This report presents the results of a mixed methods study of Nurse Practitioners (NPs), also referred to as an Advanced Practice Nurse, in primary care in Norway. It is the first comprehensive study of NPs in Norway since the introduction of two new regulations on specialist certification for NPs and the national guidelines for the master’s degree programme in 2020.
Nurse Practitioner, as well as the field of advanced practice nursing, is a relatively new profession and education in Norway, but this nurse profession can be traced back to the United States in the 1960s. The postgraduate training aims to equip registered nurses with specialised broad-based competence to deliver advanced nursing care to all patients, particularly those with chronic or complex health conditions. In Norway, NPs are also expected to contribute to innovation, change and improvement efforts within healthcare services. The purpose of establishing this education in Norway is to enhance the quality of primary health and care services.
The key research questions explored in this project are as follows:
- How many NPs are there today, and where do they work?
- What are NPs’ tasks and roles in primary care, and how is their competence utilised?
- To what extent has the introduction of NPs in primary care been strategically planned?
To address these research questions, we collected data using both qualitative and quantitative methods, based on: 1) document and literature reviews, 2) case studies of six local authorities, 3) surveys of NPs and managers of municipal healthcare services, and 4) registry data.
We define a nurse practitioner as a registered nurse with post-graduate training, specifically a master’s degree, who has qualified for specialist certification. The survey also includes registered nurses who were in postgraduate training during the data collection period.
Scope and characteristics of NPs
Registry data on the group of registered nurses who qualify for specialist certification in advanced practice nursing is only available up to 2022 and does not therefore reflect developments in recent years. However, based on a review of various data sources, we estimate that in 2024, there were between 205 and 220 NPs in Norway, in addition to those undertaking postgraduate training.
NPs are found throughout Norway, but there are significantly fewer in the northernmost counties of Trøndelag, Nordland, Troms and Finnmark. Our survey indicates that the vast majority work in primary care. They are employed in various service settings, but most work in home care services and institutions.
Furthermore, we find that NPs in primary care are characterised as professionally dedicated and stable employees. Many have worked in primary care for a long time, and the vast majority hold full-time or almost full-time positions. In terms of working hours, standard rotas with day, evening and weekend work appear to be the most common, though some work only daytime shifts or a three-shift rota that includes night work.
Tasks and utilisation of competence
In terms of tasks and areas of responsibility, we find significant variation in NPs’ roles and duties in primary care. Despite the variation, managers and NPs agree that their competence enhances the quality of healthcare services.
The survey shows that most of the respondents have taken on or been assigned new tasks and responsibilities as a result of completing a master’s degree in advanced practice nursing. A majority report that they benefit from the full range of core competencies from their postgraduate training in their daily work. Clinical skills and knowledge appear to be particularly important competencies, but many also report having tasks related to professional development and peer guidance.
Although nearly all NPs in the survey report making use of their competence, fewer than half have been given a new job description. In other words, the current situation in many municipalities reflects a lack of formalisation and embedding of the NP role. According to the NPs and their managers, this hinders their ability to contribute to quality and service development in primary care.
However, there are some examples of local authorities that have made changes in service organisation and task distribution to better utilise the APNs’ competence. We examined three models: (1) specialist nurses responsible for competence development in nursing homes, (2) general healthcare teams at medical practices and (3) interdisciplinary teams in home care services. These three models or NP functions are all tailored to local needs. They have been developed over time in collaboration with the NPs, managers at various levels, and other relevant healthcare professionals.
Lack of strategic planning regarding the NP’s competence
Overall, we find that municipalities have made few strategic assessments regarding the use of NPs. The initiative for postgraduate training has typically come from the nurses themselves, rather than being driven by strategic or systematic competence evaluations. However, our data also indicate that the municipality, as an employer, facilitates nurses’ opportunities to pursue this education, with the government wage subsidy seemingly aiding this effort.
Furthermore, the process of establishing new positions or functions seems largely to rely on the initiative of the NPs themselves. Given that both the education and the nursing role are relatively new, it is understandable that APNs need to clarify their areas of expertise to their managers.
Many municipal managers still seem to have limited knowledge or understanding of NPs’ competencies. Meanwhile, many municipalities appear to have a reactive strategy, characterised by little or delayed involvement in mapping needs and how NPs can help meet these. Part of the reason for this is likely the lack of financial flexibility and time to think strategically about competence and service development, particularly at the individual service wards.
The road ahead
Based on our findings about the NPs’ role and the utilisation of their competence in primary care, our view is that there is no single optimal model for how NPs’ competence can be best utilised in primary healthcare services. Variation in local needs requires flexible solutions based on local assessments of needs as well as cooperation between managers, healthcare professionals and NPs.
We also conclude that there is a need for better organizational embedding of the education and competence that NPs can bring to primary care. This requires effort from the municipalities themselves, but also support from national authorities through information dissemination.
Because many NPs have not been given new, formalised positions, there are few examples of significant task shifting between the NP and other occupations, such as doctors. Therefore, we do not yet have sufficient knowledge to determine whether the lack of extension of the NPs scope of practice hinder effective utilisation of NPs’ competence. More empirical evidence and research are needed before considering expanding NPs’ scope of practice, such as prescribing medication.
Lastly, we find that the breadth of the postgraduate training is beneficial for meeting the municipalities increased responsibility for complex patient groups. However, clinical skills should also be strengthened at the undergraduate level, i.e. general nurse education. Going forward, focus should be placed on coordinating bachelor’s and master’s programmes to ensure that they are relevant to clinical practice and provide opportunities for specialisation.
