Jean Toniolo
email: jean.toniolo@chu-limoges.fr

Edgard Brice Ngoungou

PhD Professor Simon Ategbo

Euloge Ibinga

MD, PhD Sydney Maghendji-Nzondo

PhD Pierre-Marie Preux

Professor, PhD Pascale Beloni

Implementation strategy for advanced practice nursing in Gabon: a multicenter

Keywords: COREQ, STROBE Advanced practice nursing implementation, Advanced practice nursing development, Africa, Chronic disease, Health policy, Implementation

INTRODUCTION

Low-and middle-income countries in Africa face numerous challenges, including health and access to care [START_REF] Ewen | Baseline assessment of WHO's target for both availability and affordability of essential medicines to treat non-communicable diseases[END_REF]. These countries are currently grappling with a double burden caused by the epidemiological transition, which encompasses both infectious and non-communicable diseases, commonly referred to as chronic diseases [START_REF] Omran | The Epidemiologic Transition : A Theory of the Epidemiology of Population Change[END_REF][START_REF] Remais | Convergence of non-communicable and infectious diseases in low-and middle-income countries[END_REF]. This transition occurs in the midst of ongoing socio-economic development, urbanization, and changing lifestyles characterized by sedentary behavior, increased junk food consumption, and tobacco and alcohol use [START_REF] Haileamlak | The Triple Challenges of Low and Middle-Income Countries[END_REF][START_REF] Oni | Why the communicable/non-communicable disease dichotomy is problematic for public health control strategies: Implications of multimorbidity for health systems in an era of health transition[END_REF]. These changes have a significant impact on health outcomes, including mortality rates. Chronic diseases account for 41 million deaths annually, representing approximately 71% of global deaths, with three-quarters (31.4 million) occurring in low-and middle-income countries [START_REF] Hay | Global, regional, and national disability-adjusted lifeyears (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016[END_REF]World Health Organization, 2021). Consequently, in addition to existing health challenges such as epilepsy [START_REF] Guinhouya | The epilepsy treatment gap in six primary care centres in Togo (2007-2009)[END_REF], sickle cell disease [START_REF] Buser | Feasibility of establishing a network of community health workers to support care of people with sickle cell disease in Kumasi, Ghana[END_REF], and infectious diseases, hypertension and diabetes mellitus [START_REF] Roth | Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015[END_REF] have emerged, further burdening already fragile healthcare systems [START_REF] Ewen | Baseline assessment of WHO's target for both availability and affordability of essential medicines to treat non-communicable diseases[END_REF].

Addressing access to care and prevention of these chronic diseases, particularly in relation to modifiable risk factors, is crucial to alleviate the burden on both the population and healthcare systems. However, resources and healthcare workforce are scarce and limited in Africa (World Health Organization, 2016). For instance, the availability of medical doctors and nurses or midwives per 1000 people only accounts for 0.29 and 1.80 respectively in Sub-Saharan Afriaca [START_REF] Haakenstad | Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019[END_REF]. Moreover, the ongoing COVID-19 pandemic has exacerbated healthcare shortages, potentially increasing the burden of chronic diseases in Africa [START_REF] Owopetu | COVID-19: Implications for NCDs and the continuity of care in Sub-Saharan Africa[END_REF].

As a potential solution to inequitable access to care in primary care settings, shortage of medical resources, and the increasing burden of chronic diseases, the implementation of advanced practice nursing (APN) has been explored in high-income countries (International Council of Nurses, 2020b). This concept was initially introduced in Canada and North America during the 1960s [START_REF] Kaasalainen | A historical overview of the development of advanced practice nursing roles in Canada[END_REF] and was more recently adopted by France in 2016 (Code de la santé publique, 2016). APN refers to "enhanced and expanded healthcare services and interventions provided by nurses who, in an advanced capacity, influence clinical healthcare outcomes and provide direct healthcare services to individuals, families, and communities" (Hamric et al., 2016;International Council of Nurses & Schober, 2020). Through additional education and training, advanced practice nurses acquire expert knowledge, complex decision-making skills, and clinical competencies to extend nursing practice (International Council of Nurses, 2020b). Clinical practice and direct care are the core competencies of advanced practice nurses, as outlined in Hamric's model, which also describes six additional generic skills for APN : consultation, evidence-based practice, leadership, collaboration, ethical decision-making, and guidance and coaching (Hamric et al., 2016). Existing evidence demonstrates the positive impact of APN on individuals, including enhanced therapeutic adherence, health literacy, quality of life, self-care skills, and improved management of glycemia and blood pressure [START_REF] Morin | Advanced nursing practice: Towards a consensus in the French-speaking world[END_REF].

Internationally, the World Health Organization and the International Council of Nurses, in alignment with their commitments to universal health coverage by 2030 (International Council of Nurses, 2020a;World Health Organization, 2023), have outlined objectives for the advancement of APN. These objectives encompass various aspects, including improving equity in access to healthcare, promoting a patient-centered approach that involves individuals, families, and communities, enhancing the quality of care through evidence-based practices, reducing costs for both users and healthcare systems through accountability and clinical leadership, and addressing the shortage of healthcare professionals by making the nursing profession more attractive [START_REF] Delamaire | Advanced nursing practices: A description and evaluation of experiences in 12 developed countries, Documents detravail de l[END_REF]International Council of Nurses & Schober, 2020;[START_REF] Morin | Advanced nursing practice: Towards a consensus in the French-speaking world[END_REF]. These organizations, along with the Secrétariat International des infirmières et des infirmiers de l'espace francophone, recognize the importance of developing APN to meet these objectives [START_REF] Morin | Advanced nursing practice: Towards a consensus in the French-speaking world[END_REF].

Interest in APN has existed in Africa for a considerable time [START_REF] Fulton | Clinical nurse specialist role and practice: An international perspective[END_REF]. In the context of infectious disease, advanced practice nurses roles have already been developed and implemented in Botswana, Ghana, and Eswatini [START_REF] Christmals | The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review[END_REF][START_REF] Iwu | Task shifting of HIV management from doctors to nurses in Africa: Clinical outcomes and evidence on nurse selfefficacy and job satisfaction[END_REF]. Moreover, in Gabon, nurses have expanded their roles to include prescription practices to address medical deserts, with acceptance from medical doctors, albeit in a non-legal manner. This initial acceptance of expanded nursing roles in Gabon could provide a favorable context for the implementation of APN. Although APN roles have been described in English-speaking African countries, such as South Africa, Kenya and Tanzania, they do not fully meet the complete role specifications of APN [START_REF] Christmals | The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review[END_REF][START_REF] Hassmiller | Advanced Practice Nursing Leadership: A Global Perspective[END_REF][START_REF] Kimani | Nurse Practitioner Role in Kenya[END_REF]Trinitas & Blood-Siegfried, 2023). For example, even though Kenya has launched its master's level APN program, there is still more work to be done to fully recognize the roles of advanced practice nurses and nurse practitioners, particularly in terms of formalizing prescription rights and institutionalizing their roles [START_REF] Kimani | Nurse Practitioner Role in Kenya[END_REF]. Implementation models, such as the PEPPA framework [START_REF] Bryant-Lukosius | A framework for the introduction and evaluation of advanced practice nursing roles[END_REF], have been used to guide the implementation of APN and adapt their roles to meet real needs [START_REF] Aguilard | Strategies for implementing an advanced practice nurse in the hospital setting? A literature review[END_REF]. The PEPPA framework, recognized and recommended by the International Council of Nurses, aims to overcome barriers, and understand the role and environment of advanced practice nurses. For example, it has been implemented in Eswatini and South Africa for the implementation of family nurse practitioners [START_REF] Dlamini | Developing and Implementing the Family Nurse Practitioner Role in Eswatini: Implications for Education, Practice, and Policy[END_REF]. Although collaboration between South and North countries is valuable for implementing and developing APN in Africa, it is crucial to ensure that implementation models are context-specific and tailored to the needs and challenges faced by healthcare providers and the population in each country [START_REF] Christmals | The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review[END_REF][START_REF] Kolars | Perspective: Partnering for medical education in Sub-Saharan Africa: seeking the evidence for effective collaborations[END_REF].

Given the aforementioned context, integrating APN into Africa could be favorable. In addition to freeing up medical time, advanced practice nurses offer innovative care pathways and expanded territorial health coverage in a costeffective manner [START_REF] Abraham | Cost-Effectiveness of Advanced Practice Nurses Compared to Physician-Led Care for Chronic Diseases: A Systematic Review[END_REF]. For this reason, Gabon is considering There is limited literature describing implementation models [START_REF] Dlamini | Developing and Implementing the Family Nurse Practitioner Role in Eswatini: Implications for Education, Practice, and Policy[END_REF][START_REF] East | Exploring the potential for advanced nursing practice role development in Kenya: A qualitative study[END_REF], no study has simultaneously assessed the needs, expectations, and challenges related to the implementation of APN among different healthcare providers, such as nurses, medical doctors, and nursing students, in Africa, particularly in French-speaking Africa and Gabon where APN is not yet well-known and recognized.

Therefore, we aimed to describe the expectations, acceptability, and challenges identified by nurses and key healthcare stakeholders regarding the implementation of APN in Gabon. The secondary objectives were to explore the perceptions, implementation possibilities, facilitators, and barriers associated with the implementation of APN in Gabon.

METHODS

Study design and participants:

We conducted an exploratory multicenter cross-sectional convergent mixed method study [START_REF] Creswell | Designing and conducting mixed methods research[END_REF]. Qualitative data were used to interpret and complement the results of the quantitative analysis (Östlund et al., 2011). To design and report this study, we followed international guidelines for mixed-method, qualitative (COREQ), and quantitative (STROBE) [START_REF] Fetters | Publishing a Methodological Mixed Methods Research Article[END_REF][START_REF] O'brien | Standards for reporting qualitative research: A synthesis of recommendations[END_REF][START_REF] Tong | Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups[END_REF][START_REF] Elm | The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies[END_REF]. The study included all nurses, medical doctors, and nursing students who agreed to participate and were present at the time of data collection at the mentioned locations. Nursing students were included because they were directly concerned with the possibility of continuing in the APN master's degree.

Data were collected from two sources, a questionnaire followed by focus groups.

Quantitative data collection and analyzes:

All participants answered a questionnaire that included sociodemographic and professional data, perceptions of nursing profession evolution possibilities, skills, related impacts on the health system, and knowledge of APN, as well as facilitators and barriers for implementation. The questionnaire was based on the PEPPA Framework's major topics [START_REF] Bryant-Lukosius | A framework for the introduction and evaluation of advanced practice nursing roles[END_REF] and literature (Hamric et al., 2016;[START_REF] Schwingrouber | Exploratory study of hospital stakeholders' perceptions of the introduction of advanced practice nurses[END_REF]. Before implementation, the questionnaire was tested by two doctors and five nurses to ensure comprehensibility and readability, and no modification were necessary.

Statistical analyzes were performed using SPSS® V22.0. Results were presented by profession. Quantitative variables were described using mean and standard deviation or median and interquartile range and compared using ANOVA or Kruskal-Wallis test as appropriate. Categorical variables were described using numbers and percentages and compared using χ2 test or Fisher's test as appropriate. A p-value <0.05 was considered statistically significant.

To assess the acceptability of APN implementation, an acceptability binary variable was created. Acceptability was considered positive if participants answered "yes" to more than 8 out of 10 items describing APN skills, following the Hamric model (Hamric et al., 2016). The "8" cut-off was chosen as it was the median of the acceptability score. To identify the independent determinants of acceptability, a stepwise backward multivariate logistic regression was performed, including variables with an association p-value for acceptability < 0.25, with attention to avoid collinearity between the variables.

Qualitative data collection and analyzes:

From the included participants, volunteers of all professions were involved in focus groups. Five focus groups were performed ranging from 9 to 12 health carers or students. Homogeneous and heterogeneous focus groups were conducted to reach saturation and exhaustivity of viewpoints [START_REF] Drapeau | Scientific criteria in qualitative research[END_REF]. The focus groups were led by two experienced researchers in qualitative research (JT and EBN) who were not acquainted with the participants. A structured interview guide based on the literature (Bryant- [START_REF] Bryant-Lukosius | A framework for the introduction and evaluation of advanced practice nursing roles[END_REF]Hamric et al., 2016;[START_REF] Schwingrouber | Exploratory study of hospital stakeholders' perceptions of the introduction of advanced practice nurses[END_REF] and previously tested for comprehensibility, guided the focus group sessions.

The questions asked were "What are the main barriers of the health system for the nursing profession?", "What do you think about the nurses' role evolution?", "What are the keys to a good evolution of the nursing profession?", "What are the barriers linked to this evolution?". The focus groups were fully recorded (4 h and 38 min) and transcribed. Anonymization (Code: DR= medical doctors, ESI= nursing students, IDE= nurses) was carried out, and thematic analysis [START_REF] Tuckett | Applying Thematic Analysis Theory to Practice: A researcher's experience[END_REF] using NVivo 12.0® was performed independently by two researchers. A triangulation process was conducted [START_REF] Carter | The Use of Triangulation in Qualitative Research[END_REF], and the coding researchers (JT, EBN and PB) held regular meetings throughout the analysis process to discuss any codes (both a priori and emerging).

Ultimately, all researchers approved and discussed the codes and analyzes.

Ethical approval and authorization.

All participants provided written informed consent, and the Gabonese Ministry of Health and directors of all involved structures granted authorization for data collection among participants. Ethical approval was obtained from the ethics committee of the Limoges University Hospital Centre (n°577-2022-233).

RESULTS

Sample characteristics:

Of 187 carers included in our study, 42 were nurses, 24 were medical doctors, and 121 were nursing students. Table 1 provides the sample characteristics.

Appendix 1 presents the results of the thematic analysis, the main themes that guided the writing of the results section. Selected quotes from the data are included throughout the findings section to illustrate the sub-themes and codes.

Acceptability of APN implementation:

Main APN skills were described for some chronic diseases in the questionnaire and are presented in Appendix 2, percentage and comparisons between groups are available in Appendix 3. Additionally, in open-ended questions, participants identified common affections like malaria (n=61), HIV and other sexually transmitted infections (n=27), tuberculosis and pulmonary infection (n=24), and gastrointestinal symptoms (n=22) to the list of diseases that an advanced practice nurse could treat. This was also cited in the qualitative analysis "Nurses know how to diagnose and treat malaria, they don't need a doctor for this" ME-IDE2. Medical doctors were also in agreement with the expansion of nurses' roles through APN implementation, "If they are trained, they can diagnose and treat" AK-DR1.

The percentages of acceptance of APN skills by profession are presented in table 2. Participants 69.5% globally thank that APN could improve chronic disease care without a statistically significant difference between professions (p=0.294). They identified home care and follow-up by advanced practice nurses as other important skills to develop, "we need home care to improve the quality of care, especially regarding wound monitoring as an example" ME-IDE3.

The planned exercise location of advanced practice nurses was also investigated with a statistically significant difference between professions for hospital and rural practice. Hospital practice remained the more favorable planned place with 85.6% of acceptance globally (n=160), 90.5% of nurses (n=38), 62.5% of medical doctors (n=15), and 88.4% of nursing students (n=107) (p=0.006). It was followed by rural practice with 82.9% of global acceptance (n=155), 90.5% of nurses (n=38), 95.8% of medical doctors (n=23), and 77.7% of nursing students (n=94) (p=0.039). Town exercise was globally accepted by 50.3% of participants (n=94) without a statistically significant difference between professions (p=0.239). The topic of exercise location was an important discussion in the focus groups. Nurses felt they do "as a doctor" ME-IDE6 in rural areas but the "population paid the price because nurses are actually not well trained in extended competencies" AK-DR3. Regarding hospital care, nurses felt devalued due to limitations induced by medical doctors "they don't allow us to do what we can do" ME-IDE5. Moreover, they felt underrecognized within their competencies "we can't use nursing diagnoses because they are not valuable for medical doctors" ME-IDE2. However, it was clearly expressed that "advanced practice nurses need to be everywhere" AK-IDE4, "in rural, town and hospital care settings" AK-DR3.

The results of the logistic regression performed to identify associated factors with acceptability are available in Appendix 4. In the univariate analysis, we found that awareness of APN existence and being in favor of the possibility of diagnosing chronic diseases for advanced practice nurses were positively associated factors for APN implementation. In the multivariate analysis, we still found the same acceptability-associated factors plus the fact of being a woman.

Representations linked to APN implementation:

"Advanced practice nursing" term and role were relatively well known with 61% of participants knowing it (n=114). There was a statistically significant difference between professions (p<0.001), with nursing students (71.9%) and nurses (47.6%) being more aware than medical doctors (29.2%).

Globally, 84% (n=157) of participants believed that advanced practice nurses could be a mainstay of chronic disease management, with 100.0% of nurses (n=42), 100.0% of medical doctors (n=23), and 93.4% of nursing students (n=103) believing so, without a statistically significant difference between professions (p=0.142). However, we found a statistically significant difference in the fact that advanced practice nurses could diagnose chronic diseases (p=0.030) and prescribe medications (p=0.044). Specifically, 78.1% of all participants (n=146) thought that nurses could diagnose chronic diseases. This belief was held by 85.7% of nurses (n=36), 58.3% of medical doctors (n=14), and 79.3% of nursing students (n=96) within the participant group. For the prescription, it was 84.0% (n=157) globally and 90.5% (n=38), 66.7%(n=16), and 85.1% (n=103) respectively.

Perceived interests in APN implementation:

Perceived interests in the APN implementation are described in table 3. Some interests regarding the evolution of the nursing profession were also described in the focus groups. The "nursing profession's evolution is necessary" US-ESI4, nurses need to be "trained by their peers, now it's done by medical doctors, and we don't focus on nursing area" US-ESI8. A Master's degree was the first step identified before Ph.D. to develop a "nursing teaching staff" US-ESI3 and improve the nursing profession and nursing care quality.

Moreover, it was identified that advanced practice nurses were not like doctors, they had to extend their competencies in the clinical area but in a nursing view "nursing role is not only based on medicine, but nurses also have a bigger place to play […] advanced practice nurses don't come to substitute to doctors" EM-ESI6. As an example, "we have to spend time with the patient, educate him […] it's global" ME-IDE5.

Barriers and facilitators linked to APN implementation:

Both the risk of division and under-recognition were identified in both qualitative and quantitative analyses.

Cleavage was a risk for 37.4% globally (n=70), 40.5% for nurses (n=17), 45.8% for medical doctors (n=11), and 34.7% for nursing students (n=42) with no statistically significant difference between professions (p=0.532). It was explained by different factors. The bad consideration of the nursing profession "medical doctors underestimate us" US-ESI2, "we have the impression that nurses are executors, i.e. they just perform the doctors' orders and that's it" ME-IDE1. A major topic in focus groups: the legal context of the nursing profession. Indeed, they "don't have legal status or council of nurses" ME-IDE8. Logically, under-recognition of advanced practice nurses' skills was a risk for 22.5% globally (n=42), 38.1% for nurses (n=16), 20.8% for medical doctors (n=5), and 17.4% for nursing students (n=21) with a statistically significant difference between professions (p=0.021). The under-recognition risk was higher for nurses, which could be explained by elements cited above but also linked to low leadership skills "if they don't have what we call leadership if they don't know how to defend their interests if they don't have the arguments they will never be valued" ME-IDE8. There was also resistance to change: "our moms who are nurses right now, they already have a way of working and don't understand why a new nurse wants to change practice" EM-ESI2.

Leadership was identified as a facilitator for APN implementation. Other factors like the master's degree "the basis of everything is training. If nurses are trained, there will be confidence" AK-DR4 and sensibilizations of health carers were important for acceptability regarding medical doctors, "it is necessary to make doctors understand what advanced practice nursing is, what are their roles" ME-IDE7. The major facilitator identified was the formalization of a legal context, which described precisely what advanced practice nurses were allowed or not to do, "We need a legal context for nurses and advanced practice nurse roles" ME-IDE12. Finally, the last barrier identified by medical doctors was the risk of "overstepping their role" AK-DR4 if they were not clearly defined.

DISCUSSION

This study represents the first mixed-method study focusing on the expectations, acceptability, and challenges of APN implementation in Frenchspeaking African country. We found that 58.8% of health carers were favorable to the implementation of APN. Notably, APN role was relatively well known among the participants. Our findings suggest that there is a need and potential for APN in various settings in Gabon, including rural, hospital, and town areas.

Factors influencing acceptability included sex, awareness of the existence of advanced practice nursing, and support for the possibility of advanced practice nurses diagnosing chronic diseases.

Barriers to implementation centered on the lack of a professional legal context and underrecognition of nursing and advanced practice nursing skills by both nurses and medical doctors. The resistance to change also emerged as a significant obstacle. On the other hand, facilitators identified in our study included the master's degree in APN, the formalization of a legal context, and the sensitization and training of medical doctors and other health carers to understand the concept of APN. Additionally, the importance of leadership in nursing independence and role clarification has been emphasized. Our study's larger sample size allowed for a more comprehensive view compared to other investigations on this topic. [START_REF] Dlamini | Developing and Implementing the Family Nurse Practitioner Role in Eswatini: Implications for Education, Practice, and Policy[END_REF][START_REF] East | Exploring the potential for advanced nursing practice role development in Kenya: A qualitative study[END_REF][START_REF] Schwingrouber | Exploratory study of hospital stakeholders' perceptions of the introduction of advanced practice nurses[END_REF]. Employing a mixed methodology, we were able to gain valuable insights into the specific needs and challenges faced by health carers in relation to the implementation of APN in Gabon. This understanding is crucial for the successful implementation of APN [START_REF] Christmals | The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review[END_REF][START_REF] Kolars | Perspective: Partnering for medical education in Sub-Saharan Africa: seeking the evidence for effective collaborations[END_REF].

The overall acceptance of APN by medical doctors, nurses, and nursing students is promising, particularly in comparison to other contexts in which medical doctors have expressed reservations [START_REF] Kleinpell | Addressing Issues Impacting Advanced Nursing Practice Worldwide[END_REF][START_REF] Kolars | Perspective: Partnering for medical education in Sub-Saharan Africa: seeking the evidence for effective collaborations[END_REF][START_REF] Pulcini | An international survey on advanced practice nursing education, practice, and regulation[END_REF]. The representations found in our study align with the expected outcomes, indicating that the implementation of APN has the potential to improve access to care and enhance the health system in Gabon, as previously demonstrated in the literature [START_REF] Htay | The effectiveness of the role of advanced nurse practitioners compared to physician-led or usual care: A systematic review[END_REF][START_REF] Woo | The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review[END_REF].

The barriers and facilitators identified were also found in recent literature [START_REF] Christmals | The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review[END_REF][START_REF] Torrens | Barriers and facilitators to the implementation of the advanced nurse practitioner role in primary care settings: A scoping review[END_REF]. Recognizing these factors will enable Gabonese authorities to devise effective strategies for the successful implementation of APN. Notably, the absence of a legislative framework and Nursing Council in Gabon emerged as the main barriers. This lack of effective nursing regulation has also been observed in other African countries [START_REF] Christmals | The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review[END_REF], and has resulted in a 13-year delay in the recognition of advanced practice nurses in Ghana [START_REF] Hassmiller | Advanced Practice Nursing Leadership: A Global Perspective[END_REF]. Moreover, Gabonese medical doctors identified the creation of a legislative framework as a facilitator of acceptability for APN. Establishing a legislative framework will help to clarify the role of advanced practice nurses and reduce ambiguities and role confusion [START_REF] Duma | Specialist and Advanced Specialist Nursing and Midwifery Practice[END_REF]. Role confusion was an obstacle for medical doctors who were afraid of the risks encountered by patients.

Our study also highlighted the importance of specific training for advanced practice nurses. The requirements for a master's degree and higher education are associated with greater patient safety [START_REF] Aiken | Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study[END_REF]. Furthermore, the quality of care provided by advanced practice nurses has been shown to be equal to, if not better than, that provided by general practitioners [START_REF] Chou | Potentially inappropriate medication prescribing by nurse practitioners and physicians[END_REF][START_REF] Htay | The effectiveness of the role of advanced nurse practitioners compared to physician-led or usual care: A systematic review[END_REF][START_REF] Swan | Quality of primary care by advanced practice nurses: A systematic review[END_REF].

The prospect of implementing APN following Hamric's model competencies appears promising in Gabon (Hamric et al., 2016). All competencies were wellaccepted, except for "peer formation," which had a lower acceptance rate, particularly among nurses and nursing students. This discrepancy may be attributed to the fact that nurses in Gabon were mainly trained by medical doctors. Developing nursing teaching staff, as emphasized in our focus groups, could elevate the nursing profession and foster further positive development in the field [START_REF] Christmals | The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review[END_REF].

Facing chronic disease in the context of the epidemiological transition is a major issue for African countries [START_REF] Oni | Why the communicable/non-communicable disease dichotomy is problematic for public health control strategies: Implications of multimorbidity for health systems in an era of health transition[END_REF][START_REF] Remais | Convergence of non-communicable and infectious diseases in low-and middle-income countries[END_REF] ; therefore, acceptability of APN regarding the management of chronic disease was evaluated. While our study focuses on chronic disease management within the context of the epidemiological transition, the significance of infectious diseases should not be underestimated. Our participants highlighted the importance of addressing infectious diseases, such as malaria and sexually transmitted infections, which warrant attention from advanced practice nurses. As such, we intend to incorporate an infectious disease module into the APN curriculum in Gabon. This exemplifies the need for a specific and tailored program for APN, rather than merely transferring models from one country to another [START_REF] Christmals | The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review[END_REF].

Our study had some limitations. First, the study focused exclusively on one French-speaking African country, potentially limiting the generalizability of our findings. Second, we did not assess the population's acceptance of APN. Even if the literature showed positive acceptance of APN by the population [START_REF] Tracy | Hamric and hanson's advanced practice nursing: An integrative approach[END_REF], the newness of the concept could be complex to accept in the Gabonese context. Third, we did not gather inputs from rural nurses and stakeholders, whose perspectives may reveal additional specific needs. Fourth, our study did not involve political stakeholders; however, it received support from the Ministry of Health in Gabon. Lastly, due to mixed methodology and focus group use, we cannot rule out desirability bias even though careful attention was paid to prevent it ; as an example, participants were exclusively voluntary and were not paid for their participation.

However, our study also had several strengths. The large and exhaustive sample combined with a multicentric and mixed-method design contributes to the robustness of our results. Moreover, to our knowledge this is the first mixedmethod study on the topic conducted in Africa, providing concrete information to design the implementation of APN and guide specific training curricula.

Recommendations for further research

Further research should focus on the specificity of rural nurses and stakeholders to understand their specific needs. Furthermore, studies assessing patient outcomes related to APN care are warranted. Additionally, investigations into patient acceptance of APN are needed.

Conclusion

In conclusion, conducting a pre-implementation study APN in Gabon was essential. This allowed us to delineate the needs and expectations of key stakeholders, design a specific curriculum, and prepare for successful implementation considering the identified facilitators and barriers.

Implications for Nursing & Health Policy

  the implementation of APN and has recently opened a master's degree program in APN at the Faculty of Midwifery and Nursing Science of Libreville in collaboration with Limoges University in France, starting in October 2023.

  Data were collected in Gabon from April to May 2022 at the Akanda Cancer Institute, the Mother and Child University Hospital Center of Jeanne Ebori Foundation, the Faculty of Nursing Science and Midwifery of Libreville, and at EM-Gabon University.

  APN is poised to play a critical role in Gabon and across Africa in addressing the shortage of health care resources and the challenges of managing chronic and infectious diseases. Establishing a regulatory framework for nursing and the APN profession, including the creation of a legal framework and nursing councils, are essential steps in implementing APN in Africa. Ensuring the effective implementation of APN requires careful preparation tailored to the specific needs of each country. This work was supported by the Limoges University Hospital Center and Limoges University.

Table 1 :

 1 Sample characteristics

					Nursing
		Global	Nurses	Medical Doctors
	Variables				students	p-value
		(n = 187 )	(n = 42)	(n = 24)	(n=121)
		147			97 (80.2%)	0.622
	Sex (female)		33 (78.6%)	17 (70.8%)
		(78.6%)
	Age (years)	28.0 [8]	39.5 [14]	38.0 [18]	26.0 [4]	<0.001
	Work place:
	• Hospital	183	42	20 (83.3%)	121	<0.001
	• City	(97.9%)	(100.0%)	7 (26.1%)	(100.0%)	<0.001
		7 (9.0%)	0 (0.0%)		0 (0.0%)
	Experience	0.0 [4]	8.0 [12]	8.5 [13]	0.0 [0]	<0.001
	(years)
	Year of studies
	• Second				3 (2.5%)
	• Third				118
					(97.5%)
	Number (percentage)
	Median [interquartile range]

Table 2 :

 2 Percentage of participant acceptance of advanced nursing's skills by profession

				Medical	Nursing
		Global	Nurses
	Variables			Doctors	students	p-value
		(n = 187 )	(n = 42)	(n = 24)	(n=121)
	Do patient follow	179 (95.7%)	41 (97.6%)	21 (87.5%)	117 (96.7%)	0.090
	up
	Do peer	88 (47.1%)	19 (45.2%)	19 (79.2%)	50 (41.3%)
	formation
	Do consultation	125 (66.8%)	30 (71.4%)	14 (58.3%)	81 (66.9%)	0.575
	Conduct	139 (74.3%)	35 (83.3%)	16 (66.7%)	88 (72.7%)	0.266
	research
	Do a patient	114 (61.0%)	27 (64.3%)	10 (41.7%)	77 (63.6%)	0.119
	clinical
	examination
	Care pathway	151 (80.7%)	34 (81.0%)	22 (97.7%)	95 (78.5%)	0.346
	coordination
	Make prevention 148 (79.1%)	34 (81.0%)	22 (91.7%)	92 (76.0%)	0.217
	Do Therapeutic	156 (83.4%)	30 (71.4%)	20 (83.3%)	106 (87.6%)	0.058
	education
	Global	110 (58.8%)	29 (69.0%)	13 (54.2%)	68 (56.2%)	0.302
	acceptability
	score
	Number (percentage)

Table 3 :

 3 Perceived interests in advanced practice nurses' implementation

		Global	Nurses	Medical	Nursing	p-value
	Variables			Doctors	students
		(n = 187 )	(n = 42)	(n = 24)	(n=121)
	Regarding the nursing profession:
	• Could valorize nursing	179 (95.7%)	40 (95.2%)	24 (100.0%)	115 (95.0%)	0.749
	• Could retain nurses	150 (80.2%)	39 (92.9%)	20 (83.3%)	91 (75.2%)	0.035
	• Could legalize existing	159 (85.0%)	37 (88.1%)	23 (95.8%)	99 (81.8%)	0.189
	practices
	Regarding the health system:
	• Could improve the	183 (97.9%)	42 (100.0%)	23 (95.8%)	118 (97.5%)	0.434
	healthcare system
	• Could improve patient	180 (96.3%)	42 (100.0%)	24 (100.0%)	114 (94.2%)	0.192
	outcomes
	• Could increase the time	150 (80.2%)	39 (92.9%)	19 (79.2%)	92 (76.0%)	0.043
	with the patient
	• Could improve care	180 (96.3%)	41 (97.6%)	24 (100.0%)	115 (95.0%)	0.614
	pathway
	• Could decrease	167 (89.3%)	39 (92.9%)	21 (87.5%)	107 (88.4%)	0.773
	inappropriate use of
	emergency services
	• Could decrease the	127 (67.9%)	37 (88.1%)	18 (75.0%)	72 (59.5%)	0.002
	hospitalization rate

Acknowledgements :

We acknowledge the University Hospital Center of Limoges for supporting this study.

Acknowledgments

We acknowledge the Limoges University Hospital Center and Limoges University for supporting this study.

This work was supported by the University Hospital Center of Limoges (No grand number available).

Funding

Declaration of interests :

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix 1 : Thema/c analysis