To meet population health care needs in developed countries, health systems must shift their focus from treating acute episodes to managing chronic conditions. With the rise of chronic care comes a new set of tasks that are more time-consuming and team-oriented. Policymakers in many countries are seeking to align the size and composition of their primary care workforce to meet these new needs, by expanding the role of advanced nurses.

In a recently published Health Working Paper for the Organisation for Economic Co-operation and Development (OECD), Claudia Maier and LDI Senior Fellow Linda Aiken analyze the changing role of nurses in response to health care workforce demands in 37 OECD and European Union countries. They document expanded nursing roles in two realms that may often overlap:

1. Task shifting (substitution) – nurses with additional training take on tasks traditionally performed by physicians. This phenomenon, along with examples of tasks being shifted, is detailed in a 2016 study by the authors.
2. Complementary tasks (supplementation) – nurses take on new tasks that center around chronic disease management.

From a series of systematic reviews and evaluations, the authors found that the quality of care provided by advanced nurses “provide at least equivalent quality of care compared with General Practitioners/physicians.” In fact, studies have shown that nurse-led primary care often results in higher patient satisfaction and lower hospital readmission rates than physician-led care. While the economic impact of advanced nursing requires further study, the evidence suggests that advanced nurses are able to enhance the primary care workforce without a loss of quality.

Maier and Aiken found that many OECD countries have implemented educational, regulatory, and financial reforms to foster the incorporation of more advanced nurses into the workforce. The authors identify policy and organizational barriers to implementation and highlight successful methods that some OECD countries have used to overcome those barriers. Through their extensive report, Maier and Aiken point to the growing importance of advanced nurses in meeting the health care needs of the 21^st century.

A Lesson for Dentistry

The strong and consistent evidence on the quality of care provided by advanced nurses has enabled, and emboldened, this policy shift.  In a parallel discussion in American dentistry, the debate centers on mid-level providers (often called dental therapists) as a potential solution to increase access to dental care. Minnesota, Maine, and Vermont, and tribal governments in Alaska, Washington, and Oregon, have passed legislation granting mid-level providers the right to practice under indirect or general supervision of dentists. The scope of practice varies, but includes extractions and simple fillings. They face significant opposition from dentists and dental students, who point out that mid-level providers are not trained dentists, and may perform “irreversible dental procedures on the public.” One of the major concerns about mid-level providers is potentially exposing certain patient populations to lower-quality care. Studies have yet to validate the quality of mid-level providers, especially as they do work previously performed only by dentists. As the example of advanced nurses shows, building a strong evidence base on quality is key in using other health professionals to improve access to care. The current debate in American dentistry would benefit from similarly rigorous studies.

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Tim Wang is a dental student at the University of Pennsylvania.