Developing the advanced practice nursing role in Slovakia: Perception, education, and practice.

BACKGROUND: Advanced practice nursing (APN) is a modern and effective nursing role that has a positive impact on health care systems around the world. Guiding principles are advanced education, expanded scope of practice, and policies supportive of the role.
PURPOSE: The aim of this study was to find out the perception of APNs of their own practice in the context of the current legislative conditions in Slovakia and to identify related factors.
METHODS: A quantitative exploratory design was selected. From 5,067 APN, 584 were conveniently selected. The adapted and modified SCAPE study questionnaire was used for data collection. Data were processed using SPSS 25.
RESULTS: There were differences between newly introduced competencies for the APN role in Slovakia and the general concept of the role that could influence practice. The level of APNs' perception of their own practice is low. Years of practice was significantly and positively related to the perception. The results in each region were significantly different. Community nurses/outpatient nurses assessed their practice at a significantly higher level. The educational curriculum lacks the subject of APN. Competencies, remuneration, and satisfaction with the status are insufficient. IMPLICATIONS FOR PRACTICE: To understand, implement, and practice the concept of APN, it is essential to change policies related to competencies, education, remuneration, and status. Creation of an educational model that includes the subject area of advanced practice nursing in the postgraduate curriculum is essential. Education and practice conditions for advanced practice nurses should be uniform in all regions of the country.

Introduction

Advanced practice in nursing (APN) is a modern and effective nursing role for patients, managements, and nurses themselves. Its concept is based on nursing activities, knowledge, skills, and experience in the field of nursing and/or specialized field, which are closely related to the requirements and competencies for the performance in education and practice. The history of APN dates back to the 1960s. Due to lack of access to care in pediatrics, nurses with advanced training were able to serve as fully qualified providers (Ford & Silver, 1967). The role is now well established in many countries, with substantial numbers of APNs providing expert care. Advanced practice nurses are engaged in research implementing evidence-based nursing into practice, in critical thinking and clinical expertise, leadership, care management, and health care services within multidisciplinary teams. They form an important part of expert teams (Barton & Allan, 2015; Hamric et al., 2014).

Background

There are several models of the APN role in terms of its development and views. The model of Professor Ann B. Hamric developed in 1996, widely used and cited, is comprehensive and versatile in the context of the role and competence. Its contents are 1) primary criteria: graduate education, certification, and clinical practice focusing on a patient/family; 2) central competencies: direct clinical practice; 3) basic competencies such as professional counseling and coaching, consultation, evidence-based practice, leadership, collaboration, and ethical decision making; 4) (added by Hanson and Spross in 2005) critical environmental factors affecting nursing practice: regulatory and certification requirements, business aspects, policymakers, reimbursement and payment mechanisms, performance evaluation and performance improvement, marketing and contracting, organizational structure and culture, collaboration, and ethical decision-making capabilities (Hamric et al., 2014).

In Slovakia, APN was legislatively defined in 2018 and is stated in the Ministry of Health of the Slovak republic (MoH SR) Decree no. 95/2018 Coll., par. 3 “…a nurse who graduated from at least the second university degree (master's), preceded by the first university degree (bachelor) in nursing, with specialization, and at least 5 years' experience in a particular specialization, or a nurse without a specialization with 8 years of professional experience.” was guided by the International Council of Nurses' recommendations (ICN, 2009). The competencies of APN involve interventions of a nurse (autonomously, on the basis of a medical doctor's indication, and in a cooperation with a medical doctor) and a nurse specialist (autonomously), and of an APN (autonomously) as following: assessment of needs; responsibility of an individual care plan; indication of prevention, nursing interventions; biological material collection after consultation with a medical doctor; decision and responsibility for the intervention and application of the drug treatment in accordance with the treatment plan specified by the medical doctor; medical aids' indication and prescription; indication of the primarily-healing wound's treatment; ensuring compliance with relevant hygiene-epidemiological procedures; deciding on patient's bed placement; nursing-team management; checking and analyzing records the nursing documentation; creation, revision and evaluation of nursing standards and maps, educational plans and application to nursing practice; monitoring and carrying out nursing research, utilizing results in nursing practice; introduction and evaluation of nursing care quality system; training of nursing students (Ministry of Health Decree no. 95/2018).

Comparing the competencies of Hamric's model from 1996 to the competencies listed in the relevant decree, there are some intersecting points but gaps as well. The Decree no. 95/2018 Coll. contains general and specific points. There are differences between the recent Slovakian decree establishing the APN role nationally and the concepts identified by Hamric. These differences may affect APN practice in Slovakia.

Objectives

This research focused on perception, education, and practice of the advanced nursing practice role. The aim was to explore whether nurses who are now considered APNs under the current conditions of preparation and practice in Slovakia perceive their own practice to be at the level of an APN role. The objectives are focused on 1) overall perception, 2) individual categories of the perception in the context of role and competence, 3) relationships between the perception and categories of participants/demography, and 4) related factors such as practice and education conditions.

Methods

Study design

A quantitative exploratory design was selected for this research.

Setting

A national online survey was conducted. Nurses holding the APN title were eligible for inclusion in the study. Respondents were recruited via the Slovak nursing board (SKSaPA). The survey was available from April until June of 2018. Survio online survey software was used to collect data from the participants.

Participants

The population of APNs was pursuant to the definition in the MoH SR Decree no. 95/2018 Coll., par. 3. The research population was contacted through the SKSaPA portal by designated staff. The sample selection was convenient.

Variables

Research variables were divided into three main dimensions: 1) demographics and categorical variables, 2) variables related to perception about nurses' own practice, and 3) two open-ended questions related to nurses' opinion about APN working conditions satisfaction, training, and education.

Data sources/measurement

The questionnaire was adapted and modified from the original questionnaire related to the role of an APN, developed and used by Begley et al. in an extensive mixed method of the Irish SCAPE study (Begley et al., 2010). Consent has been obtained for its use. Given the purpose and goal of the research, we used the second part of the SCAPE questionnaire—“Outcomes for nurses or other health professionals.” Due to the current legislation and status of APN in Slovakia, we adjusted it. The final instrument contained 11 items that the respondents rated on a Likert scale from 1 to 7 (1 = very low impact of the result; 4 = neutral impact of the result: 7 = very high impact of the result). Two open-ended questions were added to the main body of the final questionnaire. Demographic data consisted of gender, level of education, specialty, region, setting, age, and years of practice.

Bias

Within an assistance of SKSaPA, only APNs were approached and invited to participate on this research. The validity of the questionnaire used in this research was supported by linguistic and conceptual validation, and translation, and retranslation (from English to Slovak and again English language). The questionnaire translated from English into Slovak was validated by five APNs and adjusted as recommended. The instrument was then retranslated into English and reviewed by a certified translator. The reliability of the questionnaire was tested. The result of Cronbach α represented 0.927, showing high internal consistency of responses to the final questionnaire.

Ethical considerations

Ethics committee approval was obtained from the Slovak nursing chamber (SKSaPA). An informed consent to participate was obtained from all participants by completing the questionnaire, which they were informed about in the invitation letter. Confidentiality commitment was ensured through the usage of unique study identifiers, removal of identifying information, and careful data storage.

Study size

According to information obtained from the SKSaPA, the total population at the time of research process meeting these conditions was 5,067 Slovak nurses. It was a convenience selection in which all potential respondents had the opportunity to participate. The final response rate was 11.53% (N = 584) of the population.

Quantitative variables

Our goals were to describe the sample and the perception of nurses in the context of the APN role and competencies to find out the level of the total perception, to find out whether there are relationships among selected demographic variables and the total perception, and to compare our findings with results of other relevant researches.

Statistical methods

Quantitative data analysis and interpretation was processed by IBM SPSS 25 software using descriptive and inductive statistics methods. For testing relationships between variables, nonparametric Spearman ρ correlations, Mann–Whitney U, and Kruskal–Wallis tests were used. Comments from open questions were collated and quantified in categories.

Results

Among 584 participants, there were prominently more women (n = 556; 95.2%) than men, with a masters' degree (n = 568; 97.3%) and nursing specialization (n = 479; 82%). Most respondents were from Košice region (n = 175; 30%). More respondents worked in governmental (n = 324; 55.5%) than in private institutions and more in institutionalized (n = 478; 81.8%) than in community care (Table 1). The average age of the respondents was 41.85 years (SD ±7.98), and the average practice was 21.23 years (SD ±9.25) (Table 2).

Table 1.

Frequency and percentage of categorical variables and results

Categ.v.	Variable Item	Freq	%	MR	Test	Percept.	p
Gender	Man	28	4.8	343.07	Mann–Whitney U	6,312.00	.096
	Woman	556	95.2	288.89
Level of university degree	Second	568	97.3	291.7	Spearman ρ	−0.008	.856
	Third	16	2.7	283.70	Mann–Whitney U	4,135.50	.856
Specialization	With	101	17.3	32.26	Mann–Whitney U	21,911.50	.412
	Without	479	82.0	286.96
Region	Bratislava	73	12.5		Kruskal–Wallis	53.09	.000[a]
	Trnava	94	16.1	389.96
	Nitra	28	4.8
	Trenčín	9	1.5	148.56
	Žilina	39	6.7
	B. Bystrica	33	5.7
	Prešov	133	22.8
	Košice	175	30.0
Owner of setting	Government	324	55.5	291.93	Mann–Whitney U	41,690.00	.945
	Private	260	44.5	290.97
Type of setting	Community care	106	18.2	330.27	Mann–Whitney U	21,118.00	.009[a]
	Institutional care	478	81.8	282.87

p ≤ .05.

Table 2.

Results of continual variables

Cont.v.	Min	Max	M/SD	Perception
Age	24.00	60.00	41.846/7.984	Spearman ρ	0.139	.001[a]
Practice	2.00	40.00	21.219/9.251	Spearman ρ	0.172	.000[a]

p ≤ .05.

Descriptive data

The individual areas of practice in terms of achieving (implementing, applying) the result were expressed on the Likert scale. The highest mean among items (mean = 5.12; SD ±1.80) was reached in the field of educational interventions focused on patient/client (p/c), that is, the creation and use of educational materials, p/c education on self-monitoring, and the like. On the contrary, the lowest average (mean = 3.80; SD ±1.99) reached the item related to research activities in clinical practice, that is, engagement in local research, research collaboration with other research teams, development of research projects, and the like. Out of a total of 11 items, eight items reached levels above the neutral value (use of clinical guidelines, educational interventions at different levels, implementation of new clinical interventions). The three items reached levels below the neutral value related to research activities in clinical practice, research awareness, and prescription.

Outcome data

None of the items reached 75%, which was the expected level in this research (Table 3). This means that the perception of the respondents about their own practice is not at the expected level in accordance with the nurses' advanced practice competencies. Based on the overall mean of 49.63 (SD ±15.35), in comparison to the overall neutral score (M = 44), we can conclude that the respondents reached higher than the neutral score.

Table 3.

Questionnaire results by item

Items	N	Min	Max	M	SD
Use of clinical guidelines	584	1.00	7.00	4.980	1.585
Integration of research in clinical practice	584	1.00	7.00	4.459	1.763
Educational interventions: multidisciplinary	582	1.00	7.00	4.746	1.793
Research activities in clinical practice	584	1.00	7.00	3.805	1.988
Research awareness in clinical practice	584	1.00	7.00	3.872	1.874
Educational interventions: interdisciplinary	584	1.00	7.00	4.841	1.673
Clinical leadership of nurses	584	1.00	7.00	4.325	1.929
Educational interventions: patient/client	584	1.00	7.00	5.118	1.804
Implementation of new clinical interventions and activities	584	1.00	7.00	4.896	1.745
Participation in creating guidelines and standards for nursing practice	584	1.00	7.00	4.801	1.947
Prescription	584	1.00	7.00	3.851	2.382

Main results

The 95% confidence interval for mean value is between 48.38 and 50.88, which implies 95% confidence that the average perception of the population is between these values. With the normality test of Kolmogorov–Smirnov, we reached a value of p = .000, resulting in a nonparametric distribution of scores (Table 4). Based on the objectives, we analyzed the APNs' education, knowledge, skills, and length of practice and their relationships to the perception of the APN's practice. Spearman ρ 0.172 and p = .000 indicates a weak positive correlation with statistical significance (Table 2). The correlation coefficient of Spearman ρ −0.008 and p = .856 does not confirm the statistical significance of a relationship between APNs' perception of their own practice and the highest degree of education in nursing. In the next hypotheses, we assumed a statistically significant difference between the perception of nurses of their own practice in the context of APN with the second university degree and the third university degree using Mann–Whitney U test result of p = .856, which does not confirm the statistical significance. The median of respondents with the second university degree represented a higher value (MR = 291.7; n = 567) than respondents with third university degree (MR = 283.70; n = 15). Specifically, research awareness in clinical practice, clinical leadership of nurses, education of p/c, and implementation of new interventions and activities represented a higher value in respondents with second degree, whereas research activities in clinical practice and prescription represented higher value in third degree. Another hypothesis assumed a statistically significant difference between perception of nurses in their own practice in the context of APN between nurses with specialization and without specialization. The Mann–Whiney U test (p = .412) did not confirm any significance. MR in nurses without specialization was higher (MR = 286.96; n = 482) than in those with specialization (MR = 32.26; n = 96). A significant difference arose in items related to the use of clinical guidelines (p = .000), research activities in clinical practice (p = .001), and prescription (p = .000). The Kruskal–Wallis test testing the APNs' perception in individual regions of Slovakia resulted in p = .000, with the lowest score being achieved by nurses from the Trenčín region (MR = 148.56; n = 9) and highest from the Trnava region (MR = 389.96; n = 92). Furthermore, we assumed a statistically significant difference in the perception of nurses in their own practice in the context of APN of nurses working in the community care and in institutionalized care. The Mann–Whitney U test resulted in p = .009. This means a statistically significant difference between a group of nurses working in the community scoring higher (MR = 330.27; n = 106) than those working in institutionalized care (MR = 282.87; n = 476). Particularly, significant differences arose in the items regarding research awareness in clinical practice (p = .000), educational interventions toward the p/c (p = .000), implementation of new clinical interventions and activities (p = .001), clinical leadership (p = .007), and the use of clinical recommendations (p = .007), with all of the community nurses listed scoring significantly higher. The opposite was the case of educational interventions in the context of multidisciplinarity (p = .023) and prescribing (p = .000) where nurses working in institutionalized care scored higher (Table 1).

Table 4.

Overall results

Overall Results	Statistic	SD
Mean	49.63	0.636
95% confidence interval for mean
Lower bound	48.38
Upper bound	50.88
Median	51.00
SD	15.347
Minimum	11.00
Maximum	77.00
Range	66.00
Skewness	−0.360	0.101
Kurtosis	−0.549	0.202
Kolmogorov–Smirnov p value	.000

Other analyses

Finally, most of respondents were not satisfied: with competencies they currently have in practice, status among health care professionals and public, and remuneration as well (n = 434 not satisfied). Respondents answered, whether they have been trained in the subject of APN. None of the respondents were trained or educated in this specific field (N = 582) (Table 5).

Table 5.

Results of specific questions

Question	n	n
Satisfaction with work conditions	Not satisfied: 434	Satisfied: 42
Training or education in APN	No: 582	Yes: 0

Note: APN = advanced practice nursing.

Discussion

Key results

The intention of the APN role is an autonomous professional with clinical expertise. The APN is designed to be a clinical leader, researcher, consultant, and innovator. The concept of advanced practice in this text differs from the results of this study, as well as the current legislative norm defining advanced practice in terms of competencies. The results of the research confirmed that nurses' perception of their own practice within the context of advanced practice was low, with the correlations and differences presented and analyzed in this article. The level of perception did not reach the set level of 75%. Therefore, we conclude that nurses' perception of their own performance in the context of APN is unsatisfactory. The 95% confidence interval indicates that the population mean lays above the neutral mean. In a study by Begley et al. (2010), all means of the questionnaire items were higher than those in our research. This finding is possibly related to the fact that the development and implementation of the role in Ireland has its history since 1996, when the first nurse was acknowledged to be practicing at an advanced level (“emergency nurse practitioner”). By 2008, there had been several APN posts approved (O'Shea, 2008). The role is well implemented into the health care system in Ireland in comparison to Slovakia.

We found that the perception of APNs about their own practice is related or not related to several factors. The number of years of practice increases the level of perception. This should be considered when formulating policies. Higher education in nursing is not a prerequisite for improving the level of perception. No statistically significant difference was found between the perception of nurses' own practice in the context of advanced practice with the highest attained university degree of second and third level. The median of respondents with the highest educational attainment of second degree represented a higher value than for respondents with a third degree. Specifically, research awareness in clinical practice, clinical leadership of nurses, education of p/c, and implementation of new interventions and activities represented a higher value in respondents with second degree. Research activities in clinical practice and prescription represented higher value in third degree. The lowest but not significant was the implementation of new interventions and activities, whereas the highest was in the education of p/c. Except for the prescription, the results are confirming the nature of the nurses' education and practice within the second and third degrees. Furthermore, it was assumed that nurses with specialization would achieve higher scores based on a higher level of clinical expertise, especially in clinical issues. The test did not confirm any significance. MR in nurses without specialization was higher than in those with specialization, which was an interesting finding. Generally, there is no statistically significant difference in the perception of nurses in their own practice in the context of APN with and without specialization. There was a lower assumption that nurses without specialization would score higher in perception. Higher MR scores for nurses with specialization with statistical significances have been found in the use of clinical guidelines and research activities in clinical practice and prescription. Nonsignificant differences were found in educational interventions toward the p/c in the context of multidisciplinarity and interdisciplinarity and in participation in the development of nursing practice standards.

We also found a statistically significant difference in the perception of nurses in their own practice in the context of APN between individual regions of Slovakia, with the lowest score being achieved by nurses from the Trenčín region and highest from the Trnava region. The statistical significance of the differences among nurses' perception from various Slovak regions was high. This was noted in all items, which was a surprising finding as well. The working conditions of APNs are seemingly not the same, and it requires a deeper analysis. We assumed that community nurses are more autonomous than those working in hospitals and health care/services, resulting from the nature of their work. There was a difference found between groups of nurses working in the community scoring higher than those working in institutionalized care, which confirmed our assumption. Particularly, significant differences arose in the items of research awareness in clinical practice, educational interventions toward the patient/client, implementation of new clinical interventions and activities, clinical leadership, and the use of clinical recommendations, where community nurses scored significantly higher. On the other hand, nurses working in institutionalized care scored higher in educational interventions in the context of multidisciplinarity and surprisingly in prescription of medications. By analyzing results, we conclude that the reason is very likely the staffing of professionals in institutionalized care facilities. Similarly, the perception of the “prescription” variable was expected to be lower for nurses working in institutionalized care facilities compared with those working in the community. Community nurses prescribe to a greater extent and are very likely they have much greater autonomy, so they could be expected to see their own practice at a more advanced level in this area. However, supervision and consultation are very likely to be less performed in the community or outpatient nurses compared with those working in acute hospitals and long-term facilities.

Limitations

The nature of this research, aim, and the wide scope of the subject did now allow an extensive insight to the factors influencing the results. A deep analysis and interpretation of collected data could be performed in some cases. However, this would not be sufficient for this research. The set subject needs more fragmented objectives within various research designs and methods to get rigorous and specific results from different areas, divisions, and points of view.

Interpretation

Several authors presented similar results. Woo et al. (2019) found that there were significant differences between the practices and expectations of 87 nurses with advanced practice and that the readiness and acceptance of the dissemination of tasks were recognized, but several obstacles remained. The literature reveals a relatively high perception of professional practice among APNs. However, in our study, perceptions of the role were lower than expected. Results confirmed shortcomings in many areas.

Zug et al. (2016) investigated the current state of modern nursing practice, education, and regulation in Latin America and the Caribbean and the perception of the role of senior health care executives to support the Universal Access to Health and Universal Health Coverage initiatives. Participants were quite familiar with the role of APN, but most of them were not aware of existing legislation. They stated that the training needs to be advanced within educational institutions and that curriculum reforms should be encouraged to shift educational programs to a higher level of nursing training. The majority of participants believe that the population could benefit from their role in primary health care. In another study, one of the main features of the perceived benefits of APN in Hong Kong relates to the quality and safety improvement (Christiansen et al., 2013).

From the results, we conclude that it is necessary to create a subject area focus related to the APN role for the master's degree within the education in Slovakia, which would be a prerequisite for the practice of future nurses in this role. There is a need for clear, generalized competencies to be created that allow for some flexibility of action, considering the requirements of practice as well as the knowledge and skills of nurses with advanced practice, and specifically, to avoid duplication and misunderstandings of the responsibilities of individual categories of health care professionals. This recommendation is also closely linked to the creation of new terminology, nomenclature, curriculum, research opportunities, and assessment of the role of the role in practice. A qualitative research by Stanford (2016) had an aim to find out the importance of competency framework for advanced practice. She found out that the competency frameworks can identify individual strengths and weaknesses and can be used to set clear goals. Frameworks can also improve practice organization and have the potential to limit practice by boundaries. The study also found the use of frameworks in guiding the development and evaluation of educational programs. Stanford concludes that competency frameworks target the development of new advanced nurse practitioners and governs safe and autonomous practice. They ensure consistency in clinical practice skills underpinned with theoretical knowledge of nurse practitioners. They also provide a structure for career development. However, internationally, there is still a lack of definition of advanced practice and its core competencies. Inadequacies within competencies were found in our research. Stanford's research confirms the explicit impact of a competency framework to support not only practice but also education, career development, and safety of an autonomous practice of APNs. A competency framework should also be developed in Slovakia. In relation to education in APN, Gaskell and Beaton (2015) explored how the group of trainee advanced midwifery practitioners were developing core competencies (related to clinical/direct patient care; leadership, collaborative practice; quality and development of practice; development of competency) during their training on an MSc in Advanced Practice. There was an instrumental link between the university and clinical assessments regarding the extension of scope of practice. They had improved their abilities to do collaborative work with colleagues, raising their profile and acceptance of an extended midwifery role. In addition, specialized skills promoted a high degree of decision making within the service development and evidence-based care. This research supports findings of our research: the importance and need of a development and establishment of an educational curriculum of APN in Slovakia. Petersen and Way (2017) found that medical doctor's oversight was related to increased empowerment of advanced practice registered nurses. Authors recommend that if advanced practice registered nurses are to be part of the solution to the growing problem of health care access, it is important to study factors that contribute to their success. Collaboration and interaction with health care professionals could facilitate advanced practice registered nurses' empowerment. Greatest challenges are associated with the role acceptance by other health care professionals and with the public's traditional attitudes to health care provision. Therefore, professionals and the public should be educated about such a role (Christiansen et al., 2013).

The advanced practice nursing role is a new and unexplored role for nurses in Slovakia. The results of research pointed out that perception of nurses toward their own practice as advanced is low. The results are probably related to legislation and education. Advanced practice nursing and its fundamental nature, theory, models, and philosophies are not an integrated part of the educational process and practice in Slovakia. Significant gaps are related to the educational and practical preparation of nurses for the advanced practice role, relevant terminology, education, and practice. The existing decree does not provide for the explicit identification of each nursing role. Therefore, the difference among nursing roles is vague. Given the wide scope of the subject and the nature of this contribution, it was not possible to cover all the factors affecting nursing perception and their actual functioning in practice. The level of nurses' insight into their own practice on the level of advanced practice is positive but limited. Therefore, this subject requires deeper analysis, more extensive testing, and possibly a diverse approach thereto with a focus on legislation related to education, general and local competencies, conditions, and practice. Perhaps, a use of mixed methods and designs may lead to a more accurate conceptualization of the advanced practice in nursing in Slovakia.

The nature of this research, its purpose, and the wide scope of the subject did now allow an extensive insight to the factors influencing the results. A deep analysis and interpretation of data collected in some cases could be performed. However, it would not be sufficient for this research. The set subject needs more fragmented objectives within various research designs and methods to get rigorous and specific results from different areas, divisions, and points of view.

Conclusions

The advanced practice nursing role arose in the late 1960s. Since that time, the role has undergone adaptations and modifications. In comparison to legislation related to the role in Slovakia, there were several insufficiencies found. Conditions for full implementation of the role are deficient according to the nurses themselves. There is neither educational and professional nor public support for embedding the role. Therefore, the perception of nurses about their own practice within advanced practice was found to be low. This result correlates with our statement that there were differences between the conceptual model and current competencies in Slovakia. Resulting from findings, our recommendations are focusing on a multidisciplinary approach in terms of policies, role conceptualization, nomenclature, definitions, and practice conditions. Innovations in education and a creation of a competency framework will require a specific analysis of factors and conditions of advanced practice nursing in the country.