Article Text

Download PDFPDF

National mixed methods evaluation of the effects of removing legal barriers to full practice authority of Dutch nurse practitioners and physician assistants
  1. Daisy P De Bruijn-Geraets1,2,
  2. Yvonne J L van Eijk-Hustings1,2,
  3. Monique C M Bessems-Beks1,
  4. Brigitte A B Essers1,2,
  5. Carmen D Dirksen1,2,
  6. Hubertus Johannes Maria Vrijhoef1,3,4
  1. 1 Department of Patient and Care, Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
  2. 2 School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
  3. 3 Panaxea, Amsterdam, The Netherlands
  4. 4 Department of Primary Care, Vrije Universiteit Brussel, Brussels, Belgium
  1. Correspondence to Daisy P De Bruijn-Geraets;{at}


Objective To evaluate the effects of granting legal full practice authority (FPA) to nurse practitioners (NP) and physician assistants (PA) regarding the performance of specified reserved medical procedures and to support governmental decision-making.

Design Nationwide mixed methods design with triangulation of quantitative (Pre-post test design) and qualitative data (expert interviews and focus groups).

Methods Surveys focused on the performance of the procedures (monthly number, authorisation mode, consultations and procedural time) and legal cross-compliance requirements (adherence with protocols, competence). Interviews focused on competence, knowledge, skills, responsibilities, routine behaviour, NP/PA role, acceptance, organisational structure, collaboration, consultation, NP/PA positioning, adherence with protocols and resources. Data collection took place between 2011 and 2015.

Results Quantitative data included 1251 NPs, 798 PAs and 504 physicians. Besides, expert interviews with 33 healthcare providers and 28 key stakeholders, and 5 focus groups (31 healthcare providers) were held.

After obtaining FPA, the proportion of NPs and PAs performing reserved procedures increased from 77% to 85% and from 86% to 93%, respectively; the proportion of procedures performed on own authority increased from 63% to 76% for NPs and from 67% to 71% for PAs. The mean number of monthly contacts between NPs/PAs and physicians about procedures decreased (from 81 to 49 and from 107 to 54, respectively), as did the mean duration in minutes (from 9.9 to 8.6 and from 8.8 to 7.4, respectively). Utilisation of FPA was dependent on the setting, as scepticism of physicians and medical boards hampered full implementation. Legal cross-compliance requirements were mostly fulfilled.

Conclusions Informal practice was legalised. The opportunities to independently perform catheterisations, injections, prescribing, punctures and small surgical procedures were highly used. Care processes were organised more efficiently, services were performed by the most appropriate healthcare provider and conditions were met. This led to the recommendation to continue with FPA.

  • clinical governance
  • organisation of health services
  • quality in healthcare
  • medical law

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from


  • Contributors DPDBG, MCMBB, YJLvEH and HJMV significantly participated in the conception and design of the study and the interpretation of the data. DPDBG and MCMBB conducted the interviews, collected the data and were responsible for the statistical analyses. BABE provided input for the cost study. DPDBG wrote the first and subsequent drafts of the paper, and all (DPDBG, MCMBB, YJLvEH, BABE, CDD and HJMV) contributed to editing and refining. All authors read and approved the final manuscript.

  • Funding This work was supported by the Dutch Ministry of Health, Welfare and Sport (March 2011 grant number 320434) and endorsed by the professional organisations Nurses and Carers Netherlands department for nurse practitioners (NCN NP, in Dutch V&VN VS), National Association of Physician Assistants (NAPA) and the Royal Dutch Medical Association (RDMA, in Dutch KNMG). The report of this study was presented to the Dutch Minister and subsequently to the House of Representatives for further decision-making. The report, in Dutch, is available at:

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Ethical approval for this study was obtained from the Maastricht University Medical Ethics Committee in July 2011 (reference number METC 11-5-045).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data sets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.