Advanced Nurse Practitioners
– improved health care to the chronically ill
Advanced Nurse Practitioners
- improved health care to the chronically ill Redaktion: Dansk Sygeplejeråd
Foto: Lizette Kabré Layout: Dansk Sygeplejeråd Tryk: Dansk Sygeplejeråd ISBN 87-7266-308-1 Grafisk Enhed 08-97
Copyright © Dansk Sygeplejeråd 2008 September 2008
Alle rettigheder forbeholdes.
Fotografisk, mekanisk eller anden form for gengivelse eller mangfoldiggørelse er kun tilladt med angivelse af kilde.
Denmark is facing a rapid increase in the prevalence of chronic diseases. The Danish health service, however, is not sufficiently equipped to care for the chronically on their own terms, and it is therefore a pressing public issue to find new ways of solving the imminent problem.
The Danish Nurses’ Organization suggests that the Danish health service should learn from the experiences in countries with which we traditionally compare ourselves. Countries like the Netherlands, Belgium and England have introduced advanced nurse practitioners to ensure high qual-ity care to the chronically ill - patients with diabetes, asthma, heart disease, Chronic obstructive pulmonary disease (COPD) and cancer.
Advanced nurse practitioners have an expanded scope of practice within de-fined areas such as diagnosing, prescribing tests and drugs and initiating nurs-ing care and treatment. Thus, advanced nurse practitioners take care of the overall needs of the chronically ill in terms of health promotion, prevention, care and treatment.
The international experiences with advanced nurse practitioners are good: Their clinical results are equal to those achieved by physicians, and patient satisfaction is high. In addition, nurses have found a new career path close to the patients, an option that will contribute to recruiting nurses and retaining them in the profession.
I think the Danish health service must learn from international experiences in order for the chronically ill patients to experience continuity and high quality of care.
Chronically ill patients deserve a better
the prevalence of chronic disease is rising
More than 1.7 million Danes suffer from one or more chronic diseases - and the number is rising. It constitutes a huge challenge for the Danish health service, not least because of its highly specialized organization, and because it mainly is geared toward providing care to patients with acute health problems.
By contrast, the health service does not match the needs of the chronically ill patients, resulting in many chronically ill patients not getting the necessary care when it comes to health promotion, prevention, care, treatment or rehabilitation. In addition, there is a major social inequality in health as well as in the care offered to the chronically ill.
Facts about chronically ill patients
• Non-communicable diseases account for about 70% of lost good years of life because of illness, disability and premature death
• People with chronic diseases take up 70-80% of the total resources of the Danish health services
• There is significant and increasing social inequality in non-communicable diseases
• The most common diseases are: Heart disease, diabetes, cancer, COPD, musculoskeletal disorders, osteoporosis, allergy and mental illness • A significant proportion of the population lives with risk factors for one or
The Danish National Board of Health points out that many chronically ill patients are facing problems such as:
• Not getting optimal care, treatment and rehabilitation, frequently causing deterioration of illness and hospitalisation.
• Inadequate information and education about their own illness - including how to cope with it.
• Lacking priority of health promotion and prevention when it comes to citizens at risk of getting a chronic disease, as well as to patients with manifest chronic disease.
• Too many contacts with different health professionals.
• Poor continuity and consistency of patient care paths, within and between different health service sectors.
Inadequate care for the chronically ill
The lack of care for the chronically ill has a negative impact on the individual's health and quality of life, and furthermore, it is a waste of health care resources. The chronically ill patients take up 70-80% of the health care resources, for the reason among others that we do not bring into action health promotion, prevention and early diagnosis.
It is, therefore, necessary to improve the Danish health service to the chronically ill patients.
The care of cancer patients is inadequate
• The Danish Cancer Society has presented a study, ‘The World of the Cancer Patient’, showing that 32% of cancer patients do not think they have received optimal treatment. 27% missed having any guidance, advice and support, and 55% have been offered no or only some physical rehabilitation and reha-bilitation due to lack of coordination between hospitals and municipalities. 71% had not felt that their need of contact with others in the same situation had been adequately met.
Nationally, several initiatives have been launched by the National Board of Health and in some Danish regions and municipalities. National guidelines for patient care paths for the chronically ill is one example, as well as suggestions of establishing professional patient trajectory coordinators and patient education programmes. However, these initiatives cannot stand alone.
Denmark must learn from international experience
The experience in many of the countries with which we traditionally compare ourselves, e.g. England, the Netherlands and the United States, show that it is crucial to find new ways to secure the necessary care to the chronically ill. As an example, the Dutch health service has introduced a new concept: advanced nurse practitioners, nurses with expanded responsibility for the chronically ill
with diabetes, COPD, asthma or cardiovascular disease. An advanced nurse practitioner treats 65% of the chronically ill in Holland with moderate chronic disease from the hospitals’ out-patient clinics.
The results are clear:
• Their clinical results are as good or better as those attained by physicians treating chronically ill patients.
• 90% of the patients are more satisfied with this system than with care in general practice.
• The cost is lower than in the general practice.
Research in the United Kingdom shows that advanced nurse practitioners are better at guiding and providing information to patients in general practice than are physicians, and they attain just as good clinical results and higher patient satisfaction.
Studies also show that when advanced nurse practitioners act as the central health professional responsible for the chronically ill, patients achieve higher self-care and quality of life.
The Danish Nurses’ Organization calls on the Danish health politicians to learn from experience and introduce advanced nurse practitioners in the Danish health care. It is essential when it comes to designing the Danish health care to match the needs of the chronically ill on their own terms.
International experience with advanced nurse practitioners
A large number of countries have good experience using advanced nurse practitioners. Appart from the Netherlands and England, the United States and Canada have had advanced nurse practitioners since 1965. Another example is Belgium, where advanced nurse practitioners independently treat patients with diabetes and COPD. In Sweden there are good experiences as well.
In the Swedish health care centres, specially trained nurses have authority to refer patients, to prescribe a certain number of drugs, and independently treat patients.
A Danish definition
The Danish Nurses’ Organization suggests that the Danish health care adopt the term ‘advanced nurse practitioner ‘ and that the definition is as follows: • Within a restricted area of diseases/conditions, advanced nurse practitioners
has authority to independently diagnose, order and interpret diagnostic and laboratory examinations, prescribe drugs, initiate nursing care and medical treatment, refer to specialists and discharge patients.
• An advanced nurse practitioner has several years of clinical experience, followed by academic continuing education attaining knowledge and clinical skills at expert level.
• Advanced nurse practitioner is a protected title. Authorization is achieved after completed education approved by the Danish National Board of Health.
What is an advanced nurse practitioner?
nurses with expanded scope of practice at expert level
An advanced nurse practitioner provides nursing care at expert level. She has expanded competence within a specific field, including diagnosing, prescribing examinations, tests and drugs, and initiating nursing care and treatment. This means that the advanced nurse practitioner handles the chronically ill patient's overall need for health promotion, prevention, nursing care and treatment.
the tasks of an advanced nurse practitioner
Essentially, the tasks of advanced nurse practitioners in e.g. England and Holland are
• to receive patients who have not yet been diagnosed, and to perform clinical examinations and tests beyond those normally performed by nurses. The experience in UK shows that 60% of patients in general practice do not have a diagnosis until they are examined by an advanced nurse practitioner • to detect and screen patients for risk factors and early signs of disease, e.g.
cardiovascular disease and diabetes
• to diagnose within the field of authorisation, e.g. diabetes-related eye complications
• in close cooperation with the patient to plan nursing care and treatment, with emphasis on preventive measures such as anticoagulant therapy. Here, the major focus is to train the patient in self-management of oral anticoagulant therapy
• to prescribe medications within the specialty e.g. lipid-lowering drugs to patients with elevated cholesterol level
• to prescribe tests and refer to relevant specialists e.g. when it comes to a patient with cardiovascular disease developing diabetes
• to teach to self-care e.g. teaching patients and groups of patients to cope with chronic disease and how to prevent deterioration.
• to provide health promotion and prevention, e.g. guide and teach patients and families on health care issues to change their life style such as smoking cessation and exercise guidance.
Thus the advanced nurse practitioner solves a wide range of health problems beyond the usual scope of nursing as formally defined in Denmark.
In order to provide the chronically ill patients in Denmark with better health care, it is essential that the policy makers dare break tradition and expand the scope for nursing. We do need advanced nurse practitioners in Denmark.
Other Danish professions at same level of education already have expanded competencies compared to nurses. Thus, midwives have their independent authority to screen pregnant women for high-risk pregnancy.
A number of Danish nurses have expanded authority in practice – but it is not formally endorsed
Several Danish nurses do practice within an expanded scope of responsibility. However, the Danish laws on registration and health issues do not permit nurses to independently diagnose or prescribe examinations, tests or medicines.
A living example is a cardiovascular out-patients clinic where nurses have authority to prescribe anticoagulants – as long as it stays within preset physicians’ order sets. As well, nurses select patients for self-administration of anticoagulants under established criteria, train patients and monitor the quality of their anticoagulant treatment. Nevertheless, nurses are not in charge of the patients’ overall treatment - it lies with the physician.
Another good example in general practice: Here nurses are responsible for a clinic, conducting independent consultations with diabetes and lung patients. Not even here, nurses are officially in charge of the patient trajectories.
numerous benefits for the chronically ill
Introducing advanced nurse practitioners will render many benefits to the chronically ill. International research reveals that advanced nurse practitioners secure:
• Far better coherence in the patient trajectory. Studies show that patients benefit from nurse led care.
• High quality of care. Research shows that advanced nurse practitioners achieve at least the same level of quality as physicians. Studies also show that there is no difference between prescriptions or referrals made by physicians and nurses.
• High patient satisfaction. International studies show that patients seen by advanced nurse practitioners are more satisfied than those seen by physicians. One reason is that advanced nurse practitioners are good at communicating and guiding on self-care, doing more tests and spending more time with the patient.
In addition, the chronically ill indirectly benefit from advanced nurse practitioners when it comes to training patients in self-management of their disease and medication. Furthermore, advanced nurse practitioners undertake patient education, guidance and supervision of other health professionals, including implementation of new research knowledge. As well, they initiate and take part in clinical research within their field.
a limited number of advanced nurse practitioners
Far from all nurses should reach to the level of advanced nurse practitioner. Building on international experience the Danish Nurses’ Organization estimates that about 2% of all nurses should be educated to advanced nurse practitioner level – in the short term. This must be compared to the fact that the National Board of Health estimates the current prevalence to be 1.7 million chronically ill in Denmark.
The introduction of advanced nurse practitioners in the Danish health care is primarily a means of improving coherence in the chronic patients' trajectories, improving quality of care and patient satisfaction.
In addition, there is an urgent need to recruit and retain nurses in health care. Improved and rewarding career paths are a way to solve the imminent problem
Where will patients meet advanced nurse
the chronically ill patients constitute a diverse group
Chronically ill patients have different needs of care depending on the severity and complexity of their disease. At one end of the spectrum, there are chronically ill with well-regulated or newly diagnosed chronic disease without significant complications. At the other end of the spectrum, we see patients with complex chronic diseases. In between, we see patients with poorly regulated chronic disease with imminent complications.
The Dutch experiences reveal that advanced nurse practitioners particularly are of benefit to the chronically ill at level 1 and 2 in the model. These patients primarily get their care in general practice, in out-patient clinics or in the municipal health care. The most chronically ill with complex conditions need hospital based and specialised care.
Primary health care sector Hospital and specialized physicians Hospital, out-patient clinics and primary health sector
Chronic Disease Management
Level 3 Intensive and complex disease Level 2 Moderate disease Level 1 Slight, uncomplicated disease
an important role in out-patient clinics, the municipal
health care and general practice
Advanced nurse practitioners may be employed in many parts of the health care system. The international experience shows that advanced nurse practitioners mainly work in out-patient clinics and in general practice.
The same service is highly relevant in Denmark, where advanced nurse practitioners should play a significant role in the municipal health care as well. This includes the local health care centres, since the effort mainly should be locally based at the lowest possible level of expenditure.
Thus, advanced nurse practitioners will constitute a valuable supplement to e.g. consultation nurses, to specialised nurses in out-patient clinics, and to district nurses.
In England, advanced nurse practitioners work in various settings:
• Approximately 2/3 of the advanced nurse practitioners work in primary health care, primarily in general practice, where they diagnose, treat and prescribe practically all medications. The advanced nurse practitioners are either employees or partners, or they are self-employed. Thus, general practice may have a nurse led asthma clinic, clinics for cardiovascular rehabilitation and COPD.
Regions: There is a pressing need for large medical clinics staffed with physicians and nurses
New and larger medical clinics staffed with health professionals, e.g. nurses and dieticians, will be able to handle out-patient care, to diagnose and monitor the chronically ill who are currently referred to hospital care.
The Danish Regions have stressed this need: »With this model for health care in general practice it will be possible to supply more and far better treatment close to where people live. 98-99% of all health care should be handled here, «says Bent Hansen, chairman of the Danish Regions.
How will Danish patients benefit from
advanced nurse practitioners?
remove the barriers in the danish health care
It requires political willpower to introduce advanced nurse practitioners to care for the chronically ill in the Danish health care. First, it is essential to adjust the Danish laws on health and authorization, in order for advanced nurse practitioners to expand the scope of nursing. This includes nurses’ authority to diagnose, prescribe and refer patients.
Many specialized nurses in out-patient clinics, general practice and emergency departments already work within an expanded scope of responsibility. However, it is necessary to authorize and formalise the expanded scope of practice to allow advanced nurse practitioners to provide coherent care paths for the chronically ill.
Today, the workflows are awkward and time consuming, when specialized diabetes nurses have to work within a preset order set laid out by physicians, even though it is the nurses’ responsibility to monitor and guide the patients. As well, it is impractical and time consuming that nurses have limited power to refer patients to specialized care.
In addition, it is essential to formalise the expanded scope of nursing to ensure consistent high quality of health care throughout the country. This is not the case today. As an example, there are great variations in how much postgraduate education nurses get prior to taking on an expanded scope of practice in the emergency departments e.g. inducing analgesia and treating minor injuries. The Danish Nurses’ Organization recommends that the National Board of Health should work for expansion of the scope of practice for advanced nurse practitioners. In this context, the board should include the experiences in particularly England, the Netherlands and Sweden.
• Approximately 1/4 works in hospitals. Partly in out-patient clinics handling patient care paths after discharge, partly in emergency departments independently receiving patients, assessing and treating minor injuries. • About 1 out of 20 works in walk-in centres. These are open seven days a
week from morning to evening, offering health care and treatment of minor diseases as colds, coughs and infections, and minor injuries as wounds and sprains.
• About 1 out of 20 works in Minor Injuries Units. Here patients can come without prior appointment and be treated for minor fractures and scull injuries, sprains, bites, wounds, eye infections etc.
In the Netherlands, advanced nurse practitioners play an important role in general practice, where there are positive experiences with stratifying asthma patients. The general practitioner or the consultation nurse treat the mild cases, while advanced nurse practitioners take care of patients with moderate cases of asthma. The difficult cases are referred to specialised hospital care.
Many general practices are not large enough to have an advanced nurse practitioner full-time, but share one with other practices in the area.
Rethinking care for the chronically ill on a small scale
In some areas, care for the chronically ill has been reorganized in Denmark. One hospital has established a nurse led rehabilitation clinic for patients who have had vascular surgery. The clinic has proved to be very effective in preventing deterioration of the patients’ condition: After 6 months of treatment, cholesterol level and blood pressure dropped significantly and most of the patients complied with their medication regimens. After a year the proportion of smokers dropped.
Another example is a municipality with a health care centre housing 25 nurse led clinics. The centre deals with patients with chronic diseases, including rehabilitation and teaching patients how to cope with their illness e.g. asthma, COPD, cardiovascular disease and type 2 diabetes. A pilot project has proved that vulnerable patients e.g. psychiatric patients improved their coping ability and managed to establish social networks.
It is an excellent development. Moreover, it is needed if the scarce staffing resources should be used optimally.
However, in a number of places the division of labour between health professionals is too old-fashioned due to routines and traditions as barriers for reform. The Danish Nurses’ Organization, therefore, suggests that the government set up a task force to look at the overall functions in health care.
Establishing an education for advanced
create career paths for nurses close to patients
The Danish National Board of Health should establish a formal education programme leading to the title of advanced nurse practitioner.
The programme should be based on international experience. Inspiration may be found in the revised Danish postgraduate education for children’s health visitors, which is a postgraduate programme for nurses.
The Danish Nurses’ Organization recommends a postgraduate programme at master’s level with a theoretical and clinical focus. The programme should be preceded by at least 5 years of relevant clinical experience within the specialty. The duration should be 1-2 years, but dispensation should be granted for other relevant postgraduate education.
With the introduction of advanced nurse practitioners new and attractive career paths will be created, careers that will keep nurses close to the patients. Today, many nurses have to abandon patient related work, when they want to start a career, e.g. as managers, researchers and teachers. It is important for patients as well as for recruiting and retaining nurses that new career paths are created close to the patients.
Good experience with nurse prescribing
English nurses are authorized to prescribe virtually any type of medication, except certain controlled drugs. The requirement is that they have at least three years of clinical experience and undergo special education in the use of medications. In practice, the majority of prescribing nurses have more than 10 years of clinical experience. Results are positive: Nurses adhere to guidelines and patients are satisfied, one of the reasons being the thorough guidance they receive. Furthermore, physicians are generally satisfied with the solution.
In England, there has been a significant political support behind the introduction of advanced nurse practitioners. Through a series of initiatives, the British Government has actively strengthened the role of nurses in health care and has secured a formal expansion of the scope of nursing with the purpose to create a more patient centred health care. At the same time, the initiative is considered a means of recruiting and retaining nurses. Thus, the British Government has broken the medical monopoly when it comes to diagnosing, prescribing and treating patients.
focus on the division of labour between health
The division of labour between health professionals is rapidly changing. There are many examples. Medical secretaries, pharmaconomists, dieticians, and enrolled nurses now solve tasks traditionally performed by nurses. In some departments, medical secretaries have expanded roles coordinating patient care paths and administrating quality assurance programmes. At some medical and rheumatology departments, enrolled nurses provide care to patients during stable stages of their care paths. A third example is departments where dieticians play a central role when it comes to nutrition.
There are many areas where the scope of nursing is under considerable change e.g. in emergency departments where nurses treat a number of minor injuries and fractures, or out-patient clinics where nurses perform examinations and tests, and monitor patients with certain conditions such as incontinence, diabetes and cardiovascular disease.
DANSK SYGEPLEJERÅD Sankt Annæ Plads 30 Postbox 1084 1008 København K Tlf. 33 15 15 55 Fax 33 15 24 55 firstname.lastname@example.org 08-97 Grafisk Enhed
There will be still more chronic disease in Denmark. The Danish health care, however, is not sufficiently geared to deal with chronically ill on their own terms. Renewal is urgently needed.
The Danish health system should learn from international experience in countries like the Netherlands, Belgium and England, where the concept of advanced nurse practitioners has been established.
Advanced nurse practitioners have an expanded scope of practice within defined fields including diagnosing, prescribing tests and medications, and initiating nursing care and treatment. The rest of the world has excellent ex-periences with advanced nurse practitioners, They are as good at achieving high-quality results as are physicians, and patient satisfaction is high.