Introduction

Many countries have witnessed a significant increase in the number and types of advanced practice nursing (APN) roles.1 Advanced practice nursing roles include roles where nurses function at an higher level of practice than traditional nurses.1,2 To promote common understanding and to guide the development of APN roles globally, the International Council of Nurses' (ICN) Nurse Practitioner/Advanced Practice Network established a definition of an advanced practice nurse as "a registered nurse who has acquired the expert knowledge base, complex decision-making skills, and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice."2^(p.7)

The ICN Network summarized three core characteristics of APN roles:

i. Graduate education, which was proposed as a recommended entry level for APN roles.2,3

ii. Nature of practice, in which advanced practice nurses should have a more autonomous and independent advanced practice role (eg, direct clinical practice expert; coaching and guidance; consultations; research; clinical, professional, and systemic leadership; collaborations; and ethical decision-making).2,3

iii. Regulatory mechanisms, such as the authority to treat, diagnose, and prescribe medications.2

The ICN has recognized that regulations related to APN roles are country-specific.2

With the growing global interest in APN roles, many systematic reviews have been conducted to evaluate the impact of different APN roles. A recent systematic review documented that APN roles in emergency and critical care departments were associated with many positive outcomes involving patient satisfaction, length of hospital stay, mortality rates, time for consultation and treatment, and cost savings.4 Similar findings were reported by other systematic reviews in different settings, such as primary care.5,6 A systematic review evaluated the cost-effectiveness of an APN role, namely, the nurse practitioner in primary care, and concluded that nurse practitioners in alternative provider/ambulatory primary care roles are potentially cost-saving.7 These positives outcomes signify the importance of APN roles and have encouraged many countries to introduce and implement different APN roles in their health care systems.1,8

Advanced practice nursing roles globally

The emergence of APN roles was formalized in the 1950s when the role of clinical nurse specialist was recognized in the United States, following which nurse practitioner roles continued to develop in the 1960s as a response to a lack of primary care physicians, especially in rural areas.3 Currently, APN has been proposed as a solution to address the emerging challenges of health care systems, including the health care needs of populations that are aging and experiencing more chronic disease, the increasing use of advanced technologies, and complex health services.1,5 The need for flexible and cost-effective health care, especially for vulnerable and under-served communities, have fostered the development of APN roles.8 Although APN roles were initiated in the United States, they now exist in more than 50 countries.9,10 In Canada, APN roles commenced in early the 1970s. While APN roles emerged in countries such as Hong Kong and Taiwan in the 1990s, many countries have introduced APN roles since 2000, including Japan, the United Kingdom, Switzerland, New Zealand, and Germany. Most of these countries implemented APN roles to improve access to health care.9

Variations were noted in the titles of APN roles, required educational preparation, and practice regulations. In the United States, APN roles include nurse practitioners, clinical nurse specialists, nurse midwives, nurse anesthetists, and case managers.11 In countries such as Canada, China, Australia, New Zealand, and the United Kingdom, APN roles include titles such as nurse practitioners, clinical nurse specialists, and advanced practice nurses. In Africa, nurse practitioner is the only title used, and in Japan the only title used is clinical nurse specialist.9

Most of the advanced practice nurses in these countries complete a master's degree.9 The regulations and the scope of practice of advanced practice nurses vary between countries. For example, not all are authorized to prescribe medications. These variations in APN roles have further led to role confusion, and some scholars have claimed that variations could hinder the full utilization of the APN roles.1,3,8

Advanced practice nursing roles in Arab countries in the Eastern Mediterranean region

In support of the global trend in developing APN roles globally, the World Health Organization (WHO) has made efforts to support the development of APN roles in Arab countries in the Eastern Mediterranean region.8 The WHO identified 21 countries as part of the Eastern Mediterranean region: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somali, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen.12 All of these countries, except Afghanistan and Iran, are known as Arab countries in which Arabic is the official and the first spoken language. These countries formed what is known as the Arab league.13 These Arab countries share the same geographic area, religion, and culture, and have similar health care systems.6

Many Arab countries in the Eastern Mediterranean region have witnessed a growing interest in supporting the development of APN roles. Among the documented reasons for the need to integrate APN roles in this region include a lack of physicians both in number and specialties, an aging population, and the increasing number of chronic diseases due to lifestyle factors.1,7,8 APN roles were first introduced in Jordan in 1998 when the first master's programs for clinical nurse specialists in critical care, maternity, and community were established.14 In Saudi Arabia, the development of APN roles can be traced back to the 1990s when the job description of advanced practice nurses was initially developed.15 A nurse practitioner role was recently piloted both in Oman8 and the United Arab Emirates.16 To further support the development of APN roles, many Arab countries, including Oman, Saudi Arabia, United Arab Emirates, Qatar, and Jordan, have established master's in nursing programs that aim to prepare nurses for APN roles.3,8,15

With the global trend in APN roles, many reviews have synthesized evidence related to various aspects of APN roles internationally.1,9,11,17-19 Only two reviews provided brief details about APN roles in some Arab countries in the Eastern Mediterranean region, namely Saudi Arabia and Oman.3,8 An international survey conducted by Schober and Affara10 targeted advanced practice nurses and was completed by a limited number of nurses from Arab countries in the Eastern Mediterranean region. Thus, limited information about APN roles in this region is known. Considering that APN roles are country-specific, and appreciating the positive impacts of various APN roles, understanding and synthesizing evidence regarding APN roles in this region is significant. This will not only provide fundamental knowledge about the APN roles in this area but will also help to identify needed support to optimize the utilization of the roles. Two objectives of the ICN Network are to disseminate information about the APN roles internationally and to provide any needed support for implementing APN roles.2 Thus, synthesizing evidence from Arab countries in the Eastern Mediterranean region is relevant for nurses in this area and for the international nursing community.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted, and no current or in-progress systematic or scoping reviews on the topic were identified. This scoping review aims to identify and synthesize evidence related to the APN roles in Arab countries in the Eastern Mediterranean region in order to clearly define the roles. The four key areas that were included in the international survey for advanced practice nurses will be used to map the evidence in this review10: i) historical development, ii) role title, iii) regulations, such as certification and authority to prescribe medication, and iv) entry level education of advanced practice nurses. Including these four areas is expected to provide evidence aligned and comparable with the current evidence from international literature. The review will also include any other areas related to APN roles, such as role implementation and outcomes.

Review questions

i. How have advanced practice nursing roles developed and how have they been implemented in Arab countries in the Eastern Mediterranean region?

ii. What are the role regulations and titles that are used to describe APN roles in that region?

iii. What is the entry level education of advanced practice nurses in that region?

iv. What outcomes related to advanced practice nursing roles have been identified in that region?

Inclusion criteria

Participants

This review will consider studies that included advanced practice nurses, including, but not limited to, nurse practitioners and clinical nurse specialists. Advanced practice nurses are nurses who are practicing in APN roles. The ICN's definition of an advanced practice nurse2 will be used. Studies involving advanced practice nurses working in any clinical settings (eg, inpatient, outpatient, community) and with any patient populations will be included.

Concept

Studies that included any evidence about APN roles will be included, such as the historical development of the role, highlighting when and why the roles were developed and implemented; titles used to describe the roles; role regulations, such as certification or authority to prescribe medications; entry level education of advanced practice nurses, such as undergraduate or graduate education; factors impacting role implementation; and evidence related to the role outcomes, such as quality of care, cost, patient satisfaction, length of hospital stay, and symptom management.

Context

This review will consider studies that were conducted or that discussed APN roles only in Arab countries in the Eastern Mediterranean region, including Bahrain, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somali, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen.6 Studies that discussed APN roles in non-Arab countries will be excluded.

Types of sources

This scoping review will consider both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs, including case series, individual case reports, and descriptive cross-sectional studies for inclusion. Additionally, program evaluation studies and economic evaluation studies will be included.

Studies that focus on qualitative data will also be considered, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research. In addition, systematic reviews that meet the inclusion criteria will be considered. Text and opinion papers will also be considered for inclusion in this scoping review. Policy documents will be included as a subset of text and opinion.

Methods

The proposed scoping review will be conducted in accordance with the JBI methodology.20

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for PubMed (NLM). A full search strategy for PubMed (NLM) is detailed in Appendix I. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all included studies will be screened for additional studies. Studies published in Arabic and English will be included. Studies published since the inception of databases to present will be included.

The databases to be searched include CINAHL (EBSCO), MEDLINE (PubMed), PsycINFO, Embase (Elsevier), Nursing and Allied Health (ProQuest), and Scopus (Elsevier).

The search for unpublished studies and gray literature will include Google Scholar, ProQuest Dissertations and Theses, the ICN Nurse Practitioner/Advanced Practice Nursing Network, the WHO regional office for the Eastern Mediterranean website, and websites of nursing associations in Arab states and countries, including the Jordan Nurses and Midwives Council, Kuwait Nursing Association, Emirates Nursing Association, Saudi Nursing Association, Oman Nursing Association, and Qatar Nursing Association. Websites of governmental Ministries of Health (MOH) in Arab countries will be searched, including the website of MOH in Oman, Saudi Arabia, Kuwait, United Arab Emirates, Bahrain, Morocco, Palestine, Somalia, Tunisia, and Jordan. The Ministry of Public Health Qatar, Ministry of Health and Population Egypt, Syrian MOH, Ministry of Public Health Lebanon, Information and Documentation Centre-MOH Libya, and Ministry of Public Health and Population Yemen, will be searched. The Websites of universities in Arab countries that have master's of nursing programs will be included. These include King Saud University, Imam Abdulrahman bin Faisal University, King Abdulaziz University, Princess Nourah bint Abdulrahman University, Sultan Qaboos University, University of Calgary Qatar, University of Wollongong, University of Jordan, Jordan University of Science and Technology, American University of Beirut, Beirut Arab University, University of Balamand, Mansoura University, University of Khartoum, University of Bahrain, and University of Baghdad.

Study selection

Following the search, all identified citations will be collated and uploaded into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).21 The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-ScR) flow diagram.22

Data extraction

Data will be extracted from papers included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers. The data extracted will include specific details about the population, concept, context, study methods, and key findings relevant to the review objectives. A draft extraction tool is provided (see Appendix II), and will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data analysis and presentation

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objectives of this scoping review. A narrative summary will accompany the tabulated and/or charted results. The narrative result will be presented as themes representing the available evidence about APN roles in the Arab countries in the Eastern Mediterranean region. Some of these themes might include historical development, role title, role regulations, entry-level education, role implementation, and role outcomes.

Acknowledgments

This scoping review will fulfill part of the requirements of a PhD in nursing at Dalhousie University for SA.

Appendix I: Search strategy

PubMed (NLM)

Search conducted on March 10, 2020

Appendix II: Data extraction tool

References