🔦 🔍💡 Advanced nursing practice: a parliamentary report acknowledges the relative failure of deployment (3,973 APNs instead of the 6,000 to 18,000 hoped for) and outlines 20 levers to finally free APNs from the medical-centric straitjacket. ⚕️ To be read before any local pathway reform. #APN🚨 APN: the profession we created… but do not allow to work
📌This report provides, in a single document, the complete mapping of the blockages that explain why a profession intended to transform access to care remains under-deployed eight years after its creation. It precisely names what is blocking — too narrow mentions, remuneration below the viability threshold, legal framework that maintains a logic of medical subordination, invisibility in information systems — and proposes an exit trajectory. Useful for understanding the context of a colleague APN, arguing for an implantation project, or anticipating upcoming mention reforms.
📜🔗LINK to the source
1. ANALYTICAL SUMMARY
A profession recognised by law, hindered in practice. Eight years after the founding decrees of 2018, advanced nursing practice remains in a paradoxical situation: the legal framework has continued to expand (direct access, first prescription, removal of the organisational protocol, nursing law of June 2025), but the deployment remains far below expectations. There are 3,973 qualified IPAs in 2025-2026, compared to the 6,000 to 18,000 expected by the 2016 impact study. The deployment is highly heterogeneous: concentrated in public hospitals (about half of the graduates), fragile in the community (712 independent IPAs in 2025), and almost non-existent overseas (only one IPA in Mayotte, Guadeloupe, and Martinique in 2024). The target populations — chronic patients, multi-pathological, complex pathways, mental health, childhood — are nonetheless in high demand for follow-up.
Documented structural barriers and identified levers. The report attributes this under-deployment not to a lack of interest, but to four locks: mentions constructed around pathologies rather than populations, an economic model where the activity of an independent IPA earned less than €800 per month in 2022, a regulatory framework that maintains a logic of medical delegation instead of clinical autonomy, and institutional invisibility (0.5 FTE of national management, monitoring committee not convened since 2021). The reporters formulate 20 recommendations around five axes: national strategy and communication, redesign of mentions according to a population-based approach, more homogeneous and accessible training, removal of legal barriers to autonomy, and research to objectify the contribution of IPAs and establish a sustainable economic model.
2. KEY POINTS OF THE DOCUMENT
- A massive gap between ambition and reality. The impact study of 2016 estimated between 6,000 and 18,000 IPAs (1 to 3% of nurses); the Ségur aimed for 3,000 trained by the end of 2022. The Unipa census 2025-2026 reports 3,973 graduates and 1,988 in training — a real progression since the 581 graduates reported by the Court of Auditors in 2023, but insufficient for a structural effect, and already marked by a decline in applications in certain universities (p. 8).
- Medical-centric mentions deemed inappropriate. The architecture by pathologies/specialties (stabilised chronic pathologies, oncology, nephrology, psychiatry, emergencies) is described as contradictory to the transversal vocation of IPAs. The mentions that “work” are those close to a population logic (PCS chosen by half of the students; psychiatry by a quarter), while oncology and nephrology sometimes attract only one or two students per cohort (p. 9-10).
- An unviable economic model and an invisible activity. Average income of a liberal IPA below €800/month in 2022, far from the target income of €3,000-€3,300 net. The Cnam points out underactivity (active file ~330 patients, 1.2 capitation/patient/year against a model calibrated on 400 patients and 4 capitation). Amendment No. 11 revalues the capitation (initiation at €70, IPA consultation at €21) but only comes into effect in November 2026 (p. 6-7, 11-12).
- An autonomy enshrined in the texts but not applied. The removal of the city organisation protocol has not changed practices: organisations continue to operate on a logic of subordination to the doctor. Direct access remains confined to coordinated practice structures (in private practice, especially the MSPs of general practitioners), and the direct access private consultations voted in 2023 will only be billable from November 2026 (p. 13-14).
- A recognised but costly and heterogeneous training. A highly regarded Master's degree, but the total cost is estimated between €40,000 and €50,000 (expenses, salary maintenance, replacement), with the majority following in continuing education (10 students out of 730 in initial training in 2020-2021). Fewer than 10 universities out of 33 would have approved their internship sites; ARS funding is disparate, and students from Mayotte face cash flow disruptions (p. 15-16).
3. ACTION PATHS FOR LOCAL ACTORS
- Secure any implantation project with a clear job description and organisational project. Documented successes (cancer treatment centres, Robert-Debré hospital, Jeanne Garnier medical house) rely on strong institutional support and the involvement of medical teams from the outset — never on a replacement logic (p. 18).
- Anticipate the shift towards a population-based approach. The redesign of mentions (recommendations no. 5 to 8) will prioritise children/families, adults-elderly, mental health, and primary care. Position local projects now based on pathway needs (polymorbidity, coordination) rather than on an organ specialty (p. 10, 21-22).
- Map the unmet needs in your territory and request support from the ARS. The report entrusts the ARS with a strengthened mission of logistical, financial support and assistance for installation (reco n° 3), with priority attention to overseas territories. Useful for objectifying local demand (p. 20).
- Document the invisible activity of advanced practice nurses. In the absence of dedicated coding (RUM/PMSI), maintain a local record of coordination, prevention, therapeutic education and reduction of readmissions: this is the data that is missing to justify a position (p. 11, 24).
- Check the prescription framework before any follow-up organisation. The lists by mention are poorly readable and evolve less quickly than the good practice recommendations; plan for concerted modalities of medical validation a posteriori when necessary, pending the announced common list (reco n° 16-17) (p. 14, 23-24).
- Necessary adaptation identified — financial support for liberal and overseas candidates. The loss of income over two years remains the main obstacle. Locally identify the ARS and mobilisable community aids and alert on late payments (case of Mayotte) (p. 16).
4. ADDITIONAL REFERENCES
- EHESP — Documentation service, Documentary file: Nurse in advanced practice, September 2025. Structured bibliography and research references (implementation studies, stakeholder perceptions): completes the parliamentary report with the academic and evaluative angle that it lacks.
🔗 https://documentation.ehesp.fr/ajax.php?action=render&categ=document&id=1148&module=cms - Ameli.fr — The practice of advanced practice nurses (update incorporating the order of 25 April 2025 and the decree of 20 January 2025). Operational reference on fields of intervention, initial prescription and direct access.
🔗 https://www.ameli.fr/infirmier/exercice-liberal/vie-cabinet/installation-liberal/exercice-des-infirmiers-en-pratique-avancee - Légifrance — Section "Nursing practice in advanced practice" (articles R. 4301-1 to R. 4301-8-1), consolidated version amended by decree no. 2025-55 of 20 January 2025. The regulatory framework of reference, always up to date.
🔗 https://www.legifrance.gouv.fr/codes/section_lc/LEGITEXT000006072665/LEGISCTA000038549827/
5. FREQUENTLY ASKED QUESTIONS (FAQ)
- What distinguishes an IPA from a specialised nurse (IADE, IBODE, paediatric nurse)?
The IPA is based on clinical autonomy founded on reasoning, overall assessment and coordination, whereas the specialty relies on enhanced technical expertise. The report warns of the confusion introduced by the 2025 law (recommendation no. 7) (p. 10, 21-22). - Can a patient consult an IPA without going through a doctor?
Yes, via direct access (Rist law 2, 2023; decree of 20 January 2025), but only in establishments, ESSMS and certain coordinated practice structures (health centres and houses). A report is sent to the treating physician (p. 5, 13-14). - How much does a liberal IPA actually earn?
Less than €800/month on average in 2022, far from the target income of €3,000-€3,300. Many maintain a nursing activity in parallel. The revaluations of amendment no. 11 will only apply in November 2026 (p. 12). - Where are IPAs most present?
Against all odds, in public hospitals (about half of graduates), not in the city. The liberal sector remains fragile (712 IPAs in 2025) and overseas territories are very poorly equipped (p. 8). - Why is the activity of IPAs considered "invisible"?
Due to a lack of coding in the RUM/PMSI and a dedicated nomenclature, coordination, prevention, and longitudinal follow-up — the core of their value — are neither tracked nor valued: "the system finances complication, not its prevention" (Sofripa) (p. 11). - What does the nursing law of 27 June 2025 change?
It expands the places of practice (PMI, schools, occupational health, child welfare, nurseries), allows mentions according to a population-based approach, and opens a "proper" advanced practice for IADE/IBODE/nursery nurses — source of the denounced confusion (p. 6, 21). - How much does the training cost and who finances it?
Estimated total cost of €40,000 to €50,000 (expenses + maintained salary + replacement). Hospital staff can be financed by their employer; self-employed individuals bear the loss of income alone over two years. Very disparate ARS aids (p. 15-16).
6. REWRITING IN EASY TO READ LANGUAGE
What is an advanced practice nurse (IPA)?
An IPA is a nurse with an additional qualification. They have completed 2 years of study after their nursing career. They can follow patients more autonomously. They work with doctors, but not in their place.
The problem
This profession was created 8 years ago. We wanted many IPAs. Today, there are far fewer than expected. There are about 3,973 qualified IPAs. We wanted between 6,000 and 18,000.
Why is it stuck?
- IPAs are often confined to a single illness. They would like to follow the patient as a whole.
- IPAs do not earn enough money. In the city, some earned less than €800 per month.
- IPAs often have to ask for a doctor's agreement. They would like more autonomy.
- Many people do not know this profession. Even some doctors and pharmacists.
Where do the IPAs work?
- Many work in hospitals.
- Few work in the city.
- Very few work overseas. In Mayotte, there was only one IPA.
What the report proposes
The report provides 20 ideas to improve things. For example:
- Better publicise the profession.
- Change the qualifications to follow patient groups (children, elderly people).
- Pay IPAs better.
- Give them more autonomy.
7. CROSS-ANALYSIS — VALUES OF HEALTH PRACTICES
- Literacy: low; the report does not propose any tools suitable for patients' levels of understanding — it is a text intended for decision-makers, not users.
- Empowerment: users are not involved; the report recommends involving "users" in future governance (expanded monitoring committee, recommendation no. 2), without a concrete mechanism.
- Participation: the approach relies on hearings from institutional and professional actors; no co-construction with patients is described.
- Community health: present but indirect dimension — community care is cited as unmet needs, particularly overseas, without a formalised community approach.
- Ethics: the biases of the system (medical centrism, fee-for-service, under-valuation of prevention) are well identified and acknowledged as the report's bias.
- Human rights: access to healthcare equity is at the heart of the discussion (medical deserts, overseas territories, chronic diseases), without an explicit framework for non-discrimination.
- Intersectorality : strongly recommended — coordination between city / hospital / school / child welfare / medico-social, particularly for the future mention of "children and families" (rec. no. 6).
- Partnership : valued formalised collaboration models (dedicated job description for cancer control centres, mixed city/hospital/nursing home positions, rec. no. 20).
- Combating discrimination : not addressed as such; the issue of territorial inequality (overseas territories) is the only angle of equity discussed.
8. EVALUATION OF THE RELIABILITY OF THE RESOURCE
Scientific relevance — average. The report relies on solid and current sources (Court of Auditors 2023, Unipa census 2025-2026, up-to-date legislative and conventional texts until amendment no. 11 of 2026) and cites its interlocutors. But its method is declarative : it is based on hearings and written contributions from stakeholders who are often involved parties, without original medico-economic data or independent impact assessment — a weakness that the report itself acknowledges (rec. no. 19). The reported positions carry professional interests: to be read as a state of the debates, not as proof of effectiveness. Several representatives interviewed are also listed in the HATVP register (noted in the annex).
Operational relevance — high. Despite its political nature, the document is directly usable: reliable framing figures, precise mapping of obstacles, 20 concrete and prioritised recommendations, examples of reproducible successes. Excellent support for arguing, contextualising or anticipating upcoming reforms.
9. STRATEGIC HASHTAGS
#HealthPractices #IPA #AdvancedPractice #AccessToCare #CareCoordination #PopulationHealth #ChronicDiseases #HealthPolicy