International Nurse Practitioners

     The role of an advanced practice Nurse (APN) or Nurse practitioner (NP) is becoming familiar in an international level. Two main reasons for many countries to start developing the role of NPs are the shortage of physicians and the need to cut cost in healthcare spending (Kroezen, van Dijk, Groenwegen, & Francke, 2011). The International Council of Nurses (ICN) has defined the role of the Nurse Practitioner (NP) in the following statement.

A Nurse Practitioner-advanced practice Nurse as 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 s/he is credentialed to practice. A master’s degree is recommended for entry level (Pulcini, Jelic, Gul, & Loke, 2010, p. 32).

     There are vast variations in the scope of practice and education of the APN. In the following, the author will discuss the history, regulations, education and attitude of the public towards the APN/NP for a select few English speaking countries.

 

Nurse Practitioners in the United Kingdom and the Republic of Ireland

 

 

Belfast, Northern Ireland

 

     The United Kingdom (UK) medical system is ran by the government under the guidance of the National Health Service (NHS). Advanced practice Nurses in the UK are called Nurse Practitioners. The role of the NP was established in 1998 to create efficiency of use of nurses, cut cost in the NHS and to ease the deficit of physicians (known as General Practitioners [GP]) in community practice, primary care clinics and acute care settings. They are mainly highly specialized and specifically trained in roles that they are filling such as Endoscopy, Primary Care, Critical Care or Emergency. There are three main levels of prescriptive authorities in Great Britain, Independent, Supplemental, and use of Patient Group Directives (PGD) or Medical Directives (protocols). Independent NPs have full prescriptive authority and full liability whereas supplemental NPs collaborate with independent prescribers. British NPs enjoy full prescriptive authority and access to the full British Formulary including controlled and experimental drugs, access to the NHS prescribing budget for reimbursement and support from the British Medical Association (Kroezen et al., 2011). However, some of the setbacks in the role are the British nursing body’s lack of explicit description of the APN role and highly variable training. British NPs can have a bachelor degree, a post graduate diploma or a master degree. Pharmacology training for prescriptive authority is provided at a degree level and NPs only require three years of clinical experience. Also, NPs in the UK are not required to be licensed or registered. Therefore, the British public does not always embrace NPs due to their lack of confidence that NP training is adequate. Forty four percent of British NPs have had diagnostic request denied. As the NHS is cutting the budget but still demanding high quality care, there is a demand in the UK for NPs to fill positions of GPs at a cheaper price. Morgan (2010) recognized that the NPs in the US are better prepared and that the UK needs time to catch up with the US. The Nurse Practitioner United Kingdom (2010) has been lobbying since 2005 for the government to set a standard of regulation for all advanced practice nurses. This group is seeking to learn from other countries such as USA and Australia on how to regulate advanced practice in nursing.

                                         Cliffs of Moher, Republic of Ireland

     The Republic of Ireland (ROI) has a two-tier health care system; the public health care ran by the government under the Health Service Executive (HSE) and the private health care system. All citizens are entitled to use of the public health care system but only 80% utilize it. The private health care system is more attractive to the public because of the belief that it gives faster access to services and better services than the public health care system (Carney, 2010). The role of the Registered Nurse Prescriber (RNP) was established in the ROI in 2007. RNPs enjoy a vast prescriptive authority much like the UK but require registering under the Nurse Prescriber Division of Register and having a written collaborative practice agreement with a medical practitioner. More information on the RNP scope of practice can be found in the An Bord Altranais website (An Bord Altranais, 2012; Carney, 2010; Kroezen, 2011).

 

An interesting fact: NPs in the United States (US) make on average 51,000 pounds ($81,400) as British nurses make at maximum 43,335 pounds ($69,449) (Morgan, 2010).

Nurse Practitioners in Canada

                                                    Niagara Falls, Canada

      Until the 1990’s, NPs in Canada were trained only to fill position gaps in northern parts of Canada.  Now legislation has been implemented to allow NPs to work in areas outside of the Northern Provinces (Alden-Bugden, 2007). There are 3000 NPs in Canada today. Nurse practitioners in Canada can provide quality care, order tests, prescribe medications, diagnose and manage chronic diseases, and refer to specialists as needed. They work in doctor’s offices, community clinics, nursing homes, private homes, Emergency Departments and Critical Care Units. Canadian NPs are certified by passing the Canadian Nurse Practitioner Exam. However, not all provinces require NPs to take this exam. The Canadian Nurses Association is launching a campaign to educate the population about how NPs can improve access of care for Canadians as close to five million Canadians do not have a primary care provider and those who do have one have a hard time accessing care (NPCanada.ca, 2011).

     Although there are currently no colleges in Canada that has a Doctorate of Nursing Practice (DNP) program, the advent of its southern neighbors requiring their entry level NPs to have a DNP by the year 2015 is putting some pressure on nurse leaders in Canada. All entry level registered nurses in Canada are required to have a bachelor degree however advanced practice nurses can have a bachelor or master degree (Joachim, 2008).

Nurse Practitioners in Australia and New Zealand

     Australia introduced the role of NP in 2000 to relieve the burden of physician shortages. Australian NPs require a master degree, ability to demonstrate clinical assessment and clinical decision making skills and at least five years of clinical experience in order to receive prescriptive authority and endorsement as NPs. However, Australian prescriptive authority is limited compared to British NP prescriptive authority (Kroezen et al., 2011). Since Australia has various states and territories, laws and regulations for NPs vary in each one. The Nurses Registration Board of New South Wales was one of the first states to begin regulation and licensing criteria for NPs. Now Australia is in the process of forming a national regulation (Pulcini et al., 2010).

New Zealand began the role of NP in 2001. Nursing prescriptive authority was historically limited to specialized roles but was just recently expanded to all NP roles. It has similar education requirements and regulations as Australia except New Zealand require only four years of clinical experience and must maintain continuing education in order to maintain their prescriptive authority. NPs in New Zealand get reimbursed the same amount for their services as physicians (Kroezen et al., 2011).   

References

Alden-Bugden, D. (2007, May 25). Welcome to NPCanada.ca. Retrieved from http://www.npcanada.ca/portal/

An bord Altranais (2012). Collaborative practice agreement (CPA) for nurses and midwives with prescriptive authority (third edition). Retrieved from www.nursingboard.ie

An Bord Altranais (2012). An Bord Altranais flowchart for application and registration process for the registered nurse prescribers division [Flowchart]. Retrieved from www.nursingboard.ie

Carney, M. (2010). Challenges in healthcare delivery in an economic downturn, in the Republic of Ireland. Journal of Nursing Management, 18, 509–514. doi: 10.1111/j.1365-2834.2010.01078.x

Joachim, G. (2008). The practice doctorate: Where do Canadian Nursing leaders stand? Nursing Leadership, 21(4), 42-51

Kroezen, M., van Dijk, L., Groenwegen, P. P., & Francke, A. L. (2011).Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a systematic review of the literature. Bio Central Health Services Research, 11(1), 127. doi:10.1186/1472-6963-11-127

  

Morgan, S. (2010). What are the differences in nurse practitioner training and scope of practice in the US and UK? Nursing Times.net. Retrieved from http://www.nursingtimes.net/what-are-the-differences-in-nurse-practitioner-training-and-scope-of-practice-in-the-us-and-uk/5017012.article

NPCanada.ca (2011, October 17). Canadian Nurses Association says ‘it’s about time’ [Press release]. Retrieved http://www.npcanada.ca/portal/

Nurse Practitioner United Kingdom (2010). Regulation [Fact sheet]. Retrieved from http://www.nursepractitioner.org.uk/Regulation.html

Pulcini, J., Jelic, M., Gul, R., & Loke, Y. (2010). An international survey on advanced practice nursing education, practice, and regulation. Journal of Nursing Scholarship,42(1), 31-39. doi: 10.1111/j.1547-5069.2009.01322.x