First Experience with Advanced Nurse Practitioners and Physician Assistants in Dutch Emergency Departments; (Dis)Advantages to the Development

Abstract

Background: Emergency Departments (EDs) are confronted with progressive crowding. One of the main reasons is found in the growing number of “self-referrals” caused by a growing shortage in general practitioners. To cope with crowding, cost-effective solutions are being sought that preserve quality of care. Up to now, the most successful initiative is the development of Advanced Nurse Practitioners (ANPs) and Physician Assistants (PAs). Aim: The aim of this study is to compare the role and development of ANPs and PAs in Emergency Departments in the Netherlands and put it in a European perspective. Methods: An inventory concerning the first experiences with ANPs and PAs on Dutch EDs was performed. Attention was focused on the differences and similarities in responsibilities and scope of practice of both professions and the (dis)advantages observed with this development. Furthermore, information was obtained from educational institutes, national nurses' associations and governmental organisations in the Netherlands and other European countries to complete the picture, enabling the formulation of a perspective on the future. Results: In Europe (mainland), the development of ANP/PA programmes is still in a very early stage. In the Netherlands, the first year of experience with ANPs working on the ED has come to a close. In the past year, some PAs also graduated and are working in the ED as well. For both groups, liability is still an issue and legislation concerning the new professions has not yet passed. Apart from a significant overlap in job description, there are some differences to be addressed. The background of ANPs must be a masters degree in nursing, as for the PAs a different paramedical background is also allowed. The following can be said about the scope of practice and responsibilities: ANPs have a disease-focused approach, while PAs are being trained to have a speciality-focused approach. Furthermore, PAs purely do clinical work, whereas ANPs are also trained to investigate and improve the efficiency of delivered care. (Dis)advantages of ANPs/PAs: In Anglo-Saxon countries, ANPs and PAs have contributed to the relief of physician shortage and therefore it is likely that this will also be the case in the Netherlands. Furthermore, it is shown that the implementation of ANPs/PAs can occur with preservation of quality of care and patient satisfaction. However, in both professions the educational program is relatively long and expensive. Moreover, although basic medical issues are dealt with, the programmes are not aimed at preparing the trainees for specific (diagnostic) tasks. Another disadvantage concerns the loss of these practitioners for regular nursing tasks, contributing to the shortage in regular nurses. This is why an alternative is sought that maintains the benefits of ANPs and PAs and gets rid of the disadvantages. Alternative Solution: An alternative concept is to provide regular ED-nurses with short injury-specific courses, teaching them how to assess and treat specific injuries according to a protocol. Apart from regular nursing tasks, treatment of minor injuries could then be taken over from physicians. This creates flexible employees, and would help deliver cost-effective quality of care with prevention of further nurse shortage.