A World of NPs and PAs

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If you want to talk about NPs and PAs around the world, check your generalizations at the door. Quite simply, there are few statements that would apply to every PA or every advanced practice nurse (APN, perhaps a more all-encompassing term in this context) from Boston to Botswana.

In a very broad sense, the health care issues affecting the larger world are similar to those faced in the United States: shortages of providers, spiraling costs, and a growing need for health care services due to an increase in chronic and infectious diseases. At the same time, economic, cultural, and political differences have a major impact on how countries approach these problems and how they can attempt to solve them. Poverty and lack of access mean something remarkably different in Africa than they do in the US.

This is why, even as PAs and NPs enthusiastically promote their professions as a viable solution to the world’s health care problems, it is essential to remember that one size does not fit all. “We need to encourage countries to adapt what we’re doing,” says Ruth Ballweg, MPA, PA-C, Director of the MEDEX Northwest Division of PA Studies at the University of Washington in Seattle and Director of International Affairs for the National Commission on Certification of Physician Assistants (NCCPA), “not adopt what we’re doing.”

Globe Trotting
Clinicians meeting their counterparts from another country may not immediately recognize the roles. Even the names are not always the same: In South Africa, the PA-equivalent role is the clinical associate, while in Mozambique, persons trained to do basic surgery are known as tecnicos de medicina. And among APNs, a survey of 34 countries conducted by the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) turned up 17 different titles.

These professions are often designed to address a specific need. Whereas a majority of APNs in the US are family nurse practitioners in out-of-hospital settings, in Asian countries, such as Japan, Taiwan, and Singapore, “it is more common to see roles develop in hospital settings, such as critical care or mental health or emergency departments,” according to Madrean Schober, MSN, NP-C, FAANP, an international health care consultant who is currently Senior Visiting Fellow at the Alice Lee Centre for Nursing Studies at the National University of Singapore. This is because primary care services may not be available or as developed as they are in the US.

Needs can also vary within regions. Queensland, Australia, has a need for clinicians in rural and remote areas; by contrast, South Australia has shortages in surgery and specialties.

In terms of adopting the US model, Ballweg sees the PA international scene divided into two groups. “There are the developed countries, where the model looks a lot like the US model … and then there are the developing countries, where it is really a model that looks a bit different,” she says. “And the main reason these other countries look a bit different is that there is such a shortage of physicians that there aren’t any physicians to assist!”

At the same time, in the less developed countries of the world, advanced practice roles may already exist—just in an informal or unofficial capacity. “If you look at poor countries in Africa, nurses have always had, I think, what we would call expanded roles,” says Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP, Co-Chair of the Education and Practice Subgroup for the INP/APNN. “They’re very highly thought of, and they work fairly independently because there’s a huge shortage of health care providers. I think a lot of nurses in these countries might be practicing more closely to the role, and then you would educate them to validate the practice.”

A good illustration of this is Botswana—in fact, Schober, who is also the International Liaison for the American Academy of Nurse Practitioners, says it is her favorite example. Due to a physician shortage, nurses in Botswana found themselves required to provide primary care services in communities—often as the sole provider.

“Eventually, recognizing that they lacked education and skills to continue providing quality services, nurses lobbied the Ministry of Health [MOH] for more education,” Schober explained in an e-mail to Clinician Reviews. The MOH instituted a one-year FNP program, developed in consultation with an American nurse in 1986; the program, which has evolved to 18 months, is now integrating with a Master’s-level program at the University of Botswana.

The International Council of Nurses recommends a Master’s degree for APNs; practical reasons prevent it from being a requirement. “In a very highly developed country, where there are lots of standardized educational programs, it’s pretty easy to say, ‘This should be a Master’s level,’” points out Pulcini, an Associate Professor and Department Chair at the William F. Connell School of Nursing, Boston College. “But if you don’t have a lot of Master’s programs, it’s not quite as easy.”

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