Even though Advanced Practice Nursing (APN) has been demonstrated to be highly effective in many contexts, its implementation in the Americas is a pending debt. Recently, at the XVIII Pan American Nursing Investigation Colloquium, held in November 2024 at Santiago de Chile, the gaps in the implementation of APN were discussed, and the lack of consistent public policies to support its implementation was recognized ¹. According to the Regional Forum for the Advancement of Nursing in Latin America, the main challenge for the regional implementation of APN is to achieve its recognition and regulation ².

Regulation must consider stretching the role of the nursing staff, according to the specific policies of each country. In that sense, the guidelines on APN proposed by the International Council of Nurses (ICN) contemplate: Authority to diagnose and order diagnostic testing, prescribe therapeutic treatments, and refer clients/patients to other services, professionals or discharge ³. Regulation must also consider the autonomy to accept new roles in specific clinical environments and the implementation of evidence-based care ².

Nevertheless, countries in the Americas need to advance in legislation to bestow and protect the APN degree and at the same time develop regulatory mechanisms of its practice through certification, credentials or authorization for the practice of this role, according to the context of each nation. Considering there are countries which not even have legislation for Nursing, or have restrictive legislations, it is necessary to advance in the regulatory aspects to reduce inequality and political heterogeneity to achieve the social mandate of Nursing ⁴. In this sense, jurisdiction and autonomy are hard to accomplish without a previous social recognition of the training and development of the profession; a situation that has been described as complex in the Latin American context because the characteristics of the discipline are accompanied, at great length, by abstract knowledge related to the art of caring ⁵.

To address these challenges, coordinated efforts between governments, academic institutions, professional organizations and the community are needed to consistently advance in the development of a legal framework that regulates the practice of the APN role in health systems. This implies that the jurisdiction develops progressively, starting with collaborative practice agreements between doctors and APNs alongside rules and protocols that regulate the widened and autonomous practice of the role. This approach would allow to generate local evidence, strengthen teaching capacity and improve the understanding of the role by the decision-makers, facilitating in the way an eventual larger scales legislative change.

Another challenge for the implementation is to defeat the demagogy of Nursing as a support discipline of the medical profession. Between 2018 and 2020, different Latin American countries united in the global campaign Nursing Now, promoted by the World Health Organization (WHO) and the ICN to reveal the significant contribution of Nursing as a profession, foster governments' investment in the development of the nursing workforce, and encourage the introduction of APN for the betterment of universal health coverage⁶. For the implementation of APN in the Americas, the positioning of the professional role is necessary, as well as potentiating nursing leadership and permanently knocking down the view of the nursing role under doctors' supervision. This is an especially complex challenge when models centered on disease, specialist doctors and the hospital prevail. Due to their training, APN professionals are | prepared to perform direct hospital functions with a high level of autonomy, lead multidisciplinary teams, develop mentoring for other health professionals, manage research to transform the practice and collaborate in ethical decision-making. The APN role is also distinguished by providing safe care, based on evidence, and that answers to the current health demands of the population ⁷.

Inequality and inequity in academic training constitute another challenge for the implementation of APN in Latin America. Even if some countries like Chile and México have started to strengthen graduate APN programs, other countries still lack specific education programs to train nurses at that level, evidencing the need to foster a postgraduate degree in APN.

It must be also recognized that, in many countries of the region, health systems face a financial sustainability crisis and lack enough resources to fully integrate APN into their work teams. In this line, the lack of infrastructure and resources hinders the insertion of the new role.

Some American countries have faced access and coverage problems in medical attention. In this scenario, the distribution of resources focuses mainly on big cities and urban areas, generating attention gaps in rural areas. APN presents itself as an innovative solution to reduce these disparities in Latin America; however, unequal distribution of medical resources continues to be a challenge. In rural areas, medical attention is limited, and medical infrastructure frequently lacks the necessary elements to provide holistic care. In light of this reality, incorporating APN presents itself not only as a strategy to expand the service but as an attention model that strengthens equity in health and answers to the specific needs of the most vulnerable communities.

In Latin America, funding is insufficient to invest in the training of human resources with these characteristics and the options to have access to public or private scholarships to finance the training of APNs are limited. This is an important impediment to the implementation of APN in the region, given that most Latin American countries have reduced budgets that prioritize health expenditure in infrastructure and priority disease coverage, with the training of specialist doctors. Funding is also affected by the limitation of local cost-efficiency evidence of the implementation of APN. For example, in contexts like the United States, Europe, and Australia some studies show the relationship between the costs and the benefits of APN compared with other scopes, showing the implementation of this role can be beneficial both in economic terms and in improving the quality of attention ⁸. Despite that, there is not enough local evidence in the region, for this reason, it is essential to stimulate the production and diffusion of studies in this line that can support investment in APN.

Finally, the implementation of APN poses ethical challenges regarding autonomous decision-making, especially in contexts where nurses may be exposed to high medical complexity situations. In 2021, the ICN launched an update of the Code of Ethics for Nurses ⁹, that contemplates a declaration of ethical values, responsibilities, and accountability in the different functions of these professionals. It would be advisable to extend these ethical considerations to the role of APN in the next update of the code, with the aim of ensuring that advanced nurses are incorporated and that this role is developed within the wider limits of their competence to provide safe and quality care.