into Practice.
(February 25, 2000). Nursing World. http://www.nursingworld.
org/FunctionalMenuCategories/MediaResources/PressReleases/
2000/CommitmenttoBSN.aspx.
Baileff, A., & Latter, S. (2012, August). Nurse independent
prescribing 10 years on: Where are the gaps and what are the
answers. Paper presented at the 7th International Nurse
Practitioner/Advanced Practice Network Conference: Advanced
nursing practice-Global vision-global reality. London, England.
Brook, S., & Rushford (2012). The regulation of advanced
nursing practice. Paper presented at the 7th International Nurse
nursing practice-Global vision-global reality, London, England.
Buckley, C. R., & Heale, R. (2012, August). Regulation of
advanced nursing practice roles: A global update. Paper
presented at the 7th International Nurse Practitioner/Advanced
Practice Network Conference: Advanced nursing practice-Global
vision-global reality, London, England.
Carter, N., Dobbins, M., Hoxby, H., Ireland, S., Pachey, S., &
DiCenzo, A. (2012, August). Nursing and medical leaders need
information on the value added of APN roles. Paper presented at
the 7th International Nurse Practitioner/Advanced Practice
Network Conference: Advanced nursing practice-Global vision-
global reality. London, England.
Carter, N., Lavis, J., & MacDonald-Rencz, S. (2012, August).
Decision makers craft messages about APN roles n Canada.
Paper presented at the 7th International Nurse Practitioner/
Advanced Practice Network Conference: Advanced nursing
practice-Global vision-global reality, London, England.
Consensus Model for APRN Regulation; Licensure, Accred-
itation, Certification & Education. (2008, July 7). https://www.
ncsbn.org/7_23_08_Consensue_APRN_Final.pdf.
Duffield, C., Gardner, G., Chang, A., & Catling-Paul (2009).
Advanced nursing practice: A global perspective. Collegian, 16,
56–62.
IOM (Institute of Medicine). 2011. The Future of Nursing:
Leading Change, Advancing Health. Washington, DC: The
National Academies Press. http://www.nursingworld.org/
FunctionalMenuCategories/MediaResources/PressReleases/
2000/CommitmenttoBSN.aspx.
Joint Statement on Academic Progression for Nursing Students
and Graduates. (2012). http://www.aacn.nche.edu/aacn-
publications/position/joint-statement-academic-progression.
231GLOBAL TRENDS IN APN PRACTICE

Leawood, K. (2012). Primary Care for the 21st Century.
Ensuring a Quality, Physician-led Team for Every Patient.
American Academy of Family Physicians.
Lim, M., Chew, D., & Chua, C. (2012, August). Journey
towards certification as an advanced practice nurse (APN) in
Singapore. Paper presented at the 7th International Nurse
Lewis, S. (2012, August). The mental health nurse practi-
tioner role in rural Queensland, Australia. Paper presented at the
7th International Nurse Practitioner/Advanced Practice Network
Conference: Advanced nursing practice-Global vision-global
reality, London, England.
Marsden, J., Shaw, M., & Raynel, S. (2012, August). Advanced
practice in ophthalmic nursing: A comparison of roles and the
effects of policy on practice in the UK and New Zealand. Paper
vision-global reality. (p.51). London, England.
Maten-Speksnijder, A., Meurs, P., Grypdonck, M., Pool, A., &
van Staa, A. (2012, August). Nurse practitioners as new
professionals in Dutch healthcare: Opinions, policy and facts.
Paper presented at the 7th International Nurse Practitioner/
Advanced Practice Network Conference: Advanced nursing
practice-Global vision-global reality, London, England.
Philips, S. (2012, January). APRN consensus model imple-
mentation and planning. e Nurse Practitioner, 37, 23–45.
Pilani, C., Madisa, M., Goshime, Y., Magama, M., Maseko, K.,
& Mosioma, O. (2012, August). The role of family nurse
practitioners in primary health care: A case of Botswana. Paper
vision-global reality, London, England.
Pulcini, J., Jelic, M., Gul, R., & Loke, A. (2009). An
international survey on advanced practice nursing, education,
practice, and regulation. Journal of Nursing Scholarship, 42,
31–39. http://dx.doi.org/10.111/j.1547-2009.01322.x.
Scott, T., & Lindsey, M. (2011). Collaboration and Supervi-
sion in Advanced Practice Nursing: An Exploration of Current
Policy, Steps to Enact Policy Change and Educate Nurses to
Become Advocates for Change, unpublished document, Leach
College of Nursing. Francis, Joliet, Illinois: University of St.
Sheer, B., & Wong, F. (2008). The development of advanced
nursing practice globally. Journal of Nursing Scholarship, 40,
204–211.
Smolowitz, J., & Reinisch, C. (2012, August). Doctoral
preparation of advanced practice nurses to meet global healthcare
needs. Paper presented at the 7th International Nurse Practi-
tioner/Advanced Practice Network Conference: Advanced
Weiland, S. (2008). Reflections on independence in nursing
practitioner practice. Journal of the American Academy of Nurse
Practitioners, 20, 345–352.
WHO. (1988). The declaration of Alma Alta. World Health.
232 NARDI AND DIALLO

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