Strategic directions and actions for advanced practice nursing in China.

There is a need and opportunity for China to develop education and practice innovations given that advance practice nurses (APNs) improve health care and outcomes. The China Medical Board (CMB) China Nursing Network (CCNN) began planning for an Advanced Nursing Practice Program for education and career development that will facilitate CCNN's contributions to meeting national nursing policy priorities. This paper presents the discussion, recommendations and action plans developed at the inaugural planning meeting on June 26, 2015 at Fudan University in Shanghai. The recommendations are: Develop standards for advanced nursing practice; Develop Master's level curricula based on the standards; Commence pilot projects across a number of University affiliated hospitals; and Prepare clinical tutors and faculty. The strategic directions and actions are: Develop a clinical career ladder system; Expand the nursing role from hospital to community; and Build a specialty nurse accreditation system.

Introduction

In March 2015 The China Medical Board (CMB) China Nursing Network (CCNN) began planning for an Advanced Nursing Practice Program for education and career development that will facilitate CCNN's contributions to meeting national nursing policy priorities. The CCNN is made up of nursing schools in eight leading universities in China: Central South University, China Medical University, Fudan University, Peking Union Medical College, Peking University, Sichuan University, Sun Yat-sen University, and Xi'an Jiaotong University. Supported by CMB since the early 1990s, these schools have collaborated in leading higher nursing education, nursing research and nursing service in China. An Executive Committee comprised of Nursing Deans from Fudan University, Peking Union Medical College (PUMC) and Peking University was established to facilitate the advanced practice nursing (APN) planning process.

Since 2011 86 new nursing masters programs have been approved: 28 in 2011 by the Ministry of Education and 58 in 2014 by the provincial education department [1]. They will significantly increase the number of clinical nurses with master degrees. Simultaneously, specialization of medical post-graduate trainings began at three Chinese medical schools. Thus, CCNN felt some urgency to begin a planning process for advanced practice specialty nursing to prepare nurses for future practice with medical specialists. A review was commissioned by the CCNN to provide background on advanced practice nursing (APN) in Australia, Canada, Hong Kong and the US to contribute to planning of advanced specialty nursing practice [2]. The review was organized according to the three national Chinese nursing priorities: developing clinical career ladder system for advanced practice nurses, expanding the nursing role from hospital to community, and building specialty nurse accreditation system and practice model.

On June 26, 2015 a meeting was held at Fudan University School of Nursing at which CCNN deans and Directors of Nursing at hospitals primarily affiliated with the nursing schools discussed Parker and Hill's review of APN in Australia, Canada, Hong Kong and the US and the implications for China. Deans Hu, Liu and Guo, members of the CCNN Steering Committee, committed to work with Parker and Hill to synthesize the discussion, recommendations and action plans into a report about the development of an Advanced Nursing Practice Program. This paper describes the breadth of discussion that occurred at the inaugural planning meeting of the CCNN for development of the APN role in China and suggests strategic actions. It's purpose is to inform readers in the wide nursing communities of the numerous issues that must be considered in future planning for recognized ANP roles in China.

Discussion of consultants' recommendations

Prior to discussion it was agreed that it is important to have a clear understanding of the contributions of APNs and the successful educational programs to prepare them to improve care and health [3], [4], [5], [6], [7], [8]. Consensus was quickly reached that currently it is more important to develop APNs in China within the scope of nursing practice than to navigate the national policy and legislative changes required for the nurse practitioner and nurse anesthetist roles. Thus, subsequent discussion focused on forecasting a future with APNs in a role similar to the clinical specialist role recognized in Australia, Canada, Hong Kong and the US.

It was also agreed that clarity was needed about how these APNs will be fully integrated into the hospital and community health care delivery models to provide innovative, effective, cost-effective approaches for improving care and outcomes. The capabilities of APNs include managing admissions, coordinating patient care and discharge planning and applying advanced knowledge to complement and supplement the work of physicians, staff nurses, pharmacists, and others. Further, in ambulatory and community settings APNs can manage well child care, chronic illness and frail elderly services, and provide and coordinate care and transitions within and across settings. The outcomes of APN care reduce emergency department and specialty care visits, admissions and readmissions, shorten length of stay, and can lower costs. Additionally, APNs provide clinical care, preventive services in schools and work places, keep elderly out of the hospital and living independently as long as possible [9], [10], [11], [12]. Currently in some settings in China nurses perform some or all of these roles after a short term training instead of formal graduate education program, these nurses were sometimes referred to as the specialist nurses [13], [14], [15]. Importantly, within the current scope of nursing practice in China, and in contrast to other APN role abroad, Chinese APNs would not write prescriptions although future changes in regulations for APNs may allow this.

The following consultants' recommendations were proposed and questions were asked to stimulate discussion and consensus development about strategic directions and action plans.

Recommendations

Develop standards for advanced nursing practice

Standards for APNs across a range of roles and specialty areas have been developed in Australia, Canada and the USA. Nurse academic and clinical service leaders build upon these standards for the APN role in a range of subspecialty areas in China. This development should be done in consultation with the Chinese Nurses Association, the only official organization to advance and protect the profession of nursing in China. It was advised that the current conditions, potential problems and challenges be analyzed to make future planning more complete and convincing.

Develop master's level curricula based on the standards

Developing clinical courses based on the standards for advanced practice would be relatively straight forward. It would need to involve both academic leaders and clinical practitioners and meet international standards. International advisors highly experienced at the Master's level in specialty practice, standards of practice and certification could be included in the planning.

Commence pilot projects across a number of university affiliated hospitals

Pilot studies to implement the APN role and evaluate its contributions are recommended. Some projects could evaluate the role of the APN and some could evaluate the academic preparation of the APN and the role of the clinical tutor. Appropriately experienced nurses could participate as APNs and clinical tutors.

The pilots could be managed in CCNN schools with their affiliated hospitals.

Prepare clinical tutors and faculty

Some experienced nurses from specialty areas selected for the pilot projects would need to be trained to be clinical tutors of the Master's students and nurse educators. As university academic faculty will not have the requisite clinical specialty skills to support students in their advanced clinical work it is recommended that experienced nurses be selected for the pilot projects and trained to be clinical tutors to precept the APN students and educators in the Master's Programs. The future clinical tutors could be trained abroad in immersion programs and/or by experienced preceptors from abroad who come to China to teach, conduct workshops and be role models.

Discussion of strategic directions and actions

The following text summarizes the group discussion which emphasized APN role and career development. The strategic directions and actions for CCNN consideration are organized according to the three Chinese national nursing policy level priorities: develop clinical career ladder system for APNs, expand the nursing role from hospital to community, and build a specialty nurse accreditation system and practice model. During the discussion questions were asked and strategic directions and actions were proposed to stimulate discussion and consensus development.

Develop clinical career ladder system

It is noteworthy that a clinical career ladder has been developed in China. However, the educational preparation requirements for the APN role has not been incorporated into the ladder. The current regulations for nurses, launched in 2008, state that nurses can only registered by an institution which means a nurse can only work legally in that institution. Thus, a nurse cannot legally practice in a community or another institutions unless the regulation is changed. Further, the current regulation does not include any APN roles or descriptions. Thus, the law will need to be revised to protect APN practice which is why the CNA is working to have a new law for nurses and APNs.

It is impressive that to begin to establish APN role legitimacy Chinese nursing clinical and academic leaders are working together and with government to clarify the vision for APNS roles – clinical specialist, nurse practitioner, midwife and/or nurse anesthetist – and what programs need to meet related goals. It also will be necessary to distinguish the ANP roles and responsibility roles from those of staff nurses and to specify them in the professional promotion ladders including direct care provider, case manager, team member and/or leader, community health workers. The supervisors of APNs and the managers of the units where they practice will need to be included to get buy in and benefit from their knowledge of how care is delivered. It will be important to proactively identify and address facilitators and barriers to APN success. Involving other professions from the beginning will help promote collaborative practice and supportive policies. The attitudes and behavior of physicians and other professions, their recognition and appreciation of the contributions APNs can make a crucial difference in the success of the APN initiative [16]. Find exemplars and have data to objectively justify the role, the difference they make and their impact. Success will be greater if there is clarity around the APN role and support that APNs need and a commitment at all levels of the hospital or clinical setting.

Strategic Actions:

Describe the differences in job descriptions and competencies between APNs and RNs.

Identify what data are needed to demonstrate the value of APNs and how will it be collected and by whom.

Develop the case for why APNs need a master's degree.

State expectations clearly and consistently. Identify core competencies for all APNs and those with population subgroup foci.

Identify means to grandfather practicing nurses who have APN knowledge, skills and experience by fast tracking through masters programs and certifying credentials. Monitor trends in inter-professional education (IPE) and encourage innovation in methods of delivery.

Specify credentials for faculty and Identify potential faculty for APN programs.

Describe how expertise from other degrees such as education, business, sociology, statistics, and pharmacology will be recognized and how the many nurses practicing in China who have special advanced knowledge and skills who have an associate or baccalaureate degree will be credentialed.

Develop a core curriculum and additional curricula for specialization.

Explain what continuing education needs exist and who will provide programs to meet them.

Describe what plans, if any, are there to “grandfather”,

Describe who will teach the initial cohorts and if the faculties will be interdisciplinary and include some international APN faculty leaders.

Expand the nursing role from hospital to community

The needs of population and health care delivery organizations that transcend hospitals and communities were discussed. The importance of smooth, coordinated and effective patient transition from one setting to another and the need for expert nursing services in all settings were discussed. It was agreed that the role and skills of many nurses across settings need to be expanded.

Strategic Actions

Identify the APN capacity requirement in the hospitals and communities and what will it take to expand the nursing role from the hospital to the community.

Identify and include the stakeholders who need to be involved.

Clarify if the APN scope of practice, domains of activity, and referral differ depending on the site where APNs practice such as child care, women's health, chronic illness management, aging care or home care.

Build specialty nurse accreditation system

The distinction needs to be made between accreditation of educational programs and certification of individual APRNs. An accreditation system should be designed from beginning to meet general and specific standards. Common standards are fundamental yet innovation should be encouraged.

An APN performance evaluation system could be built into the accreditation and certification programs so that role expectations and competencies are aligned. The role of APRNs should be evaluated at the individual and system level along with evaluation of process and outcomes such as improved health of the populations and reduced costs.

Nursing and other professional societies and organizations that are focused on special patient populations and/or APRN roles, such as cardiovascular and oncology nurses. They can sponsor conferences for APRNs to come together to share information on best practices, processes and outcomes, to discuss opportunities and challenges in practice, management and policy. Such meetings also encourage networking with others. Look for partners in promoting the role of APRNs.

Strategic Actions:

Clarify which organization(s) has/have the responsibility for accreditation of master's programs and/or nursing performance currently and if their responsibilities can or should absorb this function.

Identify who will have primary responsibility for evaluating the performance of APNs, i.e., the employers and/or the professional association(s).

Provide support for role development.

Identify who will provide support for professional development, the employers and/or the professional societies and organizations.

Discussion

This paper describes the meeting convened by the CCNN to discuss the APN role and how planning for formalizing this role in China. The dialog was wide ranging, open and informed. Consensus was reached and is imbedded in the recommendations and strategies.

This paper recommends that curricula developed at Master's level be based on standards to be established for APN roles standards; that pilot projects can be established across a number of University affiliated hospitals; that experienced nurses from specialty areas selected for the pilot projects could be trained to be clinical tutors of the Master's students and nurse educators.

Conclusion

Advanced nursing practice is developing globally. Data are available including from the International Nurse Practitioner/Advanced Nurse Network (INP/APNN) of the International Council of Nurses. Given that APNs improve global health and given the need for better access to care and cost-containment there is a need for greater education of nurses at the post-graduate level and greater regulation of practice in some countries.

Funding and conflict of interest

The China Medical Board (CMB) Inc. funded the China Nursing Network to hold the June 26, 2015 meeting. Deans Liu, Yan and Guo are the Steering Committee of the Network. Dr.s Hill and Parker travel expenses and honorarium to participate in the meeting were paid through the CMB grant to the Network.

The CMB had no role in the conduct of the meeting or preparation of this manuscript.