Advanced nursing practice across Europe: Work in progress

Healthcare has transformed considerably in the past 50 years to meet the demands of higher patient acuity, patients with complex healthcare needs, and an ageing population living longer with multiple chronic conditions such as cardiovascular disease (CVD), diabetes and cancer for example. As these changes occurred, nursing as a profession has evolved to meet patient and healthcare service needs, including the development of advanced practice and the nurse practitioner (NP) role. The role is defined by the International Council of Nursing (ICN) as: A Nurse Practitioner/Advanced Practice Nurse 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 master’s degree is recommended for entry level.1 Those who work in advanced practice roles must be able to demonstrate expertise in the four pillars of advanced practice: clinical, research, education and management/leadership (Box 1). The ICN has articulated the requirements for those who wish to become NPs, and this is divided into the areas of educational preparation, nature of practice and the regulatory mechanisms that underpin practice in each practitioner’s country as these vary widely. International Council of Nurses characteristics of advanced practice.1 APN: Advanced Practice Nurse. International Council of Nurses characteristics of advanced practice.1 APN: Advanced Practice Nurse. Advanced nursing practice also encompasses aspects of research and management but is firmly grounded in direct care provision or clinical work with patients, families and populations. Advanced Practice Nurses (APNs) and NPs need to use a range of data, tools and techniques to improve practice and health outcomes and to be able to demonstrate their in-depth expertise, experience, professional and clinical judgement. Advanced practice roles expect the practitioner to be prepared at master’s level so that they have the relevant knowledge and skills and can apply these to a broad range of clinically and professionally challenging and complex situations, which is especially relevant for managing those with CVD. APNs often work at higher organisational levels acting as practice leaders, managing their own workload and working across professional, organisational, agency and system boundaries to improve services and develop practice within the specialty. APN/NP roles are established in a number of countries, USA, Canada, Australia, Ireland and the Netherlands, with recent launches of APNs in Hungary and the Czech Republic. The lack of data on advanced practice has previously been noted with the TaskShift2Nurses Study that identified 11 countries with NPs/APNs: Australia, Canada, Finland, Ireland, the Netherlands, England, Northern Ireland, Scotland, Wales, New Zealand and the USA.2 One study of six OECD nations demonstrated that the USA showed the highest absolute number of NPs and rate per population (40.5 per 100,000 population), followed by the Netherlands (12.6), Canada (9.8), Australia (4.4), and Ireland and New Zealand (3.1, respectively). Some areas showed greater growth in NP numbers than others with USA recording 6.1% growth, while in the Netherlands the growth rate was 27.8%.3 The article acknowledged that there is limited evidence of cost-effectiveness in this workforce and concluded that workforce monitoring based on accurate data is critical to inform educational capacity and workforce planning. In the Netherlands, APN is a validated, protected title and accredited by the Accreditation Organisation of the Netherlands and Flanders (NVAO) and APNs can register in five categories – preventive care for somatic conditions, acute care for somatic conditions, intensive care for somatic conditions; chronical care for somatic conditions and mental healthcare, with the majority working in primary care managing care of older people. In the Republic of Ireland, advanced practice nursing is defined as a career pathway for registered nurses and are autonomous expert practitioners with ANP and Advanced Midwife Practitioner (AMP) roles launched in 2019. Other countries in Europe are commencing their journey in establishment of APNs – the Czech Republic and Hungary for example. Scandinavian countries are also in the process of launching NPs (Denmark and Norway), whereas Sweden has had APNs since 2010 and these are concentrated within primary care practice. In the UK, there are many different advanced practice roles in healthcare that include nurses with an array of titles with huge regional variations in the APN role.2 Since 2017, allied healthcare professionals including physiotherapists and pharmacists have been included as advanced practitioners and are able to manage a group of patients as Advanced Clinical Practitioners with the need to reshape the workforce that included extending the skills of registered professionals and training advanced practitioners.4 APNs often run nurse-led services for a variety of conditions that include CVD, diabetes, cancer, respiratory disease and neurology. As this editorial shows, when the APN role across Europe is examined, there is no consensus on what advanced practice is, what roles and role preparation are included, and not every country recognises or supports advanced practice within their regulatory nursing profession. Nurse-led care has demonstrated positive clinical outcomes in multiple conditions such as cardiovascular prevention, heart failure and atrial fibrillation.5,,,–9 The nurses leading these programmes are usually specialists and APNs. With the increase in chronic diseases, there is a need for a workforce to be able to deliver effective cardiovascular prevention across settings, ensure that patients with cardiovascular conditions receive evidence-based care and are supported in self-management, and manage an ageing population with multiple comorbidities. The mission of the Association of Cardiovascular Nurses and Allied Professionals is to support nurses and allied professionals throughout Europe to deliver the best possible care to patients with CVD and their families and APNs play a key role in this. As 2020 is the Year of the Nurse and the Midwife, it would be timely to develop a consensus around advanced nursing practice in cardiovascular conditions, and establish criteria around required education, competencies and knowledge to address the needs of those with CVD and CVD-related risk factors. The authors are writing on behalf of the Science Committee, Association of Cardiovascular Nurses and Allied Professionals. The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. The authors received no financial support for the research, authorship and/or publication of this article.