Please cite this paper as: Delamaire, M. and G. Lafortune (2010), “Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries”, OECD Health Working Papers, No. 54, OECD Publishing. http://dx.doi.org/10.1787/5kmbrcfms5g7-en OECD Health Working Papers No. 54 Nurses in Advanced Roles A DESCRIPTION AND EVALUATION OF EXPERIENCES IN 12 DEVELOPED COUNTRIES Marie-Laure Delamaire, Gaetan Lafortune JEL Classification: I10, I18, J2 Unclassified DELSA/HEA/WD/HWP(2010)5 Organisation de Coopération et de Développement Économiques Organisation for Economic Co-operation and Development 08-Jul-2010 ___________________________________________________________________________________________ English text only DIRECTORATE FOR EMPLOYMENT, LABOUR AND SOCIAL AFFAIRS HEALTH COMMITTEE UD nE cL laS ssA ifi/H edE A / W D /H W P ( 2 Health Working Papers 0 1 0 ) 5 OECD Health Working Paper No. 54 NURSES IN ADVANCED ROLES: A DESCRIPTION AND EVALUATION OF EXPERIENCES IN 12 DEVELOPED COUNTRIES Marie-Laure Delamaire and Gaetan Lafortune JEL Classification: I10, I18, J2 All Health Working Papers are now available through the OECD's Internet Website at http:/www.oecd.org/els/health/workingpapers E n g lish J T03286585 te x t o Document complet disponible sur OLIS dans son format d'origine n Complete document available on OLIS in its original format ly DELSA/HEA/WD/HWP(2010)5 DIRECTORATE FOR EMPLOYMENT, LABOUR AND SOCIAL AFFAIRS www.oecd.org/els OECD HEALTH WORKING PAPERS http://www.oecd.org/els/health/workingpapers This series is designed to make available to a wider readership health studies prepared for use within the OECD. Authorship is usually collective, but principal writers are named. The papers are generally available only in their original language – English or French – with a summary in the other. Comment on the series is welcome, and should be sent to the Directorate for Employment, Labour and Social Affairs, 2, rue André-Pascal, 75775 PARIS CEDEX 16, France. The opinions expressed and arguments employed here are the responsibility of the author(s) and do not necessarily reflect those of the OECD. Applications for permission to reproduce or translate all or part of this material should be made to: Head of Publications Service OECD 2, rue André-Pascal 75775 Paris, CEDEX 16 France Copyright OECD 2010 2 DELSA/HEA/WD/HWP(2010)5 ACKNOWLEDGEMENTS This study has been done in collaboration with a network of national experts who provided guidance throughout the project, supplied the required data, and reviewed a preliminary version of this report. By alphabetical order of countries, the Secretariat would like to thank Rosemary Bryant and Samantha Edwards (Department of Health and Ageing, Australia), Miguel Lardennois and Olivier Caillet (Federal Public Service Health, Food Chain Safety and Environment, Belgium), Sandra MacDonald-Rencz and Alba Di Censo (respectively from the Office of Nursing Policy, Health Canada and McMaster University, Canada), Anastasia Argyrou, Chryso Gregoriadou, Christina Ioannidou (Ministry of Health, Cyprus), Nina Mullerova and Katerina Pribylova (Ministry of Health, Czech Republic), and Veronika Di Cara (Czech Nurses’Association), David Foster, Chris Caldwell and Maureen Morgan (Department of Health, England), Marjukka Vallimies-Patomaki (Ministry of Social Affairs and Health, Finland), Marie-Andrée Lautru (Ministry of Health and Sports, France), Sheila O’Malley and Siobhan O’Halloran (respectively from the Department of Health and Children and Dr Steevens Hospital, Ireland), Noriko Ishikawa, Youko Shimada, Kiyoko Okuda and Shio Sugita (Ministry of Health, Japan), Tomasz Niewiadomski (Main Council of Nurses and Midwives, Poland), and Susan Reinhard (American Association of Retired People, Center to Champion Nursing in America, United States). The project also benefited from useful comments by Yann Bourgueil, Director of IRDES, France, and from other participants at the expert group meeting held in February 2010 to discuss the preliminary findings from this study. The authors would also like to thank a number of colleagues from the OECD Health Division: Gaelle Balestat provided useful statistical assistance; Mark Pearson, Francesca Colombo and Valérie Paris provided many useful comments and suggestions; and Daniel Garley and Judy Zinnemann provided secretarial support. This study has been partly supported by a grant from the Directorate General for Public Health and Consumer Affairs of the European Commission. The contents of this paper do not necessarily reflect the views of the Commission. 3 DELSA/HEA/WD/HWP(2010)5 ABSTRACT Many countries are seeking to improve health care delivery by reviewing the roles of health professionals, including nurses. Developing new and more advanced roles for nurses could improve access to care in the face of a limited or diminishing supply of doctors. It might also contain costs by delegating tasks away from more expensive doctors. This paper reviews the development of advanced practice nurses in 12 countries (Australia, Belgium, Canada, Cyprus, Czech Republic, Finland, France, Ireland, Japan, Poland, United Kingdom and United States), with a particular focus on their roles in primary care. It also reviews the evaluations of impacts on patient care and cost. The development of new nursing roles varies greatly. The United States and Canada established “nurse practitioners” in the mid-1960s. The United Kingdom and Finland also have a long experience in using different forms of collaboration between doctors and nurses. Although development in Australia and Ireland is more recent, these two countries have been very active in establishing higher education programmes and posts for advanced practice nurses in recent years. In other countries, the formal recognition of advanced practice nurses is still in its infancy, although unofficial advanced practices may already exist in reality. Evaluations show that using advanced practice nurses can improve access to services and reduce waiting times. Advanced practice nurses are able to deliver the same quality of care as doctors for a range of patients, including those with minor illnesses and those requiring routine follow-up. Most evaluations find a high patient satisfaction rate, mainly because nurses tend to spend more time with patients, and provide information and counselling. Some evaluations have tried to estimate the impact of advanced practice nursing on cost. When new roles involve substitution of tasks, the impact is either cost reducing or cost neutral. The savings on nurses’ salaries – as opposed to doctors – can be offset by longer consultation times, higher patient referrals, and sometimes the ordering of more tests. When new roles involve supplementary tasks, some studies report that the impact is cost increasing. Keywords: nurses, advanced roles, skills, nurse practitioners, clinical nurse specialists, primary care, OECD countries. 4 DELSA/HEA/WD/HWP(2010)5 RESUME Beaucoup de pays cherchent à améliorer la prestation des soins de santé en examinant les rôles des différents corps professionnels, y compris les infirmières. Le développement de nouveaux rôles infirmiers plus avancés peut contribuer à améliorer l’accès aux soins dans un contexte d’offre de médecins limitée voire en diminution. Cela pourrait aussi permettre de contenir les coûts en délégants certaines tâches d’une main-d’œuvre médicale onéreuse aux infirmières. Cette étude analyse le développement des pratiques infirmières avancées dans 12 pays (Australie, Belgique, Canada, Chypre, États-Unis, Finlande, France, Irlande, Japon, Pologne, République Tchèque, Royaume-Uni), en se concentrant notamment sur leurs rôles dans les soins primaires. Elle analyse aussi les évaluations des impacts sur les soins des patients et les coûts. Le développement des rôles avancés infirmiers varie grandement. Les États-Unis et le Canada avaient déjà établi la catégorie des « infirmières praticiennes » au milieu de la décennie 1960. Le Royaume-Uni et la Finlande ont aussi une longue expérience de différentes formes de collaboration entre les médecins et les infirmières. Bien que le développement de la pratique infirmière avancée en Australie et en Irlande soit plus récent, ces deux pays mènent depuis quelques années une politique très active de mise en place de nouveaux programmes d’enseignement et de création de postes. Dans les autres pays de l’étude, la reconnaissance officielle de la pratique infirmière avancée n’en est qu’à ses débuts, bien que certaines pratiques avancées non officielles puissent déjà exister de fait. Les évaluations montrent que le recours aux infirmières en rôles avancés peut effectivement améliorer l’accès aux services et réduire les temps d’attente. Les infirmières en rôles avancés sont capables d’assurer la même qualité de soins que les médecins dans une gamme de services, comme le premier contact pour les personnes atteintes d’une affection mineure et le suivi de routine des patients souffrant de maladies chroniques, dès lors qu’elles ont reçu une formation appropriée. La plupart des évaluations constatent un haut taux de satisfaction des patients, principalement parce que les infirmières tendent à passer plus de temps avec les patients, et fournissent des informations et des conseils. Certaines évaluations ont tenté d’estimer l’impact des pratiques infirmières avancées sur les coûts. Lorsque les nouveaux rôles impliquent une substitution des tâches, la plupart des évaluations concluent à un impact réducteur ou neutre à l’égard des coûts. Les économies réalisées sur les salaires des infirmières par rapport aux médecins peuvent être compensées par de plus longue durée de consultation, un plus grand nombre d’adressages de patients à d’autres médecins ou une augmentation du taux de réitération des consultations et, parfois, la prescription d’un plus grand nombre d’examens. Lorsque les nouveaux rôles consistent en des tâches supplémentaires, certaines études indiquent que l’impact est une augmentation des coûts. Mots-clefs : infirmières, rôles avancés, infirmières praticiennes, infirmières cliniciennes, soins primaires, pays de l’OCDE. 5 DELSA/HEA/WD/HWP(2010)5 TABLE OF CONTENTS ACKNOWLEDGEMENTS ............................................................................................................................ 3 ABSTRACT ................................................................................................................................................... 4 RESUME ........................................................................................................................................................ 5 EXECUTIVE SUMMARY ............................................................................................................................ 8 INTRODUCTION ........................................................................................................................................ 14 PART 1: REASONS MOTIVATING THE DEVELOPMENT OF ADVANCED PRACTICE NURSING16 1.1 Responding to shortages of doctors ................................................................................................ 16 1.2 Responding to changing demand for care and promoting high quality of care .............................. 18 1.3 Responding to growing health cost ................................................................................................ 19 1.4 Improving career prospects for nurses ........................................................................................... 19 PART 2: STATE OF DEVELOPMENT OF ADVANCED PRACTICE NURSING .................................. 20 2.1 Defining Advanced Practice Nursing ............................................................................................. 20 2.2 Distinguishing broad types of APN roles ....................................................................................... 22 2.3. Identifying different categories of advanced practice nurses and their main tasks ........................ 23 2.3.1. Nurse practitioners (NPs) ............................................................................................................ 29 2.3.2. Clinical nurse specialists (CNSs) ................................................................................................. 31 2.4. Education and training requirements .............................................................................................. 31 2.5. Increasing role of advanced practice nurses in drug prescription................................................... 32 PART 3: EVALUATIONS OF ADVANCED PRACTICE NURSING ON CARE AND COST ............... 35 Introduction ............................................................................................................................................... 35 3.1 Impact on patient care (access, quality, outcomes and satisfaction) .............................................. 43 3.2 Impact on cost ................................................................................................................................ 44 Conclusions ............................................................................................................................................... 44 PART 4: BARRIERS AND FACILITATORS TO ADVANCED PRACTICE NURSING ....................... 45 4.1 Professional interests ...................................................................................................................... 45 4.2 Organisation of care and funding mechanisms............................................................................... 46 4.3 Legislation and regulation on the scope of practice ....................................................................... 50 4.4 Education and training opportunities .............................................................................................. 51 CONCLUSIONS .......................................................................................................................................... 53 BIBLIOGRAPHY ......................................................................................................................................... 56 ANNEX A: NATIONAL EXPERIENCES WITH ADVANCED ROLES IN NURSING ......................... 63 AUSTRALIA ............................................................................................................................................ 63 BELGIUM ................................................................................................................................................. 67 CANADA .................................................................................................................................................. 69 CYPRUS ................................................................................................................................................... 73 CZECH REPUBLIC ................................................................................................................................. 76 FINLAND ................................................................................................................................................. 79 FRANCE ................................................................................................................................................... 83 IRELAND ................................................................................................................................................. 87 JAPAN ...................................................................................................................................................... 91 6 DELSA/HEA/WD/HWP(2010)5 POLAND ................................................................................................................................................... 93 UNITED KINGDOM (ENGLAND) ......................................................................................................... 95 UNITED STATES .................................................................................................................................... 99 ANNEX B: NATIONAL EXPERTS INVOLVED IN THIS STUDY ....................................................... 103 Tables Table 1.1 Number of doctors and nurses per capita, and ratio of nurses to doctors, 12 countries covered under this study, 2008 (or latest year available) ........................................................................................ 17 Table 2.1 Categories of nurses in advanced practice roles, their numbers, main tasks and education level ................................................................................................................................................................... 24 Table 2.2 Key milestones in the rights of nurses to prescribe drugs in five countries .............................. 33 Table 2.3 Categories of nurses involved in drug prescription (with or without the supervision of a doctor), and required additional training ................................................................................................... 34 Table 3.1 Review of evaluations of the impact of advanced practice nursing in primary care (general role), chronic disease management and drug prescription ........................................................................ 37 Table 4.1 Predominant modes for the provision of primary care services ................................................ 47 Table 4.2 Predominant modes of payment for physicians in selected OECD countries ........................... 48 Figures Figure 4.1 Proportion of general practitioners working in group practice*, 2009 .................................... 47 Boxes Box 1.1 The development of physician assistants and/or medical assistants in Germany, the United States, Canada and the United Kingdom ................................................................................................... 18 Box 2.1 National definitions of advanced practice nursing in Australia, Canada, Ireland and the United States ......................................................................................................................................................... 21 Box 2.2 The “re-emergence” of nurse practitioners in Canada ................................................................. 29 Box 2.3 The roles of NPs, GPs and other health professionals in primary care in the United Kingdom .. 30 Box 2.4 The extended roles of nurses in rural/remote areas in Australia, Canada and Finland ................ 31 Box 4.1 Changes in the rights for nurses to prescribe drugs in the United Kingdom ............................... 51 Box 4.2 Advantages and disadvantages of increasing minimum educational requirement in nursing ..... 52 7 DELSA/HEA/WD/HWP(2010)5 EXECUTIVE SUMMARY 1. Many countries are looking at ways to improve efficiency in health care delivery by reviewing the roles and responsibilities of different health professionals, including nurses. Discussions on the scope of practice of nurses often take place in the context of broader efforts to re-organise different parts of health care systems, particularly the re-organisation of primary care. 2. It is difficult to define precisely what is meant by the term “advanced practice nursing”, as this term encompasses a large and growing variety of practices. The International Council of Nurses (ICN) has proposed the following definition: “A Nurse Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A Master’s degree is recommended for entry level” (ICN, 2008). 3. Current national definitions of advanced practice nurses are generally consistent with this broad ICN definition, although they are adapted to each national context. 4. OECD countries are at different stages in implementing more advanced roles for nurses. Some countries (e.g., the United States, Canada and the United Kingdom) have been using advanced practice nurses for a long time, initially in the primary care sector, but more recently also in hospitals. In other countries, the development of advanced practice nursing (APN) roles is still in its infancy. This latter group of countries may be able to learn useful lessons from countries that have greater experience concerning the potential benefits and costs related to the development of new advanced practice nursing roles, as well as some of the barriers that might need to be overcome for successful implementation. 5. The aims of this project were to: 1) Review the main factors motivating the development of APN roles in the group of countries participating in this study; 2) Describe the state of development of APN roles in these countries, with a particular focus on the roles of nurses in primary care; 3) Review the results from evaluations on the impact of advanced practice nursing in terms of access, quality of care and costs; and 4) Examine the main factors that have hindered or facilitated the development of APN roles in different countries, and identify how barriers have been overcome. 6. This study looks at the experience with APN roles in 12 countries: Australia, Belgium, Canada, Cyprus1, Czech Republic, Finland, France, Ireland, Japan, Poland, United Kingdom and United States. 1. Note by Turkey: The information in this document with reference to “Cyprus” relates to the southern part of the Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Turkey recognizes the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within the context of United Nations, Turkey shall preserve its position concerning the “Cyprus” issue. Note by all the European Union Member States of the OECD and the European Commission: The Republic of Cyprus is recognized by all members of the United Nations with the exception of Turkey. The 8 DELSA/HEA/WD/HWP(2010)5 These countries were selected on the basis of their willingness to provide the necessary information to carry out this study. They represent a good mix of countries that are at different stages in implementing advanced practice nursing. 7. The re-organisation of health service delivery in many countries has not been limited to developing new roles for nurses. New categories of health personnel, such as “physician assistants” or “medical assistants”, have also emerged in countries such as the United States and the United Kingdom. These assistants to doctors are carrying out a number of clinical and administrative tasks, and some of these tasks may overlap with those of advanced practice nurses. However, it was beyond the scope of this study to look at how the roles of these new physician or medical assistants relate to those of advanced practice nurses. 8. The information contained in this study comes largely from a policy and data questionnaire which was sent to designated national experts in all participating countries in the autumn of 2009. Additional information was also gathered through a review of the literature. Reasons motivating the development of new roles for nurses 9. In most countries, one of the main reasons for developing more advanced roles for nurses is to improve access to care in a context of a limited supply of doctors. Another reason for the development of APN roles is to promote higher quality of care, for instance by creating new posts to provide more intensive follow-up and counselling for patients with chronic illness in primary care or the creation of advanced nursing posts in hospitals to oversee quality improvement initiatives. In some countries, the development of APN is also seen as a way to contain cost. By delegating certain tasks from more expensive doctors to less expensive “intermediate level” advanced nurses, it may be possible to deliver the same (or more) services at a lower cost. Also, by improving quality of care, it may be possible to reduce health spending in the longer term by avoiding complications and unnecessary hospitalisations. 10. In addition, the development of more advanced roles for nurses is often seen as a way to increase the attractiveness of the nursing profession and retention rates by enhancing career prospects. State of development of advanced practice nursing across countries 11. The development of APN roles varies greatly across countries. The United States and Canada established the role of “nurse practitioners” back in the mid-1960s, initially to provide primary care to populations in rural and remote areas under-served by doctors, although their roles and practice locations have evolved a lot since then. The United Kingdom’s experience in using advanced practice nurses dates back to the 1970s, when nurse practitioners were initially introduced to increase access to primary care. Finland also has a long experience in using different forms of collaboration between doctors and nurses in primary care health centres. While the development of advanced practice nursing in Australia and Ireland is more recent, they have been very active in developing new APN education programmes and posts in recent years. In Belgium, the Czech Republic, France, Japan and Poland, the formal recognition of APN is still in its infancy, although pilot studies to test new APN roles may have already been carried out and some unofficial advanced practices may already exist in reality. 12. Advanced practice nurses include various titles in different countries, reflecting the different roles they may be playing and the degree of specialisation or focus on certain patient groups. This OECD information in this document relates to the area under the effective control of the Government of the Republic of Cyprus. 9