Update on Nurse Practitioners

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 12

Abstract

Nurse practitioners (NPs) provide specialized nursing services, under supervision of a physician for medical tasks but highly independent for nursing tasks. They are educated at master level. Education for NPs started in 1997. Currently the number of students is 429 (2007) and the number of active NPs is estimated at 635 (1 January 2008). Three quarters of them work in a hospital. Stage of policy process: adaptations of the law to recognise nurse specialists and to allow restricted actions.

Recent developments

The introduction of NPs in Dutch health care is by now accepted policy. The first education of NPs started in 1997 (see also HPM reports (1)2003 and (2)2003) and by now 9 professional universities provide a two-year master programme of Advanced Nurse Practitioner. The master programme is dual education: one day per week day courses, remainder of the week learning and working arrangements. Entry level: bachelor in nursing plus 2 years experience as a nurse.

The process of institutionalization of NPs is visible from:

• establishment of a professional organization (in 2000)
• funding of the education jointly by the Ministries of Health and of Education from 2004/5
• establishment of a Board for Specialisms in Nursing (see also section "Influences in policy making and legislation") and official registration of specialized nurses, including NPs, expected in 2009.

The current number of active NPs was estimated at 635 (1 January 2008). Most of them are working in hospitals (75%), GP practices (12%) and nursing homes or homes for the elderly (8%). The single biggest area of specialization of NPs is cardiology (17% of active NPs).

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

The structural impact of the introduction of NPs (and Physician Assistants or PAs) might have a long-term impact on the traditional system of the professions in health care. The higher end of the nursing educational continuum, with NPs and other specialised nurses, meets the lower end of the medical educational continuum, with PAs. At this point the two educational continua overlap and this may lead to shared education. Changes in the procedures that are up till now restricted to physicians threaten the traditional monopoly of the medical profession, e.g. in areas such as prescribing of drugs.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government: The Ministry of Health supports delegation and reallocation of tasks from physicians to lower educated professionals. Legislation is under way.

• Providers: The nursing association and the medical association are supportive; GP associations oppose (they see practice nurses as the solution).

Stakeholder positions

The institutionalization of NPs in Dutch health care fits into a broader policy process of restructuring the educational and occupational structure of medicine and nursing. The aim is to make education more flexible (responsive to changes in demand), to shorten education where possible, and to stimulate delegation and reallocation of tasks from physicians to nurses. Milestones were the report of the committee that reviewed the position and education of physicians (De arts van straks, 2002), the report of the committee that reviewed the implementation of a new educational continuum and task reallocation (De zorg voor morgen: flexibiliteit en samenhang, 2003), and the report of the committee that reviewed the educational and occupational structure in nursing (Verpleegkundige toekomst in goede banen, 2006). The latter report advised about the recognition of specialization in nursing at master level (thus including NPs).

The professional association of nurses (V&VN) and the Royal Dutch Medical Association (KNMG - the federation of medical practitioners' professional associations) work together towards the implementation of innovations in the educational structure. The separate associations of medical specialists support the introduction of NPs. In fact the introduction of NPs started in one of the university hospitals, based on the need for this type of professional.

The professional associations of GPs (NHG and LHV) do not support the introduction of NPs in primary care. Instead, their strategy is one of task delegation to practice nurses (who are specialised at bachelor level) who work within a GP practice. The difference between NPs and practice nurses is that NPs have a masters degree in nursing, while practice nurses have a bachelor from a professional university (Hoge School in Dutch, comparable to German Fachhochschulen). Nurse practitioners will be considered as nurse specialists. NPs work more independently from physicians than practice nurses and will be allowed to do reserved procedures (ie. procedures that have so far been reserved to physicians) on their own, while practice nurses work under the responsibility of a physician and can only do reserved procedures on the authority of a physician. GPs therefore have more authority over practice nurses than they would have over NPs. NPs enter for some parts of their work into the core domain of physicians (such as assessing the need for certain interventions and acting upon that assessment or diagnosis).

Overall, the introduction of practice nurses in Dutch primary care has been very quick and is successful.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
Nursing (professional association:V&VN)	very supportive		strongly opposed
Medicine (professional organization KNMG)	very supportive		strongly opposed
Medical specialists	very supportive		strongly opposed
General practitioners (professional associations NHG & LHV)	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

The Individual Health Care Professions Act, Wet BIG, regulates the professional practice in health care. This is a framework law, and issues such as the recognition of specialized nurses can be regulated in separate decrees. The Board of Specialisms in Nursing was modelled on the example of how this is done in medicine. The Board has devised a number of regulations, such as the definition of the specialties to be recognized (eg. there will be nurse-specialists in prevention, acute care, intensive care, and care for the chronically ill; all in the domain of somatic care), that have to be adopted by the Ministry of Health. It is expected that this will take place in 2009.   

The Wet BIG also defines actions that are restricted to specific professions. Examples of reserved procedures are: assessing the need for and/or prescribing prescription drugs, administering injections, or surgical interventions. Here the idea is that the Ministry of Health decides upon an experimental situation for a period of five years to speed up the possibility for specialized nurses to provide restricted actions. During this time nurses can already carry out specific restricted actions even though there doesn't yet exist a legal decree. In the mean time the decree within the framework law can be prepared and pass parliament.     

Legislative outcome

Enactment

Actors and influence

Government
Ministry of Health	very strong		none
Providers
Nursing (professional association:V&VN)	very strong		none
Medicine (professional organization KNMG)	very strong		none
Medical specialists	very strong		none
General practitioners (professional associations NHG & LHV)	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

The first NPs were educated from 1997 on. By now the number of students is 429 and the number of practising NPs 635. Institutionalization of the professional position of NPs is progressing. Hence, in a ten year period NPs have gained a position in Dutch health care, especially in hospitals.

Future obstacles might be in the institutionalization of nursing specialisms which might hamper the introduction of NPs in fields that are inherently non-specialized, such as primary care.

Monitoring and evaluation

There is a number of studies about the introduction and future need of NPs. The main advisory board of the Ministry of Health on the future need for professionals in health care monitors the numbers of NPs and tries to model their influence on the need for different professionals in health care. There are separate studies on implementation and outcomes of NPs. A recent modelling study based on empirical case studies in breast cancer care (Van Offenbeek MAG et al., 2007) showed:

• NPs have longer consultations and provide more continuity of care (indicating quality gains)
• Physicians fill their time with other things that they had less time for in the situation without NPs
• There is a small decrease of costs

Expected outcome

In general, task delegation from physicians to nurses has led to the same or increased quality, increased continuity of care and much less to substitution of physician care by nursing care. Depending on the area of specialization and the work organization of NPs these general conclusion more or less apply also to NPs. If the emphasis in their work is on (specialized) nursing tasks, their work is probably more additional to that of physicians than substituting; when they also provide medical tasks, there might be more substitution.  

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

Assessment of the impact of NPs in these areas requires more research. As concerns quality and equity: effects are expected to be neutral to positive. With regard to cost-efficiency, we expect the introduction of NPs to be neutral, but strongly dependent on the context (type of specialty and work organization).

References

Sources of Information

Nuijen T, Hingstman L, Heiligers Ph, Van der Velden L. Arbeidsmarktverkenning Nurse Practitioners: omvang en samenstelling van de beroepsgroep. Utrecht: NIVEL, in press.

Van Dijk JK. NP Update. Health Policy Monitor, December 2003. Available at: www.hpm.org/survey/nl/b2/1

Vulto M, Vianen G, Mutsaers H. Toekomst verpleegkundig specialisten: factoren van invloed op de benodigde capaciteit. Leiden: STG/Health Management Forum, 2008.

Groenewegen PP. Nursing as grease in the primary care innovation machinery. Quality in Primary Care 2008; 14 (5): in press.

Website of the Board of Specialisms in Nursing: www.verpleegkundigspecialismen.nl (in Dutch only)

Van Offenbeek MAG, Van Kampen TJ, Ten Hoeve Y, Roodbol PF, Wijngaard J. Scenario-ontwikkeling inzet NP en PA in ziekenhuizen met het oog op substitutie- en kosteneffecten. Utrecht: CBOG/Capaciteitsorgaan, 2007.

Author/s and/or contributors to this survey

Peter P. Groenewegen, NIVEL

NIVEL - Netherlands Institute for Health Services Research

Suggested citation for this online article

Groenewegen, Peter P.. "Update on Nurse Practitioners". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/nl/a12/2