For decades, nurses have contributed much for supporting medical care in various clinical situation. Historically, they have performed daily routine duties, but gradually there has been a demand for nurses who can handle specific medical procedures [1]. The training system for nurses regarding specified care procedures was implemented in 2015 by Ministry of Health, Labour and Welfare (MHLW). Successively, and the expansion of the role of “nurse practitioners” was institutionally recognized [2]. By completing a certain amount of training, they can carry out some of the medical procedures that were previously performed by doctors under the comprehensive instructions of a doctor. Designated procedures are currently classified into 38 categories and 21 divisions, and include medical procedures that require specialized judgment, such as inserting an arterial line, changing a tracheal tube, and designing infusions for dehydration.

Several years have passed since the system was launched, and the number of nurse practitioners has been increasing [3]. More than 8,000 nurses have completed the training until 2023, and their activities are expanding in hospitals, nursing stations and facilities [4]. These situations are particularly prominent in the following. They are i) Acute medical care: acting as a substitute for doctors in emergency outpatient clinics and ICUs, where rapid treatment is required. ii) Home medical care: they perform medical procedures as a visiting nurse, for those on home care by the doctor's instructions. iii) Community medical care: complementing limited medical resources in areas with less doctors and remote islands. These situations may reduce the workload of doctors and is evaluated as contributing efficiency of medical team.

Several advantages of nurse practitioners have been found, which are in the following [5].

• Improved Quality and Efficiency of Medical Care: Because nurses can perform specialized procedures, doctors are freed up to respond quickly and accurately to seriously ill patients. This contributes to shortening waiting times for patients and improving survival rates.
• Enhancement of Regional Medical Care: nurse practitioners can perform certain medical procedures even in areas where there are no doctors or in home medical care settings, which helps to eliminate regional disparities.
• Improved Expertise in Nursing: It is an attractive career path and has been shown to have a corresponding effect on improving nurses' professional motivation and reducing turnover rates.

In the light of their competencies, several crucial factors have been summarized in Table 1.

Table 1: Competencies of Nurse practitioner.

Taking most advantage of these procedures, 13 licensed nurse practitioners at Etoh hospital in Tokushima are each carrying out beneficial activities in several divisions [5] (Figure 1). The current procedure is the insertion of Peripherally Inserted Central Venous Catheters (PICCs) [6]. PICCs are central venous catheters inserted through the arm. Previously, when a patient required total parenteral nutrition (TPN) or vascular access, the doctor in charge would perform the procedure [7]. Sometimes this would take several hours, which would impede the doctor's work. Since then, the practical nurses have been trained and are now able to perform PICCs. When PICCs is instructed by the doctor in charge, the procedure is usually performed by the nurse practitioners within three days.  If it takes more than three days due to work or other reasons, the doctor will be notified and considered. They will intervene and perform the procedure, but the doctor will check the tip of the catheter at the last stage. Nurse practitioners perform all other tasks, which has the advantage that the doctor can perform other tasks during that time. Regarding the management of the catheter after successful insertion, nurse practitioners will visit the room provide necessary care and report the general progress to the doctor in charge.

Figure 1: Nurse practitioners and cherry blossoms.

As a matter of fact, two nurses attend PICC procedure (Figure 2). One is to perform the PICC, and another is to assist, check and deicide on the certain vein to insert using ultrasound apparatus [7]. The PICC insertion site is selected from the basilic vein in the upper arm, the superior brachial pulse, or the femoral vein in the lower leg. In this case, the PICC was inserted for the purpose of TPN. When checking the general and local condition of the case the day before, the upper limbs were moving too violently, then we chose to approach from the femoral vein in the left thigh. The procedures of PICC are summarized as follows: i) the left femoral vein is punctured while observing the blood vessels with ultrasound, ii) a guidewire is inserted, iii) local anesthesia is administered, and then iv) a 1 cm incision is made with a scalpel, v) pressure hemostasis is performed with gauze, and vi) the introducer is prepared to be inserted.

Figure 2: Insertion of PICC by nurse practitioner.

On the other hand, certain problems are gradually emerging as follows. They are i) Ambiguity of legal responsibility: There are cases where the responsibility for medical procedures performed by certified nurses is unclear, which may lead to some problems [2]. ii) Insufficient collaboration with doctors: Some doctors and facilities do not fully understand the judgment and skills of certified nurses, which can bring to poor collaboration. iii) Uneven distribution of training institutions and financial burden: The institutions that can offer training on certified procedures are concentrated in urban areas. Then, it is difficult for nurses living in rural areas to take the workshop courses. Additionally, financial burdens such as tuition fees and reduced income during training are also an issue.

In recent years, the following discussions have become active.

• Further Expansion of The System: There is a movement to expand the scope of specified acts for medical treatment. On the other hand, there are persistent cautious situations that "it may lead to excessive medical procedures by nurses" [1].
• Linkage with Medical Fees: Details have not yet been decided on how the medical procedures performed by practical nurses will be evaluated in terms of medical fees. In this regard, the institutional development is lagging behind, and a mechanism to promote implementation will be required.
• Clarification of Legal Provisions: As a future issue, legal clarification is required regarding the scope of doctors' instructions and where responsibility lies. In addition, collaboration with online medical consultations and remote medical consultations using AI is expected from 2024 onwards. In this way, it is recognized that the role of nurse practitioners may expand further in the future [8].

In summary, nurse practitioners has been established as an important system to respond to the diversification and sophistication of medical care [9]. In our hospital, several nurse practitioners have worked with satisfactory benefits for medical care. The scope of activities has expanded, contributing to improving the quality and efficiency of actual medical care [10]. However, some issues in the operation of the system, legal provisions, and disparities in training systems cannot be ignored. For future development, the crucial key will be to design the adequate system, where nurse practitioners can function more smoothly as part of the medical team and increase social recognition.

Conflict of Interest: The authors declare no conflict of interest.

Funding: There was no funding received for this paper.

1. Yamauchi R, Ohta R, Sano C. Reconsidering the Role of Nurse Practitioners in Japan: What Direction Should Japanese Nurse Practitioners Aim for? Cureus. 2024; 16: e52936.
2. Nakahara M, Hidaka M, Sakai K. A Survey on Recognition and Expectation of Nurse Practitioner-From Nurses’ Perspectives. J Jpn Acad Nurs Sci. 2021; 41: 211-219.
3. Suzuki M, Sekiguchi N, Saitoh M, Koda M, Harada N, Honda K, et al. Comparing health care outcomes before and after employing nurse practitioners in cardiovascular hospitals in Japan: A retrospective chart review. J Am Assoc Nurse Pract. 2024; 36: 629-636.
4. Kuzuya M, Arao T, Takehisa Y, Satake S, Arai H. Chapter 3 Frailty prevention. Geriatr Gerontol Int. 2020; 20: 20-24.
5. Fujita M, Takehisa Y, Takehisa T, Bando H, Yuu M, Kusaka Y, et al. Long-Term Acute Care (LTAC) With Developing Nurse Practitioners for Well-Being of the People. J Med Clin Stud. 2022; 5: 176.
6. Santos FKY, Flumignan RLG, Areias LL, Sarpe AKP, Amaral FCF, Avila RB, et al. Peripherally inserted central catheter versus central venous catheter for intravenous access: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2020; 99: e20352.
7. Chiodi C, Liu D, Omer E. Variceal Hemorrhage as Complication of Vascular Access for Total Parenteral Nutrition. ACG Case Reports J. 2024; 11: e01454.
8. Colley N, Cashin A. A Mentoring Relationship to Support the Introduction of the Nurse Practitioner Role in Japan. Mentoring in Nursing through Narrative Stories Across the World. 2023; 431-439.
9. Igarashi M, Ohta R, Kurita Y, Nakata A, Yamazaki T, Gomi H. Exploring the Competencies of Japanese Expert Nurse Practitioners: A Thematic Analysis. Healthcare (Basel). 2021; 9: 1674.
10. Suzuki M, Harada N, Honda K, Koda M, Araki T, Kudo T, et al. Facilitators and barriers in implementing the nurse practitioner role in Japan: A cross-sectional descriptive study. Int Nurs Rev. 2024; 71: 291-298.