As far back as Thierry Amourroux can remember, the broadening of nurses’ skills has been the subject of debate. “We have been talking about it for a very long time because the decree of competence for nurses has not been updated since 2004”, underlines the spokesperson for the national union of nursing professionals. “However, practices have evolved, and so have needs. It is necessary that the texts of law and practice come together,” he adds.
After long years of arm wrestling, particularly with general practitioners, and the observation of medical desertification which is inexorably increasing, the outlines of a consensus are emerging. Indeed, on October 7, the Liaison Committee of Ordinal Institutions (CLIO), which brings together the seven Orders of health professions (physiotherapists, midwives, doctors, pharmacists, nurses, dental surgeons, chiropodists), signed a agreement on joint proposals to improve access to care. Among the key measures: “the sharing of acts and activities” with other front-line health professionals, including nurses, to relieve doctors. Another major point: when there is no doctor available, the report recommends that other health professionals can ensure the orientation of the patient and his first care.
Amendments submitted to the PLFSS 2023
“It’s a historic agreement,” said Patrick Chamboredon, president of the National Order of Nurses (Oni) and elected president of the CLIO. “We managed to put the interest of the patient above the fray. It required effort from each side because there were blocking situations with regard to postures in each Order”. Now in agreement, the professionals now hope to find an echo of their proposals in a text of law, then in implementing decrees. “Discussions have already been launched with the Minister of Health François Braun”, we are told.
The legislator seems to have heard this call of the foot. This week, in the National Assembly, four amendments were tabled to this effect to the 2023 Social Security Finance Bill (PLFSS) for the discussions scheduled from October 20. To compensate for medical desertification, one of the amendments, presented by the government, proposes to extend the permanence of care to other health professionals than doctors, such as nurses. While two other amendments suggest on the one hand that advanced practice nurses (who have two years of additional studies compared to so-called standard nurses) can issue prescriptions for minor illnesses. And on the other hand, that they can sign death certificates.
First aid nurses in medical deserts?
The government’s amendment, if adopted, would, for example, allow a nurse to first assess the patient and the need for intervention by a mobile emergency and resuscitation service (SMUR). Similarly, a midwife can help a pregnant woman requiring unscheduled care. “The idea is that nurses, but not that, can be a first resort for patients, especially in areas of medical deserts”, explains Patrick Chamboredon. According to the definition of Public Health France, primary care, also called primary care or community care, represents the first level of contact between the population and the health system. In other words, in the future, nurses could receive patients who require unscheduled care, and who without doctors often end up going to the emergency room.
“It is a measure that is quite feasible, assures Thierry Amourroux. Today, there are 700,000 nurses in France, 150,000 of whom work as liberals. It is a waste not to use them to overcome the deserts medical”. Especially since a recent study by the National Order of Physicians announces that there are no “nursing deserts”. “We noted, with surprise, that the density of nurses is particularly high in areas under-staffed with doctors and not very accessible, must in rural and peri-urban areas, points out Olivier Lacoste, geographer and author of the study for the ‘Oni. There is no living area without a nurse.”
While Jérôme Marty, president of the French Union for Free Medicine, considers such a measure dangerous. “We are being told that when there are no more doctors, we put in nurses,” he annoys. “It does not solve the problem of the lack of doctors, it is to deny reality. When the nurse has to call a doctor because the care is beyond his skills, what do we do if there is no doctor Since it is supposed to land in solution in medical deserts…”
Additional acts, but which ones?
In addition to the question of placing nurses in first resort in areas without general practitioners, the amendments presented in recent days to the PLFSS 2023 also advance an expansion of their actions. Interprofessional discussions are still underway to detail the limits. But the question of the prescription, in particular of the analgesics of level one is on the carpet, just like that of the renewals of prescription. “At present, we cannot prescribe doliprane”, laments Thierry Amourroux.
An amendment has also been tabled so that nurses can issue death certificates. An act previously reserved for doctors. However, in her text tabled on October 10, LREM MP Stéphanie Rist indicates that “it very regularly happens that families are forced to wait for hours or even a whole day before a doctor writes this act, necessary for the removal of the body, for lack of available doctor”. In 2019, the idea had already been the subject of debate within the National Assembly, but Agnès Buzyn, Minister of Health at the time, had evacuated it, judging that this act should strictly remain an act medical.
And the prerogatives of nurses could “expand further” according to the National Order of Nurses, with the prescription and injection of compulsory vaccines, whereas so far nurses can only vaccinate against the flu.
“A major step forward” for some, a “palliative solution” for others
For the national union of nursing professionals, the CLIO proposals like the amendments tabled to the PLFSS 2023 are “major advances”, as for the national federation of nursing students (fnesi). “With all its proposals, comes the idea of a revaluation of the profession, which we need in view of our initial training”, notes the president Manon Morel.
But the unions of general practitioners do not see it the same way. “We all agree on the observation and on the fact that the skills of nurses must be broadened in terms of acts”, says Jérôme Marty. “But the idea of putting nurses where there are no doctors is a palliative solution, it must be temporary,” he adds, pointing out a lack of consultation. Since the publication of the CLIO report, the first union of general practitioners MG France has been annoyed on its twitter account by such a measure, relaying numerous testimonies from angry doctors. “The attending physician ensures the consistency and quality of the care pathway for patients,” writes the union. The lobbying of certain actors for direct, unregulated and uncoordinated access is a setback”. Like what, the showdown is not really about to end.