A Global SWOT Analysis of Advanced Practice Nursing: Policy, Regulation, and Practice

Background: The advanced practice nursing role has been characterized as task sharing between physicians and nurses, and commonly is a part of national or health system schemes to expand healthcare access and/or to improve eciencies. However, lack of regulatory uniformity can lead to inconsistent qualications, competencies, and a limitation of expansion of healthcare services, based on regulated scope of practice. Methods: The SWOT analysis technique (strengths, weaknesses, opportunities, threats) was used to assess the current state of advanced practice nursing worldwide, with specic focus on regulation, education, licensure, and practice. Data were collected broadly from peer reviewed, governmental and regulatory sources, as well as grey literature. Results: Key regulatory elements that frame advanced practice nursing vary signicantly by country and region and remain dynamic. However, practice and educational models are outpacing regulatory standards in all six WHO regions. Overall, advanced practice nursing is expanding at an accelerated pace in order to meet population and health system needs, despite weaknesses of the regulatory system, or threats from systems that are not ready to accept innovative strategies. Conclusion: Advanced practice nursing is an innovative role that is progressing broadly in response to the global drivers of an aging population, workforce shortages, the increasing prevalence of noncommunicable disease, and the need to develop system-based eciencies for cost containment. The role is developing organically, driven by local needs, but still lags in terms of the formal regulatory legitimization in many countries. Notably, it is being buoyed by the global movement toward universal health coverage.

However, the regulations that permit this practice vary widely. They may be regulated by diverse types of organizations depending on the national jurisdiction, i.e. central governments, professional organizations, or by individual employers. 6 Lack of regulatory uniformity can lead to inconsistent educational quali cations, competencies, and a limitation of expansion of healthcare services, based on regulated scope of practice. Further, mismatches between professional capabilities and the legal authority to practice can lead to fragmented care delivery based on local exigencies that require professionals to provide services outside of their scope, especially in the Global South. 7 Efforts that seek to address regulatory and legal inconsistencies related to scopes of practice are often slow and fraught with adversity. Incumbent professions who have more resources can overpower emerging roles with more modest means, further complicating regulatory initiatives that seek to remove barriers to care. 8 In light of the challenges that are posed to nations around the world related to the healthcare workforce in the context of aging populations and increasing rates on non-communicable disease (NCD), it is incumbent on healthcare organizations and governmental bodies to analyze policies that pertain to the nursing workforce in general, and the advanced practice nursing workforce in particular. Therefore, the objective of this analysis is to systematically review global evidence of advanced practice nursing regulation, education, licensure, and practice in order to inform key international policy and governmental stakeholders.

Methods
Publicly available data was collected from government statutory and regulatory sources, Ministries of Health, national health system websites, international health organizations, national professional associations, peer-reviewed literature, and other grey literature that is available via Google searches.
Additional peer-reviewed data was identi ed via the PubMed and CINAHL search engines using the following keywords: advanced practice nurse (APN), nurse practitioner (NP), mid-level provider, nonphysician clinician, nurse prescribing, task shifting, task sharing, APN/NP scope of practice, licensure, title protection, and education. Documents were excluded if they were greater than ten years old, unless they contained original regulatory information or provided historical context. The data includes, but is not limited to, government and organization reports, policy statements, technical reports, working papers, newsletters and conference proceedings.
The analytic process was guided by the SWOT (strengths, weaknesses, opportunities, and threats) technique which provided a framework to organize and analyze the data. Healthcare organizations, in both the public and private sphere, commonly use the SWOT analytical model in order to strategically plan for future initiatives and improvement programs. 9 It provides a clear, concise blueprint of internal and external factors that may bene t or damage an initiative by listing strengths, weaknesses, opportunities, and threats. It also provides a robust foundation for a situation analysis of a national health policy, strategy, or plan, and can inform strategic stakeholders by illuminating both internal and external factors. 10 The geographic parameters were based on the World Health Organization's six world Page 4/21 regions: The Americas, Europe, Africa, Southeast Asia, Eastern Mediterranean, and the Western Paci c.
We collected regulatory, practice, and educational data on 54 countries from these six world regions.  11 The Consensus Model codi ed the four roles of Certi ed Nurse Practitioner (CNP), Certi ed Nurse Midwife (CNM), Clinical Nurse Specialist (CNS) and Certi ed Registered Nurse Anesthetist (CRNA). Recommendations were made by the working group which were directed at standardizing legislation, accreditation, certi cation, and education. 11 As of 2020, nurse practitioners have the statutory authority to practice and prescribe medications in all 50 states and the District of Columbia, with varying levels of practice authority and physician oversight, depending on state law. Twenty two states and the District of Columbia authorize autonomous practice. 12 Current opportunities are based on work force supply, especially in primary care.
However, roles that focus on acute care are also common. Medical schools and Physician Assistant (PA) programs have not been able to produce su cient clinicians based on the need which has largely provided an impetus for growth over the past decade. 13 The expansion of the NP workforce has further been supported by several prominent national organizations and governmental agencies, including the Institute of Medicine, National Governors Association, and the Federal Trade Commission. [14][15][16] Canada has two recognized advanced practice nursing roles, the nurse practitioner (NP) and the clinical nurse specialist (CNS). Both roles have existed since the1970s. 17 The Canadian Nurse Practitioner Initiative and related legislative and regulatory framework provided the impetus for NP role integration into the Canadian healthcare system. [17][18] Provincial and territorial regulatory bodies provide licensure and the NP title is protected nationwide. 19 Nurse practitioners are able to prescribe medication and have been enabled since 2012 to prescribe controlled substances. 20 Weaknesses/Threats: In the US, NPs have not received the same level of nancial support that physicians have received from the government, especially in terms of education and training. Physician education in the United States has relied on Graduate Medical Education (GME) funding via the Medicare program and there are only small amounts of federal funding available for NP trainees. Also, generally, faculty are not well paid, and there are substantial faculty shortages. 21,22 In Canada, a variation in the scope of practice exits between the provinces/territories which may cause confusion on the part of the public. 23 Also, variation in NP specializations continues to exist across jurisdictions. 17,19 Latin America/the Caribbean: Strengths/Opportunities: Advanced practice nursing in Latin America has made positive strides over the past decade, despite a number of professional and political challenges. In 2014, the Pan American Health Organization (PAHO) introduced a strategy for universal health coverage which included an increasing interest in implementing the role of the advanced practice nurse. 24 There are now two APN programs in Chile, at the University of the Andes, which offers a Master's program in Adult Acute Care, and at the University del Desarollo. 3,25 The Caribbean has experienced a steady development of the NP role over the past two decades. There are currently ve nations, Monserrat, Trinidad and Tobago, Belize, St. Lucia, and St. Vincent and Grenadines which have regulations or statutes that authorize nurse practitioner practice as well as the authority to prescribe medicines. 24,[26][27][28][29][30] Generally, they practice broadly in primary care settings, except for Belize, where nurse practitioners are only authorized to practice in psychiatric settings. 31 Jamaica has been a leader in nurse practitioner education and practice since the inception of their rst nurse practitioner program at the University of the West Indies in the 1970s. 64 It is currently considering an amendment to the Nurses and Midwives Act which would o cially authorize nurse practitioner scope of practice and allow the prescription of medicines. 32 Additionally, Brazil, Mexico, Colombia, and Chile have been in discussions about how to integrate the advanced practice role into their national health systems. 33 2) Europe (see Additional File 3_Europe) Strengths/Opportunities: Regulation for the APN role is in place for nine of the 23 countries included in the European region: Austria, France, Greece, Hungary, Iceland, Ireland, Israel, the Netherlands and Norway. 2,25,[36][37][38][39][40][41] Most recent developments include a legislative decree in Hungary that provides title protection for NPs in six different specialties; NP in anesthesia, primary care, emergency, acute care, gerontology and perioperative care. 38 In terms of educational directives, APN education at the Master's level is available in ten of the 23 countries including related clinical apprenticeship/residency programs in some countries. Masters level APN education programs are emerging in seven additional European countries. 2,40,[42][43][44][45][46][47][48][49][50][51][52] European advanced practice nurses with Master's level education enjoy title protection in the Netherlands Advanced Practice Nursing roles that align with the ICN NP/APN Network's role de nition, role characteristics and with independent, advanced clinical activities are well established in Finland, Ireland, the Netherlands, and the United Kingdom (Scotland, Wales and Northern Ireland). 50,51 Other countries have implemented pilot programs or emerging specialty practice roles for APNs. In Southern Germany, APNs are in place within hospital settings, in Switzerland, an APN role in lung cancer care has recently been developed, and in Sweden, the surgical NP role has incorporated many of the activities typically performed only by physicians. 25,44,55 The NP role is also being developed in the emergency care context in Norway. 56 Advanced clinical activity roles are emerging in Spain where an Advanced Practice Nursing Competency assessment tool has been recently validated. 49,57 Nurse prescribing has been established in eleven of the 23 European countries included in this SWOT analysis with full prescriptive authority for APNs in place in the Netherlands. 51 In the United Kingdom, Advanced Nurse Practitioners who qualify as non-medical prescribers (NMP) are required to register with the NMP registry and can prescribe without restrictions. 58 Weakness/Threats: Weaknesses identi ed in the regulatory arena include lack of national policies, regulation and legislation that would provide standardized authority to practice at the advanced level. 3,6,40,[49][50][51]59,60 Lack of regulation contributes to role confusion, informal practice and limited availability of role related data. 51 Moreover, the identi cation and introduction of new categories of healthcare professionals can pose a possible threat to APN role development. 61 Poor country speci c strategic plans for human resources for health and nursing shortages identi ed in the European Commission report (2017) also threaten the viability of APN role development and implementation. 110 3) Africa (see Additional File 4_Africa) Strengths/Opportunities: Advanced practice nursing in the form of the nurse practitioner role is gradually expanding in Africa and, in particular, in Sub-Saharan Africa. Family nurse practitioners are now widely embedded in primary care throughout Botswana and are authorized to prescribe medicines. 24 South Africa (SA) has several o cial designations for advanced practice nurses that are de ned by the South African Nursing Council: nursing specialist, and advanced nursing specialist. The advance nursing specialist role parallels that of the nurse practitioner, that is, it is the rst point of care, and includes "medical diagnosis" and treatment. 62 Ghana also has a nurse practitioner program at the University of Development Studies, Tamale Campus which is a three year BSc. 63 While the degree and the scope of nurse practitioner practice is not clear, the role is regulated by the Nursing and Midwifery Council of Ghana. 64 In eSwatini (formerly known as Swaziland), the University of eSwatini has recently started a MNSc Family Nurse Practitioner program and the eSwatini Nursing Council has adopted broad scope of practice regulations. 63,64 Tanzania has also implemented regulations and title protection for the advanced nurse practitioner, however the educational preparation is at the Bachelor's level. 65 Most recently, Aga Khan University in Kenya has launched a MSc in Advanced Practice Nursing, however no regulation is in place as of yet to support the role. 66 Increasingly, nurses in Africa who practice at the post-basic level, are participating in strategies that are designed to mitigate shortages of physicians in environments that have a high disease burden of HIV/AIDs. Nurse Initiated and Managed Anti-retroviral Therapy (NIMART) has been widely employed, especially in Sub-Saharan Africa. [67][68][69] Nurse prescribing, which is an element of advance nursing practice, is increasingly being integrated into post-basic practice.
Weaknesses/Threats: While some countries do have regulatory frameworks for advanced practice nursing (South Africa, Ghana, eSwatini, and Tanzania), the primary challenge for many countries in Africa is to establish clear regulations for nursing practice in general, and to broaden regulatory scope for advanced nursing practice in countries that are developing these roles. 24,70 Also, the educational infrastructure does not possess the adequate nursing faculty necessary to train future practitioners. 24 And, in many countries, there is a persistent lack of political will to establish APN roles in a substantive way. 71

4) Southeast Asia (see Additional File 5_Southeast Asia)
Strengths/opportunities: Thailand has had a long history of training and integration of the advanced practice nursing role into the delivery of national health care services. The role of the advanced practice nurse has been successfully implemented throughout the country based on supportive government healthcare policies, engaged and quali ed administrators and su cient nancial resources. 72 The authority to prescribe medicines by nurse practitioners via a formulary has helped to expand their scope of practice. 73 In India, the Indian Nursing Council approved the rst national curriculum for the Nurse Practitioner in Critical Care (NPCC).
This new program is currently being offered for study at the Master's (MSc) level. 74 This new role seeks to ll critical shortages in acute care and will contain education around the initiation and management of medications, based on an approved formulary. 74 Weaknesses/Threats: In Thailand, despite certi cation and education, many APNs do not function to the full extent of the advanced practice role. 72 Also, in some areas, poor administrative support for the APN role may lead to work assignments that are not re ective of APN practice. 72 In India, the role of the nurse practitioner is not established and there is a lack of awareness of the clinical responsibilities. Only a handful of universities have adopted the program due to physician lack of awareness and resistance to a role that encourages nursing practice with skills that overlap those of medicine. 75  Advanced Nurse Specialist and this term is protected by the government. 89 There are currently three programs that offer Master's degrees for the Advanced Nurse Specialist role and the Jordanian Nursing

5) Western
Council has developed the role at the national level. 89 The State of Qatar and the Qatar Ministry of Public in 2013 developed a comprehensive regulatory document on all levels of nursing practice, including registered midwives (RM), clinical nurse specialists (CNS) and nurse practitioners (NP). 90 There are clear de nitions, title protection, and scope of practice descriptions for the CNS and NP role. 90 Oman has also been moving toward establishing a more formal role for advanced practice. This is due to a shift of emphasis by the Sultanate of Oman toward the advanced practice role based on changing demographics and the increasing demand for high quality care. 91 The Sultan Qaboos University initiated the rst Masters of Science program in nursing with a concentration in Acute Care Advanced Practice Nursing. 92 Regionally, a board of nursing will standardize licensing and will promote free movement throughout the Gulf Cooperation Council (

Discussion
The adoption of advanced practice nursing (APN) roles is accelerating rapidly worldwide in the context of escalating healthcare costs, changing burdens of disease, and the resultant need for innovative healthcare delivery models. This is occurring at a time when key international policy initiatives, such as the Sustainable Development Goals (SDGs), WHO's Global Strategy on Human Resources for Health: Workforce 2030, and Nursing Now seek to strengthen and expand the healthcare workforce in order to achieve universal coverage goals and to meet the SDG targets. 93,94 The broad implementation of advanced practice nursing over the past several decades is being propelled by several key drivers that are impacting the delivery of healthcare worldwide. First, it is estimated the global shortage of health workers, and especially nurses and midwives who make up 50% of the global health workforce, will impede the achievement of SDG 3: Health and Wellbeing. 95 The related shortage of physicians suggests that nurses, especially advanced practice nurses, are poised to address local healthcare needs and introduce e ciencies into health systems, if allowed to work to their full potential. 96,97 Second, it is well known that population factors have great bearing on how well a nation's health system is able to meet the needs of its citizens. Aging populations will test healthcare systems around the world. It is expected that between 2025 and 2050, the world's population of older adults will double to 1.6 billion, and approximately 80% of this growth will occur in non-industrialized nations. 98 The greater care needs of an older population, with the associated increased rates of chronic, non-communicable disease, necessitates innovative strategies that will support both accessibility to care and cost containment. Recent data suggest that physician substitution by advanced practice nurses achieves healthcare quality that is comparable to that of physicians in the older adult population. 99 This supports broader research that has found that care provided by advanced practice nurses (nurse practitioners in particular) was equivalent to care provided by physicians based on standard quality indicators, and better in terms of prevention interventions such as smoking cessation and general education/counseling, resulting in positive health outcomes. [100][101][102][103][104][105][106] Third, global momentum is building for universal healthcare coverage. Over 100 countries around the world have studied how to introduce government supported programs of healthcare, even in the populous countries of Indonesia, China, India, and South Africa, which comprise 40% of the world's population. 107,108 The United Nations is moving this work forward with the implementation of the Sustainable Development Goals (SDGs). 109 Goal three, to ensure healthy lives and wellbeing, includes the target of achieving universal health coverage, including access to quality essential health services. 110 This will have a substantial effect on the healthcare workforce and exacerbate shortages. Demand for healthcare workers is expected to surge from 48 million (in 2013) to 80 million by 2030. This will occur in the context of a supply gap during the same period that is anticipated to increase from 7 million to 15 million workers. 111 Furthermore, many countries have expanded services over the past two decades, especially in response to epidemics (HIV) and increasing rates of non-communicable diseases. This has resulted in a proliferation in medical and public health programs, with varying levels of fragmentation, and disorganization. The increased demand and provision of services worldwide will lead to three essential requirements that most countries must consider: 1) the ability to provide services without causing severe economic hardship, 2) the need to absorb fragmented services while providing essential healthcare to the population, and 3) the obligation to provide a healthcare workforce of su cient size and that demonstrates a deeper set of skills that can respond to greater health and organizational complexity. 112 Our analysis demonstrates that advanced practice nursing continues to progress, in response to the global drivers of an aging population, workforce shortages, and the need to develop system-based e ciencies for cost containment. Key elements that frame the role, such as regulation, education, licensure, and scope of practice, vary signi cantly by country and region and remain dynamic. However, notably, practice and educational models are outpacing regulatory standards in all six WHO regions. This indicates the role is developing organically, driven by local needs, but still lags in terms of the formal legitimization of the role in many countries. While added regulation has its supporters and detractors, it codi es the role in a way that is di cult to refute.
Finally, we cannot ignore the transformational circumstances of 2020. This Year of the Nurse and Midwife, as designated by the WHO to coincide with the 200 th anniversary of the birth of Florence Nightingale, has provided a laser focus to the critical role that nurses play, in not only health crises, but in the provision of essential health services for all. 113 Nurses have always been immersed in increasing access and improving e ciency, whether it be at the basic or advanced level. It has become clear that governments will need to recalibrate their healthcare workforce, especially for APNs, in order to better address the need to reduce NCDs and to incorporate more effective prevention and disease management strategies. 1 And, this year especially, the Covid-19 pandemic has provided clear agency to a profession that will continue to sustain the essential framework of our health systems worldwide.

Conclusion
Advanced practice nursing is a unique sector of the global healthcare workforce that has expanded healthcare access and contributed to health system e ciencies in both high income and low to middle income countries. This sector has grown rapidly, in response to aging populations, the increasing prevalence of non-communicable disease, and the global impetus toward universal health coverage. Our ndings reveal that, while the role is highly variable based on the regulatory and practice environments in which it resides, it remains a growing phenomenon that shows no sign of abating.

Declarations
Ethics approval: not applicable Consent for publication: not applicable Availability of data and materials: all data generated or analyzed during this analysis are included in this published article (and its supplementary information les).