The role of governance in implementing task-shifting from physicians to nurses in advanced roles in Europe, U.S., Canada, New Zealand and Australia
Introduction
An increasing number of countries in Europe are in the process of introducing skill-mix changes to their health workforces. Task-shifting is one strategy, whereby specific tasks and responsibilities are being shifted, for instance from the medical to the nursing profession [1]. Underlying reasons include physician shortages, limited access to or quality of care, long waiting times, high costs [2]. The effectiveness of task-shifting to specifically trained nurses has been demonstrated [1], [3], [4], [5], [6], [7], [8], [9]. However, little research has been conducted on the governance and regulatory contexts taking a cross-country comparative design [10], [11], [12]. Yet different governance models may have different implications on the implementation of task-shifting in practice.
Governance encompasses the “structures and processes through which policies (formal and informal) are enacted to achieve goals, including legislation, regulation and oversight” […], hence, it is a framework for formal policy instruments (through laws, bylaws), but also includes informal, non-regulated instruments, such as local governance measures [13]. Regulation, however, refers to legally binding policy instruments and has been defined as government (national or decentralized), setting rules and thereby limiting entry to a profession or a practice, such as by licensing and credentialing specific cadres of health professions, setting standards, limiting or licensing certain practices [14], [15]. Regulatory mechanisms can be undertaken by the government(s) itself or may be delegated to a professional body or association in accordance with set laws, referred to as self-regulation [14], [15]. Regulation can be executed at different levels: at national, state- or, province-levels. Governments can also choose not to regulate, but leaving the governance, including levels and standards of advanced practice to the discretion of the individual settings and providers, e.g. through protocols or collaborative practice agreements between nurses and employers and/or physicians [13], [16], [17], [18], [19].
Previous studies have assessed barriers and facilitators to task-shifting and cited among others, regulation, professional boundaries, organizational environment and institutional environment as influencing task-shifting in practice [11], [12], [20]. A systematic review identified six studies where legislation was referred to as a barrier to task-shifting from the medical to the nursing profession [20]. On the contrary, a comprehensive framework suggests five drivers of advanced nursing practice: healthcare needs of the population, education, workforce, practice patterns, and the legal, policy, and economic context [21]. Indeed, regulation has been identified as both, a barrier and a driver of task-shifting [12], [19], [22], however, not specifying in which contexts.
McCarthy et al. [23] provide a framework on regulatory strengthening in nursing and midwifery. It is based on a review of the regulatory elements recommended by the International Council of Nurses and the World Health Organization, among others. It suggests five overall stages of regulatory strengthening, from no to ‘best practice’ regulation, the latter defined as regulation in line with global recommendations [23]. The framework, however, was designed for strengthening the regulation of the nursing workforce overall, it did not specify standards on how to regulate Advanced Practice Nurses/Nurse Practitioners (APN/NPs), an umbrella term defined as nurses working in expanded practice, with high levels of independence, expert knowledge, complex decision-making skills and clinical competencies, holding usually a Master's level degree [24].
Research on the governance of task-shifting and specifically, nurses in advanced roles is scarce [10], [11], [12], [19]. Pulcini et al. [11] used a cross-sectional survey design and showed that 71.9% of 32 countries reported formal recognition of the APN/NP role. However, the study failed to mention which countries had regulations in place and which not. An OECD study [19] suggested that the level of detail of legislation can act as facilitator or barrier. A literature review [10] in 19 countries showed that most countries did not regulate APN/NPs, and few provided full regulation [10]. The study covered a large number of countries, however, it lacked clarity on the selection criteria for country coverage, and how regulation was measured. A survey in 26 countries concluded that there is wide cross-country variation [12]. However, it provided limited information how regulation impacts practice, moreover, it only covered ten countries within the European Union (EU).
To date, no systematic assessment of APN/NPs exists in the EU. Its single market facilitates the movement of professionals, including health professionals in the 28 EU member states, European Economic Area countries and Switzerland. Physicians and most medical specializations are automatically recognized [25], [26]. For nurses, however, only the basic nursing qualification is automatically recognized, no nurse specializations or advanced nursing practice [27], which may limit the mobility and skills transfer within the EU.
The objective of this study was to take stock of task-shifting practices with a particular focus on governance models for APN/NPs, based on data from the 2015 International TaskShift2Nurses survey. Two research questions were addressed: how is task-shifting governed in countries with APN/NP practices, and what are the implications of different governance models on the implementation, patient safety, role clarity and the availability of workforce statistics.
A cross-country comparison is relevant for two reasons: first, an increasing number of countries are in the process of implementing APN/NP roles, one of the reasons may be the increasing number of countries that are moving the primary educational level of nurses to the Bachelor's level plus increasing numbers of Master's programs, triggered by the Bologna process in Europe [27], [28], [29], [30]. These countries are faced with the policy question of whether and to which extent new, advanced roles of nurses should be regulated. Second, from an EU perspective, due to its free movement principle, the question of regulation is relevant as it may have implications on the mobility of this workforce, the level of skills-transfer and quality of advanced practice when crossing borders.
Section snippets
Literature scoping review
A comprehensive literature scoping review was carried out using Medline, CINAHL, Web of Science, the Cochrane library and google scholar. In addition, the websites of the WHO, OECD, International Council of Nurses, European Federation of Nurses were searched.
Survey
Data from the international TASK-SHIFT2Nurses Survey 2015 with a focus on primary care, fed into the analysis, in which 93 country experts from 39 countries participated (response rate 85.3%), including all European Union (EU) Member
Results
This study focuses on the sub-group of eleven countries with established advanced nursing practice at the APN/NP level, to assess if and how these advanced roles are regulated and second, what implications different governance models have in practice.
Discussion
Large differences existed across countries if and how APN/NPs are governed and particularly the role of regulation within governance models. Levels and locus of regulation ranged from no, decentralized to nationwide. These models were identified as having different implications on the practice and implementation, role clarity and data availability.
This international study is the first of its kind to assess the governance models in countries with established APN/NP professions, and linking it to
Conclusions
Task-shifting from physicians to nurses has been implemented in an increasing number of countries. For this workforce strategy to be effective, it requires implementation into routine healthcare. The role of governance and specifically, regulation is crucial, since it can facilitate or hinder full implementation. Regulation was identified as barrier if outdated and overtly restrictive or as enabler to advanced practice, if up to date with competency levels, yet the evidence base is limited.
Conflict of interest statement
The author reports no conflicts of interest.
Acknowledgements
The input and comments on the overall study design and draft manuscript provided by Linda H Aiken, Center for Health Outcomes and Policy Research, University of Pennsylvania are gratefully acknowledged. This research has been supported by The Commonwealth Fund through the Harkness Fellowship. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.
Furthermore, my sincere thanks go to Gilles Dussault (Institute of
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2021, Nurse Education in PracticeCitation Excerpt :Similarly, an audit showed that the lowest prescribing error rate in the ICU was associated with NPs, compared with medical staff (Carberry et al., 2013). Only few countries in Europe have developed APN-specific educational programs and variation exists in requirements, regulation and scope of practice (Endacott et al., 2015; Heale and Rieck Buckley, 2015; Maier, 2015). The nomenclature for advanced or extended nursing practice varies internationally as do roles, terms, titles and training (Bryant-Lukosius and Dicenso, 2004; Dury et al., 2014).
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2020, CollegianCitation Excerpt :According to the NMBA, APN is not a job title or pay grade but rather, a level of practice (Nursing and Midwifery Board of Australia, 2019). While Maier (2015) outlines that the APN in Australia is highly regulated, the author fails to acknowledge the only APN role recognised and therefore regulated by the NMBA is the NP (Australian Health Practitioner Registration Agency, 2016). The reasoning for this lies in Australian research that suggests that APN roles that have a national curriculum substantiated by research and reliable evidence, are recognised by a national governing body and have national competencies, have validation (Gardner et al., 2007, 2017).