Advanced Practice Nurses: Who are they now available without going through a doctor ?

Jessica Martinez, advanced practice nurse at ICM Val d’Aurelle, and a patient, Thursday, January 23. Midi Libre – SYLVIE CAMBON

The decree allowing direct access to advanced practice nurses, the "IPA", was published on January 20. In Occitanie, 252 professionals are trained in this different and expanded exercise of their missions: from now on, they can perform certain clinical examinations of a patient without an intermediary, and prescribe biological assessments, radiological examinations or even certain medications.

“I participated in writing the decree” : representing independent nurses at the URPS, the regional union of health professionals in Occitanie, Jean-François Bouscarain is very familiar with the subject of “advanced practice”, an exercise that is still little known in the nursing profession. He welcomes the publication, on January 20, of the decree that allows IPAs to gain autonomy over acts that previously required the approval of a doctor.

What's changing? Explanations.

Jean-François Bouscarain represents independent nurses at the URPS, the regional union of health professionals. Midi Libre – MICHAEL ESDOURRUBAILH

Advanced practice nurses, what are we talking about?

The profession is not new: the term “advanced practice nurse”, , introduced by the Touraine law (2014), appeared in France in 2016 and was taken up by the Rist law of 2023. It outlines the profile of a new generation of nurses, more autonomous, with expanded skills after two years of dedicated training.

“We understand the mission right away: the advanced practice nurse, the APN, works with broader practices compared to the state-certified nurse, in particular on the clinical examination, on the prescription and on the analysis, she can make a diagnosis”, explains Jean-François Bouscarain.

The APN “does not replace the doctor”. But, until now, she had to go through him: “It was absolutely necessary to transmit everything to the doctor and get his opinion”. Now with direct access, “the IPA gains a lot of autonomy”, without ceasing to interact with the medical profession: “Depending on the diagnosis, you can make a prescription, or refer to a doctor or a hospital. If the IPA has prescribed a biological or radiological assessment, the doctor will already have, in advance, a clinical collection, and, possibly, the diagnosis of the nurse”.

Very concrete example: “You are diabetic, you feel that your diabetes is unbalanced. You need a blood test. No need to go see your doctor, you can go see your APN who manages diabetes”.

Or: “I am out of breath, my APN, who has the right to do an electrocardiogram, can intervene”.

Or : “I have a chronic condition, I am followed by my doctor but I feel that at the moment, my treatment is not suitable. The APN will be able to adapt the treatment before a new appointment with the doctor”.

The IPAs work in private practice, in hospitals or in a health establishment, an Ehpad, a specialized care network of the “Aider” type for patients with renal failure.

Five specializations are possible: chronic diseases, cancerology, emergencies, renal failure, psychiatry and mental health.

“We are not a low-cost solution”

In 2016, Alexis Blanc, a pediatric nurse at the Montpellier University Hospital, took to the streets against a €3 billion savings plan planned for Social Security. “Times haven't changed much since”, smiles the nurse.

He, on the other hand, has transformed himself: having arrived in Langogne in 2021, he was for a long time the only advanced practice nurse in Lozère (there are now six), and has taken over the presidency of the Association of IPAs of Occitanie.

Working at the MSP (multi-professional health center), his schedule is very full:“I manage common chronic pathologies and multiple pathologies in collaboration with general practitioners. We are not a low-cost solution to replace absent doctors. With doctors, we now think in pairs, each at our own level. We avoid delays in care, and I alert the doctor when necessary, we each work at our own level and it works”, explains the neo-Lozérien, who remains in his place: “Me, my goal is not to cure at all costs, but to treat, yes. Often, patients just come to renew a prescription. And they stay for an hour because we do a physical, psycho-social assessment…"

For Alexis Blanc, "the new decree is not going to change much"  : “With the doctors, we see each other every day, and we will continue to talk”. But if he could attract to Langogne “an IPA specialized in mental health” to complete the range of care…

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Thanks to the autonomy gained, the IPA would no longer need to be backed by a psychiatrist's office. And the need is great: “In my patient base, one in two people suffer from depression, anxiety, have difficulty managing their emotions…”

Lherm, 3422 inhabitants. At the other western end of the region, in Haute-Garonne, but still in rural areas, still in the specialty “chronic diseases”, Patricia Van Kaam, 55, an advanced practice nurse since 2020, in another MSP, puts much more stake in the arrival of the reform.

“It's a revolution. Today, it's difficult for us. People don't know me", explains the nurse, who is faced with reluctance, if not hostility, from doctors in the area.

"In tandem" and "in close collaboration" with doctors, at the ICM-Val d'Aurelle in Montpellier, Jessica Martinez, 40, an IPA in oncology, has a completely different.

The decree will not change much: she shares the doctors' office.

Delighted by a "major development" which, in 2022, gave her "new responsibilities", she is inexhaustible about her daily life in a clinical trial unit, and her follow-up consultations, listening to ailments that she can relieve, or that need to be alerted: “Doctors don't have this time to listen to patients, and the nurse that I was, busy with technical care, didn't have the skills”.

The cancer care center, which now has four APNs, had no trouble letting them take their place, she says: “Doctors have no trouble letting go, on the contrary, they are overwhelmed and they have all understood the interest of our professions and our missions”.

Where are they, how many are there ?

In Occitanie, there are 252 advanced practice nurses, including 76 independent nurses. Why so few ? “The two-year training is very demanding and is done in person, they have to stop working”.

According to the URPS, however, it is in the private sector that the needs are greatest: “Given the number of general practitioners in practice, 1,360 APNs could already be set up”. A tenth, therefore, of the liberal nurses established in the region, there are 13,000 of them, for a total of 50,350 nurses, all practices combined.

According to projections, in 2025, Occitanie should have 319 IPAs, and 403 in 2026.

When will the reform be implemented??

“It's immediate”, specifies Jean-François Bouscarain.

How to find an IPA close to home ? “In the centers where they practice, they are identified.”

Why was it highly anticipated… and feared?

The objective is clear: to overcome the lack of doctors and respond to medical deserts. In France, according to Health Insurance, 472,000 patients with ALD (long-term illness) were still without a treating physician in December 2023.

“The figures are clear, we are heading towards a catastrophe“, recalls Jean-François Bouscarain, in view of the “medical demography figures”, “on a downward curve until 2035”, and the “aging of the population”, “a third of the population of Occitanie will be over 60 years old in 2030”.

The advanced practice nurse, “an intermediate profession between a doctor and a state-certified nurse”, will allow, he says, to follow “a certain number of chronic patients with serious pathologies who need to see doctors several times a year”.

With an unknown: “There is some reluctance among doctors. In hospitals, it has become commonplace. It is more difficult in private practice, there are competitive tensions. Doctors have full waiting rooms, but are afraid of losing their influence. It all depends on how professionals will take hold of the reform. If doctors stick to their practices, there will be little effect on the population.“

For Jean-François Bouscarain, “we must stop saying that there are no more doctors, since there are other professionals”. But nurses are not exempt from recruitment problems: “40% drop out of school before completing their training”.

And tomorrow?

“Imagine, you have a plumber, and he doesn't have his kit”. It's the same for APNs, assures François Bouscarain: “APNs do not yet have the possibility of performing or prescribing a certain number of acts to which they would like to have access, in particular medications that are still reserved for the medical field”.

For example ? “They cannot prescribe Doliprane, while the patient can pick it up at the pharmacy”.

This is also the case “for level 2 or level 3 painkillers”, such as Tramadol.

Another project to be undertaken: direct wound management, which “is part of the general demands, both for state-certified liberal nurses and for APNs”.

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