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Evolvement of French advanced practice nurses Galadriel Bonnel, PhD, RN, FNP (Nurse Practitioner) Public Health Laboratory EA 3279, Faculty of Medicine, Aix-Marseille University, Marseille, France

Keywords Advanced practice nurses; healthcare reform; nursing education; quality of care; France; United States. Correspondence Galadriel Bonnel, PhD, RN, FNP, Public Health Laboratory EA 3279, Faculty of Medicine, Aix-Marseille University, Marseille, France. Tel: +33-609-223734; Fax: +33-095-6243235; E-mail: [email protected] Received: March 2012; accepted: July 2012 doi: 10.1002/2327-6924.12061

Abstract Purpose: The purpose of this review is to chronicle the development of the advanced practice nurse (APN) in France and compare international APN indictors of quality care with French studies. Data sources: A review of the literature was performed by accessing the MEDLINE, Science Direct, and Cochrane Databases for studies of quality of care by APNs during 1965–2012. The author’s participation on a national task force in collaboration with the French Ministry of Health provided additional information. Conclusions: After applying limits of this search, 36 studies fulfilled inclusion and exclusion criteria. In both the French and international APN nursing literature, the most frequently described quality of care measures were level of patient satisfaction and other patient outcomes (clinical and laboratory measures) according to evidence-based guidelines. In three French studies (nephrology, neuro-oncology, and urology settings), nurses performed direct patient care and were legally permitted to take on some limited responsibilities usually held by French physicians, including clinical examinations, diagnosing, and prescribing. Implications for practice: Creation of the APN role in France can respond to public health challenges including the rising incidence of chronic diseases and an impending physician shortage. Future APN research should focus on rigorous, innovative design development including collaborative care models.

Purpose and background In the context of French healthcare reforms, research has begun on introduction of the advanced practice nurse (APN) role. The purpose of this review is to chronicle the educational and legal development of the advanced nursing profession in France and compare international indicators of APN quality care to French studies of the APN role. A decade ago, the most recent World Health Organization (WHO) report ranking the world’s health systems rated France as a global leader, providing the best model of health care (WHO, 2000). Currently the French healthcare system, like other developed countries, is fiscally impacted by the increasing prevalence of chronic illnesses along with an aging population. For example, a study of France’s health insurance system reported that the prevalence of diabetes treated by oral hypoglycemic agents or insulin rose from 2.6% in 2000 to 4.4% in 2009, a 6% average annual increase (Direction of Research, Studies, Evaluation and Statistics,

2011). This trend is because of increasing longevity of the French population, and the escalating incidence of obesity. The incidence of end-stage renal disease increased by 16% between 2005 and 2009 among older adults aged 75 years and older. Additionally, the prevalence of high LDL (low-density lipoprotein) cholesterol in 2007 indicates that 19% of adults aged 18–74 years old were affected, and this peaked to 55% for adults between 65 and 74 years old. Likewise, the French healthcare system faces overwhelming activity in acute care specialties such as the emergency department (ED) and ambulance emergency medical services. An evaluation in 2005 showed an increase in ED activities with an additional 3%–3.5% visits, ambulance services with 4% more interventions, and emergency call centers with an additional 10%–12% calls (Grall & Minister of Health, Direction of Hospitals and Healthcare Organization, 2007). The potential creation of the APN role in France represents not only a response to increased healthcare services

C 2013 The Author(s) Journal of the American Association of Nurse Practitioners 26 (2014) 207–219 

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utilization, but also a solution to an evolving shortage of healthcare professionals. The National Demographics Observatory of Health Professions (ONDPS) confirmed that a sudden wave of retiring physicians in the next several years (by 2025) should create a need for increased healthcare services, especially in the area of general medicine. A proposed solution to this was “skill transfer,” or collaboration between healthcare professions (ONDPS, 2004). In 2004, a national provisional law was passed allowing for nurses to practice outside of their usual competencies for a specific number of pilot research studies, in order to evaluate skill transfer to nurses. By 2006, the first five studies were completed (discussed later in the Results section). Leading investigators Berland and Bourgueil positively reported that “the accomplishment of medical activities by previously trained paramedical (nursing) professionals is feasible in satisfactory, safe conditions for patients . . . It should provide an adapted framework to continue studies on the cooperation and delegation of tasks between health professionals” (Berland, Bourgueil, & National Demographics Observatory for Health Professionals, 2006). Furthermore, the politics of French healthcare reform have increasingly centered on healthcare quality and mandated the evaluation of professional practices (Vignally, Gentile, Bongiovanni, Sambuc, & Chabot, 2007). The French National Authority for Health (Haute Autorite´ de Sante´ or HAS) was created, not only for the purposes of accrediting healthcare establishments, but also to validate standards of quality care and evidence-based practice in order to improve patient care (Journal Officiel, 2004). While the landscape of France’s healthcare system appears to be favorable to change, several factors, including the traditional nursing education system, may represent a barrier. After the Bologna Declaration (European Ministers of Education, 1999), the majority of European Union countries have moved toward the three-cycle higher education system (Bachelor’s, Master’s, and Doctorate). As of 2009, after years of challenging the situation of French nursing education, which was a vocational 3.5-year diploma school, a national law was passed to grant a Bachelor’s degree to nurses completing an accredited nursing education program (Journal Officiel, 2010). In 2007, the author was a member of a working task force involving French health authorities (HAS and ONDPS). This task force recommended the advancement of nursing education and the potential creation of APNs/nurse practitioners (NPs). The International Council of Nurses (ICN) defines the NP/APN as a “a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competen208

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cies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A Master’s degree is recommended for entry level” (ICN, 2012). In line with these recommendations, the first Master’s in Nursing Science program was started in 2010 by the University of AixMarseille and the French School of Public Health and to date it is only one of two programs in the country (followed by St. Anne Formation- l’Universite´ de Versailles St. Quentin, which started in 2011). The 2-year curricu` de la pratique lum prepares the APN (or “IPA,” infirmiere ´ to work in the settings of oncology or gerontolavancee) ogy, or as a case manager. Upon graduation, however, the only way to potentially practice as an APN is to request approval from HAS for a specific “skill transfer” to be established within a strictly defined framework. Master’slevel training is a real advancement for nurses in France, and the future will reveal if this change becomes an educational standard requirement with formal acceptance of the APN role. The potential introduction of the APN role in France necessitates a literature review comparing the main indicators of APN quality care reported in the international literature to recent French studies. To our knowledge, there has not been a review conducted on the quality of care of APNs, which encompasses the French situation.

Data sources/methods A comprehensive review of the literature of APNs was performed by accessing the MEDLINE, Science Direct, and Cochrane Databases during the 1965–2012 interval. Search terms specified criteria for quality of care by APNs/NPs in both the management of acute and chronic illnesses, employing Medical Subject Headings (MeSH) and keywords to identify health care provided by APNs with increased role responsibility. This review was not limited to randomized controlled studies, as relatively few exist in this domain, and the work setting of the APN was not limited to any specialty, in order to obtain the most indicators of quality care possible. Outcome measures such as the cost-effectiveness of APNs were not included, as they did not meet the objective of this review and few studies exist in this domain. Also, studies that did not give APN-specific results (i.e., included physician’s assistants) were excluded. In addition, French studies that have not yet been translated into English or included in the MEDLINE database were consulted, primarily from HAS and the French Public Health Database (BDSP). Additional sources were selected from references of identified articles, and the full text of potentially relevant articles was obtained and assessed. The author’s participation as

Review of French APNs

G. Bonnel

a member of a national task force in collaboration with HAS supplemented the understanding of these studies. Regular meetings focused on the assembly of data, the review of experts, and lastly the development of national recommendations regarding advanced practice nursing education.

Results After applying limits of this search, 93 articles were identified. Thirty-six studies fulfilled inclusion criteria, and among them, 13 used randomized controlled methodology and were relatively recent. The most common study design was observational (n = 18 studies), and least frequent was retrospective (n = 5). Most studies were performed in the United States (n = 11) and United Kingdom (n = 10), followed by France (n = 7), Canada (n = 5), Australia (n = 2), and the Netherlands (n = 1). International studies are summarized in Table 1, and Table 2 describes the seven French exploratory studies in detail including their design, outcome measures, and results. While the majority of settings were in primary care (n = 15) and the ED (n = 6), the remainder represented a wide variety of healthcare domains (see Tables 1 and 2). Dermatology and nephrology were each areas where two studies were done. One study was completed in each of the following settings: bronchiectasis clinic, cardiology, endocrinology, gastroenterology, gynecology, neonatology, neuro-oncology, prehospital/ambulance, preblood transfusion, telemedicine, and urology. In general, French studies showed that nurses with advanced training offered safe and efficient health care, including the management of patients with chronic kidney disease undergoing renal dialysis, in neuro-oncology and urology (HAS/ONDPS, 2008). The international literature usually showed that APNs with or without an interdisciplinary team offered an equal or higher quality of patient care when compared to physicians alone (Allen et al., 2011; Caine et al., 2002; Counsell et al., 2007; Hogg et al., 2009; Litaker et al., 2003; Russell et al., 2009). The most frequently described indicators of quality of care were the level of patient satisfaction (Byrne, Richardson, Brunsdon, & Patel, 2000; Caine et al., 2002; Dawes et al., 2007; Edwards, Bobb, & Robinson, 2009; Gambino, Planavsky, & Gaudette, 2009; HAS/ONDPS, 2008; Jennings, Lee, Chao, & Keating, 2009; Kinnersley et al., 2000; Lenz, Mundinger, Kane, Hopkins, & Lin, 2004; Litaker et al., 2003; Mundinger et al., 2000; Schuttelaar, Vermeulen, Drukker, & Coenraads, 2010; Venning, Durie, Roland, Roberts, & Leese, 2000; Wilson& Shifaza, 2008), and other patient outcomes in accordance with current guidelines (laboratory and clinical values such as HbA1c and blood pressure; Allen

` & Yilmaz, et al., 2011; Bourgueil, Le Fur, Mousques, 2008; Caine et al., 2002; HAS/ONDPS, 2008; Gambino et al., 2009; Grant et al., 2004; Lee, Campoy, Smits, Vu, & Chonchol, 2007; Litaker et al., 2003; Mundinger et al., 2000; Ohman-Strickland et al., 2008; Russell et al., 2009; Schuttelaar et al., 2010). Although direct comparison cannot be made between studies with differences in populations and methods, when specified, the proportion of patients who were satisfied with NP care was high, ranging from 83% in cardiology (Gambino et al., 2009) to 100% in gastroenterology (HAS/ONDPS, 2008). The relation of the French studies to the international literature is highlighted hereafter under the broad categories of acute and chronic illness care.

Acute illness care The system of urgent care in France differs from the United States, notably in the prehospital setting. American paramedics and Emergency Medical Technicians undergo a shorter training than that of nurses, and possess the responsibility to perform medical services, transport the ill patient, and can offer varying levels of care. Generally, the focus is upon achieving the fastest possible arrival to the hospital, where further care can take place. In France, emergency physicians are charged with the responsibility to transport the patient, with the focus on stabilizing the patient first and subsequently to arrive to the hospital as soon as possible. Nurses typically assist in this process, carrying out actions within the nursing scope that are ordered from the physician in his or her presence. Although research in the area of advanced practice nursing is infrequent in France because of the nurse’s limited role in emergency care, a study that addressed this was carried out between 2003 and 2006 by SAMU ´ 83 (Service d’Aide Medicale Urgente), the prehospital ambulance emergency medical services of a hospital in Toulon in the Var region of France (Arzalier, Feuerstein, Poirier, & Valliccioni, 2004). In this case, within strict parameters and protocols, the physicians delegated prehospital, ambulance care of nonsevere patients to nurses. Nurses conducted 30% of the ambulance activity (5369 interventions) and increased the total ambulance activity, permitting doctors to focus on more urgent cases. The most frequent diagnoses were hypoglycemia, seizures, and traumatology. A retrospective analysis of these data found that the quality of care of the emergency ambulance team composed of nurses was comparable to that of doctors in the management of hypoglycemic patients (Istria, 2013). The nurse group showed significantly higher mean scores for concordance with recommendations (p < .001) and quality of medical records (p = .005). 209

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Primary care

Setting

Management of each provider; patient and staff satisfaction questionnaires regarding consultations.

Randomized controlled trial

Descriptive comparative study

Randomized controlled trial; intention-to-treat analysis performed

Randomized controlled trial

Descriptive comparative study Randomized study

Randomized trial

Cross-sectional

Counsell et al., 2007 (United States)

Edwards et al., 2009 (United Kingdom)

Hogg et al., 2009 (Canada)

Kinnersley et al., 2000 (United Kingdom)

Lenz et al., 2004 (United States)

Litaker et al., 2003 (United States)

Mundinger et al., 2000 (United States)

Ohman-Strickland et al., 2008 (United States)

Surveys and clinical assessments of hypertensive, asthmatic, and diabetic patients. Clinical measures: pre- and poststudy HbA1C, HDL-C, preventive care including annual exams and vaccination, patient education, QOL, satisfaction. Initial appointment: patient satisfaction. 6 months later: health status, satisfaction, physiologic test results, and service utilization over 1 year. Adherence to guidelines in assessment, treatment, and achieving clinical goals.

Differences in quality of care (QOC) in chronic disease management (CDM) based on adherence to guidelines. Secondary measures: quality of preventive care and clinical outcomes. Patient satisfaction, resolution of symptoms at 2 weeks, care and information provided to patients.

Improvement in lipids, blood pressure (BP), glycated hemoglobin (HbA1c), and patient perceptions of quality of their chronic illness care. Medical outcomes scale (SF-36), ADLs survey (activities of daily living), and ED visit characteristics.

Outcome measures

Randomized controlled trial

Study design

Allen et al., 2011 (United States)

Study (country)

Table 1 APN role: international studies

Continued

Practices with NPs were more likely than MD-only practices to assess HbA1C (66% vs. 49%) and lipid levels (80% vs. 68%; all p ≤ .007).

No significant differences between NP and MD groups regarding health status, physiologic test results among diabetics and asthmatics, health services utilization, or satisfaction. At 6 months, for hypertensive patients, the diastolic value was significantly lower for NP patients (82 vs. 85 mmHg, p = .04).

Patients in the NP/community health worker group had significantly greater overall improvement in total cholesterol, LDL-C, triglycerides, systolic and diastolic BP, HbA1c, and perceptions of the quality of their care compared to usual care by primary care provider. NP plus interdisciplinary team had better overall quality of medical care and improved quality of life (QOL) measures than usual care group. Significant improvements in medical outcomes scales (general health, vitality, social functioning, and mental health) and ED visit rate per 1000 was lower in the intervention group. NP was significantly more likely to prescribe, to assess patients in person, and less likely to manage consultations by advice alone (p < .001) compared to MD. No differences between NP and MD were found for home-visiting rate, hospital admissions, outpatient referral, or patient satisfaction. Quality of chronic care to older, at-risk patients improved with addition of NP and pharmacist to form a collaborative healthcare team. Controlling for baseline demographic characteristics, the collaborative care approach improved CDM QOC from baseline to study endpoint by 9.2% (p < .001) and also improved preventive care by 16.5% (p < .001) compared with usual care. No differences were found between groups in secondary outcome measures. Satisfaction with care of NPs versus GPs was higher among children, as well as adults in three practices (with no significant differences in the other seven practices). Resolution of symptoms and care provided were similar between groups. Patients cared for by NPs received significantly more information. No significant differences between the NP or MD groups for self-reported health status (using surveys), physiologic measures, overall satisfaction with care, and use of specialist/ER/urgent care and frequency of hospitalization. Patients had significantly improved HbA1C in NP-MD group (−0.7%, p = .02), HDL-C (+2.6 mg/dL, p = .02), higher satisfaction with care in several subscales, overall better preventive care, and more evidence of education compared to PCP group. Health-related QOL change over time and HDL-C did not differ between groups.

Results/conclusions

Review of French APNs G. Bonnel

ED

Setting

To determine whether an NP could obtain adequate Pap smear samples from the transformation zone of the cervix. Prescriptions, referrals, patient satisfaction, health status, follow-up visits.

Satisfaction with practitioner.

Patient satisfaction questionnaire (16 questions).

Adequacy of care (history taking, clinical exam, interpretation of radiographs, treatment decision, advice, and follow-up).

Retrospective study

Multicenter, randomized controlled trial

Descriptive

Descriptive

Randomized trial

Prospective observational study

Byrne et al., 2000 (United Kingdom)

Jennings et al., 2009 (Australia)

Sakr et al., 1999 (United Kingdom)

Steiner et al., 2008 (Canada)

To determine if NP assessment, investigation, treatment, and disposition were “all equivalent to emergency physician care” (AEEPC; >50% deemed an autonomous level).

Diagnosis, if prescriptions needed (note that NP had to arrange for MD to write them), and patient questionnaire (for the first 100 patients seen by the NP).

Descriptive comparative study

Continued

Emergency nurse practitioners (ENPs) were significantly more likely to give health education and discharge instructions compared to MDs. Patients seen by an ENP were less worried about their health, received more health education, and received discharge instructions more than those seen by an MD (p < .05). Greater patient satisfaction was found in the ENP group versus MD group; significant differences in favor of ENPs were found in 12 of 16 questions (p < .05), and in the remaining questions a trend in favor of the ENP was observed. Compared with the gold standard of an experienced MD, NPs and junior doctors made clinically important errors in 9.2% and 10.7% of patients, respectively (insignificant difference). NPs were better at recording medical history, and fewer patients cared for by an NP sought follow-up regarding their injury. Accuracy of assessment, treatment, and planned follow-up were similar between groups. NP care (evaluated by MDs) was AEEPC for 43% of encounters, with highest rates found for follow-up categories (including 91.7% for diagnostic imaging). Other scores >50% included lacerations (63.6%) and isolated sore throats (53%). With teaching, care improved over time.

NPs carried out significantly more tests and requested more follow-up visits (both p < .01) compared to GPs. Prescribing and health status did not differ between groups. Patients were more satisfied with NPs (p < .001).

Mortality, physical function, emotional function, and social function.

Randomized trial

Sackett, Spitzer, Gent, & Roberts, 1974 (Canada) Salisbury, & Tettersell, 1988 (United Kingdom)

Thommasen, Lenci, Brake, & Anderson, 1996 (Canada) Venning et al., 2000 (United Kingdom)

Chronic disease management was best in interprofessional community health centers (CHCs). Clinical outcomes were not different between groups, except diastolic BP readings that were lower in Health Service Organization (capitation) patients. Measures of diabetic processes of care were higher in CHCs (except blood glucose control). Independent of model, high quality care was associated with the presence of an NP, lower patient–physician ratios, and practices with four or fewer family MDs. After 1 year of care, difference in mortality was not significant between NP and MD groups, and there were similar levels of physical, emotional, and social function between groups. Of all problems treated, 43.3% were new problems seen by the NP, versus 53.8% by the MD (p < .001). The NP managed 10.9% of consultations with arranging for a prescription versus 57.2% for the MD (p < .001). All 70 patients who completed the questionnaire were satisfied or very satisfied with the NP’s care, and 97% would consult the NP again. 100% of Papanicolaou smears collected by the NP showed endocervical or metaplastic cells, compared to slightly over 90% of MD samples.

Chronic disease management score (based on adherence to indicators from guidelines); clinical intermediate outcomes for patients with diabetes and hypertension (HbA1C and BP); reporting of factors associated with chronic disease management.

Cross-sectional survey

Results/conclusions

Russell et al., 2009 (Canada)

Outcome measures

Study design

Study (country)

Table 1 (Continued)

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Caine et al., 2002 (United Kingdom)

Gambino et al., 2009 (United States)

Bronchiectasis clinic

Cardiology

Descriptive

Randomized controlled, cross-over trial

Continued

With NP care, average total cholesterol level decreased by 48 mg/dL; LDL, by 36 mg/dL; triglycerides, by 99 mg/dL; usCRP, by 3.68 mg/L. HDL increased by 3.5 mg/dL. BP improved significantly, and BMI was unchanged. High patient satisfaction scores were achieved for NPs (from 83% to 96% with excellent or very good scores in five of eight questions; n = 59–145).

There was no difference between NP and MD groups in terms of FEV1 . The measures with significant differences were patient compliance with antibiotic use (100% for NP vs. 81% for MD, p = .024), and patient satisfaction that was in favor of the NP regarding communication and time spent with the patient.

Primary outcome measure: lung function as measured by forced expiratory volume in 1 second (FEV1 ). Secondary measures: QOL, patient satisfaction, compliance. Lipids, BP, body mass index (BMI), and ultrasensitive C-reactive protein (usCRP) at baseline (pre-NP care) and follow-up. Survey of patient satisfaction was completed.

Nephrologist in training and NP groups similar in terms of demographics and follow-up time. Patients in NP-run clinic had higher hemoglobin (p = .0239) and serum albumin (p = .0020) levels, most had a functioning permanent vascular access (p < .0001), and significantly lower BP at dialysis initiation. After 12 months, there were fewer all-cause hospitalizations in the renal NP-led clinic (p = .0024).

Patients’ quality of life, family impact of AD and SCORAD scores improved significantly at 12 months for both MD and NP groups, and the between-groups differences were similar throughout the study. Satisfaction levels were significantly higher in the NP group.

After 6 weeks, the DLQI similarly improved for both groups (p = .83). Patients cared for by a nurse were significantly more likely to know the length of treatment application (p = .05), and no group differences were found regarding the amount of treatment to apply. 33% of MD follow-up appointments were able to be cancelled.

Majority of NP visits were for minor injuries. 96.3% triaged level 4 and 94.4% triaged level 5 (least urgent) were seen within the recommended time frame. 82% were discharged after minimal treatment. 91.3% were satisfied with their care and 93% thought the NP was competent. LOS and time to sedation were significantly lower for NPs versus MDs across diagnoses (p < .01) and there were no differences between NP and MD for severe airway complication rates.

Results/conclusions

Data on BP, glomerular filtration rate, other lab results, and all-cause hospitalizations.

Randomized parallel-group study

Schuttelaar et al., 2010 (Netherlands)

Retrospective

Improvement in quality of life (using Dermatology Quality of Life Index, DLQI), patient knowledge of disease (eczema, psoriasis), and number of consultations. Change in QOL and family impact of childhood atopic dermatitis (AD), eczema severity (SCORAD) and patient satisfaction at 4, 8, and 12 months.

Randomized parallel-group study

Gradwell, Thomas, English, & Williams, 2002 (United Kingdom)

Lee et al., 2007 (United States)

Evaluation by practitioner, sedation, discharge, length of stay (LOS) in PED, and safety.

Retrospective

Wood et al., 2007 (United States)

Presenting complaint, patient satisfaction.

Outcome measures

Retrospective

Study design

Wilson & Shifaza, 2008 (Australia)

Study (country)

Nephrology

Dermatology

Setting

Table 1 (Continued)

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Grant et al., 2004 (United States)

Dawes et al., 2007 (United Kingdom)

Hall & Wilkinson, 2005 (United Kingdom)

Galli, Keith, McKenzie, Hall, & Henderson, 2008 (United States)

Gynecology

Neonatology

Telemedicine

Study (country)

Endocrinology

Setting

Table 1 (Continued)

Perinatal mortality, neonatal encephalopathy rates, and a review of sentinel events.

A new telemedicine system was evaluated in terms of adherence to protocols and satisfaction.

Descriptive

59.6% of patients were treated independently by NPs, and the rest by NP and MD collaboration. Of 434 patients surveyed, majority (93.6%) were comfortable/very comfortable with the system, and 87.3% thought care was as good or better than care from MD alone.

In an advanced neonatal nurse practitioner (ANNP)-led service, intrapartum and neonatal death among women with a singleton pregnancy fell 39% between 1991–1995 and 1996–2000 (5.12 vs. 3.11 deaths per 1000 births); 27% (4.10 vs. 2.99) decline for region.

Addition of APN associated with significantly decreased postoperative length of hospital stay (p = .001), improved delivery of discharge information and patient satisfaction compared to routine discharge.

A significantly higher proportion of patients were tested for HbA1C (p = .004) and LDL cholesterol (p < .001) in the intervention (with NP) than control sites. Testing rates and metabolic control improved for all groups. Diastolic BP was the only risk factor that was significantly more improved in the intervention group (p < .001), perhaps partly because of excellent care at baseline.

Changes measured for risk factor testing (HbA1C, LDL, and BP), prescriptions, and risk factor levels from baseline to follow-up. Questionnaire before surgery and 6 weeks. Complications, duration hospital stay, readmission, discharge, and patient satisfaction at discharge and 6 weeks.

Results/conclusions

Outcome measures

Descriptive

Randomized controlled trial

Multiclinic, controlled, observational (longitudinal) trial

Study design

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Prospective observational

Retrospective, before and after study

Multicenter, prospective observational

Prospective, observational

Primary care; Bourgueil et al., 2008

Preblood transfusion; HAS/ONDPS, 2007

Nephrology; HAS/ONDPS, 2008

Study design

Prehospital/ambulance; Arzalier et al., 2004

Setting; study

Table 2 APN role: French exploratory studies

Phase 1: nurses consulted MDs for 19 patients (0.09%), comparable to training MDs. For the rest, the concordance rate was 96.4% [95.5–97.2; confidence interval (CI) 95%] with a Kappa coefficient of 0.81 [0.77; 0.90; CI 95%]. Disagreement in donor aptitude occurred for 3.6% of patients. Phase 2: median donor refusal was 12.1% for nurses versus 10% for MDs with median difference of 1.8% [−2.3; +4.8; CI 95%]. This new nursing role is feasible/comparable to MDs. Compared to before introduction of expert nurse role, there was a significantly higher occurrence (all p < .05) of normal lab values for the measure of dialysis adequacy (Kt/v, ranging from 68.2% to 90.4%), nutritional status (NPCR, 60.8%–86%), and hemoglobin (55.1%–81.6%), and more EPO prescriptions (88.6%–96.3%). High patient satisfaction was found concerning the role of the expert nurse (85.8%, n = 14).

Determine the feasibility and efficacy of this new nursing role, and concordance between nurses and MDs.

Determine the feasibility, safety, and quality of care of this new nursing role by analyzing clinical and biological indicators, prescribed exams and renewed prescriptions, and patient satisfaction.

Phase 1: 1940 donor candidates seen by both nurses (n = 6) and MDs (n = 6) consecutively, and Phase 2: 3222 candidates seen by nurses and 20,956 candidates seen by MDs.

18 patients received hemodialysis throughout study and were cared for by a nephrologist or a supervised expert nurse who performed clinical evaluation, diagnosis, and ordered labs or renewed prescriptions.

Preblood transfusion test (usually done by MDs) delegated to nurses over a 1-year period. Nurses and MDs followed a 5-day transfusion course, and additional 15 days for nurses (France)

Continued

More patients in the nurse/GP group compared to GP group had an HbA1c ≤ 8% (87.6% vs. 77.2%, respectively; p < .01). The probability of HbA1c being ≤8% was nearly twice as high in the nurse/GP group than the GP only group (odds ratio = 1.7, p < .05) and was more likely to occur with an education visit (odds ratio = 2.6, p < .01). The chance of proper follow-up was better for the nurse/GP group (2.1 times higher for the number of HbA1c tests [≥3 tests/year] and 6.8 times more for the annual number of microalbumin tests).

Improvement of biological results (HbA1c) and care processes (proper follow-up regarding exams).

Care compared between nurse/GP team (n = 588 and 838 patients for two measures, respectively) and GPs only (n = 202 and 1018). Nurse flagged reminders to GP of required exams and performed education visits.

Cooperation between GPs and nurses in care of patients with Type 2 diabetes mellitus over 1 year (in France where care is currently performed by GPs)

Nurses who were “experts in dialysis” were delegated care of dialysis patients (usually done by nephrologists) over 21 months (France)

Nurses conducted 30% of the ambulance activity (5369 interventions): 2880 primary interventions and 2489 secondary (or transfers). This represented an increase of the total ambulance activity, and permitted doctors to focus on more urgent cases.

Results/conclusions

Productivity of nurses in emergency care.

Outcome measure

One nursing team compared to one emergency physician team.

Population/Interventions

Prehospital setting where emergency medical care in ambulances (usually done by MDs) was delegated to nurses over 6 months (France)

Setting background

Methods

Review of French APNs G. Bonnel

Prospective, observational (retrospective phase not described because of methodological problems)

Prospective, observational

Prospective, observational

Neuro-oncology; HAS/ONDPS, 2008

Urology; HAS/ONDPS, 2008

Study design

Gastroenterology; HAS/ONDPS, 2008

Setting; study

Table 2 (Continued)

According to the MD’s judgment, 86.7%–100% of readings were satisfactory and 90%—100% were interpretable. All patients accepted to be part of the study, and 100% of patients were satisfied with 96.4% satisfied or very satisfied. Depending on the test, of 1040 studies performed in the service over 1 year, the nurse accomplished 12.7%–26.2% of the activity. There was a high level of concordance between nurse and MD (from 93.8% to 99%) regarding chemotherapy treatment, steroid treatments, antiepileptics, antiemetics, anticoagulants, radiation therapy, prophylactic pneumonia treatment, granulocyte-colony stimulating factor, and erythropoiesis stimulating agents. A high proportion of patients were satisfied (83.3%) with 75% satisfied or very satisfied (n = 72) and 88.2% thought this new cooperation could be proposed to other patients (n = 68). In 50% of visits the nurse performed a technical act (mostly intracavernosal injection therapy). The nurse prescribed/renewed medication in 96% of patients, and ordered a PSA in 66.5%. Of 167 consultations where MD’s opinion was evaluated, at least 97% were judged to be pertinent and complete. Patients were highly satisfied (mean satisfaction score of 9.7/10 and 9.5/10 for nurse alone and nurse with MD, respectively).

Safety, reliability, and quality of the delegated tasks, patient satisfaction, and organizational impact.

Interprofessional reliability of clinical assessment; MD’s opinion on the nurse’s proposal regarding continuing/modifying chemotherapy and other treatments; patient satisfaction.

To determine the safety, feasibility, and quality of care, and patient satisfaction.

87 patients had GI tests performed by nurse (reread by MD).

A nurse (n = 2) and MD (n = 6) independently performed 280 patient evaluations.

One nurse (with an MD validating in about 50% of cases) cared for 466 patients (506 consultations) with benign or malignant prostate disorders.

Gastroenterology service where MD had delegated to experienced nurse the act of performing certain gastrointestinal studies without interpreting them (esophageal and rectal manometry and esophageal pH monitoring; France)

Urology service where MD delegated clinical assessment and prescriptive responsibility to a trained nurse (assistant in prostate disorders) over 12 months (France)

Outpatient neurology service where MDs delegated clinical assessment and diagnostic/prescriptive responsibility of neuro-oncology patients to experienced nurses over 8 months (France)

Results/conclusions

Outcome measure

Population/Interventions

Setting background

Methods

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Studies identified outside of France typically relate to care in the ED, and those which investigated patient satisfaction found patients to be highly satisfied with emergency NPs (Jennings et al., 2009; Wilson & Shifaza, 2008). A U.K.-based study (Byrne et al., 2000) demonstrated that significantly more patients seen by an ENP worried less about their health, and received more health education and discharge instructions compared to those seen by an MD (p < .05). In Australia, where the ENP role is being introduced, patients were also highly satisfied with care (Jennings et al., 2009; Wilson & Shifaza, 2008). Other outcome measures such as mortality were also explored. Intrapartum and neonatal mortality rates dropped by 39% after the start of a U.K. neonatal service run by advanced neonatal NPs (Hall & Wilkinson, 2005).

Chronic illness care Nine of the 13 randomized controlled trials concerned primary care or chronic illness care. A hospital-based study in the United States showed that chronic illness care among patients with type II diabetes was better performed by a team of both doctors and nurses, compared to a team of only doctors (Litaker et al., 2003). The quality of healthcare indicators were HbA1C (long-term measure of glycemic levels) and HDL-C (high-density lipoprotein cholesterol), which both improved after 1 year of care. Besides this 2003 study, all randomized controlled trials included in this review between 1974 and 2006 had a similar study design, comparing NP care with that of physicians. Since then, a move away from this direct comparison can be observed. A general trend appears to be developing toward comparing primary care interdisciplinary teams (including NPs) with usual care (Allen et al., 2011; Counsell et al., 2007; Hogg et al., 2009). French studies mainly addressed chronic illness care, and similarly to the international literature, indicators of quality care usually encompassed patient satisfaction and other patient outcomes in accordance with guidelines or the supervising physician (Bourgueil et al., 2008; HAS/ONDPS, 2008). In three studies, nurses with advanced training or experience performed direct patient care and were legally permitted to take on some limited responsibilities that are usually held by French physicians, including clinical examinations, diagnosing, and prescribing (HAS/ONDPS, 2008). This spanned from the management of patients with chronic kidney disease undergoing renal dialysis to neuro-oncology and urology. In the nephrology study, there was a significantly higher rate of normal lab values measuring dialysis adequacy, nutritional status, and hemoglobin compared to before the expert nurse role was introduced (all p < .05), and 86% of patients were satisfied with this new role. In the 216

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neuro-oncology setting, a high level of concordance was observed (from 94% to 99%) between the nurse and MD regarding chemotherapy treatment, radiation therapy, and the prescription of steroids, antiepileptics, antiemetics, anticoagulants, prophylactic pneumonia treatment, granulocyte-colony stimulating factor, and erythropoiesis stimulating agents. A high proportion of patients were satisfied (83%), and 88% of patients thought this new cooperation could be implemented with other patients. Lastly in a urology department, a trained nurse (entitled “assistant in prostate disorders”) performed a technical act in 50% of the visits (mainly intracavernosal injection therapy), prescribed or renewed a medication in 96% of patients, and ordered a prostate-specific antigen (PSA) in 66.5%. A physician judged at least 97% of nursing consultations to be pertinent and complete, and patients were highly satisfied. Two of the French studies did not necessarily concern direct patient care by APNs, although new tasks usually practiced by physicians were delegated to nurses. One study showed that the HbA1c results of Type 2 diabetic patients improved when a nurse (who flagged reminders of necessary exams and performed health education) worked with a general practitioner (GP), compared to a GP alone (Bourgueil et al., 2008). The other study found a high concordance rate between nurses and physicians in performing screenings for blood transfusion (HAS/ONDPS, 2008).

Discussion Results of the current review corroborate a recent meta-analysis performed by the Cochrane Collaboration. The Cochrane study found that the majority of available studies indicate that APNs (or NPs), when appropriately educated, can offer high quality care and achieve healthcare outcomes of similar quality when compared to primary care doctors (Laurant et al., 2004). Further studies are necessary to build upon the evidence supporting the ability of APNs to meet the criteria for standard quality of care. The Cochrane report also highlighted that few studies were deemed methodologically rigorous or had patient follow-up greater than 12 months, and generally this continues to be the case. In the current review, retrospective studies were included despite their potential for producing bias, because they were considered to add valuable information. The complicated nature of healthcare quality research does not always conform to experimental standards, and it can be difficult to evaluate with conventional research designs (Øvretveit & Gustafson, 2002). Although a multiple-arm randomized controlled trial may be optimal in terms of methodology, the design

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could become unfeasible, involving large numbers of patients and practices. The historical international literature covered in this review is valuable for the French context and future APN role development. It is interesting to note that even though a need for further research in this domain exists, as previously mentioned, a general trend appears to be developing toward the innovative design of comparing primary care interdisciplinary teams (including NPs) with usual care. An example of this is in the randomized controlled trial by Hogg et al. (2009), where the quality of care was compared between a team of physicians providing usual care, and a collaborative team consisting of an NP, physician, and a pharmacist. The quality of care in following chronic disease guidelines improved with the addition of an NP and pharmacist. As the APN role grows to be defined and accepted in France, particularly by physicians, research can expand to other quality outcomes beyond the equivalence of quality of care with physicians by using similar collaborative care designs. Furthermore, the primary care setting predominates in the international APN literature. As this also stands as a public health priority in France, it would likely be interesting and appropriate for future research to further explore primary care and preventive services. As previously mentioned, nurses can request permission from HAS to perform advanced skills. This strictly regulated program, which may appear as a barrier to the advancement of the nursing role, was actually designed to meet specific needs of the population. In this way, it will be important for French nurses to propose advanced roles based on this population-focused approach. This is consistent with a recent systematic review of APN outcomes by Newhouse et al. (2011), which recommended that research of APN care be founded on the needs of priority populations and health policy. Public health challenges in France, including the rising incidence of chronic diseases and an impending physician shortage, will continue to impact the priority areas of health care. Our findings also suggest that there are common indicators of quality health care between existing studies in France and other countries; this is an important factor in finding a basis of communication between healthcare professionals. Differences may be accounted for by the smaller amount of literature originating from France, greatly because of the very recent history of the advanced practice nursing movement when compared to that of the United States and United Kingdom. However, this could actually be a benefit, as the evolution of the French healthcare system can progress with a heightened awareness of what has preceded (both positively and negatively) in other countries. For France, it is of note that the seven studies described in this review (Table 2) rep-

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resent a rather large number when considering that the APN role is not yet formally developed. Careful study of the APN role in its very early stages may be a key point of success for France in later years. Both healthcare systems in the United States and France, in particular, have faced major barriers and made adjustments in strategy to face them. It is interesting to compare and draw applications from historical advancements in nursing between countries. In the United States, the NP role was created in the 1960s to provide primary healthcare services to populations with unmet needs to improve access to health care. The foreseeable physician shortage in France is perhaps not far removed from the past beginnings of APNs in the United States. Some physician groups stood as a challenge to the spread of this change (although this has improved over time), especially if it was thought to be overstepping boundaries into the doctor’s traditional domain of expertise. Although this may occur in France, the very fact that some leading doctors are backing the interests of advanced practice nursing and higher education signifies that a true cooperation and mutual respect between health professionals can exist, and appears to be already underway. Some other positive trends in the United States include the evolution of the Doctorate of Nursing Practice for APNs (with a Master’s degree and national board certification required), the population’s heightened education and understanding of the NP role, and also research that continues to support the quality care and effective outcomes furnished by NPs. As France positions itself for educational reforms ahead, perhaps there can be a pertinent dialogue with U.S. professors of nursing as both countries strive to produce excellently educated nurses. HAS, in collaboration with ONDPS and experts of task forces, proposed recommendations regarding future cooperation between healthcare professionals in France, namely in the areas of education reform, finances, and legal issues (French National Authority for Health Task Force et al., 2007). This recent move to endorse the creation of the advanced practice nursing role, along with education and legal reforms, underlines the potential acceptability of this role both culturally and in terms of their healthcare system’s needs. In their book sponsored by the ICN, Schober and Affara state that advanced nursing practice “must be anchored within the local health system and tailored to meet the needs of the client or population group” (Schober & Affara, 2006). It is certain that the state of advanced practice nursing will not look the same in France as it does in the United Kingdom or the United States, nor should it. However, it is vital that nurses and other health professionals collaborate and learn together on an international level, constantly 217

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searching for windows of opportunity that our profession may advance and be further molded to meet the needs of our patient populations.

Implications for practice There exists a progressive window of opportunity for France’s nursing profession, as it strives to situate itself in the context of an evolving Europe as well as an advancing role internationally. The creation of the APN role can respond to public health challenges including the rising incidence of chronic diseases and an impending physician shortage. In a similar fashion, the nursing profession in the United States continues to find its strategic place in the context of a challenged healthcare system. In view of the fact that reviewing the literature of these countries generally indicates that common criteria exist for quality of care in advanced practice nursing, it is strikingly clear that mutual learning can occur between countries with different advanced practice nursing roles. Future APN research should focus on rigorous, innovative design development including collaborative care models.

Acknowledgments The author would like to thank Sharon L. Sheahan, PhD, FNP and Sharon E. Lock, PhD, APRN for their review of the manuscript, as well as the French health care professionals who are involved in promoting the APN role.

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