Problem: Shortage of physicians, particularly in rural areas; high volume of nurses compared to the WHO European Regional average; limited autonomy and scope of practice for nurses.
Solution highlights: The Ministry of Social Affairs and Health promoted the shift of responsibilities from physicians to nurses through implementing supportive policies, legislation and incentives; partnerships and international networks facilitated information exchanges and offered inspiration for activities during the initiative’s design; national legislation provided the necessary framework for aligning changes in the professional scope of practice for nurses; the development of postgraduate advanced nursing programmes in partnership with universities supported the sustainability of the initiative and ensured the continuing development of nursing skills; advancing nursing roles contributed to professional empowerment and improved workplace well-being for both nurses and physicians.
Description of practice
In 2000, Finland faced a shortage of physicians with only 241 per 100 000 population, compared to a WHO European Regional average of 302 per 100 000 population. This shortage made responding to patient demands challenging and contributed to geographic inequities in care access. In contrast, Finland had an above-average volume of nurses with 954 per 100 000 population, compared to a WHO European Regional average of 666 per 100 000 population. However, the relatively limited scope of practice and autonomy for nurses compromised the extent to which nurses could support service provision in underserved areas.
Based on an analysis of 31 pilot projects conducted between 2003 and 2004, the Ministry of Social Affairs and Health recommended shifting responsibilities from physicians to nurses to address the problems caused by physician shortages. The Ministry backed this recommendation with incentives for municipalities to further encourage the restructuring of health providers. To ensure nurses had the necessary skills to take on additional responsibilities, Finnish universities developed various postgraduate advanced nursing programmes. Subsequent government policies provided further support for the advancement of nursing roles. In 2010, legislation was enacted to allow nurse prescribing for a defined list of medications and a new postgraduate programme was developed to support this. As a result of these combined efforts, advanced practice nurses have been positioned to autonomously deliver a range of health services to patients. Supported by evidence-based guidelines, advanced practice nurses perform consultations, order and carry out diagnostic tests, manage patients with chronic disease and treat minor acute conditions, among other responsibilities.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The Ministry of Social Affairs and Health led the initiative through issuing official recommendations to support the advancement of nursing roles and encouraged municipal uptake of recommendations with complementary policies, legislation and incentives. Cooperation between national and municipal governments was important and municipal councils were invited, along with other stakeholders, to participate in planning discussions. The majority of stakeholders were supportive of the initiative, with the exception of medical associations. However, as providers were largely in favour of the proposed changes, the Ministry was able to work with medical association executives to overcome resistance. International nursing recommendations and models provided inspiration for activities and the Thematic European Nursing Network offered Finnish universities exposure to advanced nursing programmes being implemented abroad. Finnish universities played a key role in developing new higher-education programmes to train advanced practice nurses to take on the additional responsibilities being advocated for by the Ministry.
Several small-scale evaluations have recorded the impact of the initiative and reported positive outcomes. Advanced practice nurses now manage approximately half of all patient visits in health centres. Furthermore, according to a study carried out at a rural health station, advanced practice nurses met patients’ care needs without a physician up to 70% of the time. Early studies indicate both physicians and nurses have reported improved workplace well-being as a result of changes under the initiative. Patients also appear satisfied with the care they receive from advanced practice nurses. A national-scale evaluation on nurse prescribing is currently underway. The results of this evaluation, which are expected by the end of 2015, will be used to inform future directions for nurse prescribing in Finland.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Marjukka Vallimies-Patomäki
- Ministry of Social Affairs and Health