Introduction
Advanced practice nursing (APN) plays a crucial role in modern healthcare delivery, providing expert care and guidance to patients with complex health needs. Advanced practice nurses work in various settings, including hospitals, clinics, and community health centers, and are highly valued for their clinical expertise, leadership skills, and ability to improve patient outcomes [1, 2]. Although the demand for APN is growing rapidly, information concerning how to guide its successful implementation and utilization remains limited [3]. According to Bryant-Lukosius and DiCenso [3], advanced practice nurses are hired to maximize the available nursing knowledge and skills that can advance and improve healthcare delivery. Most countries utilizing APN roles have implemented specialized APN programs, primarily at the master’s degree level or higher [4]. Graduate education for APN encompasses research, clinical practice, leadership, and professional development [3]. Furthermore, APN education and training primarily focus on developing competencies in critical thinking, problem-solving, and clinical decision-making [4]. Advanced practice nurses are uniquely positioned to take on leadership roles, collaborate with other healthcare professionals, apply evidence-based practice, and shape healthcare policies and reforms to impact healthcare delivery and health outcomes [5].
The Healthcare Sector Transformation Program in Saudi Arabia, launched as part of Vision 2030, aims to transform the healthcare system to make it more comprehensive, effective, and integrated. This transformation is essential for meeting the evolving healthcare needs of the Saudi population. A key benefit of APNs in transforming the healthcare system in Saudi Arabia is improved access to care. By providing routine, preventive, and specialized healthcare services, APNs can operate across various healthcare settings, including primary care, to enhance access to care in Saudi Arabia. In doing so, they can increase the availability of healthcare services, particularly in underserved areas, ensuring that a greater number of Saudi citizens receive timely access to healthcare.
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The successful implementation of APN roles remains complex, highlighting the need to engage key stakeholders—especially academic leaders—to address the necessity of APN roles and ensure that their education and training align with international standards [3]. Evidence has emphasized the importance of establishing academic-practice partnerships to develop innovative roles for APN education and training [6]. Establishing collaborative partnerships between academic institutions, healthcare facilities, and regulatory agencies is essential for successfully transitioning graduate nurses into practice and ensuring the successful implementation of APN roles [7].
Few studies have explored APN roles in Saudi Arabia. Both nurses and physicians hold positive perceptions regarding the potential impact of APN roles in the country [8, 9], as do nursing clinical leaders, such as chief nursing officers and executive directors [10]. Notably, previous research has indicated that APN tasks and activities are already being implemented within the Saudi healthcare system, highlighting the need for further efforts to clearly define APN roles, role requirements, and scope of practice [11]. Additionally, a recent study reported positive patient experiences with APN-provided care in two healthcare settings that have integrated APN roles [12]. However, there remains limited knowledge regarding the extent to which academic institutions in Saudi Arabia are contributing to national efforts to implement APN roles.
Despite the crucial role of APNs in healthcare, the debate regarding their role and scope of practice is ongoing. Nursing academic leaders, responsible for educating the next generation of nurses and shaping the profession’s future, are key stakeholders in this discussion. Understanding their perspectives on APN roles can provide valuable insights into the challenges and opportunities and may contribute successfully implementing roles and establishing programs for APNs that are based on healthcare needs [13]. Academic leaders’ perspectives may also help in understanding the regulatory and accreditation challenges that need to be addressed when establishing guidelines. Additionally, academic nursing leaders’ views can significantly influence policymaking processes related to APN education, regulation, and practice. Therefore, exploring their perceptions of APN roles and how they contribute to healthcare delivery is essential [14].
Evidence has shown considerable variation in establishing and implementing APN roles globally [15]. To fully implement APN roles, countries must establish appropriate legislation to regulate their education practice. Involving academic leaders as key stakeholders is crucial for developing policies, frameworks, and strategies that support the implementation of APN initiatives [15]. However, the perspectives of academic nurse leaders in Saudi Arabia on APN roles are largely unknown. This qualitative study aimed to explore the perspectives on APN of academic nurse leaders in academic settings in Saudi Arabia.
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Methods
Design
This study used a descriptive explorative approach and semi-structured interviews with nurse academic leaders in Saudi Arabia. Such an investigative approach aims to unveil a deeper insight into a particular phenomenon, its underlying processes, or the worldviews of the people involved. The findings are presented following the Criteria for Reporting Qualitative Research (COREQ) guidelines [16].
Recruitment and participants
Academic nurse leaders in local Saudi universities were invited via phone calls, text messages, and email. A purposive sampling method was adopted by one of the research team members. The academic nurse leaders were defined as department heads of nursing departments, vice-deans for graduate nursing programs, and deans of nursing colleges in Saudi Arabia. The inclusion criteria were that participants had to be working as academic nurse leaders at the time of the study; the final sample included 13 academic nurse leaders with various experiences and backgrounds.
Data collection
The first author digitally recorded semi-structured interviews on the Zoom application over 6 months in 2022/2023. The semi-structured interview guide (supplemental file 1) was developed based on a review of the relevant literature [17‐19] and input from the research team to capture the description of APN and APN roles, need for APN, current situation of APN, focus of APN programs, recommended admission requirements for APN programs, challenges and barriers to implementing APN programs, and future of APNs. The academic nurse leader interviews ranged between 30 and 60 min. Before initiating the interviews, each participant was sent a special code to match the demographic identities with the transcribed recorded interviews. Demographic information was collected via an online survey before the interview, and the data analysis did not include the participants’ identities. The digitally recorded interview was transcribed using NVivo, and a graduate assistant checked the transcription to ensure fidelity to the recording before analysis by the research team. Moreover, two of the research teams performed partial random checks for accuracy purposes.
Data analysis
Descriptive statistics were used to analyze the demographic characteristics of the individuals. Continuous variables were recoded into categorical variables, which were expressed as numbers and percentages with other categorical variables. SPSS version 28 (SPSS Inc., Chicago, IL, USA) was used for all descriptive statistics. All interviews were conducted in English were recorded on secured cloud storage, transcribed verbatim by NVivo, de-identified, and subsequently checked for accuracy by a graduate student assistant. Thematic data analysis followed Braun and Clarke’s approach [20] was conducted to ensure systematic coding, theme development, and validation. Three authors independently familiarized themselves with the data and generated initial codes—one using NVivo and two conducting manual coding. One author consolidated the codes into a single document for refinement. The research team then reviewed and grouped codes into themes and subthemes, ensuring inter-coder reliability. Themes were further refined and validated through team discussions. The interpretation of findings and participant quotes were reviewed with authors not involved in data collection to enhance credibility. The final results were written up, reviewed, and revised based on team feedback to ensure analytical rigor and coherence.
Ethical consideration
The study was reviewed and approved by the Institutional Review Board of King Saud University College of Medicine (IRB # No. 22/0594/IRB). Participation was voluntary; participants who expressed interest in joining the study received an email that included links to the informed consent form and demographic data survey. The informed consent form introduced the study, explained the data-collection methods, described the risks and benefits of participation, and informed participants that they had the option to withdraw from the study at any time through a link. Participants were asked to open the link and indicate their agreement to participate before completing the demographic survey and beginning the interview.
Rigor and reflexivity
Our study adhered to a series of structured steps to establish the credibility, dependability, confirmability, and transferability of its analysis and findings. To ensure credibility, the research team consisted of experts primarily specialized as advanced practice nurses (APNs) and professionals from regulatory and clinical fields, whose expertise was crucial in developing and refining interview questions addressing the regulatory and operational aspects of APN implementation. To ensure reliability, we carefully documented the research process, providing a clear audit trail for others to follow. Confirmability was ensured through collaborative discussions among the authors, reaching consensus on the emerging codes and themes to minimize researcher bias, with study’s findings reported according COREQ guidelines. Finally, to ensure transferability, we provided rich, detailed descriptions of every aspect of the phenomenon under investigation, which enables others to determine the applicability of the findings in different contexts.
Results
The sample’s demographic characteristics are presented in Table 1.
Table 1
Demographics characteristics (N = 13)
Variables | n (%) |
|---|---|
Gender | |
Man | 6 (46%) |
Woman | 7 (54%) |
Experience in nursing | |
11–15 years | 2 (15%) |
16–20 years | 6 (46%) |
20–25 years | 4 (31%) |
> 25 years | 1 (8%) |
Type of school | |
College of Nursing | 9 (75%) |
College of Applied Medical Science | 4 (25%) |
Current academic position | |
Dean | 7 (58%) |
Vice Dean for Graduate studies | 1 (8%) |
Department Head | 2 (17%) |
Other | 2 (17%) |
Years of experience in the current academic leading position | |
>10 | 11 (85%) |
11–15 | 2 (15%) |
Highest level of education | 13 (100%) |
Holding advanced practice degree | |
Yes | 6 (46%) |
No | 7 (54%) |
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The data analysis revealed several key themes regarding academic nursing leaders’ perspectives on APN. APN was described as a specialized field requiring advanced skills and scholarly expertise and an autonomous practice with roles varying by regional model. The participants reported the need for APNs to improve patient outcomes, support healthcare transformation, and increase cost-efficiency. Moreover, the participants noted that the field is in an early stage and that programs are limited. They stated that APN roles vary across countries. In addition, they indicated that entry requirements include a bachelor degree in nursing, field experience, and mastering the language of instructions. Furthermore, the results highlighted organizational and regulatory obstacles to and facilitators of APN program implementation, suggesting a promising but challenging future for APN. This indicates that ongoing efforts are required for full integration of APN into healthcare systems.
Description
Four dominant themes emerged through analysis, painting a comprehensive picture of how participants perceived APN: specialized, advanced clinical skills and education (advanced clinical scholarship), autonomous practice, and variation based on regional models.
Specialized
The participants frequently mentioned APN; this enables them to perform certain skills in their area of specialty, which is different from that of the general nurses.
that would allow her to do certain responsibilities based on the specialty that she will be specialized in.
Advanced practice nurses’ specialties differentiate them from the classical roles of general nurses.
they are specialized, and maybe they have different specialties in advanced practice nursing. So, it’s not focused on general nursing.
Advanced clinical skills and scholarship
In addition to acknowledging specialties, participants acknowledged the extensive educational level of APN. Many indicated that APN is a higher and advanced level of education that grants nurses advanced skills and expands the general nurse’s role beyond the traditional one. This level of education is higher than a bachelor’s degree.
It’s a higher level, high level of education, higher than the bachelor’s degree, almost equivalent to the master’s degree.
From the participants’ point of view, nurses with this degree possess advanced clinical training that enables them to care for complicated cases and that is beyond the skills of general nurses:
high level nurse who can take a difficult or more complicated cases where they start with the physical assessment.
This skill advancement helps APNs perform different roles from those of traditional general nurses.
advanced nursing practice is something we are looking to promote higher level of skills in my opinion, it is not generally nursing. Everyone has to be a general nurse. And then can we do advanced nursing practice to promote specific skills for career development.
Autonomous practice
The participants highlighted that APNs are authorized to practice independently beyond the scope of general nurses, such as writing prescriptions and performing medical care. These activities include but are not limited to practicing independently and providing care similar to that provided by physicians.
APNs are clinicians who can provide care that is similar and almost better than having or going to the GPS, who are busy, and they will not provide the appropriate care.
This authority and freedom enable them to write prescriptions:
the nurse that has their own clinic, that has their own freedom or clinical freedom, and has authority to write prescriptions.
Some participant leaders see this practice as an integrated model of the nursing and medical model of care.
autonomy, practice of nursing. It’s not solely under the umbrella of nursing care, the typical or nursing care. It’s a mix in the paradigm between medical and nursing care.
Varied roles based on regional models
Although participants described APNs as specialized in the field, with advanced clinical knowledge, and independent, they also indicated a variation in advanced practice nursing based on the regional context:
I came with the American model of nursing practice. Also, when I look to the European model of nursing practice, there is quite a difference between the two.
This variation is based on roles, as one participant stated:
According to the US standards for the advance practice nursing role, they have a high level of practice, mainly currently, which is the nurse practitioner role.
Healthcare needs
The participants acknowledged a high need for APNs as they perform unique roles in addressing the gap in the healthcare system and improving patient outcomes.
Improve patient outcomes
Participants emphasized the importance of APN in improving patient outcomes via skills that APNs have.
There is a huge need for advanced practice nursing that focuses on clinical skills and competencies. This can elevate the standard of nursing in Saudi Arabia and improve patient outcomes.
Transformation and cost-efficiency
Participants recognized the importance of APN in addressing the gap in the healthcare system in addition to its role in improving patient outcomes:
The need for advanced practice nursing is mandatory due to healthcare transformations and cost efficiency. It addresses shortages and prepares for the changing healthcare landscape.
The current status of advanced practice nursing in Saudi Arabia
APN programs are still in the infancy stage in Saudi Arabia. This delay in the full implementation of APN roles/programs has been attributed to the limitation in APN graduate programs.
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Infancy stage
APN programs are in their infancy in the country.
Are still under in the foundation phase, a lot, unfortunately, a lot of the vision is here, and we have the capabilities for a healthcare transformation.
Limited programs
Participants acknowledged the scarcity of APN graduate programs. Only one program in Saudi Arabia has been acknowledged as an APN graduate program.
I actually know only one program in Saudi Arabia, that is, I’m not sure if this program was accredited by the Saudi Health Commission. I think it’s what I know; it’s only one program. But you know, we need to have a standard to follow and agreement between the Ministry of Health and Ministry of Education.
APN roles
Participants acknowledged that APNs perform different roles. APNs practice in the healthcare setting based on the scope of practice, levels of educational preparation, and country-specific variations in APN practice.
Specific roles in the healthcare system
APNs play different roles in the healthcare system, each with their unique set of responsibilities and contributions. For example, nurse anesthetists work with patients in emergency settings; nurse practitioners practice independently, and nurse midwives focus on maternity care.
Nurse anesthetists play a critical role in surgical and emergency care settings, while nurse-midwives focus on maternity care.
Other participants indicated that nurse practitioners practice independently and have different responsibilities, such as prescribing and contributing to the patients’ treatment plan. For example, one participant stated,
Some nurse practitioners will have their own clinic they can order, or they can write prescription; they can assist the patient, and sometimes they need to refer back to the physician.
Country-specific variations in APN roles
APN differs based on the countries-specific educational requirements, competencies, approach, and country contexts as other countries require a specific level of education preparation (e.g., Bachelor of Nursing and master’s degree).
So, it depends on the rules and regulations of the state or the country. What responsibility do they have? But they have an advanced degree, so they need to have a bachelor’s degree, and then they continue to a master’s degree, which is the nurse practitioner.
Participants indicated that the approaches of United Kingdom and Australia leaned toward non-clinical courses during their education:
I think, it’s Australia, the same as UK.……… at the end of the, before they graduate, they give them elective or optional courses if they would like to participate in hospitals. But it was not mandatory, like in the USA.
The focus of advanced practice nursing education
The perspectives on the focus of APN education are different and consider diverse specialties across age groups as important. Many participants highlighted a need for all specialties. For example, one participant stated,
I think we need all the specialty still a green line to put the seeds for all the specialties… It’s still very novice in our healthcare system, so we need all of them.Another participant said,I think we currently need geriatrics because the population is getting older and older. So, we’re on the lower part of the spectrum, and then we can take the middle for the family nurse practitioners who will help everything.
Admission requirements for APN programs
APN programs have universal admission requirements, such as having a degree in nursing, clinical experience, and English proficiency. However, some academic leaders have mixed views of the requirements for APN.
Degree with experience
Holding a bachelor’s degree in nursing is an essential requirement.
Bachelor’s degree first; they have a bachelor’s degree in nursing.
Two years of experience in their area of interest has been frequently identified as a requirement:
The person should have two years of experience in the same specialized area where they want to be advanced practice nurses.
Mastering the Language of instructions
English proficiency is another essential requirement for studying in APN programs.
They need to be highly skillful in communication, especially Arabic and English.
Other admission requirement based on APN roles
While many participants believe that admission requirements for APN programs should be similar, some participants believe that they should differ based on the roles and expected outcomes of the program.
“For sure. Yes. The difference will come from their experience. For example, if you are offering or preparing to have a program in, let’s say, clinical advanced practice, then the student should come from the clinical field or, let’s say, from the medical or surgical world and so on. But if you are offering a program in midwifery, then the student should be experienced or have expertise in midwifery.”
Challenges facing the implementation of advanced practice nursing programs
Organizational and institutional factors influence the introduction and implementation of APN programs. Institutional factors include lack of classification/professional recognition of APN graduates after graduation, of clear roles, of scope of practice, and of inter-institutional collaboration, and awareness of the APN. Organizational factors influencing the introduction and implementation of APN programs include a lack of infrastructure resources and qualified faculty and preceptors.
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Organizational factors
Infrastructure readiness
The availability of training resources for APN programs is insufficient.
“We don’t have enough high-fidelity simulation labs… suitable and high standard training sites are a challenge.”
Moreover, some regions lack qualified hospitals for student training.
We have our teaching hospital. So, I will not have any problem implementing such a program. But for other cities, I think they will face a problem with that because they didn’t have a teaching hospital.
Lack of qualified faculty
The lack of qualified faculty who can teach and supervise the APN programs is a challenge in the students’ preparation.
Recruitment of faculties who are able to supervise, train, and educate the applicants is one challenge.
Lack of qualified preceptors
In addition to the lack of qualified faculty, the lack of qualified preceptors poses a challenge to preparing students of APN programs in the training sites.
I think the main challenges is having a preceptor who can percept, who can guide these students in their clinical courses.
Inter-institutional collaboration
The lack of inter-institutional collaboration and support is a challenge, in addition to the lack of collaboration between different institutions. For example, one participant stated,
There is no collaboration between the Ministry of Education and Ministry of Health… no guarantee of job improvement after graduating.
Regulatory factors
Lack of classification
The lack of classification is a major challenge to implementing APN programs. The Saudi Commission for Health Specialists does not classify APN graduates based on their education and training. Participants expressed concerns over this issue:
We have a huge issue with the classification for those nurses or nursing in general.
Another participant highlighted the potential risks this poses for new programs:
Graduates’ acceptance by the health commission is uncertain, posing risks for new programs.
Lack of scope of practice
The absence of a scope of practice for APNs is a major challenge as the governmental regulatory bodies do not provide clear regulations for APN activities. Participants highlighted these concerns:
We don’t have a clear title; we don’t have clear rules and scope of practice; there are no competencies provided by the Ministry of Health to the universities to guide them when they design those programs, or they have to have what they have to in their curriculum. The outcome of those programs should align with those competencies and regulations.
This lack of regulation also creates barriers to APNs practicing their specialty in various healthcare settings:
“Our main obstacles are that they are not practicing their specialty in Saudi Arabia because we miss and there is some gap in regard to the legislation application policy that gives them the authority to practice their specialty in the hospital or even in primary clinic.”
Lack of awareness
The lack of awareness of the value of APN roles is a challenge for APN programs.
Awareness of nurses about advanced nurse practice is a challenge… once they are aware, they will value the program.Population may resist new ideas and lack understanding of the benefits of advanced practice nursing.
Facilitators to implement advanced practice nursing programs
Organizational factors
Provide access to resources
The lack of supportive resources is a challenge for implementing APNs. Access to the resources and funds for APN education should be increased. These resources, such as qualified training sites and laboratories, will facilitate the program’s implementation.
“In the Ministry of Education, they need to facilitate and provide all needed faculties with information, labs, budget, electronic materials, book all needed rules a let’s say, a reward for the faculties because this is valuable and unique programs.”
Qualified graduates
Benefiting from the skills and expertise of graduates from international universities facilitates the implementation of the APN program.
Most of our graduates who finished their postgraduate studies, came back to Saudi, and they will start to teach the postgraduate program.Some who have just finished their PhD in the United States or any other place, who are really interested or certified in these programs.
Regulatory factors
Supportive scope of practice laws and regulations
Practice regulations should allow APNs to practice to the full extent of their education and training. These laws/regulations come from the licensing body, and the Ministry of Health will facilitate the introduction of APN programs. For example, the licensing body will ease the implementation by classifying APNs with other entities in developing regulations/laws that grant APNs supporting legal rights.
The Ministry of Health, they need to provide very clear vision values and job description for the graduates.“Give a nurse practitioner their own clinic and give them their freedom and give them their rights as a nurse practitioner to write prescriptions”.The Saudi Commission, they are really a very strong board in playing the role of laying the ground or the foundation for advanced nursing practice rules and regulations and scope of practice and everything.I’m sure if there is a clear scope of practice and these clear regulations. I’m sure, the Ministry of Health and universities will be more encouraged to open more APN programs.
Institutions must work together and develop collaboration mechanisms to facilitate the implementation of APN programs. The collaboration mechanism should be between related institutions such as universities, the Ministry of Education, Ministry of Health, and Saudi Commission for Health Specialties to recognize APNs in the healthcare system.
For example, this collaboration would be between the Ministry of Education and Ministry of Health.
It’s what I know; it’s only one program. But you know, we need to have a standard to follow and agreement between the Ministry of Health and Ministry of Education.
Moreover, collaboration in recognizing APNs between the Ministry of Health and Ministry of Education and support from the licensing body are facilitators.
First of all, the Saudi Commission, which would classify this target population, if we will have more schooler returnee from outside and Minister of Health, Education and the Ministry of Health, they should recognize those population because they will improve our quality here in Saudi Arabia.
Involving experts
Involving experts in the field is seen as a facilitator. Those experts can be specialized nurses in APNs, nurse leaders, or professional nursing organizations, and they will help set regulations and implement APN programs.
We have to be with the people who are specialized in advanced nursing practice to debate and to put the clinical practice standard at a government level.I think most of the deans among the university and nursing college in the universities are specialized, so they will understand the needs of advanced nurse practice.We need a board of nursing to regulate nursing practice, and we really need that because it’s not only for the advanced practice degree; it’s for all nursing degrees.
Raising awareness
A lack of awareness has been identified as a barrier to implementing APN programs. Raising awareness of stakeholders and society is an important facilitator in initiating the APN program. Those stakeholders could be the leaders in the licensing body or related institutions such as universities, the Ministry of Education, or the Ministry of Health.
We need to sit with stakeholders, like the Ministry of Education, Ministry of Health, and Saudi Commission, to explain the need and gain their support.Awareness, we need more awareness and to sit down with the stakeholders of that and leaders in these universities.
Moreover, societal awareness of the roles will facilitate the acceptance of APNs among healthcare recipients.
First of all, to change the perception or the image of nursing to enhance people awareness’s; explain nurses’ role, because they have a huge role; and provide not only basic patient care but more than basic care.
Optimistic and challenging future
The future of APN programs appears promising and supported. However, while most academic nurse leaders expressed optimism about APNs, some participants had concerns regarding the challenges of role implementation.
APN programs are anticipated to have a bright future.
The future of the APN programs is very bright.
However, concerns remain about regulating rules and its implementation process.
We should really think about how to implement it.They have to have clear rules and legislation.
Discussion
In this qualitative study, we embarked on a journey to capture the diverse perspectives of academic nurse leaders within the academic environment regarding APN. The data collected from these leaders, who are at the forefront of nursing education and practice, shed light on four critical themes that shape the landscape of APN in Saudi Arabia. In this study, the major themes that emerged were the description and roles of APNs, the demand for and current status of APN programs, admission requirements and the educational focus of such programs, and challenges and facilitators involved in implementing APN programs. This exploration was set against the backdrop of evolving healthcare needs in Saudi Arabia, aiming to contribute insights on integrating APNs into the healthcare framework in a contextually relevant manner.
The study’s findings revealed a degree of ambiguity and inconsistency surrounding the role and definition of APNs among participants. This ambiguity is not uncommon in the global context as the scope and functions of APNs can vary considerably between regions and within healthcare systems, often influenced by a country’s developmental level, education, and policy factors [21‐24]. The inconsistency in defining the APN role could lead to challenges in role implementation, professional identity, and scope of practice, which may in turn affect the integration of APNs into healthcare teams and the services they provide [24, 25]. However, most academic leaders in this study articulate a vision of APNs not merely as enhanced versions of general nurses but as highly specialized practitioners with advanced clinical competencies. This finding further supports the idea of enabling APNs to practice with a degree of autonomy previously reserved for medical professionals, showcasing a paradigm shift in patient-care delivery where APNs are integral to bridging the gap between nursing and medicine [22, 24]. Consequently, establishing a clear and consistent definition of the APN role at the national level is essential to overcome these challenges and promote the future implementation of APNs in the Saudi context to enhance healthcare delivery and improve patient outcomes.
Most participants in this study acknowledged the pressing need for APNs in the healthcare system and recognized the positive impact of APNs on patient outcomes. This consensus aligns with the body of evidence that supports the role of APNs in enhancing access to care, improving the quality of healthcare services, and providing cost-effective solutions to patient management [22, 25]. APNs, with their advanced clinical training and education, are well positioned to address complex healthcare needs and contribute to filling service gaps, particularly in areas of primary care and chronic disease management and in rural regions [24, 26]. Additionally, the insights from study participants highlight the value of integrating APNs into the healthcare workforce to achieve better health outcomes and respond to the evolving demands of patient care. This finding aligns with several previous studies that have reported the successful integration of APNs and their achievement of outcomes comparable to those of physicians in primary care, such as in the USA [27], in Canada’s rural and remote communities [28], and in Australia in areas such as emergency care, chronic disease management, and elderly care [29]. Moreover, an Israeli study has shown that the integration of APNs has successfully relieved the shortage of physicians and delivered care that is safe, of equivalent quality, and effective across a wide variety of medical specialties [30]. Therefore, the Ministry of Health in Saudi Arabia should consider a strategic plan for implementing and integrating the role of APNs, mirroring the successful approaches taken in developed countries.
Academic leaders in this study underscore the importance of diverse specialties and sub-specialties in APN education to address the healthcare system’s comprehensive needs. Emphasizing the requirement to fill healthcare gaps—especially in high-demand areas such as geriatrics and chronic disease management—they advocate for an APN curriculum that aligns with market needs and international benchmarks. Aligning APN specialties with market demands is crucial, as seen in Australia, where aged care nursing is prioritized to meet the needs of its aging population, ensuring that APNs are equipped to deliver targeted, high-quality care [29, 31, 32]. In this study, the participants agreed that APN program admissions should require a nursing bachelor’s degree, two years of clinical experience, and English proficiency, with criteria adjusted for the specific APN role. This is in agreement with the global standard for APN program admission, which typically requires a minimum of two years of clinical experience as a registered nurse [33].
In the study, participants highlighted several challenges encountered in the implementation of APN programs, including issues related to infrastructure readiness, scarcity of qualified faculty and preceptors, lack of professional classification, and limited awareness of APN roles. These challenges are not unique to this context but have been reported in several countries as leading factors hindering the development and expansion of APN roles and educational initiatives [24, 25]. Moreover, the study participants emphasized the lack of professional classification and a defined scope of practice for APNs by the Saudi Commission as a major obstacle to APN implementation in Saudi Arabia. This challenge aligns with findings in other regions such as Switzerland [34] and New Zealand [25], where clear regulatory frameworks are deemed essential for the effective integration and recognition of APNs in healthcare systems [24, 25]. Several studies have suggested that clearly delineating scopes of practice and professional roles is essential for APNs to fully engage and effectively contribute to patient care [10, 11]. The lack of such regulatory clarity can lead to underutilizing APNs and hinder their ability to practice to the full extent of their capabilities.
In this study, academic leaders pointed out that the absence of necessary resources such as teaching hospitals, faculty members, and qualified hospital preceptors in some Saudi regions impedes the initiation of any APN programs. This shortage aligns with the findings in the global APN literature and is the main challenge to APN programs [30, 35, 36]. In their work, Schober et al. [25] assert that the disparities in educational resource availability across different countries are shaping the development of APN programs. Thus, in Saudi Arabia, starting APN programs in main cities such as Riyadh or Jeddah could address resource shortage issues more effectively.
However, this study revealed numerous factors that effectively facilitate the establishment and advancement of APN programs and roles within the Saudi healthcare system. Nursing academic leaders agreed that Vision 2030’s emphasis on healthcare transformation presents a strategic opportunity to support APN program initiatives. Under Saudi Vision 2030, the Healthcare Transformation Program (HTP) focuses on enhancing public health and healthcare delivery, including the expansion of nursing career pathways to make the profession more appealing [37]. The initiative also aims to enhance primary healthcare access and anticipates a rise in service needs owing to an aging population, suggesting that APNs could be instrumental in addressing these healthcare delivery challenges [10, 37]. Moreover, study participants considered that raising awareness among stakeholders and the broader society is essential for gaining support and facilitating the acceptance of APNs in the country. Overall, despite some concerns about the challenges of implementation, the future of APN programs in Saudi Arabia is promising.
Considering the broader context of APN implementation in Saudi Arabia, the findings of this study provide a clear understanding of how APN programs in Saudi academic institutions should be structured to align with both national healthcare priorities and international best practices. The study highlights the necessity of defining APN roles at the national level, ensuring that educational programs are tailored to meet local healthcare demands while maintaining alignment with global competency frameworks. Additionally, the identified challenges—such as regulatory ambiguity, resource limitations, and faculty shortages—underscore the need for a coordinated approach between academic institutions, healthcare organizations, and regulatory bodies to facilitate the effective integration of APNs. By addressing these barriers and leveraging facilitators such as Vision 2030’s healthcare transformation agenda, Saudi Arabia has the potential to establish a robust APN framework that enhances patient care delivery, expands nursing career pathways, and optimizes healthcare system efficiency. This study contributes to the ongoing discourse on APN implementation by offering context-specific insights that can inform policy development, curriculum design, and workforce planning, ensuring that APN integration is both sustainable and impactful.
Our findings should be interpreted by considering the study’s strengths and limitations. This is the first study that explores academic nurse leaders’ perspectives on APN implementation in the region. Listening to the academic nurse leaders of different universities with various expertise and backgrounds from both genders offers relevant insights essential for enhancing the implementation of APNs in the education system. By using explorative semi-structured interviews, we developed a comprehensive, nuanced, and contextual understanding of the topic. We used the participants’ quotes in presenting the study findings to enhance credibility and authenticity, engaging the readers with contextual understanding and presenting diverse perspectives.
As a qualitative exploratory study, this research is not meant to be generalized to all academic nurse leaders. However, it is worth noting that including more participants could enhance the depth and context of the findings. Moreover, the affiliated institutions’ politics could influence the perspectives of academic nurse leaders; the leaders may have a more favorable opinion toward promoting APN if the institution promotes it.
The study findings have essential nursing implications in education, policy, practice, and research. As APN programs are still in their infancy, their development, promotion, or improvement could benefit from our study findings, especially with regard to admission requirements and curriculum development. Our findings indicate a need for policy advocacy and development, particularly the scope of practice and classification of APNs in Saudi Arabia. Highlighting the organizational and institutional challenges and facilitators in implementing APN roles can help nursing leaders and decision-makers develop strategies to support and promote their implementation. The lack of inter-institutional collaboration influences the implementation process of APNs; thus, education and healthcare institutions should work more closely together.
Further qualitative research is recommended to explore the ways of cooperation among education and healthcare institutions. Documents analysis is needed to understand the current health policies and their effect on the APN role’s implementation in Saudi Arabia to guide policy development or modifications that support such role. Future quantitative research is recommended to assess the impact of implementing APNs on health outcomes.
Conclusion
This study explored diverse perspectives of nurse leaders regarding APNs within the academic environment. The study’s significant themes highlighted the potential of APNs’ role in improving patients’ health and system outcomes. The findings revealed the need to establish a clear and consistent definition of the APN role at the national level to promote its future implementation in the Saudi context. Academic leaders underscore the importance of diverse specialties and sub-specialties in APN education to address the comprehensive needs of the healthcare system and advocate for an APN curriculum that aligns with market needs and international benchmarks. Limited program availability, infrastructure readiness, the availability of resources, scope of practice, unclear professional roles, scarcity of qualified faculty and preceptors, limited awareness of APN roles, and lack of inter-intuitional collaboration are challenges that must be addressed. However, this study revealed that healthcare transformations, such as Vision 2030, present a strategic opportunity to facilitate the establishment and advancement of APN programs and roles within the Saudi healthcare system. The study findings emphasize the importance of integrating academic leadership perspectives in shaping the future of nursing education and practice, particularly in implementing APN roles to improve patient and system outcomes.
Acknowledgements
Authors extend their appreciation to the Researchers Supporting Project (RSPD2024R876), King Saud University, Riyadh, Saudi Arabia.
Declarations
Ethics approval and consent to participate
Approvals from the Institutional Review Boards were obtained from King Saud University College of Medicine (IRB Reference number: 22/0594/IRB). All methods were carried out in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines and the declaration of Helsinki. The informed consent form was obtained from all the subjects for participation in this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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