2023-07-07 08:38:19
The Court of Auditors has just released the conclusions of its “flash mission” on advanced practice nurses (IPA), highlighting the “powerful” and multiple obstacles to their deployment. The first and most fundamental is the reluctance of physicians to entrust procedures and patients to APNs. The second, in the extension of the first, stems from the economic model, in town, which does not allow IPAs to live from their activity. The third results from the training conditions. The fourth and final obstacle consists in the existence of other professionals with whom doctors collaborate in a more natural way..
In response to the challenges posed by the difficulties of access to general practitioners and the increase in chronic pathologies due to the aging of the population, the legislator introduced in France the concept of “advanced practice” of the paramedical professions, resulting from a process of reflection, initiated in the early 2000s. It is less a question of raising the level of technicality of the acts practiced by these professionals, than of broadening the transversal skills and responsibilities of the paramedical professions beyond the legal and regulatory framework current: performance of certain acts without prior medical prescription, prescription of biological examinations, renewal or adaptation of drug prescriptions, etc. The issue explains the tensions surrounding the implementation. The possibility of an “advanced practice” exercise was opened up to all medical professions by law no. 2016-41 of January 26, 2016 on the modernization of our health system. However, the regulatory texts now reserve it only for nurses.
The significant benefits expected by the Ministry of Health
The concept of advanced practice corresponds to the broadening and transversality of skills and responsibilities. To qualify for this exercise, in a city or in a health establishment, nurses must have three years of practice experience, then have completed additional training lasting two years at master’s level, in one of the five “references” retained by the legislator: stabilized chronic pathologies, oncology and hemato-oncology, chronic kidney disease, dialysis and kidney transplantation, psychiatry and mental health, emergency room. Although open to all paramedical professions, advanced practice is still only organized for nurses. A large degree of autonomy is granted to “advanced practice nurses” (IPA) in the exercise of their skills, provided that they work under the coordination of a doctor. However, the texts that define the prerogatives of IPAs do not mention either the missions or the functions that they are called upon to assume and which, however, are presented as the essential justification for this new status. The Ministry of Health expects a lot from IPAs: 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 the context of aging of the population and offer nurses new career prospects.
“The notion of “advanced practice” is ambiguous because it suggests that it is a question of specializing at a higher level of technicality the practice of nurses when it is a question of broadening and transversality of skills and responsibilities, issue of a completely different dimension which is at the origin of the tensions surrounding its implementation. »
Powerful Obstacles
The ministry had set a target of 3,000 RPNs trained or in training by 2022 and, ultimately, 6,000 to 18,000 practicing RPNs. However, in 2021, only 581 IPAs were graduates and 1,366 in training. Several obstacles stand in the way of the deployment of advanced practice: reluctance of doctors constitute the most fundamental of them. The reference care pathway remains that of the primary relationship between the patient and a general practitioner, guarantor of his good orientation in the health system and remunerated on a fee-for-service basis. However, when APNs are installed in the city, doctors too often refuse, out of ignorance or fear of competition, to refer to them patients with chronic pathologies, whose state of health would require monitoring by these professionals. paramedics, currently the economic model does not allow liberal IPAs to live from their activity, even though they have made a significant training effort – studies, which are part of a continuing education framework, being expensive. Furthermore, the doctors collaborate more naturally with medical assistantsor with nurses employed by associations, whose field of competence and economic model do not constitute a factor of direct competition for the medical professions.
“The interest of nurses is not in question in view of the numerous requests on their part aimed at having their specialty recognized as falling within an advanced exercise (anaesthesia-resuscitation, childcare, gerontology, etc.), at the risk of elsewhere to lose its specificity, that is to say the exercise of broader powers.«
Recent structural developments
Faced with these obstacles, the ministry has considered changes: allowing patients “direct access” to IPAs without going through a doctor and granting IPAs the right of first prescription. A recently enacted law ruled in favor of these developments. All the difficulties have not yet been resolved. It is up to the ministry to define guides or reference systems specifying the missions of APNs, or, on the model of certain foreign countries, to provide additional training preparing APNs for the right to prescribe in first intention. The obstacles encountered by IPAs reflect the limits of the conception of the French health system, which is still too marked by the isolated exercise of general medicine. This conception must evolve so that cooperation between health professionals becomes the general practice, while the offer of city care continues to shrink and many patients do not have an attending physician.
“The law having been adopted, it is necessary to fully support the IPA profession despite the persistent opposition of some doctors. To achieve this, the Ministry must respond to the fears expressed, for example by defining guides or reference systems specifying the missions of IPAs, or, on the model of certain foreign countries, by providing additional training preparing them for the right to prescribe in first intention”.
The main lessons of the survey to remember
The Ministry of Health expected a lot from the creation of the APN profession and had set a target of 3,000 APNs trained or in training by the end of 2022 and, therefollowing, from 6,000 to 18 000 IPA in practice. However, in 2021, only 581 IPAs were graduates, for 1,366 in training and 131 practiced in town. The number of IPAs employed in health establishments and in medico-social structures is not known. There are many obstacles to the deployment of advanced practice. The first and most fundamental is the reluctance of physicians to entrust procedures and patients to APNs. The second, in the extension of the first, stems from the economic model, in town, which does not allow IPAs to live from their activity. The third results from the training conditions. The fourth and final obstacle consists in the existence of other professionals with whom doctors collaborate in a more natural way. Faced with these obstacles, the legislator reacted, without waiting for the results of experiments that were slow to be implemented, by granting patients direct access to APIs and, to APIs, a right of first prescription.
• Read the report of the Court of Auditors, flash audit, July 2023, “ Nurses in advanced practice: a necessary evolution, powerful obstacles to overcome« .
• Read also
– 47.6% of IPA students have difficulty finding an internship, Mental Health, June 30, 2023.
– Direct access to nurses in advanced practice (IPA) established by the Rist law, Mental Health, May 11, 2023.
– IPA: the difficult construction of a profession with a fragile exercise, Mental Health, April 13, 2023.
– APNs still lacking recognition, Mental Health, April 20, 2023.
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