Evolution of the nursing profession and training

The Ministers for Solidarity and Health and for Higher Education, Research and Innovation have asked the General Inspectorate for Social Affairs (IGAS) and the General Inspectorate for Education, Sport and Research (IGÉSR) to conduct an analysis and make proposals for the evolution of the nursing profession. Against the backdrop of increasing demand and crisis in the healthcare system, the mission letter emphasizes the need to draw on “nurses to pursue major transformations” of the health system and thus better mobilize their expertise while carrying out an “in-depth review of their training”.
In this context, the mission was asked to conduct a very broad analysis:

• on professional practice, in terms of the current decree of nursing procedures and on the nature of the activities and skills to be developed “by integrating the evolutions in accordance with the reality of the profession”;
• on training, in terms of student pathways, the impact of the 2009 reform with the recognition of bachelor’s equivalence for students who have obtained their State nursing diploma, the impact of the Parcoursup platform and the desirable changes in the training framework.

The mission did not intend to conduct a consultation. However, its findings are based on numerous interviews conducted at national level with representatives of nurses and other health professions (in particular doctors), students in training institutes for nursing (IFSIs) and universities. We went on three trips to Auvergne-Rhône-Alpes, Brittany and Île-de-France to meet the regional leaders, professionals and students in IFSIs and healthcare, medico-social and private practice institutions. Due to the wide variety of practice settings of the 637,644 nurses, the mission decided to focus its analysis on three sectors: public and private healthcare hospitals, private practice and residential centers for dependent elderly people. We conducted a survey of social affairs advisors to gain an international perspective.

Cooperation between healthcare professionals is a fundamental issue. To address this issue, the report seeks to analyze potential changes in nursing skills within a broader framework integrating other health professionals and the overall objective of better coordinating their interventions, by integrating their financing and remuneration models.
Due to the period during which the mission was conducted, its work was carried out on the basis of very open guidelines from the sponsors, particularly regarding professional practice. Furthermore, the mission could not refer to previous technical work in this area. Therefore, in view of the consultation to be undertaken, the recommendations for changes presented in the report are intended to be refined after arbitration on the preferred focus areas.

The career path of students and professionals

At the start of the 2020 academic year, 91,605 students were enrolled in the 330 IFSIs, 32,450 of which were in their first year. The strong attraction of nursing training has been confirmed since the integration of IFSIs on the Parcoursup platform in 2019 with approximately 100,000 applicants each year. It is the most in-demand training on Parcoursup. This demand means that Parcoursup applicants fill more than 80% of the open places in nursing training. The attendance objective for IFSIs has been reached even though 6,600 additional places have been created under the Ségur de la santé plan and the France Relance plan. However, the drop in the proportion of nursing students coming from the professional training route is a cause for concern.

The profile of students is changing and not just since the introduction of Parcoursup: they are younger, fewer and fewer of them have a general scientific degree and more of them have grants. There is a significant drop between the number of students starting the program and the number of graduates three years later. On average, about 5,100 students out of a class of 30,000 do not graduate (i.e. 17%). There are various reasons for this: dropouts, particularly in the first year, with fluctuating rates that the mission was unable to confirm; study pathways with breaks in the course; and a pass rate for the state diploma of 85% on average over the past ten years.

The career path of nurses is characterized by:

• strong growth in the number of nurses over the last twenty years and in their density in relation to the population;
•  unequal geographical distribution in favor of the southern and eastern territories, but an overall increase in the accessibility of nursing care over the recent period;
• a wide variety of practice locations. As of January 1, 2021, more than 63% of nurses were working in public or private healthcare hospitals. 19% of nurses are private practitioners and 6% work in EHPADs.
• easy professional insertion despite a recent increase in their unemployment rate.

All of the indicators confirm there are recruitment tensions. These indicators reflect issues related to attractiveness of the role and retention of professionals, particularly in healthcare institutions, which are not issues specific to France but are all the more worrying in that many nursing jobs are expected to continue to be created by 2040 to cope with an ageing population.

The mission highlights that these findings are based on data that are not very recent and/or sometimes unreliable. This situation does not allow us to make a solid diagnosis and a strategy concerning current and future needs for professionals and their translation into numbers to be trained each year. This statistical work should be prioritized. In terms of training, the data collection methodology must be redefined as soon as possible through collaborative monitoring by the Directorate for Research, Studies, Evaluation and Statistics and Subdirectorate for Information and Statistical Studies Systems (DREES-SIES).

Tensions between the legal framework and evolving needs

The professional practice of nurses is currently based on a decree of professional procedures with a level of detail unique to France. In most countries, the nursing profession is generally defined by main duties. This system of professional procedures inhibits the continuous evolution of healthcare needs, which calls for the development of more general duties such as the coordination of the healthcare pathway or prevention, to which nurses already make significant contributions. In addition, the evolution of medical demography requires us to rethink the organization and distribution of skills between healthcare professionals.

Despite their benefit, neither cooperation protocols nor the development of advanced practice will be able to sufficiently address these challenges. While many cooperation protocols involve nurses, professional adherence to them is still low. The protocols suffer from a lack of national monitoring and a lack of clarity as to whether they will eventually be integrated into the core skills framework of nurses. At the same time, the development of advanced practice nursing is still not widespread and the quantitative objectives set for the number of advanced practice nurses (APNs) will not be achieved.

Points to arbitrate in order to develop skills

The mission’s findings call for a scaling-up of the evolution of nurses’ area of expertise. However, the variety of nurses’ current duties and places of practice leads to two possible approaches: one based on developing the decree of procedures, the other consisting of determining duties in which nurses could have greater autonomy. These two approaches are not exclusive.

In view of the many stakeholders working on the basis of the decree of procedures, a first approach based on the current structure of this decree should not be overlooked in order to identify which procedures could be integrated into the core skills framework of nurses. Therefore, the report describes the procedures identified as already performed by some nurses in the field, in private practice or in hospitals, outside their area of expertise. Some of these procedures could become part of the nurse’s own role and thus no longer require a medical prescription. In addition, certain procedures delegated under the 43 cooperation protocols involving nurses are intended to be integrated into the core skills framework. The decision whether or not to integrate these protocols must be based on a more detailed analysis of their actual implementation and clarification of the criteria for widespread application of the protocols.

The second approach involves determining the duties to be developed, based firstly on the needs that are insufficiently covered by the current system, and secondly on the capacity of the nursing profession to respond to them in conjunction with the other healthcare professions. The nurses surveyed by the mission highlighted several specific features of their role: a “comprehensive” view of the patient that differentiates them from other paramedical professionals, a regular presence in the homes of certain patients and therefore a greater capacity for “outreach” than that of doctors, and a digital influence and presence throughout the country, despite significant differences in distribution.

On this basis, and based on the international comparisons available, the mission recommends carrying out, from the beginning of 2023, a consultation on the expansion of nurses’ area of expertise based on the duties to be developed, in particular prevention, coordination and local care.

These developments will inevitably have to deal with two points of tension that also sit on the line between medical and nursing practice:

• prescriptions, for which the mission recommends to go beyond the specific procedures already afforded to nurses to assess a broader prescribing ability that would be defined in accordance with the nurses’ priority duties;
• consultation, for which the mission recommends changes for specific conditions and for the purposes of coordinated systems in order to guarantee smooth coordination with doctors. Only APNs would be allowed to provide direct access consultations.

The exercise of greater autonomy by the nursing profession must occur under safe procedures. In this respect, the mission emphasizes the need to invest more in the professional training of nurses. In certain fields, additional training should help bring about an expansion of nurses’ area of expertise. This would also help guarantee improved recognition of their experience and more varied career paths. It would therefore be necessary to distinguish between the core skills framework level acquired in initial training, available to future nurses as soon as they get their diploma, and an “expert” level with a broader skills area acquired through additional certification.
The certifications obtained by nurses through professional training must be transferable, meaning they must be structured as much as possible in skills units, and accessible as much as possible through the validation of acquired experience. For example, involvement in a cooperation protocol and taking the associated training should open up the option of acquiring a certification giving the professional a skill that they will retain throughout their career.

Safeguarding nursing practice must also involve the promotion of interprofessional collaboration through coordinated practice. Certain duties currently performed under cooperation protocols could be performed outside of these protocols in the future, but always as part of a coordinated system and in cooperation with a doctor.

The matters raised by the mission on the evolution of the nursing profession affect other healthcare professionals, and the proposed changes for some will inevitably result in new expectations for others. The affected professionals are mainly doctors, but also nursing assistants and APNs, whose area of expertise was developed before the question of “core” skills was raised. The healthcare policy work of the French National Council for Refoundation is an opportunity, based on the problems experienced in the field, to align skills of healthcare professionals with the population’s current and future needs. The mission therefore encourages the integration of changes in the skills of nurses, APNs and nursing specialties into a common strategy, taking into account the role of other healthcare professionals.

The evolution of nurses’ area of expertise would also require a review of the legislative definition of the profession by structuring it according to duties using the model of what was planned in 2008 and drawing on foreign examples. The mission also calls for a more structured process for updating the decree of professional procedures in order to set regular intervals for evaluating it and completing the necessary consultations.
Lastly, the mission raises the question of the longer-term evolution of the nursing profession towards a profession with defined skills.

Guidance to follow regardless of evolution in the area of expertise

The attractiveness of the profession and of training raises issues that reach far beyond the question of nurses’ area of expertise. This is why the mission has highlighted several levers that must form part of a review of nursing skills.

Despite the measures taken to improve the situation under the Ségur plan, the issue of remuneration is still being strongly raised, particularly in healthcare institutions. The questions raised relate to the level of remuneration in comparison with other countries, to the consideration of time constraints or specific functions such as nurse mentoring, and to the fairness of the various category-specific bonuses. The mission therefore recommends that a comprehensive review on nurses’ remuneration be launched immediately. In addition, it is necessary to continue to take action to improve working conditions, which are widely cited as the first reason for leaving a position or even the nursing profession. These working conditions are likely to result in a loss of meaning, with nurses indicating that they no longer have the time to apply the interpersonal skills that are at the heart of their work, or even of their professional motivation. In healthcare institutions, the rigidity of the organizations and the lack of recognition of nursing duties are highlighted. Lastly, the mission recommends to better regulate the development of temporary employment, the effects of which can be detrimental to the overall organization of work.

The professionalization of the training process, from selection to graduation, must be improved. The way training is currently structured, which is a shared responsibility mainly between the Ministry of Health, the Region and the training operators, IFSI and universities, is a source of complexity. On top of this, the network of IFSIs is fragmented, which calls for improvement of the organization and mission of the forty-odd groups formed when the IFSIs were integrated into the Parcoursup platform, by consolidating the role of coordinators and enhancing their functions.

Addressing the candidate selection quality in IFSIs is one of the first areas of recommendation. It is important to consolidate the entry requirements to IFSIs via the Parcoursup platform and not to introduce a pre-selection and oral exam that are sources of risk. The work of the selection committees during the selection phase must be based on an improved definition of the criteria for analyzing the applicants’ motivations and on the determination of the academic and scientific requirements expected of those with relevant qualifications, which will guarantee the success of the students selected. During the preparation phase for submitting applications in Parcoursup, it could be useful to offer applicants a self-assessment test, as has been used in other fields of study. To further develop the access route to continuing professional training, it is essential to revise the timeline for funding decisions by the skills operators (OPCO) and the French National Association for the Continuing Education of Hospital Staff (ANFH) and to better inform all applicants of the selection processes for all IFSIs.

There are several major training constraints: the need to comply with the European directive in order to address the 400-hour training deficit, the necessary evolution of nursing skills, the inclusion of the Bachelor’s, Master’s and PhD (LMD) scheme, and the objective of maintaining a manageable amount of time in terms of student workload. In view of the European Commission’s formal notice to France, compliance with the European directive requires an increase in training from 4,200 to 4,600 hours, including 2,300 hours of clinical training. In light of this, the mission proposes that the three-year training course should include 2,300 hours of clinical training, internships and mock practical health exercises and 2,300 hours of theoretical teaching, including 500 hours of supervised personal and group work. This structure should not excessively increase the time spent on classroom teaching and the personal workload of students.

The 2009 training framework, which is prescriptive and too detailed, no longer aligns with changes in the profession. It should be revised to take into account the arbitrations relating to nursing practice, structured in skills units and comply with the three main principles, which are the awarding of a bachelor’s degree, being less prescriptive in nature and being evaluated by the High Council for the Evaluation of Research and Higher Education (HCERES).

With many institutions dealing with a shortage of staff, shortfalls in the coordination, materials and induction of trainees substantiates the finding that training is incomplete and has a major impact on the attractiveness of the various practice sites. In view of this situation, the mission believes it is essential to improve the coordination of internships by recognizing and enhancing the role of nursing internship tutors, and to create internship coordination resources in all health cooperation groups, with the aim of developing and diversifying the offering.

Regardless of the increasing evolution of the nursing profession, achieving university integration is crucial. The trials in progress are paving the way for exchanges between the various healthcare training courses by establishing transfer options, shared teaching, and even joint courses. University integration requires a shift towards the awarding of a national diploma in health sciences, with a specialization in nursing, instead of the current state diploma in nursing. This change should help improve the interprofessional skills needed to address the complexity of healthcare needs. It will allow us to establish of a body of knowledge created and validated by research and to develop a disciplinary field in nursing, and will give student nurses the same rights of access to university services and further study as all students. Lastly, it will also improve the attractiveness of the profession.

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