https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article Knowledge and Perspectives of Postgraduate Nurses regarding compe- tency of Advanced Nursing Practice in Kurdistan Region of Iraq ABSTRACT INTRODUCTION Advanced nursing practice (ANP) is a high degree of knowledge, skill and experience that is applied within the nurse-consumer relationship to achieve optimal outcomes through critical analysis, problem solving and accurate decision-making *1+. ANP has always existed because nursing is continually evolving, and this might be reflecting on patients and community service needs *2+. Besides, the role of the advanced nurse has grown continuously over the last centuries due to pressures related to reimbursement and managed care, a growing patient advocacy, and changing attitudes about role of nurses. Background and objectives: Advanced nursing practice (ANP) involves integration role do- mains, which are related to clinical practice, education, research, professional de- velopment and organizational leadership. The objectives of this study were to assess the knowledge and perspective of graduated nurse regarding competency of advanced nursing practice and explain the domains of advanced nursing practice competency. Methods: This cross-sectional study sought to determine knowledge and perspective of graduated nurses regarding advanced nursing practice in Kurdistan region from 20th June 2014 to 20th December 2014. Nurses who held degrees including Master of Science, and Philosophy of Doctorate or both were invited to participate. One hundred and fifty participants met the inclusion criteria, and 50 completely responded to the questionnaire. Data were analyzed by using Statistical Package for the Social Sciences (SPSS) Version (20). Results: The total 50 of interviewed participants responded to the survey, with 24 (48%) considering that an ANP should have autonomy in clinical practice. While 28 (56 %) and 35 (70 %) of participants mentioned that an ANP should be able to manage complexity throughout clinical placement. Conclusion: Considerable number of participants in this study did not have adequate and satisfactory knowledge regarding advanced nursing practice. Keywords: Advanced nursing practice, Knowledge, Nurse. Bootan Hasan Ahmed ; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Ribwar Arsalan Mohammed; Department of Nursing, College of Nursing, University of Raparin, Sulaimaniya , Iraq. Sanaa Hassan Abdulsahib ; Department of Nursing, College of Nursing, University of Raparin .Sulaimaniya , Iraq. Vian Afan Naqshbandi; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: ribwar@uor.edu.krd) 64 Erbil Journal of Nursing & Midwifery Received: 2/9/2017 Accepted: 28/10/2017 Published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article As a result, these phenomena were helpful in developing role of nurse *3+. Studies have demonstrated that many reasons and events that are helpful in emerging and developing role of ANP but are not limited including the health care needs of the population, practice pattern and new models of care, education, workforce issues and the legacy and policy context *12+. Similarly, another study introduces that socio-political environment, government policy and support, intra/ inter professional collaboration and developing nursing education shaped ANP *4,5+. Furthermore, health cares policy and culture of the health care settings where nurse work played a considerable role in shaping and defining role of ANP *10+. The concept of advanced nursing practice (ANP) and/or advanced practice nurse (APN) have been used interchangeably among the literature and studies; however, they represent the same meaning *4, 6, 12, 13+. There is no single definition of ANP but there is a consensus agreement that it extends traditional scope of nursing, highly autonomous practice of nurse, increase the use of nursing knowledge and participating to the development of profession *14, 15+ APN has been defined in different forms in studies. For example, International Council of Nurses (ICN) defines ANP as a “registered nurse who has acquired the expert knowledge base, complex decision making skills and clinical competencies for expanded practice the characteristics for which are shaped by the context and / or country in which s/he credentialed to practice. A master’s degree is required for entry level” *7+. Thus, there is lack of worldwide acceptance regarding the definition of ANP and this led to inconsistency about competencies that are required for this level of practice *11, 18+. However, there are three features that distinguishes APN from basic nursing practice including specialization of care for a specific population of patient with complex health care needs, acquisition of recent knowledge and skills as well as autonomy extending in scope of nursing practice *14, 15+ Competence and skills are required to achieve ANP but describing these two terminologies is complex and dynamic *10, 13+. Competency is a quality or characteristics of a person that is related to effective performance including combination of knowledge, skills, motives and traits *19+. On the other hand, ICN defines competency as the level of performance demonstrating the effective application of knowledge, skills, judgment and personal attributes required to practice safely and ethically in a diagnosed role and setting *7+. Distinguishing the role of APN is less difficult in countries including the United States, where legalization, regulatory mechanisms, protected titles for clinical nurse specialist, nurse midwives, nurse anesthetists and nurse practitioners exist *10+. Because problems might arise when several roles are applied to the same title, such as nurse specialist, there is now an international agreement about the utilization of titles to distinguish the ANP role. Bryant-Lukosius and DiCenso (2004) stated that roles of ANP would be clearly distinguished due to lack of regulation and protective title for nurses in clinical nurse specialist. The role is defined as the competences related to clinical practice, education, research, organizational leadership, and professional development *10+. In the Kurdistan Region (KR) of Iraq, the College of Nursing was created in three provinces including Erbil, Sulimani, Dohuk and Raparin in 2001 in order to develop the nurse workforce. Increasing the number of undergraduate students, developing higher education 65 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article composed of knowledge regarding competencies of ANP. The third section was the perspective of participants regard- ing developing ANP in KR. The questionnaire was given to participants to complete individually. Eligible criteria to participate in this study were nurses who were holding Master of Science in Nursing (M.Sc.), Philosophy of Doctorate (PhD) or both; having a scientific degree that is not less than assistant lecturer and being able to speak and write in English. Both Diploma and M.Sc. degree considered studying of graduate for 2 years separately, whereas PhD degree was considered studying of graduate degree for three to four years. Participants were attending schools of nursing in public universities including Hawler Medical University, University of Raparin, Duhok University, public and private hospitals. Prior to commencement of the study, written confirmation was obtained from Research Committee in College of Nursing in Hawler Medical University. A total 150 participants met the inclusion criteria. Data collection was done by self-administered questionnaire, and given to the participants in the given areas, and only 50 completely responded questions in the questionnaire; the remaining rejected to participate in the study. Data were analyzed by using Statistical Package for the Social Sciences (SPSS) Version (20). In which mean and standard deviation of participants were taken in terms of age and their experience as a nurse. Then, frequency and percentage of participants with respect to each question was introduced. degrees (Master, and PhD) in nursing fields, increasing workload on the physicians, and developing more subspecialties in clinical practice demonstrate ANP in nursing education in the KR. This I because when health care delivery increases via consumer demands, ANP may emerge *4+. Surprisingly, in KR, there is no a scientific evidence regarding the perspective of graduated nurses on ANP at nursing academic institutions. ANP in academic settings are introduced to change pattern of practice, identification of skills and specialization in a relevant field *20+. As health-care is always evolving, innovative clinical practitioner is required in order to play a major role in health care settings *14+. The primary aim of this article is to assess the knowledge of graduate nurses regarding competence of ANP and to examine their perspectives toward incorporation of ANP in Kurdistan Region health care facilities. A quantitative cross-sectional study was carried out to assess knowledge and perspective of graduated nurses regarding competency of ANP in Kurdistan region of Iraq from June 20, 2014 to December 20, 2014. Following an extensive reading of ANP literature, and specifically advanced nursing practice toolkit *21+ a constructed questionnaire was developed to meet the purpose of the study. It was reviewed by two expertise's in order to improve internal validity and internal consistency reliability of the questionnaire. The questionnaire was composed of three sections. The first section was demographical characteristics of participants. The second section was 66 Erbil Journal of Nursing & Midwifery METHODS RESULTS Regarding demographical data, Mean and Standard Deviation of the participant age https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article and years of experience in nursing were 40.08 ±9.52 and 6.58 ±4.46 respectively. The majority of participants were studying inside of Iraqi universities (78%), whereas 22% of them were finished the postgraduate degree abroad. Most held a Masters degree (68 %). The academic titles of the participants were mainly assistant lecturer (48 %), while lecturer, assistant professor and professor were 28%, 12% and 2% respectively as revealed in the table 1. Table 1: Participant Characteristics Table 2: Knowledge of participants re- garding, pre-requisites qualification and roles of advanced nursing practice Table 3 reveals that almost all participants (86%) posited that decision-making, clinical judgment and problem solving are the main competencies that an advanced clinical practitioner must have, during their clinical practice. On the other hand, 24 (48 %) and 21 (42 %) considered that an ANP should have autonomy in clinical practice and managing risk respectively. While 28 (56 %) and 35 (70 %) of participants mentioned that an ANP should be able to manage complexity and have a good communication skill with colleagues throughout clinical placement respectively. Table 4 shows number of participants believed that an ANP should develop their ability to access research 17 (34 %) and implement research findings 17 (34 %) in clinical placement. However, low number of participants suggested that ANP need to 67 Erbil Journal of Nursing & Midwifery Participant characteristics Frequency % Roles Educator and Researcher 40 80 Leader 5 10 Clinical Practitioner 5 10 Total 50 100 Academic title Assistant lecturer 24 48 Lecturer 14 28 Assistant Professor 6 12 Professor 1 2 No academic title 5 10 Total 50 100 Qualification MSc 34 68 PhD 16 32 Total 50 100 Regarding the prerequisite qualification to take ANP role, 22% of participants thought that holding a diploma was a minimum requirement, compared to 20% who believed that holding a Masters degree was required. The majority believed that ANP must be an advanced clinical practitioner (76%), whereas only 4% of them highlighted that an ANP should play all roles. (Table 2). Pre- requisite qualifica- tion of ANP Frequen- cy % CBTC 10 20 Diploma 11 22 BSc 10 20 MSc 10 20 PhD 9 18 Total 50 100 ANP roles Clinical/ Professional Leadership 4 8.0 Facilitating Learning 5 10.0 Research and Develop- ment 1 2.0 Advanced Clinical Practice 38 76.0 All above 2 4.0 Total 50 100.0 https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article develop their ability in terms of presenting seminar in conference 14 (28 %) and publication 12 (24 %) Table 3: Perspectives of participants re- garding skill abilities and characteristics of advanced clinical Practice Table 4: Perspective of participants re- garding research, and development com- petency domains of advanced nursing practice Table 5 reveals that participants supposed that being able to learn and improve nurse’s capability and building capacity 17 (34 %). However, 10 (20 %) and 14 (28 %) of participants demonstrated that an ANP should be able to provide information and develop principles of teaching respectively. Table 6 shows that 19 (38 %) participants believed developing the team in working place was the main skill of this type of nurse’s role. A small number of responders highlighted that equality and diversity 10 (20%) are the main clinical leadership skills of an ANP. Regarding perspectives of an ANP, table 7 shows that majority of participants 40 (80 %) suggested that ANP should be incorporate into context of health care including primary health care centers and hospitals in KR. Besides, 23 (46 %) participants thought that ANP can meet health care needs of society, while 3(6 %) 68 Erbil Journal of Nursing & Midwifery Advanced Clinical Practice Frequency % Decision making / clinical judgment and problem solving 43 86 Critical thinking and analytical skills incorporating critical reflection 35 70 Managing complexity 28 56 Assessment, diagnosis referral, discharge 34 68 Developing higher levels of autonomy 24 48 Assessing and managing risk 21 42 Prescribing 25 50 Developing confidence 29 58 Developing therapeutic nursing to improve patient outcomes 33 66 Higher level communication skills 35 70 Patient Focus / Public Involvement 31 62 Research and Development Frequen- cy Per- cent % Ability to access research/ use information 17 34 Critical appraisal / evaluation skills 14 28 Involvement in research / audit 13 26 Ability to implement research findings into practice- including use of and development of policies / protocols and guidelines. 17 34 Conference presentations 14 28 Publications 12 24 https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article participants mentioned that governmental health policy is helpful to introduce ANP into health care sectors of Kurdistan region. In other words, as is clarified in the table 7, most participants thought developing of ANP in Kurdistan region may be difficult due to deficiencies of job descriptions in the health care system (46 %) and lack of inter and intra professional cooperation 6 (12 %) among health care staff at the hospitals. In addition, 4 (8%) considered that socio-political environment of hospitals is another difficulty in front of introducing ANP in Kurdistan region. 69 Erbil Journal of Nursing & Midwifery Table 5: perspective of participants regarding facilitating-learning ANP competency domain. Table 6: Perspective of participants about clinical leadership basic skills. Facilitating Learning Frequency % Principles of teaching and learning 17 34 Supporting others to develop knowledge and skills 15 30 Promotion of learning / creation of learning environment 16 32 Service user/ career teaching and information giving 10 20 Developing service user/ career education materials 14 28 Mentorship and coaching 15 30 Building capability and capacity 17 34 Clinical /Professional Leadership Frequency % Identifying need for change, developing case for change including service development. 16 32 Clinical Governance 11 22 Equality & Diversity 10 20 Ethical decision-making 16 32 Developing case for change 13 26 Negotiation and influencing skills 13 26 Incorporate values-based care into practice 12 24 Networking 13 26 Team Development 19 38 https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article 70 Erbil Journal of Nursing & Midwifery Table 7: Participant perspectives regarding incorporation of the ANPs in health care sectors and obstacles of introducing ANP into health care settings in KR Incorporation of the ANP into health settings Frequency % Yes 40 80 No 10 20 Total 50 100 Incorporate ANPs To meet the health needs of society 23 46 Health care work loads 5 10 Governmental policy and support 3 6 Development of nursing education 15 30 No answered 4 8 Total 50 100 Obstacles of introducing of ANP Frequency (%) Lack of Job description in the health care sys- tem 23 46 Absence of the high qualified nurses 5 10 Socio-Political environment of the health agen- cies 4 8 Lack of inter-intra professional coopera- tion’s 6 12 No answered 2 4 Total 50 100 The present study found that most of the participants believed that holding a diploma certificate in nursing (those who graduate in technical institute) (22%) is required to be appointed as an ANP, whereas (20%) and (18 %) of participants highlighted that M.Sc. and PhD are required for being an ANP respectively. As indicated in the literature, nurses working at advanced level during extensive clinical practice experience of a specific field and following completion of Master’s level or above can work as ANPs. Various studies support having a Masters degree as the minimum to appointed as ANP *2, 5, 7+. This study has found that few participants had acceptable knowledge about the roles of ANP. It might be due to this role is not delineated in Iraq, and Kurdistan region. Most participants are not studying abroad specifically in United Kingdom (UK) and the United States or other countries where nurses have this role. In contrast to this study, for the first time in the UK a study found that an ANP must be an expert practitioner, educator, researcher and consultant in clinical practice *13+. Moreover, three studies have suggested that role of the ANP should not be introduced as a homogeneous category, however; it needs to be introduced as heterogeneous sub-roles *5, 10+. With respect to characteristics and skills of ANP DISCUSSION https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article that the responsibility of APNs should be clarified for nurses at hospitals and other health care settings. Finally, it is Recommended that a module of ANP have to in corporate into postgraduate curriculum in nursing faculties. Inadequate knowledge regarding sub roles, competences of ANP, and required qualify cation to enter the level of ANP were identified. Participant attitudes toward developing ANPs in KR were positive. The role of ANP need to be more clearly defined to all postgraduate nurses in order to improve and meet health care needs in this region. There is no conflict of interest to declare regrading this study. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector *1+ Mantzoukas S, Watkinson S. Review of advanced nursing practice: the international literature and developing the generic features. J Clin Nurs. 2007;16(1):28-37 *2+ Department of Health. Advanced level Nursing: A position statement. Leeds: UK Government; 2010 *3+ Keane A, Becker D. Emerging Roles of the Advanced Practice Nurse. In: Joel AL (eds) Advanced practice nursing essentials for role development. Nursing, Joanne Patzek DaCunh. The domains as shown in the table (2), participants of this study did not provide insight regarding competencies of ANP in terms of clinical performance, characteristics of clinical leadership and conducting research. This is might be due to two factors: there is no such kind of nursing roles in the Iraq and Kurdistan region and advanced nursing has not been incorporated into postgraduate curriculums. Numerous studies regarding ANP have stated that it must play the key roles in competencies of advanced nurse practitioner, being educator in clinical practice, researcher, leader and manger in clinical practice *18+. Most participants have diverse views regarding ANP sub-role competencies; this might be referred to lack of inadequate knowledge regarding this role. Incorporating ANPs into the health care system in the Kurdistan region is seen as essential by the participants in which 40 (80%) supported that ANP should be introduced in health care system of KR. This is because all felt that role of nurses has to be expanded to improve the health care services and to meet patients’ needs. Implementation of new roles might be confronted variety of challenges and problems. A total 46% expected that developing such kind roles in KR is likely to face a number of challenges including a lack of job description, supporting of professional bodies, and role recognition by authorities. Most participants supposed that lack of job description and lack of inter and intra-professional cooperation were the main obstacles *22+. Additional study with more participants, including all nurses who hold B.Sc. or High and Diploma in nursing, and medical doctors, and other stakeholders, should be conducted. The concept ANP need to be explained for nurses who hold M.Sc., PhD or both of them in order to provide an insight regarding ANP. Additionally,, it is important 71 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICT OF INTEREST: FUNDING SOURCES: REFERENCES: https://doi.org/10.15218/ejnm.2018.09 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article *13+ Manley K. A conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/consultant nurse role. Journal of Clinical Nursing. 1997:6(3):179-190. *14+ Canadian Nurse Association, Advanced Nurse Practice: A national Framework *Internet+. 2008.. 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Philadelphia: F.A. Davis; 2009. *21+ Advanced Nursing Practice Toolkit *Internet+. 2015 *cited 31 October 2015+. Available from: http:// www.advancedpractice.scot.nhs.uk *22+ Kleinpell R. Evolving Role Descriptions of the Acute Care Nurse Practitioner. Critical Care Nursing Quarterly. 1999:21(4):9-15. 73 Erbil Journal of Nursing & Midwifery