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.”
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.”
American clinicians who want to share their experience and accumulated wisdom with countries seeking guidance need to bear in mind that while the NP or PA model is a great idea, it may not work exactly the same way in another part of the world. The most well-intentioned efforts can be undermined if proper attention is not given to the cultural contexts of the country in question.
“You don’t just import something and say, ‘This model is going to work here,’” Ballweg says. “You actually go through a fairly detailed process to say, ‘What are our needs?’ Otherwise, you could end up with PAs and NPs in any of these countries working in the specialty hospitals, for the people who are fee-for-service and make a lot of money, and you wouldn’t have accomplished anything.”
Schober, who has worked with more than 20 different countries that are exploring the APN roles, notes, “All too often, countries are seduced by the concept but are unaware of the complexities and difficulties associated with developing and implementing the roles. ”
Issues of reciprocity between nations are already creeping up (however premature in most cases), bringing to the forefront a number of practical and ethical concerns. “There is this whole issue of whether there should be an international certifying exam for PAs,” Ballweg observes. “What needs more discussion is the ‘should we.’ Everybody is still working all this through, but I think I can safely say that we [the NCCPA] do not want to create an infrastructure that encourages brain drain. At the same time, we want to provide assistance to countries and regions that want to develop credentialing mechanisms.”
It would be unethical to prevent a clinician from taking advantage of better opportunities in another country. But at the same time, the goal of developing APN or PA roles in these nations is to better meet the needs of the people within that country. This is a complicated issue, Schober says, “with no easy nonpolitical answer.” One positive step that countries can take to offset the risk of a “brain drain” is to create incentives that will attract and retain homeland clinicians.
Differences in language and cultural norms, and even in the practice of medicine, may make a universal exam impractical, anyway. “That doesn’t mean that a credentialing process isn’t a good thing,” Ballweg says. “It just might look very different in Africa than it would in the United Kingdom or the European community, compared to the US and Canada.”
American clinicians who interact with their international counterparts must be prepared to be diplomats, in a way. In addition to being sensitive to cultural differences, it is essential to understand how the US fits into the world stage. “Become knowledgeable about the world in general” is Schober’s advice. “In working internationally, you are often expected not only to comment on the value of APNs to health care systems but also to provide your opinion on the US approach to foreign policy or to the economic downturn.”
Sharing information encourages learning on both sides and promotes mutual respect. It also provides an opportunity to prevent missteps that may have been made previously. “In many places, in the early days, PAs and NPs were pitted against each other,” Ballweg points out about the US, “and some people still view us as competitors.”
Ballweg shares the Clinician Reviews philosophy of NPs and PAs working together. Whenever people in other countries ask about the NP/PA relationship—and yes, the question does come up—she provides examples of how the professions can support each other.
“I try to make the point that if you just have individual training programs, then you just have training programs,” Ballweg says. “But if you have PAs and NPs working together and moving ahead on a policy front, then you have a movement.
“That’s really what we want—to create this movement that has to do with access to care and improving global health everywhere.”