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ADVANCED PRACTICE

NURSES: CHANGE

REQUIRED, POWERFUL

OBSTACLES TO BE

OVERCOME

FLASH AUDIT

July 2023

EXECUTIVE SUMMARY

Major benefits expected from APN status by the Ministry of Health

Belatedly in comparison with Anglo-Saxon countries, the option of “advanced practice” in

paramedical professions was recognised in France by the law of 26 January 2016

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. This

concept is an ambiguous one because it suggests that the aim is to specialise the practice of

these professionals at a higher technical level, whereas what is at issue is the broadening and

cross-disciplinary nature of their skills and responsibilities – an issue of a completely different

dimension which is at the root of the tensions surrounding its implementation.

Although open to all paramedical professions, advanced practice is still only structurally

arranged for nurses. “Advanced practice nurses” (APNs) have been given a great deal of

autonomy in exercising their skills, which brings them closer to existing practice in medical

professions, except – until very recently – for the right of first prescription, and on condition

that they work as part of a team, under the coordination of a doctor. However, legislation

defines the specific prerogatives of APNs only in terms of the particular technical acts they are

authorised to perform. They make no mention of the tasks and duties they will be called upon

to perform, which are nevertheless presented as the essential justification for this new status.

The Ministry of Health has high expectations of nurses: to facilitate access to care by

distributing the workload differently between nurses and doctors, whose demographics are

under pressure; to improve the management of chronic diseases in view of an ageing

population; and to offer nurses better career prospects by creating a new profession.

To be eligible to practise as a nurse, whether in the community or in a healthcare

establishment, nurses must have been practising for three years and must then have

completed two years’ additional training at Master’s level in one of the five “specialities” chosen

by the legislator: stabilised chronic conditions (SCCs); oncology and haemato-oncology;

chronic kidney disease (CKD), dialysis and kidney transplantation; psychiatry and mental

health; and emergencies.

Powerful obstacles

The Ministry had set itself a target of 3,000 APNs trained or in training by 2022 and, ultimately,

between 6,000 and 18,000 practising APNs.

However, by 2021, only 581 APNs had qualified and 1,366 were in training; 131 were practising

in towns and cities. No data is available on the work of these professionals in healthcare and

medical/social institutions.

The interest from nurses is not in doubt, given the many requests they have made for their

speciality to be recognised as advanced practice (anaesthesia-intensive care, childcare,

gerontology, etc.), despite the risk of losing its specific character, i.e. the exercise of extended

skills.

However, there are a number of obstacles to the introduction of advanced practice.

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Law no. 2016-41 of 26 January 2016 on the modernisation of our healthcare system

.

The reluctance of doctors is the first and most fundamental problem. The benchmark care

pathway remains that of the primary relationship between the patient and a general

practitioner, who ensures the patient's correct guidance through the healthcare system and is

remunerated on a fee-for-service basis. However, in cases where APNs (community nurses)

are based in towns and cities, doctors all too often refuse to make referrals to them for patients

whose situation falls within the remit of these paramedical professionals, out of ignorance or

fear of competition, despite the fact that until the advent of Law 2023-379 of 19 May 2023 on

improving access to care through confidence in healthcare professionals, and only for APNs

practising in coordinated structures, patients could not access them directly.

The second obstacle, which follows on from the first, stems from the economic model which,

in towns and cities, does not enable APNs to make a living from their work. This model has

changed and is now more favourable, but it does not remove the obstacle of doctors referring

patients, which keeps them in a precarious economic situation. Meanwhile, salaried practice

in health centres, health establishments or medical/social establishments is scarcely any more

attractive. In view of the training effort that has been made, the financial opportunities and the

posts on offer are, to a still unknown extent, of less interest than initially announced and then

expected.

The third obstacle results from the training conditions. The studies, which form part of a

continuing education framework, are expensive (€48,000 according to an estimate by the

Fédération hospitalière de France, including accommodation and catering) and require

sacrifices on the part of the nurses themselves or their employers, the latter being faced with

a labour shortage that does little to encourage them to send their employees on training

courses. Added to this is the fact that it is virtually impossible to use apprenticeships or to take

advantage of acquired experience, and that the content of courses varies from one university

to another.

The fourth and final obstacle is linked to the existence of other professionals with whom doctors

more naturally collaborate. These are medical assistants, Asalée nurses

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, and workers

covered by cooperation protocols, whose highly circumscribed field of competence and (mainly

salaried) economic model do not pose a threat to the medical professions, particularly from a

financial point of view.

Recent structural changes

Faced with these obstacles, the Ministry had planned to make changes, based on the results

of experiments that had taken time to set up: one to allow patients access to APNs without

going through a doctor (“direct access”), the other to grant APNs the right of first prescription.

The legislator has been ahead of the Ministry: the recently promulgated law has decided in

favour of these developments.

Now that the law has been passed, it is time to breathe life into the APN profession, despite

persistent opposition from some doctors. To achieve this, the Ministry must respond to the

fears expressed; for example, by drawing up guides or standards specifying the tasks of the

APNs or, following the example of a number of other countries, by providing additional training

to prepare them for the right to issue first-line prescriptions.

On a more structural level, beyond the single issue of sharing skills between healthcare

professionals, the difficulties encountered by APNs reflect the limitations of the design of the

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Nurses employed by the Asalée association, trained in therapeutic patient education and working in support of

general practitioners on prevention, screening and advice for patients with chronic diseases.

French healthcare system, which is still characterised by general practitioners working in

isolation and fee-for-service remuneration. This concept needs to evolve, beyond the changes

already underway (development of “maisons de santé” nursing homes and regional

professional health communities), so that cooperation between healthcare professionals

becomes standard practice. This is all the more necessary as the supply of local care continues

to shrink, while at the same time needs are growing and many patients do not have a general

practitioner.

The main findings of the survey

The Ministry of Health had high hopes for the creation of the APN profession and had set itself a target

of 3,000 APNs trained or in training by the end of 2022 and, thereafter, between 6,000 and 18,000

practising APNs. However, by 2021, only 581 APNs had qualified; 1,366 were in training, and 131 were

practising in towns and cities. The number of salaried APNs working in healthcare and medical/social

establishments is not known. There are many obstacles to the introduction of advanced practice. The

first, and most fundamental, of these is the reluctance of doctors to entrust procedures and patients to

APNs. The second, which follows on from the first, stems from the economic model in towns and cities,

which does not enable APNs to make a living from their work. The third obstacle results from the training

conditions. The fourth and final obstacle is the existence of other professionals with whom doctors more

naturally collaborate. Faced with these obstacles, the legislator has responded, without waiting for the

results of experiments that were taking time to implement, by granting patients direct access to APNs

and, for APNs, a right to issue first-line prescriptions.

Audit recommendation

1.

Define the content of hospital APN posts and monitor their effective implementation (Ministry

of Health).

2.

Facilitate access to training for APNs, by opening such training up to apprenticeships and

validation of experience, providing a better framework for its content and removing financial

barriers (Ministry of Health and Prevention).