Advancement of research on nurse practitioners: Setting a research agenda.

BACKGROUND: Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them. PURPOSE: We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce. METHODS: Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions. DISCUSSION: The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives. CONCLUSION: The agenda can advance evidence on the NP workforce to guide policy and practice.

Regulating the health workforce in Europe: implications of the COVID-19 pandemic.

In the European free movement zone, various mechanisms aim to harmonize how the competence of physicians and nurses is developed and maintained to facilitate the cross-country movement of professionals. This commentary addresses these mechanisms and discusses their implications during the COVID-19 pandemic, drawing lessons for future policy. It argues that EU-wide regulatory mechanisms should be reviewed to ensure that they provide an adequate foundation for determining competence and enabling health workforce flexibility during health system shocks. Currently, EU regulation focuses on the automatic recognition of the primary education of physicians and nurses. New, flexible mechanisms should be developed for specializations, such as intensive or emergency care. Documenting new skills, such as the ones acquired during rapid training in the pandemic, in a manner that is comparable across countries should be explored, both for usual practice and in light of outbreak preparedness. Initiatives to strengthen continuing education and professional development should be supported further. Funding under the EU4Health programme should be dedicated to this endeavour, along with revisiting the scope of necessary skills following the experience of COVID-19. Mechanisms for cross-country sharing of information on violations of good practice standards should be maintained and strengthened to enable agile reactions when the need for professional mobility becomes urgent.

The COVID-19 pandemic presents an opportunity to develop more sustainable health workforces.

This commentary addresses the critically important role of health workers in their countries' more immediate responses to COVID-19 outbreaks and provides policy recommendations for more sustainable health workforces. Paradoxically, pandemic response plans in country after country, often fail to explicitly address health workforce requirements and considerations. We recommend that policy and decision-makers at the facility, regional and country-levels need to: integrate explicit health workforce requirements in pandemic response plans, appropriate to its differentiated levels of care, for the short, medium and longer term; ensure safe working conditions with personal protective equipment (PPE) for all deployed health workers including sufficient training to ensure high hygienic and safety standards; recognise the importance of protecting and promoting the psychological health and safety of all health professionals, with a special focus on workers at the point of care; take an explicit gender and social equity lens, when addressing physical and psychological health and safety, recognising that the health workforce is largely made up of women, and that limited resources lead to priority setting and unequitable access to protection; take a whole of the health workforce approach-using the full skill sets of all health workers-across public health and clinical care roles-including those along the training and retirement pipeline-and ensure adequate supervisory structures and operating procedures are in place to ensure inclusive care of high quality; react with solidarity to support regions and countries requiring more surge capacity, especially those with weak health systems and more severe HRH shortages; and acknowledge the need for transparent, flexible and situational leadership styles building on a different set of management skills.

Time trends in the regional distribution of physicians, nurses and midwives in Europe.

BACKGROUND: Country-level data suggest large differences in the supply of health professionals among European countries. However, little is know about the regional supply of health professionals taking a cross-country comparative perspective. The aim of the study was to analyse the regional distribution of physicians, nurses and midwives in the highest and lowest density regions in Europe and examine time trends. METHODS: We used Eurostat data and descriptive statistics to assess the density of physicians, nurses and midwives at national and regional levels (Nomenclature of Territorial Units for Statistics (NUTS) 2 regions) for 2017 and time trends (2005-2017). To ensure cross-country comparability we applied a set of criteria (working status, availability over time, geographic availability, source). This resulted in 14 European Union (EU) countries and Switzerland being available for the physician analysis and eight countries for the nurses and midwives analysis. Density rates per population were analysed at national and NUTS 2 level, of which regions with the highest and lowest density of physicians, nurses and midwives were identified. We examined changes over time in regional distributions, using percentage change and Compound Annual Growth Rate (CAGR). RESULTS: There was a 2.4-fold difference in the physician density between the highest and lowest density countries (Austria national average: 513, Poland 241.6 per 100,000) and a 3.5-fold difference among nurses (Denmark: 1702.5, Bulgaria: 483.0). Differences by regions across Europe were higher than cross-country variations and varied up to 5.5-fold for physicians and 4.4-fold for nurses/midwives and did not improve over time. Capitals and/or major cities in all countries showed a markedly higher supply of physicians than more sparsely populated regions while the density of nurses and midwives tended to be higher in more sparsely populated areas. Over time, physician rates increased faster than density levels of nurses and midwives. CONCLUSIONS: The study shows for the first time the large variation in health workforce supply at regional levels and time trends by professions across the European region. This highlights the importance for countries to routinely collect data in sub-national geographic areas to develop integrated health workforce policies for health professionals at regional levels.

Nurse prescribing of medicines in 13 European countries.

BACKGROUND: Nurse prescribing of medicines is increasing worldwide, but there is limited research in Europe. The objective of this study was to analyse which countries in Europe have adopted laws on nurse prescribing. METHODS: Cross-country comparative analysis of reforms on nurse prescribing, based on an expert survey (TaskShift2Nurses Survey) and an OECD study. Country experts provided country-specific information, which was complemented with the peer-reviewed and grey literature. The analysis was based on policy and thematic analyses. RESULTS: In Europe, as of 2019, a total of 13 countries have adopted laws on nurse prescribing, of which 12 apply nationwide (Cyprus, Denmark, Estonia, Finland, France, Ireland, Netherlands, Norway, Poland, Spain, Sweden, United Kingdom (UK)) and one regionally, to the Canton Vaud (Switzerland). Eight countries adopted laws since 2010. The extent of prescribing rights ranged from nearly all medicines within nurses' specialisations (Ireland for nurse prescribers, Netherlands for nurse specialists, UK for independent nurse prescribers) to a limited set of medicines (Cyprus, Denmark, Estonia, Finland, France, Norway, Poland, Spain, Sweden). All countries have regulatory and minimum educational requirements in place to ensure patient safety; the majority require some form of physician oversight. CONCLUSIONS: The role of nurses has expanded in Europe over the last decade, as demonstrated by the adoption of new laws on prescribing rights.

Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries.

BACKGROUND: Countries vary in the extent to which reforms have been implemented expanding nurses' Scopes-of-Practice (SoP). There is limited cross-country research if and how reforms affect clinical practice, particularly in hospitals. This study analyses health professionals' perceptions of role change and of task shifting between the medical and nursing professions in nine European countries. METHODS: Cross-sectional design with surveys completed by 1716 health professionals treating patients with breast cancer (BC) and acute myocardial infarction (AMI) in 161 hospitals across nine countries. Descriptive and bivariate analysis on self-reported staff role changes and levels of independence (with/without physician oversight) by two country groups, with major SoP reforms implemented between 2010 and 2015 (Netherlands, England, Scotland) and without (Czech Republic, Germany, Italy, Norway, Poland, Turkey). Participation in 'medical tasks' was identified using two methods, a data-driven and a conceptual approach. Individual task-related analyses were performed for the medical and nursing professions, and Advanced Practice Nurses/Specialist Nurses (APN/SN). RESULTS: Health professionals from the Netherlands, England and Scotland more frequently reported changes to staff roles over this time period vs. the other six countries (BC 74.0% vs. 38.7%, p < .001; AMI 61.7% vs. 37.3%, p < .001), and higher independence in new roles (BC 58.6% vs. 24.0%, p < .001; AMI 48.9% vs. 29.2%, p < .001). A higher proportion of nurses and APN/SN from these three countries reported to undertake tasks related to BC diagnosis, therapy, prescribing of medicines and information to patients compared to the six countries. Similar cross-country differences existed for AMI on prescribing medications and follow-up care. Tasks related to diagnosis and therapy, however, remained largely within the medical profession's domain. Most tasks were reported to be performed by both professions rather than carried out by one profession only. CONCLUSIONS: Higher levels of changes to staff roles and task shifting were reported in the Netherlands, England and Scotland, suggesting that professional boundaries have shifted, for instance on chemotherapy or prescribing medicines. For most tasks, however, a partial instead of full task shifting is practice.

Health workforce planning: which countries include nurse practitioners and physician assistants and to what effect?

BACKGROUND: An increasing number of countries are introducing new health professions, such as Nurse Practitioners (NPs) and Physician Assistants (PAs). There is however limited evidence, on whether these new professions are included in countries' workforce planning. METHODS: A cross-country comparison of workforce planning methods. Countries with NPs and/or PAs were identified, workforce planning projections reviewed and differences in outcomes were analysed, based on a review of workforce planning models and a scoping review. Data on multi-professional (physicians/NPs/PAs) vs. physician-only models were extracted and compared descriptively. Analysis of policy implications was based on policy documents and grey literature. RESULTS: Of eight countries with NPs/PAs, three (Canada, the Netherlands, United States) included these professions in their workforce planning. In Canada, NPs were partially included in Ontario's needs-based projection, yet only as one parameter to enhance efficiency. In the United States and the Netherlands, NPs/PAs were covered as one of several scenarios. Compared with physician-only models, multi-professional models resulted in lower physician manpower projections, primarily in primary care. A weakness of the multi-professional models was the accuracy of data on substitution. Impacts on policy were limited, except for the Netherlands. CONCLUSIONS: Few countries have integrated NPs/PAs into workforce planning. Yet, those with multi-professional models reveal considerable differences in projected workforce outcomes. Countries should develop several scenarios with and without NPs/PAs to inform policy.

Effects of Regulation and Payment Policies on Nurse Practitioners' Clinical Practices.

Increasing patient demand following health care reform has led to concerns about provider shortages, particularly in primary care and for Medicaid patients. Nurse practitioners (NPs) represent a potential solution to meeting demand. However, varying state scope of practice regulations and Medicaid reimbursement rates may limit efficient distribution of NPs. Using a national sample of 252,657 ambulatory practices, we examined the effect of state policies on NP employment in primary care and practice Medicaid acceptance. NPs had 13% higher odds of working in primary care in states with full scope of practice; those odds increased to 20% if the state also reimbursed NPs at 100% of the physician Medicaid fee-for-service rate. Furthermore, in states with 100% Medicaid reimbursement, practices with NPs had 23% higher odds of accepting Medicaid than practices without NPs. Removing scope of practice restrictions and increasing Medicaid reimbursement may increase NP participation in primary care and practice Medicaid acceptance.

Expanding clinical roles for nurses to realign the global health workforce with population needs: a commentary.

Many countries, including Israel, face health workforce challenges to meet the needs of their citizens, as chronic conditions increase. Provider shortages and geographical maldistribution are common. Increasing the contribution of nurse practitioners and other advanced practice nursing roles through task-shifting and expansion of scope-of-practice can improve access to care and result in greater workforce efficiency. Israel and many other countries are introducing reforms to expand nurses' scope-of-practice. Recent international research offers three policy lessons for how countries just beginning to implement reforms could bypass policy barriers to implementation. First, there is substantial evidence on the equivalence in quality of care, patient safety and high consumer acceptance which should move policy debates from if to how to effectively implement new roles in practice. Second, regulatory and finance policies as well as accessible advanced education are essential to facilitate realignment of roles. Third, country experience suggests that advanced practice roles for nurses improve the attractiveness of nursing as a career thus contributing to solving nursing shortages rather than exacerbating them. Designing enabling policy environments and removing barriers will gain in relevance in the future as the demand for high-quality, patient-centered care is increasing.

Mobility of health professionals pre and post 2004 and 2007 EU enlargements: evidence from the EU project PROMeTHEUS.

BACKGROUND: EU enlargement has facilitated the mobility of EU citizens, including health professionals, from the 2004 and 2007 EU accession states. Fears have been raised about a mass exodus of health professionals and the consequences for the operation of health systems. However, to date a systematic analysis of the EU enlargement's effects on the mobility of health professionals has been lacking. The aim of this article is to shed light on the changes in the scale of movement, trends and directions of flows pre and post 2004 and 2007 EU enlargements. METHODS: The study follows a pan-European secondary data analysis to (i) quantitatively and (ii) qualitatively analyse mobility before and after the EU enlargement. (i) The secondary data analysis covers 34 countries (including all EU Member States). (ii) Data were triangulated with the findings of 17 country case studies to qualitatively assess the effects of enlargement on health workforce mobility. RESULTS: The stock of health professionals from the new (EU-12) into the old EU Member States (EU-15) have increased following EU accession. The stock of medical doctors from the EU-12 in the EU-15 countries has more than doubled between 2003 and 2007. The available data suggest the same trend for dentists. The extremely limited data for nurses show that the stock of nurses has, in contrast, only slightly increased. However, while no reliable data is available evidence suggests that the number of undocumented or self-employed migrant nurses in the home-care sector has significantly increased. Health professionals trained in the EU-12 are becoming increasingly important in providing sufficient health care in some destination countries and regions facing staff shortages. CONCLUSION: A mass exodus of health professionals has not taken place after the 2004 and 2007 EU enlargements. The estimated annual outflows from the EU-12 countries have rarely exceeded 3% of the domestic workforce. This is partly due to labour market restrictions in the destination countries, but also to improvements in salaries and working conditions in some source countries. The overall mobility of health professionals is hence relatively moderate and in line with the overall movement of citizens within the EU. However, for some countries even losing small numbers of health professionals can have impacts in underserved regions.

Advancing the role of nurses and midwives in Ireland: pioneering transformation of the health workforce for noncommunicable diseases in Europe: good practice brief

A survey that included 32 countries in Europe in 2015 found that more than two thirds had extended the official scopes of practice of nurses in primary care. Ireland is one of those countries. The first Nurse Prescriber was registered in 2008. Independent evaluation found increased patient satisfaction with the care and information they received, greater professional satisfaction of nurses and midwives and consensus among clinical stakeholders that the new roles resulted in the delivery of effective, high-quality care to patients while reducing some of the workload of primary care physicians.

Health professional mobility and health systems: evidence from 17 European countries

The mobility of health professionals affects the performance of health systems, and increasingly so since the European Union (EU) enlargements in 2004 and 2007. This publication presents research on the gaps in knowledge about the numbers, trends, impacts and policy responses to this dynamic situation, in particular in Austria, Belgium, Estonia, Finland, France, Germany, Hungary, Italy, Lithuania, Poland, Romania, Serbia, Slovakia, Slovenia, Spain, Turkey and the United Kingdom. Conducted within the framework of the European Commission’s Health PROMeTHEUS project, the research posed a set of questions of key interest to policy-makers: what are the scale and characteristics of health professional mobility in the EU?; what have been the effects of EU enlargement?; what are the motivations of the mobile workforce?; what are the resulting impacts on health system performance?; what is the policy relevance of those impacts?; what are the policy options to address health professional mobility issues? In answering these questions, this publication offers policy-makers evidence of the nature and extent of health professional mobility in the EU, analyses its impact on country health systems and outlines some major policy strategies to address mobility.