Advanced Practice Nurses: A Global Role

Marilyn W. Edmunds, PhD, CRNP


June 01, 2010

Description and Evaluation of an Initiative to Develop Advanced Practice Nurses in Mainland China

Wong FK, Peng G, Kan EC, et al
Nurse Educ Today. 2010;30:344-349


Over the past few decades, a global trend has emerged in which the role of the nurse has been advanced and expanded on the basis of new scientific and clinical knowledge and on greater use of technology. It is clear that nurses can assume more responsibility in the care of patients throughout the world. Systematic reviews of research show that in primary care settings, highly trained nurse practitioners can provide care that is equivalent to that of physicians and that may even be better, in terms of patient satisfaction and quality of care. This recognition has heightened interest among many countries in developing educational curricula that will facilitate the advanced practice of nurses.

Article Summary

Among the 1.31 million nurses in China, 64.5% have diploma-level education, provided primarily through high school-level programs; 24.3% are educated at college level (similar to AD programs), and 1.3% are BS graduates. The China Nursing Development and Strategic Planning document (2005-2010) identifies the need to develop advanced practice nurses (APNs). Wong and colleagues describe an initiative to develop the APN role in mainland China and the evaluation of outcomes of a pilot postgraduate educational program in Guangzhou, China, during 2004-2005.

Thirty-eight degree students were admitted to this postgraduate program, which relied heavily on nursing educational consultants from Hong Kong and followed the American Association of Colleges of Nursing Master’s Essentials curricular recommendations for 3 levels of instruction:

  1. Core content (eg, English, management, etc);

  2. Speciality content (pathophysiology, treatments and nursing interventions, prevention of complications.

  3. Theoretical foundation of the APN role, specialty content, and clinical experience. Students could choose to specialize in diabetes care, geriatric care, intensive care, or infection control.

Data related to curriculum content and process, student performance, self-reported competence, and program effects were collected. Quantitative data, such as demographic data and student performance, were analyzed using descriptive statistics, and before-and-after self-reports of competence were compared using chi-square tests. Qualitative data, such as case reports and interviews, were examined using thematic analyses. Reflective journals and case studies revealed the attributes of APNs in managing clinical cases at advanced levels, applying theory to practice, and exercising evidence-based practice. The relatively modest self-reported competence results suggested that the graduates were novice APNs and needed continued development after the completion of the program. This study suggests a useful curriculum framework for education of APNs.


Because nursing is still primarily a female occupation in many countries, recognition of the growing abilities of nurses parallels the growing respect for and independence of women in general. Although the ability of nurses to learn new content and implement new skills is now recognized, it is up to society and culture to allow their role to advance -- not easy in a male-physician dominated society. Thus, preparing APNs is the first step; the second is finding jobs that will allow new graduates to use their new skills.

China faces particular challenges as it seeks to upgrade the knowledge, skills, and abilities of its nursing workforce. The fact that China has twice as many physicians as nurses and that the person at the bedside caring for a very ill patient in China is a physician suggests that role development for nurses may involve some uphill battles. Although the current expectation for nurses is to be quiet, submissive, and do as they are told, Chinese society and its medical system have strong female role models who are leaders and policy-makers. If sufficient resources are allocated to allow educational upgrading of the nursing workforce, it will be interesting to see what the next decade holds.

The choice to have more APNs become clinical specialists rather than nurse practitioners was probably a wise one. The way in which the nurse practitioner role has developed to date more often mirrors the physicians’ role, whereas clinical specialists clearly practice within nursing. In the context of a burgeoning geriatric population who for the first time in Chinese history do not have large families to care for them, geriatric APNs could become integral to the healthcare system. Educational programs that provide nurses with knowledge and the skills to help both patients and families of older patients will probably be the easiest to implement because this need is so apparent.

My experience with the fledgling development of the nurse practitioner role in the United States suggests that all APNs need a strong science core in their education. In addition, they must master basic physical and mental health assessment skills. With this background, they can educate patients with greater authority and confidence and master the knowledge and vocabulary that will allow them to demonstrate to physicians that they are competent and deserve to be their professional colleagues.



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