Advanced Practice Nursing in India

Snapshot

APN Role Exists in Country Today:
No

Title:
Nurse Practitioner (in development)

Contact:
Indian Nursing Council

Role

With 72% of the Indian population residing in rural areas and 75% of medical providers residing in urban areas, India is currently experiencing significant shortages of physicians, particularly in rural areas (Penn Nursing Science, 2013).  In addition, the overall country has a shortage of nurses and physicians, so much so that is it estimated that there is only one physician for every 1700 people (Kumar, 2013).  While the normal standards for nurse to physician ratios often reflect between a 2.0 to 3.0 nurses per physician, India has an alarmingly low nurse to physician ratio estimated around 1.22 nurses per physican (Munjanja, Kibuka, & Dovlo, 2005).  With alarmingly low health care professionals in the country, there is significant need for advancement of those few who have the education as a nurse may well be the exclusive healthcare professional in a rural area.

Recently the region of West Benghal started training Advanced Practice Nurses, identified as Nurse Practitioners (Kumar, 2013).  While this role has just begun, India has found significant resistance to developing an advanced nursing role primarily based on strong pressures by medical organizations to not increase the scope of practice of nurses.  This is primarily related to the country’s health system that has traditionally held very limited roles for nursing and maintained physicians as sole individuals to provide advanced healthcare (Penn Nursing Science, 2013).

Meanwhile, in the region of Kerala, some have reported that graduate level Nurse Practitioner courses are already offered from the Kerala Institute of Medical Sciences (shahinshahul, ClinicalResearchSociety.org, 2012, May 28).  While such programs are offered through various independent schools throughout the country, there is yet a standard identified for a Nurse Practitioner or specific advanced practice role.

Education and Certification

Education standards in India vary from diploma programs for general nursing, bachelor programs consistent with international standards, and masters and PhD programs in nursing (CurrentNursing.com, 2013).  While these programs do offer education allowing individuals to learn advanced practice nursing concepts, the current healthcare structure in the country does not provide ample opportunities for nursing advancement at the bachelor level, let alone at the masters and PhD levels, leading to many individuals leaving their areas and country to pursue more adventitious employment (Baumann & Blythe, 2008; Penn Nursing Science, 2013).  While many of the individuals who practice nursing in India are not bachelor educated, according to Nochols, Davis and Richardson (2009), India has begun to phase out their non-bachelor programs.

Midwifery is a standard of general nursing practice in India.  Regulation varies according to state and in the country no nurse is allowed to have permission to practice in more than one state at a time.  In some states, it is illegal for males to perform midwifery and obstetrics care and as it is a part of general education, there is a greater shortage of nurses in those regions (Nichols, Davis, & Richardson, 2009).

Individuals interested in attaining permission to practice in India require permission by the Equivalency Council at selected charities for a limited duration (Indian Nursing Council, 2013).  Such provisional permission to practice in India is granted for diploma, bachelor, and master prepared nurses and granted permissions.

While an individual of foreign education may have a master degree in nursing, the provisional permissions currently in India allow them to work in the administration, but no part of the application requires specific education on patient care, indicating an individual can likely not practice at any Advanced Nursing level without exclusive permission by the nursing council (as has been granted to Penn State in the region they are attempting to initiate Nurse Practitioner education) (Indian Nursing Council, 2013).

Specialties

Not applicable at this time.

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References:

Baumann, A. & Blythe, J. (2008). Globalization of higher education in nursing.  The Online Journal of Issues in Nursing, 13(2), manuscript 4.  doi: 10.3912/OJIN.Vol13No02Man04

CurrentNursing.com (2013).  Nursing Education In India.  Retrieved October 2, 2013 from: http://currentnursing.com/nursing_education/nursing_education_in_india.html

Kumar (2013, September 23).  India has just one doctor for every 1700 people.  The New Indian Express.  Retrieved from: http://newindianexpress.com/magazine/India-has-just-one-doctor-for-every-1700-people/2013/09/22/article1792010.ece

Indian Nursing Council (2013).  Home.  Retrieved October 2, 2013 from: http://www.indiannursingcouncil.org/

Munjanja, O.K., Kibuka, S., & Dovlo, D. (2005).  Issue Paper 7: The Nursing Workforce In Sub-Saharan Africa.  International Council of Nurses.  Retrieved from: www.ghdonline.org/

Nichols, B.L., Davis, C.R., & Richardson, D.R. (2011).  Appendix J: International models of nursing.  The Future of Nursing: Leading Change, Advancing Health.  Institute of Medicine.  Retrieved from: http://www.nap.edu/catalog/12956.html

Penn Nursing Science (2013).  Utilizing APNs to Solve Provider Shortage in Rural India.  Retrieved October 2, 2013 from: http://www.nursing.upenn.edu/gha/Pages/UtilizingAPNstoSolveProviderShortageinRuralIndia.aspx

[Updated 2013, October 30]

Advanced Practice Nursing in the Netherlands

Snapshot

APN Role Exists in Country Today:
Yes

Title:
Nurse Practitioner

Nationally Certified:
Yes

Recognize Foreign Licensure:
Uncertain

Treatment Authority:
Yes

Prescribing Authority:
Yes? (conflicting information)

Practice Autonomously:
Yes

Contact:
Dutch Ministry of Health

Role

The role of Advanced Practice Nurses in the Netherlands is the Nurse Practitioner.  Introduction of this role started in 1997 (Storedur & Leonard, 2010).  The Nurse Practitioner role in the Netherlands has been focally evaluated as alternatives for general practice physicians based on a general practitioner shortage (Dierick-van Daele, 2010; Stordeur & Leonard, 2010; Zwijnenberg & Bours 2012).  According to Zwinjenberg & Bours (2012), on average Nurse Practitioners perform procedures on their patients 20% of the time.  As such, they have additionally been seen as a possible route of increasing cost-effectiveness of healthcare in the Netherlands (Dierick-van Daele, 2010; Zwijnenberg & Bours 2012).  The scope of practice for Dutch Nurse Practitioners primarily includes:

  • Advanced assessment (Dierick-van Daele, 2010)
  • Diagnosing and making decisions for further treatment (Dierick-van Daele, 2010)
  • Prescriptive Authority (Dierick-van Daele, 2010; Pulcini, Jelic, Gul, & Loke, 2009; Sheer & Wong, 2008)
  • Provision of procedures necessary for medication treatment (Zwinjenberg & Bours, 2012)
  • Referrals to primary or secondary services (Dierick-van Daele, 2010)

While several authors have stated that Nurse Practitioners have prescriptive authority in the Netherlands (see above, second bullet-point), Stodeur and Leonard (2010) state this is not the case and HAI Europe (2012) states that prescriptive authority is currently under legislation.

Since the introduction of the Nurse Practitioner role in the Netherlands, studies began showing that the role significantly addressed areas of patient care that were not previously adequately addressed by their physician staff (Stordeur & Leonard, 2010).  While the role is not intended to replace that of physicians, it has been greatly observed as a complimentary role and is pursuing more autonomous roles for Nurse Practitioners to perform patient care in patients homes and management of chronic illnesses (Storeur & Leonard, 2010).

Education and Certification

A four-year bachelor degree is necessary to work as a registered nurse in the Netherlands (Robinson & Griffiths, 2007).  The advancement of nursing practice to become a Nurse Practitioner requires an individual to receive a Master of Advanced Nursing Practice degree (Dierick-van Daele, 2010; Stordeur & Leonard, 2010).  The Dutch have been very proactive in developing a model to facilitate this role development, including having their APN students experience through immersion the Nurse Practitioner role outside their country (Ter Maten & Garcia-Maas, 2010).   Registration for Advanced Practice Nurses in the Netherlands requires individuals to register under a separate registry from that of registered nurses, maintained by a division of the Central Information Centre for Professional Practitioners, an branch under the Ministry of Health, Welfare, and Sport (Robinson & Griffiths, 2007).

Specialties

Currently, the role of Advanced Practice Nurses in the Netherlands greatly incorporates primary health care  based on the needs of the country (Dierick-van Daele, 2010).  Of note, the midwife role in the Netherlands is different than that of nurse midwives in much of the rest of the world, and is seen as its own independent profession.

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References:

Delamaire, M. & Lafortune, G. (2010). Nurses in advanced roles: A description and evaluation of experiences in 12 developed countries.  OECD Health Working Papers, 54, OECD Publishing.http://dx.doi.org/10.1787/5kmbrcfms5g7-en

Dierick-van Daele, A. (2010).  The Introduction of the Nurse Practitioner in General Practice [electronic publication].  Schering-Plough.  Retrieved from: http://arno.unimaas.nl/show.cgi?fid=20140

Pulcini, J., Jelic, M., Gul, R, Loke, A.Y. (2009).  An international survey on advanced practice nursing, education, practice, and regulation.  Journal of Nursing Scholarship, 42(1),31-39.  doi: 10.1111/j.1547-5069.2009.01322.x

Robinson, S. & Griffiths, P. (2007).  Nursing education and regulation: International profiles and perspectives [online publication].  Retrieved from:http://eprints.soton.ac.uk/348772/1/NurseEduProfiles.pdf

Sheer, B. & Wong, F.K. (2008).  The development of advanced nursing practice globally.  Journal of Nursing Scholarship, 40(3),204-211.

Stordeur, S. & Leonard, C. (2010).  Challenges in physician supply planning: The case of Belgium.  Human Resources for Health, 8(28),1-11.  doi:10.1186/1478-4491-8-28

Ter Maten, A. & Garcia-Maas, L. (2010).  Dutch advanced nursing practice students: Role development through international short-term immersion.  Journal of Nursing Education, 48(4), 226-231.

Zwijnenberg, N.C. & Bours, G.J. (2012).  Nurse practitioners and physician assistants in Dutch hospitals: their role, extent of substitution and facilitators and barriers experienced in the reallocation of tasks.  Journal of  Advanced Nursing, 68(6),1235-1246.  doi: 10.1111/j.1365-2648.2011.05823.x

Advanced Practice Nursing in Finland

Snapshot

APN Role Exists in Country Today:
Yes

Title:
Nurse (with advanced degree)
Public Health Nurse (with advanced degree)
Nurse Midwife

Nationally Certified:
Uncertain

Recognize Foreign Licensure:
Uncertain

Treatment Authority:
Yes

Prescribing Authority:
No

Practice Autonomously:
No

Contact:
Terveydenhuollon Oikeusturvakeskus (National Authority for Medico-Legal Affairs)

Role

There are two chief roles identified for Advanced practice Nurses in Finland, namely that of the Advanced Nurse and Public Health Nurse, both of which are prepared with graduated level schooling (Delamaire & Lafortune, 2010).  There is additionally a nurse midwife role available in Finland, but is understood as a registered nurse specialization rather than that of an advanced practice role (Robinson & Griffiths, 2007).  This will be described further under the specializations category below.  The roles for APNs in Finland can be delineated as follows (Delamaire & Lafortune, 2010):

  • Public Health Nurse
    • Advanced assessment, consultation, diagnosis, ordering and interpretation of diagnostic tests, management of various chronic diseases (follow-up, monitoring, and education), and referral to specialists
  • Advanced Nurse
    • Advanced assessment, consultation, diagnosis, ordering and interpretation of tests, and management of various chronic illnesses (follow-up, monitoring and education for non-acute cases)
    • Triage for prioritization of patients

The first Advanced Practice Nurses in finland graduated in 2006 (Fagerström & Glasberg, 2011).   While this role has recently been added to healthcare in Finland, the role primarily expands the autonomy and scope of practice of current nursing in the country.  According to Fagerström and Glasberg (2011), the role of APNs primarily was observed as beneficial in the care of acute and chronic health conditions.  Acutely, nurses and doctors in Finland have a longstanding cooperative relationship allowing nurses to participate in various roles (Delamaire & Lafortune, 2010).  These may appear as nurses providing greater triage or reception of patients, or even working along side a doctor as a dual discipline team.  Additionally, APNs in Finland also play an influential role in providing care to more rural areas underserved by physicians while also providing care at a lower cost than care provided by physicians (Delamaire & Lafortune, 2010).  Often in these situations, nurses will provide the general examination of patients and have further electronic consultation with doctors for providing complicated care, often providing 70% of patient care (Delamaire & Lafortune, 2010).

Meanwhile, Delamaire and Lafortune (2010), reported that Finland was of the top nations with the highest number of nurses per 1000 people in the country at 15.5; thus indicating a surplus of nurses.  Meanwhile, they indicated that Finland held a mildly below average ratio of doctors per capita (2.7 to 1000 people; European average was 2.8) (Delamaire & Lafortune, 2010).  As a result, Finland presents itself as good place to further develop the Advanced Practice Nursing role, with a higher ratio of nurses and a lower number of doctors per capita, similar to that of the United States and United Kingdom (Delamaire & Lafortune, 2010).

Proposal to expand the role of APN practice in Finland to include limited prescriptive authority to those working in public health centers is currently underway (HAI Europe, 2012; Tynkkynen, n.d.).

Education and Certification

Education for Advanced Practice Nurses in Finland produced it’s first graduates in 2006 (DeGeest et al., 2008; Fagerström & Glasberg, 2011).  Education for the registered nurse usually requires 3.5 years, and 4 years for the public health nurse (Robinson & Griffiths, 2007).  The advanced degrees are available afterward to those who desire further advancement in scope of practice at the graduate level (Delamaire & Lafortune, 2010).  While registration and certification is available for nursing in Finland, it is not currently provided for APNs (Robinson & Griffiths, 2007).  Registration for healthcare individuals within Finland is maintained by the National Authority for Medico-Legal Affairs (Terveydenhuollon Oikeusturvakeskus).

Specialties

At this time, APNs have been working in various roles including rural healthcare, general practice, and acute care (Delamaire & Lafortune, 2010).  However, registered nurses in Finland have the choice of specializing in various categories nearing graduation of nursing school in acute care, geriatric care, mental health, multi-cultural, pediatrics, palliative care and youth and adolescent care (Robinson & Griffiths, 2007).  Additionally, an individual can choose to be a nurse midwife with an additional year of schooling (Robinson & Griffiths, 2007).

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References:
De Geest, S., Moons, P., Callens, B., Gut., C., Lindpainter, L., & Sprig, R. (2008).  Introducting advanced practice nurses/nurse practitioners in health care systems: A framework for reflection and analysis.  Swiss Med Weekly, 138(43-44),621-628.

Delamaire, M. & Lafortune, G. (2010). Nurses in advanced roles: A description and evaluation of experiences in 12 developed countries.  OECD Health Working Papers, 54, OECD Publishing.http://dx.doi.org/10.1787/5kmbrcfms5g7-en

Fagerström, L. & Glasberg, A.L. (2011).  The first evaluation of the advanced practice nurse role in Finland – The perspective of nurse leaders.  Journal of Nursing Management, 19, 925-932.  doi:10.1111/j.1365-2834.2011.01280.x

HAI Europe (2012). The next chapter in promotion of healthcare professionals: Nurse prescribers [fact sheet]. Retrieved from: http://haieurope.org/wp-content/uploads/2012/02/27-July-2011-HAI-Europe-Nurse-Prescribers-Factsheet.pdf

Robinson, S. & Griffiths, P. (2007).  Nursing education and regulation: International profiles and perspectives [online publication].  Retrieved from: http://eprints.soton.ac.uk/348772/1/NurseEduProfiles.pdf

Tynkkynen, L.K. (n.d.). Limited right for nurses to prescribe medication.  Health Policy Monitor.  Retrieved from: http://www.hpm.org/en/Surveys/THL_-_Finland/15/Limited_right_for_nurses_to_prescribe_medication.html

Advanced Practice Nursing in Poland

Snapshot

APN Role Exists in Country Today:
Yes

Title:
Nurse Specialist
Nurse Midwife

Nationally Certified:
No

Recognize Foreign Licensure:
RN and Midwife Nursing licensure is recognized from EU

Treatment Authority:
Varies according to specialty

Prescribing Authority:
No

Practice Autonomously:
No

Contact:
Ministerstwo Zdrowia (Poland Ministry of Health)

Role

Development of the Advanced Practice Nurse Role in Poland has been greatly driven by the financial benefit that APNs can provide equal care at a lesser cost than that of physicians (Delamaire & Lafortune, 2010).  According to Strózik (2006), Poland has almost 2 nurses per every doctor in the country, and has about 2.3 physicians per 1000 individuals, not significantly lacking.  However, there is also reportedly slower waits to see physicians and consultants (more experienced and knowledgable physicians) and in the emergency rooms than most of the EU (europe-cities.com, 2013).

The expanded roles of nurses in specialty positions perform advanced physiologic and psychologic assessment.  The role of APNs as nurse specialists in Poland are not uniform according to specialty, but are based on the healthcare needs within the country for more urgent care and intensive management.  As a result, such expanses of scope of practice include management of some chronic illnesses (i.e. diabetes and end-stage renal disease), perform triage for patient prioritization, or some emergency procedures (i.e. emergency intubation or tracheotomy) (Delamaire & Lafortune, 2010).  APNs in Poland however do not have prescriptive authority (Delamaire & Lafortune, 2010).

According to Delamaire & Lafortune (2010), the chief barriers to advancing nursing practice in Poland is four fold:

  • Medical association opposition
  • Lack of government funding for new roles
  • Legislation
  • Methods of compensation for physicians

Education and Certification

Nurses are trained regularly at the bachelor level based on a 3 year post high school education.  They can opt for an extended track that allows for midwifery practice, totaling a 5 years of post graduate coursework (Rechel, Dubois, & McKee, 2006).  Coursework is directed and approved by the Poland Ministry of Health and a post graduation licensure exam is required to practice (Nichols, Davis, & Richardson, 2011; Strózik, 2006).

Specialties

Nurses have opportunities to obtain post bachelor graduate education in midwifery, pediatric, psychiatric, and additional opportunities (Strózik, 2006).  While these specializations offer further education and knowledge application, information is lacking on the extent, if any that the scope of practice may be expanded.

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References:
Delamaire, M. & Lafortune, G. (2010). Nurses in advanced roles: A description and evaluation of experiences in 12 developed countries.  OECD Health Working Papers, 54, OECD Publishing.http://dx.doi.org/10.1787/5kmbrcfms5g7-en

europe-cities.com (2013).  Healthcare in Poland.  Retrieved from: http://www.europe-cities.com/en/633/poland/health/

Nichols, B.L., Davis, C.R., & Richardson, D.R. (2011).  Appendix J: International models of nursing.  The Future of Nursing: Leading Change, Advancing Health.  Institute of Medicine.  Retrieved from: http://www.nap.edu/catalog/12956.html

Strózik, M. (2006). Chapter 7: Poland. The Health Care Workforce in Europe: Learning from experience.  World Health Organization: Copenhagen, Denmark.  Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0008/91475/E89156.pdf

Advanced Practice Nursing in Switzerland

Snapshot

APN Role Exists in Country Today:
Yes

Title:
Advanced Practice Nurse
Nurse Anesthetist

Nationally Certified:
Yes

Recognize Foreign Licensure:
Uncertain

Treatment Authority:
Uncertain

Prescribing Authority:
No

Practice Autonomously:
No

Contact: 
University of Basel

Role

The role of the Advanced Practice Nurse in Switzerland has been developing since 2000 with the first advanced practice nursing program.  While there is no current scope of practice that is identified in the country, Switzerland has been developing the role of APNs that most closely resemble Clinical Nurse Specialists (Sprig, Schwendimann, Spichiger, Cignacco, & De Geest, 2009).  Often individuals who are prepared at the APN level will function not at the clinical level, but rather in leadership, quality, and process improvement levels (Sprig et al., 2009).  Additionally, APNs in Switzerland have been working with more advanced assessment and specialized patient care as well, but is more done so on an organizational-based program (Imhof, Naef, Wallhagen, Schwartz, & Mahrer-Imhof, 2012).  Because the development of APNs in Switzerland has been more driven on creating new healthcare models and improved outcomes rather than a physician shortage, there is little regulation at this time that defines a clear scope of practice (De Geest et al., 2008).

The Nurse Anesthetist role is also in existence in Switzerland (International Federation of Nurse Anesthetists [IFNA], n.d.).  Reportedly there are approximately 1900 Nurse Anesthetists in Switzerland today, more than that of anesthesiologists in the country (INFA, n.d.).  Regulations vary according to region, but in general Nurse Anesthetists administer general anesthesia under the supervision of an anesthesiologist (INFA, n.d.).

Education and Certification

Education for the APN in Switzerland is provided at the masters level after an individual achieves a bachelor degree in nursing (Sprig et al., 2009).  The programs for APNs in Switzerland require an individual to have English proficiency, 2 years of clinical professional experience in nursing, and have a degree in nursing (Sprig et al., 2009).  Additionally, individuals in nursing have also graduated at the doctorate level (PhD) in nursing (Sprig et al., 2009).

Education for a Nurse Anesthetist in Switzerland requires a nurse after obtaining a four-year nursing diploma an additional 400 hours of classroom education and approximately 200 hours of clinical time (INFA, n.d.).

Specialties

While there are various specializations that APNs may function within Switzerland, those observed in the literature were of HIV/AIDS, gerontology, and general practice (primary health care) (Imhof et al., 2012; Sprig et al., 2004).

Have information to add to this page?

References:
De Geest, S., Moons, P., Callens, B., Gut., C., Lindpainter, L., & Sprig, R. (2008).  Introducting advanced practice nurses/nurse practitioners in health care systems: A framework for reflection and analysis.  Swiss Med Weekly, 138(43-44),621-628.

Imhof, L., Naef, R., Wallhagen, M.I., Schartz, J., & Mahrer-Imhof, R. (2012).  Effects of an advanced practice nurse in-home health consultation program for community-dwelling persons aged 80 and older.  Journal of the American Geriatrics Society. 60(12),2223-2231.  doi: 10.1111/jgs.12026

International Federation of Nurse Anesthetists [IFNA] (n.d.). Switzerland Country Page.  Retrieved from: http://ifna-int.org/ifna/page?38

Sprig, R., Nicca, D., Voggensperger, J., Unger, M., Werder, V. & Niepmann, S. (2004).  The advanced nursing practice team as a model for HIV/AIDS caregiving in Switzerland.  Journal of the Association of Nurses in AIDS Care.  15(3),47-55.  doi:10.1177/1055329003261960

Sprig, R., Schwendimann, R., Spichiger, E., Cignacco, E., & De Geest, S. (2009).  The leadership role of the Institute of nursing Science, University of Basel in launching advanced practice nursing in the German speaking European countrires.  Universitat Basel.  Retrieved from: http://nursing.unibas.ch/fileadmin/pflege/redaktion/Institut/090206_ANP_ICN_Website.pdf

Advanced Practice Nursing in Sweden

Snapshot

APN Role Exists in Country Today:
Yes

Title:
Advanced Clinical Nurse Specialist

Nationally Certified:
No (Nurse Specialist title is restricted to individuals graduating from specific programs in Sweden)

Recognize Foreign Licensure:
Uncertain (likely no at this time)

Treatment Authority:
Varies

Prescribing Authority:
Yes

Practice Autonomously:
No

Contact:
Vårdförbundet

Role

The Advanced Clinical Nurse Specialist role was initiated through programs first offered in 2005 (Lindblad, Hallman, Gillsjo, Lindblad, & Fagerstom, 2010).  While the role of Nurse Specialists has existed and the title is protected, the advanced practice nursing (APN) role has been in development.  The role of APNs in Sweden has been under evaluation and experimentation in general practice (primary health care) and has been based on an institutional-specific model allowing varying levels of scope of practice (Lindblad et al, 2010).  Because of the lack of APN role identification, the role is currently under development to be of the greatest benefit to the Swedish health care system (Lindblad et al., 2010).  Further, it appears the Swedish health care system has a strong need for more Nurse Specialists (Vårdförbundet, 2013).  As a result, if there are not enough individuals in the country to provide the supply of Nurse Specialists, there may additionally not be enough supply of individuals who desire additional training to increase their scope of practice.  In Sweden however, nurses have been given the nurse prescribing authority since 1994, initiating nursing prescriptive authority in Europe (HAI Europe, 2012).

Education and Certification

Nurse Specialists are trained at the masters level (Vårdförbundet, 2013).  The current programs in Sweden have been educating individuals for the Advanced Clinical Nurse Specialist role since 2005 (Lindblad et al., 2010).

Specialties

At this time APNs have been primarily working in general practice (primary health care).

Have information to add to this page?

References:
HAI Europe (2012). The next chapter in promotion of healthcare professionals: Nurse prescribers [fact sheet]. Retrieved from: http://haieurope.org/wp-content/uploads/2012/02/27-July-2011-HAI-Europe-Nurse-Prescribers-Factsheet.pdf

Lindblad, E., Hallman, E.B., Gillsjo, C., Lindblad, U., & Fagerstom, L. (2010).  Experiences of the new role of advanced practice nurses in Swedish primary health care–A qualitative study.  International Journal of Nursing Practice, 16, 69-74.  doi:10.1111/j.1440-172X.2009.01810.x

Vårdförbundet (2013).  Specialist Nurse [translated by Google Translate].  Retrieved from: https://www.vardforbundet.se/Min-profession/Sjukskoterska/Specialistsjukskoterska/