Advanced practice nursing in Latin America and the Caribbean: regulation, education and practice

Abstract Objective: to identify the current state of advanced practice nursing regulation, education and practice in Latin America and the Caribbean and the perception of nursing leaders in the region toward an advanced practice nursing role in primary health care to support Universal Access to Health and Universal Health Coverage initiatives. Method: a descriptive cross-sectional design utilizing a web-based survey of 173 nursing leaders about their perceptions of the state of nursing practice and potential development of advanced practice nursing in their countries, including definition, work environment, regulation, education, nursing practice, nursing culture, and perceived receptiveness to an expanded role in primary health care. Result: the participants were largely familiar with the advanced practice nursing role, but most were unaware of or reported no current existing legislation for the advanced practice nursing role in their countries. Participants reported the need for increased faculty preparation and promotion of curricula reforms to emphasize primary health care programs to train advanced practice nurses. The vast majority of participants believed their countries' populations could benefit from an advanced practice nursing role in primary health care. Conclusion: strong legislative support and a solid educational framework are critical to the successful development of advanced practice nursing programs and practitioners to support Universal Access to Health and Universal Health Coverage initiatives.

The aim of this exploratory, descriptive study was to identify the current state of APN regulation, education, and practice in Latin America and the Caribbean (LAC) and the potential for development of this role, particularly in the provision of PHC. To do so, the survey was conducted in 26 countries in the LAC region.

Literature Review
Nurses have fulfilled a key role worldwide by providing PHC services in urban, rural, and underserved areas long before the existence of a formal APN role. In many countries, scope of practice was unregulated and nurses pursued the skills and expertise most pertinent to the needs of their population (5) . In recent decades, those seeking to formalize this role in some countries have urged hospitals, universities, and policymakers to support formally recognized APN programs for PHC (6) .

Countries such as the United States of America and
Canada have actively incorporated the APN role into their health care systems to provide PHC for their populations, with an emphasis on the most underserved communities.
With over 50 years of experience incorporating APNs, the role in the United States was built upon the role of public health nurses. Currently, over 205,000 nurse practitioners (NPs) are licensed in the United States, two-thirds of whom practice in PHC (6) . Regulations for practice exist in all 50 states and the District of Columbia, and at least 21 states and the District of Columbia allow for full practice authority (7) . The United Kingdom, Canada and Australia also have systems to utilize APNs but progress in other parts of the world varies especially in use of APNs in primary health care (4) . Ample evidencebased research demonstrates that NPs predominantly work in PHC, provide high-quality, cost-effective care yielding comparable or better patient outcomes than their physician counterparts (5) (8) . However, NPs in Jamaica are still unable to legally prescribe medications without physician oversight and their effective integration into the health care system never fully came to fruition (9) .
The Belize School of Nursing first offered a Psychiatric Nurse Practitioner Certificate program in 1992, training 16 psychiatric NPs in collaboration with the Ministry of Health. The psychiatric NP's role is specifically tailored to address mental health needs of the population through outpatient consultation, and has effectively reduced the demand for inpatient psychiatric services in Belize (10) .
Psychiatric NPs do possess prescriptive authority, but only for psychotropic medications (11) . However, the psychiatric NP certification is earned via a certificate program; a master's degree is not required for practice.
Role confusion with that of psychiatric nurses and comparably low financial compensation for psychiatric NPs have not incentivized prospective applicants to the program in Belize (10) . Standardized education, role clarification and wage reform are integral to permanently establishing this and other expanded nursing roles.
Regarding APNs in public health, it is important to note that the field of public health varies across the region, according to local, regional and national demands of the health system and is influenced by a broad range of cultural, historic and economic climates (12) .
In many LAC countries, the public health nursing role is multifaceted, including disease prevention, patient education, managing immunization programs (including vaccination administration), and in some cases, home visitation (12)(13) . However, public health nurses have limited recognized professional autonomy, which restricts their ability to diagnose, construct management plans and prescribe medications (13) . Public health nurses are the largest group of professionals in public health within the region and express frustration at the lack of a clear public health nurse job description, which seems to vary depending on the health system infrastructure region to region (13) .  (14) . Doctorate level nursing degrees have since been introduced in Argentina, Colombia, Cuba, Chile, Mexico, Peru and Venezuela (14) .
Although graduate programs in LAC might not be actively changing the scope of nursing practice at the regulation level, they are still promoting professional development, research, leadership and improving clinical decision-making at the practice level (14)(15) . Nurses with graduate degrees often enter managerial roles, or become professors or researchers at universities (15) .

Several nations in LAC have specialization certificate
programs for nursing specialty areas, but most of them are for hospital-based specialties as opposed to primary care and do not appear to expand scope of practice in PHC (15) . Resolution (1) . Since the conference, a framework for collecting further data and planning implementation of the APN role in LAC has been established and future steps toward ongoing collaborations pursued (16) . Several countries such as Brazil, Mexico, Colombia and Chile have begun their own discussions to explore the viability of introducing the APN role in their national model of health care (17) .

Methods
This study used a descriptive cross-sectional design  The vast majority of participants (81%, n=140) indicated they were university employed and 70% (n=121) indicated they worked as educators. Eight percent (n=14) worked in Ministries of Health and 7% (n=12) worked as policymakers. Participants who selected "other" indicated they were heads and officers of nursing associations as well as key players in regional and local health initiatives. Figure 2 depicts education level and place of employment of participants.
surveys were considered and implemented, the survey was translated from English to Portuguese and Spanish.
Master's level-educated nurses from LAC performed the translation. The two translators are well versed in health care terminology, and fluent both in English and in their native language (Portuguese and Spanish, respectively).

Participants/Sample
Using convenience sampling with a snowball technique, the initial contacts were asked to send the survey on to five more nursing leaders or key informants in their country to extend the reach of the survey to influential voices in nursing leadership identified by the primary contacts. The initial sample was drawn from the PAHO/WHO Nursing Network list. A final sample of 173 persons from 26 countries was obtained after distributing the survey in English, Spanish, and Portuguese to 468 nursing leaders in LAC (response rate: 37%). Figure 1 depicts the number of participants by country.

Regulation/Legislation
Participants were questioned about current regulation and legislation for licensed nursing (bachelor-

Regulation and Nursing Roles
Participants were asked about title protection of the     It will be a long journey for the role of the APN in LAC countries to become established, implemented and well positioned in the health care system, but the development of this role is a significant step toward achieving Universal Health in the region.