Jasper Erwin L.

Tolarba, DNP, RN, NEA-BC

Director of Nursing, Tufts Medical Center, Boston,
Massachusetts

Benchmarking on Global Best

Practices in Nursing Education, Jasper L. Tolarba, DNP, RN, NEA-BC

Practice and Life Long Learning

 Describe the emerging trend of advanced roles
of nurses worldwide

Define the role of Advanced Practice Nursing

(APN)

Differentiate the role of APN from other

disciplines (e.g. MD/DO, PA)

Identify the educational requirements and

trainings to be an APN

Demonstrate evidence of good clinical

outcomes and measures of performance of
Objectives
APNs

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Global Trend of Advanced Practice Nursing (APN)
First started in the US in the 1960s as response to
shortages of physicians especially in rural areas and
also due to the rising of health care cost.

The number of advanced practice nurses (APNs) has

been growing worldwide

More formal APN formations are primarily in English-

speaking countries, such as the United States, Canada,
Australia, and the United Kingdom.

There is very little research about the status of APN

worldwide resulting in the creation of International
Nurse practitioner-advanced practice Nursing Network
(INP-APNN) in 2000.

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 Advanced Practice Nurses Around the World
(27th AANP Conference, 2012)

Singapore - APN is relatively new in this country but the APN

title is legally protected. There are 150 APN graduates so far. It
was a move to prevent brain drain of nurses.

United Kingdom - Nurse practitioners in UK have full

prescribing rights. One of the obstacles is around standardizing
educational requirements, formal title protection, registration,
and other policy issues.

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 Canada - Nurses in Canada launched the successful Its about
time initiative to encourage public interest in APN. There are
over 3,400 practitioners in the country.

Australia - APNs have been able to achieve national registration

as well as reimbursements or their services. There are currently
740 nurse practitioners in Australia.

South Africa - There is no formally recognized APN role

but there are advanced practice nurses such as midwives,
clinicians in primary care and wound care specialists.

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 Other Countries with variable APN programs

Different countries with

APNs have many variations
in:
Belgium New Zealand
nomenclature
educational
qualifications,
scope of practice Thailand
Botswana
prescriptive authority
licensure, and
regulatory practice
Sweden South Korea
(Pulcini, et al.,.2009)
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 Combined CNSs and CNPs

Clinical Nurse Specialists (CNSs)

United States
Certified Nurse Midwives (CNMs)

In 2004, the number of

registered nurses (RNs) Certified Nurse Practitioners (CNPs)
prepared to practice in at
least one advanced practice Certified Nurse Anesthetists (CRNAs)
role was estimated to be
240,461, or 8.3 percent of the
total RN population.
(Source: 2004 U.S. Department of Health and Human Services,
Health Resources and Services Administration)

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 APNs: Who are they?

An Advanced Practice Nurse (APN) 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 s/he is credentialed to practice. A masters degree is recommended
for entry level. (ICN, 2001)
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Certified Registered Nurse Anesthetist
A CRNA is a registered nurse who is educationally prepared for and
competent to engage in the practice of nurse anesthesia.

CRNAs administer approximately 27 million anesthetics in the United States

each year.

CNRAs can also administer every type of anesthetic and provide care for
every type of surgery or procedure, from open heart to cataract to pain
management.

When anesthesia is administered by a nurse anesthetist, it is recognized as the

practice of nursing and is not a medically delegated act (AANA, 2007).

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Certified Nurse-Midwife
CNMs are licensed health care practitioners educated in the two disciplines of
nursing and midwifery.

CNMs provide primary health care to women of childbearing age, including

prenatal care, labor and delivery care, care after birth, gynecological exams,
newborn care.

CNMs provide assistance with family planning decisions, preconception

care, menopausal management, and counseling in health maintenance and
disease prevention.

CNMs attend more than 10 percent of the births in the United States; 96
percent of these are in hospitals (ACNM, 2007).

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Certified Nurse Practitioner
NPs are registered nurses who are prepared, through advanced education
and clinical training, to provide a wide range of preventive and acute health
care services to individuals of all ages.

NPs take health histories and provide complete physical examinations;

diagnose and treat many common acute and chronic problems; interpret
laboratory results and x-rays; prescribe and manage medications and other
therapies

NPs provide health teaching and supportive counseling, with an emphasis on

prevention of illness and health maintenance; and refer patients to other
health professionals as needed.

NPs, by far, are the largest of all of the four APN roles.

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Clinical Nurse Specialist
CNSs are expert clinicians in a specialized area of nursing
practice. The specialty may be a population (e.g., pediatrics), a
setting (e.g., critical care), a disease (e.g., cardiovascular or
mental health), or a type of problem (e.g., wound or pain).

CNSs are engaged in direct clinical practice; function as

consultants in their area of expertise; provide expert coaching
and guidance.

CNSs interpret, evaluate, and participate in research; provide

clinical and professional leadership; collaborate; and employ
ethical decision-making.

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APRN Regulatory Model

Source: APRN Joint Dialogue Group Report, July 7, 2008

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 Advanced Practice Nurses (APN) in the US
1. Practice independently (i.e., without MD
supervision or collaboration) in the most
of states
2. In all states, NPs have independent
prescribing authority
3. Gets reimbursement for primary care
services:
- Medicaid/MediCare Part B
- Commercial insurance
4. Hospital admitting privileges

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 Whats the Difference?

MD versus APN
Medical Board Exam Nursing Board Exam

Specialty Exams APN Exam/Certification

Medical Model of Care (i.e. Curing) Nursing Model of Care (i.e. Caring)

Licensing = Medical Board exam + Licensing = Nursing Board Exam +

Specialty exam APN Exam
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 Whats the Difference?
MD APN
B.S. (pre-med) B.S. (Nursing/RN)
Medical School (4 yrs) Masters Degree (2-3 yrs)
Internship (1yr) Didactic/clinical (internship)
Residency (varies) other specialty training
(varies)

versus

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 What kind of difference REALLY matters?
Meta-analysis of 38 studies comparing NP/CNM and
MD

http://www.hcatodayblog.com/2014/07/02/anchoring-care/
Number and cost of drugs similar between MD
and APN
More lab tests ordered by APN but cost 8% less
Patient knowledge similar
APNs received higher scores on
1. Resolution of pathologic conditions
2. Patient satisfaction
3. Patient compliance
Average number of visits similar but fewer
hospitalizations for patients seen by APNs
(Brown & Grimes, ANA, 1993)

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 What are the Outcomes?
2,000 patients randomized to MD or
NP serving as primary care provider
showed little or no difference in health
status, disease specific physiologic
measures, patient satisfaction, resource
utilization.
- (Mundinger et al, JAMA, 2000)

NPs can effectively treat 90% of all pediatric patients and 80% of all adult patients.
Outcomes are equal to or better than care by physicians.
- (Office of Technology Assessment, 1987)
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 Bridge to APN Development
The political environment of a country can have
tremendous impact on the development of the
APN role (Pulcini,et al, 2012).
Lack of understanding of the APN role and
ambiguity in scope of practice and prescriptive
authority still present major challenges (Pilane,
Ncube, & Seitio, 2007)
While the goal is to bring APN education to the
masters level, not all countries have reached this
goal. (Loke, 2005; Schober, 2004)
High policy and legislative work as well as
political influence to create and implement APN
in the country.

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Advanced Practice Nursing is the Future of Health Care

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 Questions?

Jasper L. Tolarba, DNP, RN ,NEA-BC

jaspererwin.tolarba@yale.edu
+1-860-999-2916

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 REFERENCES
https://papertreiger.files.wordpress.com/2012/06/yale.jpg

http://www.mynursingdegree.com/resources/advanced-practice-nurse-designations.asp

http://aprncertification.com

https://cartagenasurgery.wordpress.com/2012/06/24/nurse-practitioners-around-the-world-27th-aanp-conference/

International Council of Nurses: International Nurse Practitioner-Advanced Practice Nursing Network, Research Subgroup. (2001).
Update: International survey of nurse practitioner-advanced practice nursing roles. Retrieved August 12, 2008, from http://icn-
apnetwork.org/

American Assocation of Nurse Anesthetists. [Accessed February 15, 2007]. http://www .aana.com/

American College of Nurse Midwives. [Accessed February 15, 2007]. http://www .acnm.org/

Avorn L, Everitt DE, Baler MW. The neglected medical history and theraputic choices for abdominal pain: a nationwide study of 799
physicians and nurses. Arch Intern Med. 1991;141:69498.

2004 National Sample Survey of Registered Nurses, U.S. Department of Health and Human Services, Health Resources and Services
Administration. http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm.

OGrady ET. Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality. In: Hughes RG, editor. Patient Safety and
Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter
43. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2641/

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 REFERENCES (cont.)

https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf

http://thedoctorweighsin.com/do-you-know-the-nursing-specialties-2/

Pilane, C.N., Ncube, P., & Seitio, O.S. (2007). Ensuring quality in affiliated health training institutions: Advanced diploma
programme in Botswana. International Nurse Practitioner-Advanced Practice Nursing Network Bulletin, 7, 23.

Loke, A.Y. (2005). Hong Kong scenario. International Nurse Practitioner-Advanced Practice Nursing Network Bulletin, 4, 2.

Schober, M. (2004). Dimensions and dynamics of international advanced nursing practice. Conference presentation at Third
International Council of NursesInternational Nurse practitioner-advanced practice Nursing Network.

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