Structural determinants of scope of practice in advanced practice nursing in anesthesia: A global scoping review and thematic synthesis

BACKGROUND: Advanced practice nursing in anesthesia (APNA) has emerged as an important workforce strategy to address global anesthetist shortages and rising surgical demand. However, the scope of practice and level of professional autonomy granted to APNAs vary substantially across healthcare systems. Existing literature has focused primarily on clinical competencies while paying less attention to the structural conditions shaping APNA roles. OBJECTIVES: To examine global variation in APNA scope of practice and identify the structural determinants influencing professional autonomy across healthcare systems. METHODS: A scoping review of peer-reviewed and gray literature published between 2001 and 2025 was conducted using the Arksey and O'Malley framework and reported according to the Preferred Reporting Items for Systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines. Searches were performed in PubMed, Embase, CINAHL, PsycINFO, the Cochrane Library, and selected organizational websites. Data were charted and synthesized using inductive thematic analysis. RESULTS: Thirty-five sources were included. Thematic synthesis identified a global spectrum of APNA autonomy ranging from independent practice to strict physician supervision. Six interrelated structural determinants shaped this variability: legislative and regulatory mechanisms, educational standards and credentials, economic incentives and reimbursement models, health system demands and access, professional power and interprofessional conflict, and macro-political forces and policy reform. Across jurisdictions, formal regulatory frameworks frequently diverged from actual clinical practice, particularly in rural and resource-constrained settings where workforce shortages expanded APNA responsibilities beyond statutory boundaries. CONCLUSION: Global variation in APNA scope of practice appears to be shaped more strongly by structural and political conditions than by clinical capability alone. Harmonized educational standards, clearer regulatory recognition, and reimbursement policies not contingent upon physician supervision may facilitate more consistent integration of APNAs within the global anesthesia workforce.