Santé et Services sociaux Québec.
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Brief analytical summaries or syntheses #1

Nurses in advanced roles: a description and evaluation of experiences

in 12 developed countries


This health working paper from the OECD Directorate for Employment, Labour and Social Affairs looks at the development of advanced practice nurses in 12 countries: Australia, Belgium, Canada, Cyprus, Czech Republic, Finland, France, Ireland, Japan, Poland, United Kingdom and United States. Many countries are seeking to improve healthcare delivery by reviewing the roles of health  professionals, including nurses. Developing new and more advanced roles for nurses could improve access to care in situations of limited or diminishing supply of doctors. The redefinition of roles might also contain costs by delegating some of the tasks currently accomplished by expensive doctors to nurses, especially in primary care. The paper also assesses how the reorganization of work impacts the quality of patient care.


Advanced nursing roles vary significantly between countries. The International Council of Nurses (ICN) defines the role as an expansion of basic practice, shaped by the context and country in which the nurse practices, that generally requires a Master’s degree.

In Canada and the United States, ‘nurse practitioners’ have been recognized since the 1960s. The United Kingdom and Finland have been experimenting with different forms of collaboration between doctors and nurses for a number of years. More recently, Australia and Ireland have been very active in establishing higher education programs and posts for advanced practice nurses. In other countries included in this study, the formal recognition of advanced practice nurses is still in its infancy, although unofficial advanced practices may already exist.  

The development of new roles for nurses is motivated by the need to:

  • Relieve doctor shortages;
  • Improve access to care and meet fluctuating demand for care;
  • Promote higher quality of care;
  • Contain cost increases in health care;
  • Enhance nurses’ career prospects.

Analysis and results

Quality of care
This study shows that the use of advanced practice nurses can improve access to services and reduce waiting times. Advanced practice nurses are able to deliver the same quality of care as doctors for a range of services (for example, routine follow-up of patients with chronic conditions, first contact for people with minor illness), provided they have received proper education and training.  Most evaluations find a high patient satisfaction rate, mainly because advanced practice nurses tend to spend more time with each patient and provide detailed education and counseling.

Cost of care
When new roles involve a transfer of tasks from doctors to nurses, the impact is either cost reducing or cost neutral.  However, the use of advanced practice nurses can increase costs as they tend to provide for longer consultations, make a greater number of patient referrals, and sometimes order more tests.  When new roles involve supplementary services over and above what doctors provide, the impact is cost increasing.  

Barriers or facilitators to the development of advanced nursing roles

  1. Professional interests
    In most countries, opposition from the medical profession has been identified as one of the main barriers to the development of more advanced nursing roles. To reduce opposition, some countries have adopted collaborative strategies involving different professional associations in efforts to define each group’s scope of practice.

  2. Organization of care and funding mechanisms
    In some countries, health care is based mainly on solo physician practice, while in others, group practices involving many different health professionals are the dominant mode. The organization of care and funding mechanisms influence the expansion of advanced nursing roles.

  3. Regulation and legislation
    In many countries, legal barriers limit the roles nurses can play (for example, in prescribing drugs or assuming certain roles in primary care). The implementation of advanced roles for nurses requires changes to legislation and regulation.

  4. Education and training
    The development of advanced skills requires that training programs be adapted and expanded. In some countries, new programs must be created. Financing these programs presents another challenge.


OECD countries are at very different stages in implementing advanced nursing roles.  Some have already formally implemented such new roles while others are only just beginning to explore possibilities.  This provides good opportunities for countries where the introduction of new roles is being considered to learn from experience elsewhere and adapt development to their national context. However, even in countries that are further ahead, the number of advanced practice nurses is often only a very small proportion of all nurses. Given the highly diverse contexts of the countries included in this study, it is difficult to draw any general conclusions. But the paper clearly demonstrates that the use of advanced practice nurses can help improve population access to primary care. 

Implications and recommendations

  • Adapt legislation and regulation
    In all countries, the implementation of advanced nursing roles has required some changes to legislation and regulation related to scope of practice. Laws regarding scope of practice differ significantly between countries. It is more difficult to adopt new roles when legislation defines in very specific terms what each health profession can (or cannot) do.
  • Adapt professional training programs to new roles
    The importance of ensuring that education and training programs are available to train nurses with more advanced skills was evident in most countries in this study. Financing these programs must be assured, and there may be a need to strengthen interprofessional education for both doctors and nurses.
  • Obtain political commitment to support advanced nursing roles
    In all countries where nurses now assume more advanced roles, governments have had to support the process by mobilizing the support of all relevant parties, adapting the legislative and regulatory framework, providing financial incentives for the creation of advanced practice nursing positions and helping to finance new education and training programs. 
  • Evaluate the impact of new roles on the quality and cost of care
    The development and implementation of advanced practice nursing roles should be evaluated in terms of their impact on patient care and costs. These evaluations must consider the overall organization of services and not simply nursing practices alone.


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