“Nurse practitioners combine nursing with medical skills and knowledge, allowing them to be able to deliver more holistic, integrated care for patients,” explains Inge Rinzema, who is among the more than 5000 nurse practitioners in the Netherlands and Chair of the Dutch Professional Association for Nursing Specialists (V&VN VS).
Inge has been caring for older adults since 2014, mainly in a nursing home in the city of Groningen but also through home visits to those too infirm to visit a health-care centre. She provides consultancy to local general practitioners as well. Over the years, Inge has noticed that the needs of her patients have changed considerably, reflecting how our populations are ageing.
“Previously, it was much easier to move into a nursing home, but nowadays, you have to be really, really frail and have a complex need for medical and/or nursing care before you qualify,” she says. “As a result, many more older people with medical conditions are living at home, with community-care services unable to keep up with demand. That is why the outreach of nurse practitioners is more important than ever.”
In the nursing home, Inge serves a population of 1200 residents and works within a team of 12 specialists, 10 resident physicians and 7 nurse practitioners. She is responsible for providing medical treatment and services to residents, including to maintain or improve mental health and fitness and to encourage social activity.
When needed, she also ensures that medical recommendations promote a better quality of life and ultimately align with residents’ wishes. Sometimes this involves foregoing certain treatments, although always with the person’s needs and safety as the highest priorities.
“Being a nurse practitioner means I get to spend more time with my patients,” Inge points out. “I get to know them really well and so have a better understanding of what nursing care and medical treatment they might need and how to integrate them into a treatment plan.”
Inge’s work also includes providing and organizing palliative and end-of-life care. Palliative care aims to improve quality of life and provide relief from pain and other symptoms. “One of the most rewarding things about my job is that I’m able to make the last stages of a patient’s life as good as they can be, to allow them to die gracefully, so without pain, without trouble, without any prolonged suffering. You only get one opportunity to get that right for a patient and their loved ones, and as a nurse practitioner I’m able to do that.”
Promoting the acceptance of nurse practitioners
Inge amply demonstrates the positive difference nurse practitioners can make, but it took a long time to get the role adopted nationally. The Dutch Ministry of Health introduced the role of nurse practitioner in 1997 as an advanced position for nurses to better respond to growing population health needs across the country. The Government then also introduced a graduate university degree to support the expertise and capacity of nurse practitioners.
Even though there was a framework in place, it was still very hard to roll out in a standard way across the Netherlands. This left patients in some regions of the country underserved by nurse practitioners.
Reasons for this included scepticism and concern about patient safety, especially with nurse practitioners taking on some duties normally carried out by physicians, such as prescribing medication and performing certain medical procedures.
V&VN VS therefore suggested taking a new approach, proposing a nationwide experiment and an experimental law through which nurse practitioners would be given the right to work in their expanded roles across the entire country, but only for a defined period of 5 years. After this period a comprehensive evaluation would take place, involving both V&VN VS and the Royal Dutch Medical Association.
The resulting report was positive, showing that nurse practitioners were indeed able to deliver safe, good-quality care leading to high patient satisfaction. Nurse practitioners were there to stay, with their independent full practice authority passed into law in September 2018.
Physician workloads also benefit
Having nurse practitioners in these settings has made a big difference, as Inge’s colleague Arnold Bisschop, a geriatric care physician, is happy to acknowledge.
“Our organization was the first in our region of the Netherlands to start employing nurse practitioners, to bridge the gap between the nurses and physicians and to let them take over a part of the medical care. This turned out to be a golden opportunity,” he recalls.
“Since starting, nurse practitioners have been positioned as full members of the medical team, with their own professional responsibilities and patient wards. We work together as a team; physicians are not supervisors, but colleagues with different knowledge and different skills. The clearly defined skills and responsibilities of nurse practitioners means that physicians and nurse practitioners are clearly differentiated and we are therefore very happy working with them.”
Arnold concludes, “Having more nurse practitioners in our medical team – they now constitute a third of the team – has allowed us to broaden the spectrum of treatments we offer and has improved quality of care.”
As countries face widespread workforce shortages, despite increased numbers of health workers, health systems around the WHO European Region are seeking solutions that maximize and optimize skill sets to serve growing and changing health needs, including inequities in access to care. Advancing nursing roles is an innovation that helps motivate, retain and attract people to the nursing profession.
Recognizing the importance of expanding nurses’ roles to improve health care, WHO/Europe recently published a technical brief for governments, policy-makers and other decision-makers. The brief defines pathways to advancing roles, provides evidence on the outcomes of doing so and shares lessons from countries that have introduced schemes to make this possible.
Helping retain more nurses
While many countries across the Region are struggling to retain or attract enough nurses, advancing their roles and responsibilities to those of nurse practitioners can help motivate staff through meaningful career progression.
Inge is keen to emphasize this point: “Here in the Netherlands, applying to be a nurse practitioner gives you the opportunity to get a master’s degree, subsidized by the Government. It also gives you a new, exciting occupation that spans both nursing and medicine, with the full practice authority that goes with that.”
Unfortunately, the number of nurses that can become nurse practitioners is limited by the number of subsidized degree places available. Currently, this is around 450 a year, meaning that the universities of applied sciences in the Netherlands that run the advanced nursing master’s programme all have long waiting lists of nurses with bachelor degrees wanting to upgrade their profession.
“This is such a pity because I think health care in general would benefit so much if there were many more nurse practitioners,” Inge says. “The vision of our organization [V&VN VS] is that in 2030 every patient in the Netherlands will have access to the integrated care and treatment of a nurse practitioner.”
Advancing nursing roles in the WHO European Region
Across the Region, many countries are expanding the roles and responsibilities of nurses, including by introducing the role of nurse practitioner, to bring innovation to health-care systems, improve access to care, and achieve better health outcomes while reducing costs.
Although the nature of these new roles varies according to the context of each country, they tend to share the common characteristics of increased specialist knowledge, the ability to make complex decisions and expanded areas of clinical practice.
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On 12 January 2024, the text of the article was updated to better reflect the status of the rollout of the degree across the Netherlands.