Development and regulation of advanced nurse practitioners in the UK and internationally

Enablers and barriers to nurse practitioners working in Australian aged care: A scoping review

OBJECTIVE

To identify evidence reporting on nurse practitioners working in aged care in Australia and to categorise the reported factors found to be barriers or facilitators to operation in terms of establishment, sustainability, and expansion.

INTRODUCTION

Nurse practitioners work in a variety of aged care contexts throughout Australia but are underutilised and uncommon. Despite evidence for their effectiveness, it is unclear what barriers or enabling factors contribute to the successful and sustainable implementation of nurse practitioners working in this sector.

METHODS

Based on an a-priori protocol the JBI methodology for scoping reviews was used and the review reported against the PRISMA extension for scoping reviews (PRISMA-ScR). Databases searched included MEDLINE, Embase, Emcare, Web of Science, and Scopus. Peer reviewed and grey literature describing the role of Australian nurse practitioners in aged care were included.

RESULTS

Of 2968 retrieved sources, 18 were included representing studies of a variety of designs from all Australian states and territories. Residential care and in-home care contexts as well as metropolitan, regional, and remote locations were represented. Overall, 123 individual barriers and facilitators were identified across seven inductively derived categories: staff/individual, organisational, system, operational, resource, data, and consumers/clients/residents. In many cases, factors appeared across both positive (facilitators) and negative (barriers) categories.

CONCLUSIONS

Nurse practitioners can improve the quality of care being provided to older people accessing aged care in Australia. When establishing or maintaining nurse practitioner roles in aged care knowledge users should have a comprehensive understanding of the range of factors potentially contributing to or limiting success or sustainability. As implementation is highly contextual, various types of organisational and sectoral factors as well as individual and overarching factors related to the regulation of nurse practitioners practice should be considered.

Factors influencing the development, recruitment, integration, retention and career development of advanced practice providers in hospital health care teams: a scoping review

BACKGROUND

Advanced practice providers (APPs), including physician assistants/associates (PAs), nurse practitioners (NPs) and other non-physician roles, have been developed largely to meet changing healthcare demand and increasing workforce shortages. First introduced in primary care in the US, APPs are prevalent in secondary care across different specialty areas in different countries around the world. In this scoping review, we aimed to summarise the factors influencing the development, recruitment, integration, retention and career development of APP roles in hospital health care teams.

METHODS

We conducted a scoping review and searched Ovid MEDLINE, Ovid Embase, Ovid Global Health, Ovid PsycINFO and EBSCOhost CINAHL to obtain relevant articles published between Jan 2000 and Apr 2023 that focused on workforce management of APP roles in secondary care. Articles were screened by two reviewers independently. Data from included articles were charted and coded iteratively to summarise factors influencing APP development, recruitment, integration, retention and career development across different health system structural levels (macro-, meso- and micro-level).

RESULTS

We identified and analysed 273 articles that originated mostly from high-income countries, e.g. the US (n = 115) and the UK (n = 52), and primarily focused on NP (n = 183) and PA (n = 41). At the macro-level, broader workforce supply, national/regional workforce policies such as work-hour restrictions on physicians, APP scope of practice regulations, and views of external collaborators, stakeholders and public representation of APPs influenced organisations' decisions on developing and managing APP roles. At the meso-level, organisational and departmental characteristics, organisational planning, strategy and policy, availability of resources, local experiences and evidence as well as views and perceptions of local organisational leaders, champions and other departments influenced all stages of APP role management. Lastly at the micro-level, individual APPs' backgrounds and characteristics, clinical team members' perceptions, understanding and relationship with APP roles, and patient perceptions and preferences also influenced how APPs are developed, integrated and retained.

CONCLUSIONS

We summarised a wide range of factors influencing APP role development and management in secondary care teams. We highlighted the importance for organisations to develop context-specific workforce solutions and strategies with long-term investment, significant resource input and transparent processes to tackle evolving healthcare challenges.

Advanced Practice Nursing: "Training" Pillar in Supporting the Proposal in Brazil

OBJECTIVES

to present the pillars that support what has been called Advanced Practice Nursing and discuss the necessary training for its implementation.

METHODS

elements contained in assessment documents for graduate programs proposals, reports of presentations by international professors in countries and selected scientific publications were gathered to compose the argument.

RESULTS

practice/competency (adds broad and in-depth knowledge about health processes and scientific evidence, clinical reasoning and clinical skills for therapeutic indications); 3) professional regulation (corresponding legislation and monitoring); and 4) funding (broad training and professional practice policy).

FINAL CONSIDERATIONS

the agenda for implementing Advanced Practice Nursing in Brazil involves joining efforts to identify stakeholders for a work to legitimize their importance in the country's health and education overview.

The top 100 cited Nurse Practitioner publications: a bibliometric analysis

BACKGROUND

Development of the Nurse practitioner role and the specialisation of practice is an increasing focus in healthcare. To date, a bibliometric evaluation of scholarly work referring to Nurse Practitioners, has not been located in the published literature.

OBJECTIVE

With the aim of identifying the top 100 cited articles in the Nurse Practitioner domain, the Scopus™ database was searched for Nurse Practitioner studies during 2007-2021. Using bibliometric analysis we identified prolific authors; annual trend; citation rates; countries of origin; and study design.

RESULTS

There were 1768 papers identified across 360 peer reviewed journals in 33 countries.

CONCLUSIONS

Finding from this analysis provides evidence of an evolving research area of inquiry which contributes to knowledge of the Nurse Practitioner role and scope of practice.

Nurse practitioner models of care in aged care: a scoping review protocol

OBJECTIVE

The objective of this review is to identify current and potential use of nurse practitioner models of care in aged care and to examine factors that have been linked to their failure or success in terms of establishment, sustainability, and expansion.

INTRODUCTION

Nurse practitioners work across a variety of sectors, including aged care. Nurse practitioner models of care have been found to be safe, effective, and highly regarded by clients and patients across many areas. They have particular benefit in areas where access to physicians is challenging, as well as for vulnerable populations. This review will provide a consolidated evidence base to determine the current state of the evidence on nurse practitioner models of care in the aged care sector.

INCLUSION CRITERIA

The review will consider studies on nurse practitioner models of care within aged care that report barriers/challenges and facilitators/success factors to their establishment, sustainability, and expansion. Evidence from all countries will be examined. Published and gray literature primary studies in English produced from 2010 onward will be eligible for inclusion. Expert opinion, including literature reviews, commentaries, and discussion, papers will be ineligible.

METHODS

This review will utilize the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Databases to be searched include MEDLINE, Emcare, Embase, Web of Science, and Scopus. Figurative, tabular, and accompanying narrative synthesis will be used to present the results, in line with the review questions.

Competency Gradients in Advanced Practice Nurses, Specialist Nurses, and Registered Nurses: A Multicentre Cross-Sectional Study

(1) Background: Identifying differences in the competencies of different areas of nursing is a crucial aspect for determining the scope of practice. This would facilitate the creation of a formal structure for clinical practice in advanced and specialised services. The aims of this study are to analyse the distribution of advanced competencies in registered, specialist and advanced practice nurses in Spain, and to determine the level of complexity of the patients attended by these nurses. (2) Methods: A cross-sectional study was developed on registered, specialist and advanced practice nurses, all of whom completed an online survey on their perceived level of advanced competencies and their professional characteristics. (3) Results: In total, 1270 nurses completed the survey. Advanced practice nurses recorded the highest self-perceived level of competency, especially for the dimensions of evidence-based practice, autonomy, leadership and care management. (4) Conclusions: Among registered, specialist and advanced practice nurses, there are significant differences in the level of self-perceived competencies. Patients attended by advanced practice nurses presented the highest levels of complexity. Understanding these differences could facilitate the creation of a regulatory framework for clinical practice in advanced and specialized services.

Button batteries in the ear, nose and throat: a novel survey of knowledge of UK advanced nurse practitioners

BACKGROUND

Button battery (BB) impaction in the ear, nose and throat can result in significant morbidity. Advanced nurse practitioners (ANPs) are increasingly responsible for initial patient assessment and prompt escalation to otolaryngologists for definitive management.

AIM

Our novel national study aimed to assess ANPs' knowledge with respect to the assessment and management of patients with BBs in the ear, nose and throat.

METHOD

A national 13-point survey was disseminated among ANPs over a 2-week period. Knowledge was assessed through eight multiple choice questions with a maximum attainable score of 21.

FINDINGS

A total of 242 responses were analysed. Knowledge deficits were identified in all domains (mean overall score 8.5/21), including presenting clinical features, preliminary investigations and intervention strategies. The overwhelming majority of respondents (97%; n=234) advocated for further training.

CONCLUSION

A need for further education has been highlighted by this surveyed cohort of ANPs. Implementation of standardised protocols, virtual resources and simulation platforms may address knowledge deficits.

A multidisciplinary learning approach: training, preparation and role transition

AIM

To explore trainee and qualified advanced practitioner learning experiences, how training has prepared learners for clinical practice and role transition. Evaluation of a multidisciplinary learning approach was sought, identifying its impact on developing collaborative learning and working partnerships.

DESIGN AND METHODS

A small-scale, mixed-methods cross-sectional study was used to gather descriptive data. Convenience sampling was used with two groups: trainees and qualified advanced (paediatric) nurse practitioners/advanced clinical practitioners (ANPs/ACPs). All participants had completed or were undertaking master's level training. An anonymous, voluntary online survey was used to gather quantitative and qualitative data reflecting participant learning experiences. Evaluation research methodologies and their application were examined through exploration of three advanced practice frameworks and a well-established framework for evaluation of training.

FINDINGS

Overall, responses indicate positive learning experiences, and that current and previous ANP/ACP training in the UK does adequately prepare trainees for practice. However, further improvements in curriculum content are suggested. Consistent with the literature, collaborative multidisciplinary teaching, learning and mentorship were identified as key elements in the learning process and role transition.

A multidisciplinary learning approach: a narrative review

Advanced nursing/clinical practice has emerged worldwide in response to the demands of changing complex healthcare needs and ageing populations, and the need to improve services and outcomes, decrease waiting times and reduce overall healthcare cost. A reduction in medical practitioners' working hours has meant other healthcare disciplines have to develop medical skills. Evidence suggests there are global differences in the advanced nursing/clinical practice role definition, expectations and scope of practice. Education and training for role development varies around the world. Part 1 of this review, which explores international approaches to advanced practice, examines literature findings that look at learner experiences of training and preparation and highlights a gap in educational research in this field. A small-scale cross-sectional mixed methods study that was subsequently undertaken will be discussed in part 2.

A qualitative study of perceptions of senior health service staff as to factors influencing the development of Advanced Clinical Practice roles in mental health services

WHAT IS KNOWN ON THE SUBJECT?: Advanced clinical practitioners (ACPs) are, typically, non-medical healthcare professionals, who possess advanced clinical skills, a master's level qualification and evidence of leadership, management and research abilities. Most ACPs are nurses and new ACP roles are increasingly being established around the world. The views of senior staff towards new mental health nursing roles in organizations are likely to influence their introduction and sustainability Research on mental health nursing ACP roles is sparse. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper uniquely provides specific information as to factors perceived by senior staff as affecting the implementation of ACP roles in mental health services. A wide range of mental health services were perceived as potentially benefiting from ACPs. Establishing role clarity for MHN ACPs is perceived as being as essential to successful introduction of the role, as has been found for other specialities. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Participants identified a need for early engagement with service users and professions about new ACP roles and for processes that can evaluate ACP roles once they established. Some mental health nurses may require long-term developmental pathways to help prepare them to take on a master's level course and then the ACP role. ABSTRACT: Introduction Advanced clinical practice (ACP) roles are increasingly being developed internationally. Identifying factors perceived as affecting the development of ACP can support effective implementation. Aim To understand the views of senior health service staff as to factors influencing the development of ACP roles in mental health services. Method Focus group and semi-structured interviews. Participants were directors of nursing (n = 10) and other senior staff from roles important to workforce development (n = 10). Results Content analysis suggested seven categories: understanding the role and national guidelines, attitudes to the role, learning from implementing other roles, understanding prerequisites for development, challenges, opportunities and future support/actions. Prerequisites for success would include early engagement with stakeholders. Medical attitudes towards ACP roles were perceived as generally more positive than previously. Discussion The study provides unique information regarding perspectives of senior staff regarding the implementation of ACP roles in mental health services. A wide range of mental health services were perceived as potentially benefiting from ACPs, with the importance of role clarity being highlighted and long-term developmental pathways for staff. Implications for practice Successful Implementation of ACP roles may require clear role definition, early engagement with stakeholders and processes to evaluate role outcomes.

Mapping of advanced practice nursing actions in the Family Health Strategy

OBJECTIVES

to map advanced practice nursing actions implemented in the Family Health Strategy context.

METHODS

cross-sectional exploratory study carried out with Family Health Strategy nurses. Data obtained in the mapping were compared to the characteristics that define advanced practice nurses and are adopted internationally by using a checklist based on the International Council of Nurses Guidelines.

RESULTS

the mapping allowed to identify advanced practice nursing actions, such as advanced assessment, judgement, decision-making, and diagnostic reasoning skills and authority to diagnose and prescribe medications, diagnostic testing, and therapeutic treatments. However, evidence found in the educational preparation domain indicated evident fragility, expressed as the low percentage of nurses credentialed with a professional master's degree.

CONCLUSIONS

the present study showed that nurses in the Family Health Strategy carry out advanced practice nursing actions without the professional master's degree recommended for credentialing, with pertinent legislation, which requires initiatives to be taken by nursing leaders to overcome this deficiency.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review

OBJECTIVES

In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK.

DESIGN

A scoping review was undertaken following JBI methodological guidance.

METHODS

13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative.

RESULTS

191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway.

CONCLUSION

This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

Perceptions of competency in advanced clinical practice

BACKGROUND

Historically, there has been limited research carried out on the competency of individuals undertaking advanced clinical roles.

AIMS

To research advanced clinical practitioner (ACP) perceptions of the term competency, and how they evidence their competency in practice.

METHODS

A cross-sectional, qualitative study used semi-structured interviews, which were analysed by content analysis. Six participants were recruited to the study.

FINDINGS

There is disparity in the definitions of 'trainee' and 'qualified' ACP in clinical practice as well as disparity and ambiguity regarding being able to work in a supernumerary capacity during training and master's level study. There is a lack of agreement over the benchmark for qualified ACP status and the road to getting there.

CONCLUSION

ACPs should be employed in a supernumerary capacity while training and work towards a full MSc in advanced clinical practice. They should maintain a portfolio of their competency. Work must also be carried out nationally to identify both generic and specialist curricula for ACPs to benchmark against.

Advanced practice nurses' experiences and well-being: Baseline demographics from a cohort study

AIMS

To create a cohort of advanced practice nurses from across the UK and to report the initial questionnaire including demographics, work experiences and well-being.

BACKGROUND

In the UK, advanced nursing practice is not regulated. This has led to the concern that advanced nurses are working in very different ways with different levels of autonomy and support.

METHODS

Participants were recruited via university and Royal College of Nursing mailing lists, and social media adverts. They completed the initial questionnaire about their background and workplace, work experiences, credentialing and well-being.

RESULTS

A total of 143 nurses were recruited to the cohort and 86 completed the survey. Over 40 job titles were reported, across five pay bands. Job title was not correlated with pay band (p = .988). Participant well-being was not significantly different from the UK general population, but they reported high rates of work-related stress (44.2%) compared with the National Health Service national average (37.9%).

CONCLUSION

There is a wide disparity in pay, which is not reflected in title or setting. The high levels of work-related stress require further exploration.

IMPLICATIONS FOR NURSING MANAGEMENT

The range of experiences reported here should encourage managers to evaluate whether title, pay and support mechanisms for Advanced Practice Nurses in their organisations align with suggested national standards set by Royal Colleges and government departments.

Nurses in advanced roles as a strategy for equitable access to healthcare in the WHO Western Pacific region: a mixed methods study

BACKGROUND

The Western Pacific region constitutes one-quarter of the world's population and has diverse health needs. While dialogue on and promotion of advanced practice nurses are ongoing, this study investigated the current responsibilities of nurses in advanced roles, future healthcare needs, and the implications of these components for nurses' professional development within the Western Pacific region.

METHODS

This study employed three phases, a descriptive survey on the current status of nurses in advanced roles in the Western Pacific region, followed by a Delphi survey, and exploratory interviews. A total of 55 national experts with clinical, academic, and/or government-related backgrounds from 18 countries participated from December 2017 - December 2018. The descriptive survey via email to identify the status of nurses in advanced roles and a working definition was developed. This formed the basis for the Delphi survey, which identified key barriers and challenges for enhancing the development of nurses in advanced roles within the country (round 1) and for the region (rounds 2 and 3). Lastly, semi-structured individual interviews were conducted to identify strategies for establishing nurses in advanced roles to improve equitable access to healthcare.

RESULTS

Thirty-seven roles and characteristics were identified and categorized for nurses performing advanced roles. Emergency care, critical care, elderly health, child health, and rural/remote communities were identified as fields with particular need for nurses in advanced roles in the Western Pacific region. Providing effective services, influencing government leadership, and advocating for health system sustainability were deemed necessary to improve equitable healthcare access. We found that nurses in advanced roles are not limited to clinical tasks within the hospital but are poised for active participation in primary healthcare, education/teaching, professional leadership, quality management, and research.

CONCLUSIONS

Demand for nurses in advanced roles is high in the Western Pacific region and 15 items were identified across five core strategic areas to enhance development of nurses in advanced roles. Governmental-level recommendations include establishing legislative protection, improving systems for remuneration, strengthening supportive channels, and conducting national needs assessments.

Sources of satisfaction, dissatisfaction and well-being for UK advanced practice nurses: A qualitative study

AIMS

To examine and explore organisational and role conditions that promote or inhibit job satisfaction and workplace well-being for advanced practice nurses.

BACKGROUND

The advanced practice role is common across the world. Research shows it is well regarded by patients and improves patient outcomes, but there is little evidence about what the role is like for nurses.

METHODS

A subsample of an existing cohort of advanced practice nurses were invited for interview. Twenty-two nurses were interviewed over the phone. Interviews transcripts were analysed using thematic analysis.

RESULTS

Four themes were derived from the data; 'the advanced nurse role and professional identity', 'feeling exposed', 'support for the advancement of the role' and 'demonstrating impact'.

CONCLUSION

Nurses report considerable dissatisfaction with role identity and concerns relating to isolation on a daily basis, and these negatively affect well-being. However, they also identified significant satisfaction with the role, particularly when well supported and able to recognize the unique contribution that they made to the lives of patients and to their organisations.

IMPLICATIONS FOR NURSING MANAGEMENT

Clear role definitions, provision of high-quality clinical supervision and addressing issues of isolation are likely to improve the job satisfaction of advanced practice nurses.

The Role and Development of Advanced Clinical Practice Within Allied Health Professions: A Mixed Method Study

OBJECTIVE

To investigate the profiles of advanced clinical practitioners (ACPs) in the allied health professions (AHPs) and their skills, attributes, experiences and involvement in new models of care.

METHODS

A 2 phase, cross sectional, mixed method survey of AHP ACPs across London was conducted in 2018-2019. Online questionnaires were completed by 127 AHP ACPs and then semi-structured interviews were conducted with 15 AHP ACPs.

RESULTS

The survey results gave a comprehensive overview of the attributes of AHPs in ACP roles across London. There was considerable variability between role titles, types and levels of qualification, and evolution of the roles. The respondents predominately worked in clinical practice, and less frequently in other ACP domains (research, leadership and management, education). The interview findings provided in-depth insights into the AHP ACP roles within four themes: being advanced, career pathways, outcomes of the advanced practitioner role and influencing and transforming. The "Being advanced" theme highlighted that expert practice comprised confident and autonomous practice, leadership, and applying specialist and expert decision-making skills. "Career pathways" highlighted the diversity within the participants' roles, titles, career opportunities and development. In the "Outcomes of the advanced clinical practitioner role" theme, the ACPs described their services as prompter, more accessible and providing an improved patient journey. The "Influencing and transforming" theme highlighted networking and dissemination and ideas for innovation, influencing and transforming services.

CONCLUSION

This is the first comprehensive profile of ACP roles across AHPs and indicates that these roles are already having a positive impact on healthcare services and supporting new models of care. However, establishing the necessary infrastructure, standardization and governance for ACP roles across sectors, along with the career pathways, funding, sustainability and education, could increase impact in the future.

The experiences of cancer nurses working in four European countries: A qualitative study

Purpose

Cancer nurses across Europe are being tasked with delivery of an increasing number of complex treatments and supportive care interventions as a result of ongoing advances in cancer research, and a rise in cancer incidence due to demographic changes. However, all health systems delivering cancer treatment innovations require access to an educated and motivated nursing workforce to meet demand.

This study by the European Oncology Nursing Society examines comparative features of cancer nursing in Estonia, Germany, the Netherlands (NL) and the United Kingdom (UK).

Methods

Descriptive qualitative study using focus groups and individual interviews drawing on the views of cancer nurses, managers and stakeholders from four European countries (n = 97). Data collection was designed around national cancer nursing conferences held in Berlin (Germany), Ede (NL), Harrogate (UK) and Tallinn and Tartu (Estonia) between May 2017 and April 2018. Participants included a mix of nursing grades and specialisms.

Findings

According to the participants education and career structure for cancer nursing was most well-developed in the Netherlands and the United Kingdom. In Germany and Estonia developments were taking place at Masters level. None of the countries had recordable qualifications in cancer nursing. Variations existed in terms of advanced practice roles and salary. Workload pressures were common, and were rising, and wellbeing initiatives were not identified. Nurses reported gaining positive feedback from caring for patients.

Discussion

As demand for cancer treatment continues to grow there is a need to ensure an adequate supply of cancer nurses with the appropriate education and career structure to support patients. This study provides insights from four countries and suggests the need for better recognition as well as working conditions, education and career structures that advance the potential of the cancer nursing role in Europe.

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Increasingly high nursing workloads are evident in Europe alongside workforce shortages.

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Major changes taking place in the treatment of cancer require more individualised and targeted treatment approaches.

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In some countries, cancer nurses adopt advanced roles that include prescribing, treatment co-ordination and clinical procedures.

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Comparative qualitative insights are provided concerning cancer nursing in Estonia, Germany, the Netherlands and the United Kingdom.

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Despite common European Union Directives disparities exist in the availability of cancer nursing education and working across EU countries.

Advanced musculoskeletal physiotherapy practice: Informing education curricula

INTRODUCTION

Physiotherapists are operating at an advanced level of practice, usually on ad hoc basis with inhouse training, in response to the increasing burden of musculoskeletal (MSK) disorders. Discrepancies in role-specific education of advanced practice physiotherapists (APPs) creates challenges in ensuring a quality service, workforce mobility and formal recognition. This study reviewed existing MSK APP competency frameworks and education offerings, and explored physiotherapist learning needs with a view to informing international standardisation of MSK APP education curricula.

METHODS

A scoping review of the literature and relevant university and regulatory websites identified APP competency frameworks and education curricula, which were verified by international experts. Content analysis, performed on the identified competencies and modules, produced a list of themes existing in MSK advanced practice internationally. A survey based on those themes identified the learning priorities of physiotherapists (n = 25) participating in an APP symposium in Ireland.

RESULTS

Six APP competency frameworks and eleven curricula from the UK, Canada and Australia were identified. Themes emerging, regarding MSK APP practice internationally, included both entry-level physiotherapy (e.g., Assessment and Diagnosis) and traditionally medically-controlled tasks (e.g., Injection Therapy), as well as Research, Leadership, Service Development, Professional-related Matters and Education. Participating physiotherapists more commonly prioritised competencies which would be deemed beyond entry level physiotherapy skills (i.e., Radiology versus Manual Therapy).

CONCLUSION

Despite variances in profiles of APPs both between and within countries, common themes emerged regarding their expected competencies and skills. This study provides the foundation for the adoption of internationally-recognised MSK APP competencies and education standards.

Advanced Clinical Practitioners in Primary Care in the UK: A Qualitative Study of Workforce Transformation

Escalating costs and changing population demographics are putting pressure on primary care systems to meet ever more complex healthcare needs. Non-medical ‘advanced clinical practitioner’ (ACP) roles are increasingly being introduced to support service transformation. This paper reports the findings of a qualitative evaluation of nursing ACP roles across General Practices in one region of the UK. Data collection involved telephone interviews with 26 participants from 3 different stakeholder groups based in 9 practice sites: ACPs (n = 9), general practitioners (n = 8) and practice managers (n = 9). The data was analysed thematically. The study found a high degree of acceptance of the ACP role and affirmation of the important contribution of ACPs to patient care. However, significant variations in ACP education, skills and experience led to a bespoke approach to their deployment, impeding system-wide innovation and creating challenges for recruitment and ongoing professional development. In addition, a context of high workforce pressures and high service demand were causing stress and there was a need for greater mentorship and workplace support. System wide changes to ACP education and support are required to enable ACPs to realise their full potential in primary care in the UK.

Examining variable nurse practitioner independence across jurisdictions: A case study of the United States

BACKGROUND

Nurse Practitioners have the potential to reduce primary care shortages for underserved populations. Yet, scopes of practice in some political jurisdictions (e.g. states, provinces) are more restrictive than others, and prevent Nurse Practitioners from working to the full extent of their training. The research is limited as to which intrastate or interstate characteristics contribute to understanding why scope of practice differences exist.

OBJECTIVES

To estimate associations between intrastate/interstate characteristics and US state-level Nurse Practitioner Scope of Practice policy.

RESEARCH DESIGN

Retrospective study of state-level factors influencing Nurse Practitioner Scopes of Practice.

SUBJECTS

U.S. states from 2001 to 2015.

MEASURES

Our dependent variable is state-level Scope of Practice policy, indicating the extent to which Nurse Practitioners are autonomous in a state (Independent, Collaboration or Supervision). The intrastate characteristics that we include are numbers of Nurse Practitioners, Primary Care Physicians and rural hospitals per capita, state Board of Medicine governance and Nursing License Compact membership. We also measure the number of border-states that adopt specific policies in order to indicate the extent to which interstate characteristics influence focal states to adopt similar policies.

RESULTS

Among intrastate characteristics, we found that rural hospital concentrations (Odds Ratio=0.78; 95% Confidence Interval: 0.71-0.85) and Nursing License Compact membership (Odds Ratio=0.23; 95% Confidence Interval: 0.0-0.60) were associated with lower levels of restrictions, while Board of Medicine governance (Odds Ratio=27.36; 95% Confidence Interval: 5.75-130.20) was associated with increased levels of restrictions. Among interstate characteristics, higher numbers of border-states adopting Nursing License Compact membership (Odds Ratio=0.51; 95% Confidence Interval: 0.32-0.80) was associated with lower levels of restrictions.

CONCLUSIONS

Barriers to Nurse Practitioner independence are largely attributable to unfavorable governance arrangements and non-participation in reciprocal licensing networks. Achieving Nurse Practitioner independence will require cooperation between nursing, medicine and policy makers. We offer some suggestions as to where parties interested in seeing increased Nurse Practitioner independence should focus their efforts when attempting to remove restrictions on Nurse Practitioner practice.

Factors Associated with Perception of the Quality of Physicians' End-of-life Communication in Long-Term Care Facilities: PACE Cross-Sectional Study

OBJECTIVE

To examine factors associated with perceived quality of communication with physicians by relatives of dying residents of long-term care facilities (LTCFs).

DESIGN

A cross-sectional retrospective study in a representative sample of LTCFs conducted in 2015. In each LTCF, deaths of residents during the 3 months before the researcher's visit were reported. Structured questionnaires were sent to the identified relatives of deceased residents.

SETTINGS AND PARTICIPANTS

A total of 736 relatives of deceased residents in 210 LTCFs (in Belgium, Finland, Italy, the Netherlands, and Poland).

METHODS

The Family Perception of Physician-Family Communication scale (FPPFC) was used to assess the quality of end-of-life (EOL) communication with physicians as perceived by relatives. We applied multilevel linear regression models to find factors associated with the FPPFC score.

RESULTS

The quality of EOL communication with physicians was perceived by relatives as higher when the relative spent more than 14 hours with the resident in the last week of the resident's life (b = 0.205; P = .044), and when the treating physician visited the resident at least 3 times in the last week of the resident's life (b = 0.286; P = .002) or provided the resident with palliative care (b = 0.223; P = .003). Relatives with higher emotional burden perceived the quality of EOL communication with physicians as lower (b = -0.060; P < .001). These results had been adjusted to countries and LTCF types with physicians employed on-site or off-site of the facility.

CONCLUSION

The quality of EOL communication with physicians, as perceived by relatives of dying LTCF residents, is associated with the number of physician visits and amount of time spent by the relative with the resident in the last week of the resident's life, and relatives' emotional burden.

IMPLICATIONS

LTCF managers should organize care for dying residents in a way that enables frequent interactions between physicians and relatives, and emotional support to relatives to improve their satisfaction with EOL communication.

Advanced musculoskeletal physiotherapy practice in Ireland: A National Survey

BACKGROUND

Since 2011, advanced practice physiotherapists (APPs) have triaged the care of patients awaiting orthopaedic and rheumatology consultant/specialist doctor appointments in Ireland. APP services have evolved across the major hospitals (n = 16) and, after 5 years, profiling and evaluation of APP services was warranted. The present study profiled the national musculoskeletal APP services, focusing on service, clinician and patient outcome factors.

METHODS

An online survey of physiotherapists in the allocated APP posts (n = 25) explored: service organization; clinician profile and experience of the advanced role; and patient wait times and outcome measures. Descriptive statistics were used to analyse hospital- and clinician-specific data, and a content analysis was performed to explore APP experiences.

RESULTS

A 68% (n = 17) response from 13 sites was achieved, whereby 20 whole-time APP posts existed in services led by 91 consultant doctors. Co-location of APP and consultant clinics at 11 sites facilitated joint medical-APP processes, with between-site differences in autonomy to screen referral letters, and arrange investigations, injections and surgery. Although 83% had postgraduate qualifications, APPs also availed themselves of informal role-specific training. Positive APP experiences related to learning opportunities and clinical support networks but experiences were consultant dependent, with further service developments and formal training required to manage workloads. APPs reported reduced wait times and most commonly chose to capture function/disability in future evaluations.

CONCLUSIONS

Variances existed in the organizational design and operating of APP services. Although highly experienced and qualified, APPs welcomed additional formal training and support, due to the complex, more medical nature of APP roles. Further formal evaluation, capturing patient outcomes, is proposed.