Moving towards universal health coverage: advanced practice nurse competencies

Objective: this paper aims to describe the first phase of a project whose general goal was to develop a consensus-based set of advanced practice nurse competencies applicable to Latin American countries and, based on these competencies, produce an advanced practice nurse curricular prototype adapted to Latin American countries. The project was framed in a competency-based approach to advanced practice nursing education. The specific aims of the first phase of the project described in this paper were: 1) to identify a set of potential advanced practice nurse competencies that would serve as the template for Core Advanced Practice Nurse Competencies in Latin American countries and 2) to establish consensus for Core Advanced Practice Nurse Competencies in Latin American countries. Method: advanced practice nurse competencies were derived from a comprehensive review of published competencies and informed the development of a survey designed to assess the relevance of advanced practice nurse competencies in Latin American countries. The survey was distributed to nurse leaders and nurse educators. Data were analyzed using descriptive statistics. Results: consensus for Core Competencies was established. Conclusion: the Core Advanced Practice Nurse Competencies presented can provide a structured framework to build educational programs aligned to the needs of the regional environment.


Introduction
An expanded role in nursing is emerging globally, responding to the need for increased human resources in support of a unanimous United Nations resolution to move forward the goal of Universal Health Coverage (UHC) and Primary Health Care (PHC). Universal Health Coverage was adopted by the World Health Organization (WHO) and a global coalition of over 500 health organizations. The resolution states that UHC provides access to an efficient and affordable health system staffed with well-trained health workers (1) . In turn, according to the Declaration of Alma-Ata (1978), Primary Health Care "is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford (2) ." Together, UHC and PHC provide the overarching objectives for global strategic planning. They serve as a clarion call for countries to strengthen their health systems and establish new models of care, and build health professional capacity in primary health care. Evidence supports that nurses who take on advanced roles are able to provide primary health care to large populations (3) . One strategy to achieve UHC and PHC is to enrich and maximize the scope of nursing practice with capacity to meet patient-    This first phase was included in a competencybased approach to nursing education, specifically, APN competencies. The process that was undertaken to establish APN core competencies in LAC is outlined.

Method
The aim of the study is to identify a set of potential APN competencies that would serve as the template for APN Core Competencies in LAC. A set of potential APN competencies was derived from a comprehensive review of established and published APN competencies.
Using the PubMed database and searching for grey literature, the research team collated documents aimed at identifying APN competencies (8)(9)(10)(11)(12)(13) . Using an iterative and deductive process, two experts in competency- Descriptive statistics including frequencies and rates was used to summarize the data.

Results
Eighty-nine nurses from a total of ten LAC, including

Advanced Practice Nurse Core Competencies
In the questions related to advanced practice nursing competencies, the respondents rated each competency on a scale from "strongly disagree" to "strongly agree" as 1) a valued component of primary health care and universal access, and 2) a realistic goal for advanced practice nursing in their country. The competencies were rated agree/strongly agree (above four on the five-point Likert scale) in all four domains.  Integrate knowledge of bio-psycho-social and behavioral sciences, pharmacology, developmental stages, pathophysiology, epidemiology, environmental factors, family history and genetics.
Perform health assessments, formulate diagnoses and diagnostic strategies and design therapeutic management plans.
Integrate and interpret knowledge of normal, variations of normal and abnormal clinical manifestations, health maintenance, episodic and acute illness, chronic and comorbid illness and the trajectory of illnes and emergency care Integrate cultural sensitivity, patient information and evidence based practice.
Translate health information and provide health information that integrates the principles of teaching/learning and shared decision-making.
Apply knowledge of pharmacotheraopy and evidence-informed practice in prescribing and monitoring drugs.

4.5
Valued component of primary health care and universal access

Realistic goal for advanced practice nursing in your country
Collaborate with the health care team to provide interprofessional patient-centered care along the continuum of care.
Collaborate with the health care team to promote evidence-based practice and the translation of evidence into practice.
Collaborate with patients incorporating patient preferences, cultural and spiritual preferences, beliefs and values in health care in a model of Consult with and refer patients to other health care and non-health care providers, other disciplines, and community resources along the continuum of care while maintaining the patient as the focus of care.
Act as consultant and accept referrals from other health care and non-health care providers, other disciplines, and community resources as appropriate.
Use effective health communication skills and integrate the principles of health lieracy and shared decision-making.
Maintain patient-centered care and communication that integrates the principles of confidentiality, privacy, trust and respect.
shared decision making for a mutually acceptable plan of care. Integrate the principles of resource allocation and cost-effectiveness into clinical care decisions.
Facilitate and advocate for a health care evironment that incorporates evidence based practice, implementation of standards of care and quality assurance programs.
Evaluate outcomes of one´s own practice.
Apply knowledge of organizational structure for optimal service delivery.
Collaborate in planning for care coordination across the continuum of care.
Initiate and lead quality improvement iniatives at the individual, organizational and systems level.

COMPETENCY
Advocate for and participate in developing policies that promote a health care environment that supports universal access. Critically appraise research findings and other evidence to inform practice and policy for optimal patient outcomes.
Engage in evidence-based practice that analyzes and applies research best practice, and guidelines in healthcare decision making.
Develop and implement strategies that translate evidence into practice and evaluate outcomes.
Derive and synthesize evidence from practice that contributes to knowledge development and improves patient outcomes.

Discussion
The results of this study add to the body of work that seeks to advance the role of nursing and contribute to the goal of UHC and PHC. Consensus regarding the PHC and APN competencies provides a framework to build education programs for advanced practice nurses and provides a structure for regulation.
The implementation strategy for advanced practice in LAC includes "adaptation of the existing framework, utilization of recent research, and application of knowledge of experts on advanced practice nursing and primary health care" (14) . Historically, advanced practice roles evolved to fill gaps as apprenticeship, non-degree models (15) and, in some countries, transitioned into formal academic programs.  (16) . Therefore, the APN core competencies included in this study build on the strengths of the existing nursing education and include untapped knowledge and content for primary health care.
Nursing leaders (N=173) were surveyed to better understand the scenario in LAC with respect to advanced practice nurses. The participants identified the lack of regulation for advanced practice nurses or plans to develop such regulation. Ninety percent of the participants (N=155) agreed that advanced practice nurses would be very beneficial to their country and its population. Although they reported that students would be interested in pursuing an advanced degree for the advanced practice role, faculty preparedness to teach in such programs was identified as a concern (17) . This study confirms that LAC are at the initial stage of APN to build context-specific APN competencies and to tailor context-specific curricula. Figure 5 outlines the Core Advanced Practice Nurse Competencies.

Conclusion
The small sample size with participants from 10 countries represents a limitation of this study, which implies that the results must be interpreted with caution.
The number of countries and the heterogeneity among LAC represent a barrier to making statements that apply throughout LAC. More than half of the participants were predominantly nurse faculty members, which may have skewed the results. It is important to recognize that Rev. Latino-Am. Enfermagem 2019;27:e3132.
the Core APN Competencies is a starting point to build context-specific competencies from which curricula and regulation can emerge.
The next step for the Core APN Competencies is their specific modification in each country-for the best adequacy within educational programs, faculty resources, and primary health care gaps, as well as optimization of the country's strengths while addressing the challenges. Furthermore, the competencies will be further described using learner-specific performance objectives. Sample content will be included, and this will aid the development of the curriculum. The final document will be disseminated through publications and webinars.