Health Policy$ense

A Global Perspective on Advance Practice Nurses in Primary Care

New study documents task-shifting across countries

In a new paper in the European Journal of Public Health, Harkness Fellow Claudia Maier, and LDI Senior Fellow and Director of Penn Nursing’s Center for Health Outcomes and Policy Research Linda Aiken document the shifting of tasks that reflect expansion of nurses’ scope-of-practice in 39 countries. Their work shows that the current debates on scope-of-practice laws across US states have analogues in Europe, Canada, Australia, and New Zealand, as many countries seek to meet the primary care needs of their populations.

Through an international expert survey and literature scoping review, Maier and Aiken found evidence of “task-shifting” (where nurses take on advanced roles from physicians) in 27 countries, albeit to different degrees. They identified three clusters:

  • 11 countries with extensive shifting (Australia, Canada, England, Northern Ireland, Scotland, Wales, Finland, Ireland, Netherlands, New Zealand and US) where Nurse Practitioners or other Advanced Practice Nurses (NP/APN) exist in primary care and are authorized to work at high levels of advanced practice;
  • 16 countries with limited shifting where nursing roles have expanded, but not at an NP/APN level; and
  • 12 countries with no task shifting.

The map below presents their results.

What, tasks, exactly, are being shifted? They include writing prescriptions, making diagnoses, ordering tests, having patient panels, referring for treatment, and being first point of contact. The authors document the extent of the policy, finance, and educational reforms that underlie these changes. As shown below, countries with greater task shifting have enacted policies that remove regulatory and to a lesser extent, financial barriers; countries with more limited shifting are primarily reforming their education. The review suggests that later adopters of advanced nurse practice roles could learn from decades of research and experiences of early adopters like the U.S. and avoid regulations that are unnecessary to safeguard the public but impair access and increase costs of care.

In a companion invited perspective in the Israel Journal of Health Policy Research (Israel is considering adopting advanced practice nurse roles), Maier and Aiken consider the policy lessons from this international research. They note:

First, there is substantial evidence on the equivalence in quality of care, patient safety and high consumer acceptance which should move policy debates from if to how to effectively implement new roles in practice.

Second, regulatory and finance policies as well as accessible advanced education are essential to facilitate realignment of roles.

Third, country experience suggests that advanced practice roles for nurses improve the attractiveness of nursing as a career thus contributing to solving nursing shortages rather than exacerbating them.

Not content to simply publish their findings, Maier and Aiken also wrote a major report for the OECD on the topic for a June 2016 workshop entitled, Towards a more efficient use of health human resources: What lessons can we learn from innovations across OECD countries? The report will be published as an OECD Health Working Paper by the end of the year, as the OECD considers this and other reforms to increase workforce efficiency and improve access to care.