Our study showed that NPs and PAs had wide ranging but different responsibilities in Dutch public hospitals. NPs spent 25% of their working week on medical procedures, while PAs spent 40%, showing that NPs and PAs function as substitutes for doctors. However, many NPs and PAs experienced policy/organizational, legal, financial or facilities-related barriers in the reallocation of tasks, which affected the extent of substitution.
The strengths of this study were the mixed method we used and the high response rate, resulting in a representative sample. However, there were also several limitations.
The majority of the NPs and PAs in our study were still in training, so their job content was still developing during the study. Consequently, the extent of substitution reported by our participants may be an underestimation. As more NPs and PAs graduate, the results regarding the extent of substitution may become even more positive.
Data were acquired by means of questionnaires and interviews, which may have led to recall bias and subjectivity and to biased results. A more objective measurement design, i.e. an observational study, might have resulted in slightly different outcomes.
The study used a very detailed questionnaire to precisely determine the responsibilities of NPs and PAs. Participants found it difficult to divide their work into such detailed subtasks. In practice, some tasks are not always performed separately, but are more or less integrated (e.g. taking medical history and performing physical examination at the same time). This may have somewhat hampered the validity of the results.
Finally, the blueprint for the interview was different for participants recruited from the first hospital and those from the other hospitals; to gain a more comprehensive view of the responsibilities of NPs and PAs, some questions were added after the first participants had been interviewed. For participants from the first hospital, the added questions were not scored at all (subjective extent of substitution) or scored on the basis of the questionnaire and other interview findings (tasks performed), when possible. This may have caused some misinterpretation of these results. However, the change in the blueprint for the other participants did result in more detailed and precise information.
Discussion of results
The large numbers of NPs and PAs who were still in training may have contributed to the relatively high percentage of their time spent on training to improve their own expertise, which is in agreement with research by Tempelman (2005). However, NPs at a university medical centre in the Netherlands only spent around 10% of their time on training to improve their own expertise (Kemps 2006); the difference in result may have been caused by the smaller proportion of NPs in training.
The present study showed that NPs spent a quarter and PAs almost half of their time on medical procedures. This shows that NPs and PAs function as substitutes for doctors, which is also confirmed by previous research (Richardson et al. 1998, Van Offenbeek et al. 2004). Richardson et al. (1998) showed that between 25% and 70% of the tasks of doctors, mostly general practitioners, could be carried out by non-physician practitioners. However, Roodbol (2005) reported that substitution did not occur at all in Dutch health care, because physicians remained responsible for the medical tasks. Roodbol also found that it was patient groups which were delegated, rather than medical tasks. In contrast to Roodbol (2005), we found that it was not only a matter of delegating tasks, but that medical procedures were also permanently reallocated. Roodbol’s finding concerning the delegation of patient groups instead of medical tasks was not investigated in the present study.
Evidence shows that substitution of tasks is justifiable in terms of quality of care and patient outcomes (Laurant et al. 2009). It is also likely that employing ‘the lowest cost provider’ (Reay et al. 2003) will mean that healthcare systems benefit in terms of efficiency and cost containment. After all, the salaries of NPs and PAs are lower than those of doctors. However, findings on healthcare costs have been mixed (Laurant et al. 2009) and previous research had several methodological limitations (Dierick-van Daele et al. 2008, Laurant et al. 2009). Savings in salaries may, for example be offset by lower productivity as NPs or PAs might take more time for their patients. In addition, the role of NPs or PAs is additional to the existing care process, as the care process is not being redesigned, so this does not result in efficiency gains (Health Council of the Netherlands 2008). More research concerning the economic evaluation of employing NPs and PAs in Dutch hospitals is needed to determine if substitution of tasks contributes to more efficient care and results in cost savings.
Nurse practitioners and PAs also performed new tasks or tasks for which there was previously not enough capacity, which is in agreement with previous research (Van Offenbeek et al. 2004, Van Offenbeek 2008). This suggests that NPs and PAs also function as supplements to doctors by providing additional services which are intended to complement or extend those provided by doctors (Richardson et al. 1998, Laurant et al. 2009).
Substitution of tasks may also be important in light of recent developments concerning the opportunities offered by health care and the use of Internet (eHealth or Health 2·0). In these new forms of healthcare delivery, individuals (i.e. patients and healthcare professionals) are brought together by social media to discuss health and health care (Eysenbach 2008, Council for Public Health and Health Care [RVZ] 2010). NPs and PAs are perfectly able to perform care tasks based on this kind of health care, against lower costs. This would allow doctors to focus on their core task of treating patients with more complex medical problems.
The majority of the NPs and PAs experienced policy/organizational, financial, legal or facilities-related barriers in the reallocation of tasks. The NPs and PAs also mentioned facilitators for the reallocation of tasks, e.g. support by management and healthcare professionals. These findings are consistent with those of previous studies (Marsden et al. 2003, Kenbeek & Rademakers 2006, Thrasher & Purc-Stephenson 2007, Keating et al. 2010). Marsden et al. (2003) reported, for example, that NPs need the freedom to innovate, sufficient support and appropriate training to allow true autonomy, and that practice is hindered by limited prescribing authority and restrictions on requesting tests. In a Dutch context, Kenbeek and Rademakers (2006) showed that legislation, funding, support, supervision, characteristics of the NP/PA and evident quality improvements were success and failure factors for employing NPs and PAs in Dutch hospitals.
Some of the barriers experienced by NPs and PAs in this study, for example, resistance from other healthcare professionals, might be due to the fact that the introduction of NPs and PAs was still in a pioneering stage. However, doctors still seem reluctant to change their ways by reallocating tasks (Health Council of the Netherlands 2008). Apparently, doctors find it hard to delegate the final responsibility for medical tasks towards non-physician practitioners (Van Rooijen 2003). The majority of the NPs and PAs in this study delivered care that was partly or completely based on protocols. Making use of protocols can probably increase interprofessional trust (Health Council of the Netherlands 2008), which can ultimately have a positive influence on the extent of substitution. For this purpose, it has to be clear to healthcare professionals which tasks others can or cannot perform. Professional organizations of NPs and PAs can take up the responsibility to inform other professions about the competencies possessed by NPs and PAs and the professional scope of practice of NPs and PAs.
The legal obstacles for NPs and PAs found in our study are gradually being removed. A change has been proposed to the Individual Health Care Professions Act, which makes it possible for NPs and PAs to autonomously prescribe medication and carry out other reserved activities (Ministry of Health, Welfare and Sport [VWS] 2009). This revised act has recently been approved by the Dutch Parliament and will come into force in 2011. Even with this revised act, however, removing the organizational, financial and facilities-related barriers need to be addressed by managers and policy makers in the hospital setting.