APN in developing countries:

From previous discussions of APN role development, it was evident that various environmental factors have been instrumental in APN role development. However, it is appropriate to argue that such inhibiting and facilitating factors are unique to those countries where APN roles have existed and that such roles cannot be blindly transferred to countries such as Palestine with unique contextual factors.

Internationally, economic demand on health care systems, the development of nurse education and changes in health care needs were instrumental in the global development of APN (Hamric, 2013). As a result, APN roles either exist of currently being developed in some 50 countries worldwide (Sheer and Wong, 2008). From their survey the authors further identified two critical factors in the global development of APN roles: availability of nurses (ratio of nurses to the general population) and the improvement of nurse education (Sheer and Wong, 2008).

For nurses to undertake APN roles, they need to demonstrate that they provide adequate generalist care to their patients. This requires that sufficient numbers of nurses are trained to undertake such responsibility. The availability of educational institutions that is capable of

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providing advanced practice nurse education and training is also important to support the introduction of APN in developing countries.

The characteristics of health care needs in developing countries may vary considerably from those in developed countries. Therefore, for APN to be successfully implemented in developing countries, it needs to address the various environmental and cultural values of each nation. Crabtree (2005) further argues that discrepancies in causes and treatment of diseases in developing nations necessitate alteration in the groundwork of APN roles in order to meet the unique needs of developing countries. Screening for diseases, provision of immunization, ensuring clean water supply and improving nutrition may be priorities for many developing countries in the world (Crabtree, 2005). Furthermore, Madubuko (2003), coordinator of nursing affairs at West African College of Nursing, recognized the need for APN roles to screen and manage breast and cervical cancer, prevent the spread of HIV/AIDS, reduce maternal/child mortality and morbidity and decrease starvation. Such a difference in the health needs between developed and developing countries, requires modification in education for APN roles in developing countries.

The WHO (2001) advocated that APN deserves important consideration in developing counties where both communicable diseases and chronic conditions are on the increase. In previous discussions, it was evident that functions of APN roles in the developed world included

promoting healthy practices and the provision of holistic approach to care. In addition the World Bank (2007) pointed out that Middle Eastern countries face a dual burden of disease because of decreasing rates of communicable diseases and increasing rates on non-communicable diseases. The WHO (2013) further explains that in 2010 in the Middle East chronic diseases accounted for

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53% of disease burden. To be effective chronic disease care must be provided from a flexible, individualised approach (Hancharurnkul, 2007) and health management must be tailored to fit illness phases, biological needs and interests as well as the cultural setting in which the care is to be carried out (Cumbie et al, 2004).

APN can be exceptionally qualified to provide the necessary and effective care for chronic illness. This is true because nursing is steered by a humanistic principle wherein persons care is viewed holistically rather than just medically (Cumbie et al, 2004). Furthermore, for health promotion and illness prevention to occur, expert and well-informed professionals are needed to work with societies where many illnesses can be related to cultural practice. APNs can be ideally situated to conduct such primary care activities. It can be further argued that an emphasis on primary care is needed in developing countries and that the role of APN can fulfil this role (Mahmoud, 2013). This is especially valid as many developing countries suffer from shortages in medical staff (WHO, 2013) which may result in neglecting primary and community care for marginalised populations. It could be argued that with such scarcity of medical

resources, it would be a waste to post doctors to work in outlying areas. Some APN roles

emerged in the USA to care for the underprivileged and marginalised, improve access to care and provide care to specific groups of patients (Sheer and Wong, 2008). This shortage of medical staff in some developing countries, as compared to the health care needs, can be addressed by copying the experience of APN roles in the USA and where such roles originally flourished due to lack of physicians’ interest in rural settings (Stark et al, 1999).

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Various obstacles may hinder the introduction and development of APN roles in developing countries, including lack of government regulations, nurse education as well as the status of nursing as a profession (Crabtree, 2005). Many laws regulating the work of health care professionals are outdated and very hindering (WHO, 2010; Stanley, 2005). As a result, many NPs around the world are actually practicing outside the law particularly with regard to

prescribing drugs (WHO, 2010). In order to ensure full utilization of APN, such outdated laws and regulations need to be changed to provide APN with the legal coverage for the care they deliver. Updated regulations at the national level can then be reflected at the organizational level where APN role definition and scope of practice can be realised. The WHO (2010) further recommends that the scope of NPs (as an example of APN) should be well-defined and principles of education and autonomy of practice illuminated.

To address this, the International Council of Nursing created the International Nurse Practitioner/Advanced Practitioner Network. This network is actively involved in defining advanced practice roles, identifying role scope and standards of practice at the international level. However, Crabtree (2005) argues that such an initiative of APN role development need to take into consideration cultural, economic and nursing practice around the world. This

advocates that such role development needs to be discussed in a setting applicable to such countries. For instance, nurses in many developing countries may be required to practice as advanced practice nurses however, they have not received the required legitimacy by

governments or other institutions in those countries (Sheer and Wong, 2008; Stanley, 2004). Such an obstacle in the path of APN role development can be due to the traditional opinions about women in addition to the power and status of physicians in such countries (Jones and Davies, 1999).

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Further to that, instability of political systems in some developing countries (such as Palestine) does not permit strategic and long term health service planning which in turn may have adversely affected development of APNs in such countries (Crabtree, 2005).

In their attempt to meet the health care needs of their countries, nurses working in

developing countries need to challenge local traditional beliefs and professional margins (WHO, 2010). Nurses’ roles do not exist in isolation but rather in ever changing and sometimes complex health care environments. It is appropriate to suggest that understanding the specific needs and values of health care systems is essential before such roles are implemented in any jurisdiction (Hain and Fleck, 2014). It could therefore, be argued that the preparation of APN for practice in developing countries may be different from that in developed countries. As the role of an APN is client/patients focused, and that the health care needs of people living in developing countries vary from those in developed countries, it is likely that APN role and scope of practice are different as well. In addition, cultural beliefs, values and socio-economic factors are instrumental in shaping each nations customs and needs (Crabtree, 2005).

It has become apparent that APN roles are well established, at least in developed countries, and that they form the forthcoming frontline of nursing practice (Bryant-Lukosius et al, 2003; Gardner et al, 2007). Continued development of APN role appears to correspond with health care progress, societal developments and developments in the nursing profession to meet the ever changing health care needs of the society (Hain and Fleck, 2014; Sangester-Gromley et al, 2010). One strength of APN roles is the extent to which they can be flexible to accommodate the complex and challenging health care systems (Kleinpell et al, 2014). It is this flexibility that permits APN to meet the unique health care needs of the people in developing countries.

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Therefore, giving consideration to the nature of the work nurses perform and limited resources available in developing countries, may help to legitimize APN roles in such countries.