The nurse practitioner in primary care: alleviating problems of access?

Patient view of the advanced practitioner (AP) role in primary care: A realist-informed synthesis

BACKGROUND

Approximately 30% of general practitioner consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat a range of MSKDs, and could provide the first point of contact for primary care patients. There is limited evidence on whether this role is acceptable to patients; however, previous research has explored advanced practitioner (AP) roles in primary care, which could inform this new initiative.

AIMS

This study used realist synthesis to explore factors that influence patient acceptability of AP roles in primary care. MATERIALS & METHODS: A realist synthesis was undertaken to identify initial programme theories regarding acceptability. Databases were searched to identify relevant literature. Identified studies were subject to inclusion and exclusion criteria, resulting in 38 studies included for synthesis. Theory-specific data extraction sheets were created and utilised. Data were analysed through identifying contexts, mechanisms and outcomes to formulate hypotheses. Hypotheses were validated through consultation with expert stakeholders.

RESULTS

Eight theory areas were identified that potentially impacted on patient acceptability of the role: patient's prior experience of condition management; patient's expectations of condition management; communication; continuity of the individual practitioner; practitioner's scope of practice; accessibility; professional hierarchy and promoting the role. Nineteen hypotheses on the AP role were developed around these theory areas.

DISCUSSION

Role acceptabiliy was influenced significantly by context and may change as the role develops, for instance, as waiting times change.

CONCLUSION

Hypotheses will inform a subsequent realist evaluation exploring the physiotherapy AP role in primary care. Future research is needed to understand the acceptability of first contact physiotherapists delivering certain skills.

Barriers and facilitators to the implementation of nurse's role in primary care settings: an integrative review

Background

The rapid evolution of the epidemiological picture and the recent SARS-COV-2 pandemic has expressed the vulnerabilities of health systems and focuses attention on the population’s needs.

The nurse’s figure in the care teams is universally identified; however, the implementation of the role within some care settings turns out to be complex and challenging. This integrative review aims to identify the barriers and facilitators in implementing the role of the nurse in primary care settings.

Methods

An integrative review was conducted on the Medline and Cinahl databases until 9 June 2020. Qualitative, quantitative, and Mixed-method research studies were selected to identify studies related to the barriers and facilitators of the nurse’s role in nursing facilities’ primary care. For the extraction of the results, the Consolidating Framework for Research Implementation (CFIR) was used to identify the factors that influence implementation in health care.

Results

Following the duplicates’ removal, the search identified 18,257 articles, of which 56 were relevant to the inclusion criteria; therefore, they were included in the summary.

The selected studies were conducted in thirteen countries, most from Oceania, Europe, North America, Latin America, and the Caribbean.

The barriers reported most frequently concern the nursing profession’s regulatory and regulatory aspects within the contexts of care, cultural and organizational aspects, training, and the transfer of specific skills, which were previously designated to doctors.

The facilitators are mainly linked to the nurse’s adaptability to the various contexts of care, recognizing the patient’s role, and the desire to develop multidisciplinary and effective working groups to respond to the health needs of the population in primary care contexts.

Conclusion

This review highlighted the main barriers and facilitators in implementing the nurse’s role in primary care settings. These results offer useful elements for stakeholders to identify effective strategies in preparing programs and activities for implementing the nurse’s role, acting on the elements identified as barriers and favouring the aspects that emerge as facilitators.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00696-y.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review

OBJECTIVES

In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK.

DESIGN

A scoping review was undertaken following JBI methodological guidance.

METHODS

13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative.

RESULTS

191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway.

CONCLUSION

This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

'She taught me': factors consumers find important in nurse practitioner and pharmacist prescriber services

BACKGROUND

Advanced practitioner services, such as those nurse practitioners and pharmacist prescribers provide, are an opportunity to improve health care delivery. In New Zealand, these practitioners remain underutilised, despite research suggesting they offer safe and effective care, and considerable international literature recording patient satisfaction with these roles. This study aimed to explore factors underlying consumer satisfaction with primary health care nurse practitioner and pharmacist prescriber services.

METHODS

As part of a larger realist evaluation, 21 individuals receiving advanced practitioner services participated in semi-structured interviews. These interviews were transcribed and coded against context-mechanism-outcome configurations tested and refined throughout the research.

RESULTS

Study findings emphasise the importance of consumer confidence in the provider as a mechanism for establishing advanced practitioner roles. Underlying this confidence is a recognition that these practitioners work in a more accessible manner, engage at the individual's 'level', and operate with passion.

CONCLUSIONS

This research offers learnings to re-engineer service delivery within primary health care to make best use of the entire health care team by including consumers in the design and introduction of new roles.

Nurse Practitioners in Swiss Family Practices as Potentially Autonomous Providers of Home Visits: An Exploratory Study of Two Cases

In Swiss primary care, general practitioner (GP) home visits have decreased due to impending GP shortages particularly in rural areas. Nurse practitioners (NP) are newly introduced in family practices and could potentially offer home visits to the increasing number of multimorbid elderly. We analysed consultation data from two pilot projects (Practice A and Practice B) with the goal to measure the frequency and patient characteristics of NP consultations both in the practice and on home visits, and to determine the NPs’ autonomy based on the required GP supervision. In Practice A, 17% of all NP consultations were home visits, in Practice B 51%. In both practices, the NPs saw older patients and reported higher autonomy on home visits compared to consultations in the practice. In Practice A, the NP encountered a higher share of multimorbid patients on home visits than in the practice, and the NP’s proportion of autonomously conducted consultations increased from 0% in the first month to 19% after 13 months of GP supervision. In Practice B, the NP was autonomous in about three-quarters of consultations after 2 years on the job. These first cases provide some evidence that NPs could reach a relatively high degree of autonomy and might pose a potential solution for the decreasing numbers of GP home visits to multimorbid elderly in Swiss primary care.

Advanced Clinical Practitioners in Primary Care in the UK: A Qualitative Study of Workforce Transformation

Escalating costs and changing population demographics are putting pressure on primary care systems to meet ever more complex healthcare needs. Non-medical ‘advanced clinical practitioner’ (ACP) roles are increasingly being introduced to support service transformation. This paper reports the findings of a qualitative evaluation of nursing ACP roles across General Practices in one region of the UK. Data collection involved telephone interviews with 26 participants from 3 different stakeholder groups based in 9 practice sites: ACPs (n = 9), general practitioners (n = 8) and practice managers (n = 9). The data was analysed thematically. The study found a high degree of acceptance of the ACP role and affirmation of the important contribution of ACPs to patient care. However, significant variations in ACP education, skills and experience led to a bespoke approach to their deployment, impeding system-wide innovation and creating challenges for recruitment and ongoing professional development. In addition, a context of high workforce pressures and high service demand were causing stress and there was a need for greater mentorship and workplace support. System wide changes to ACP education and support are required to enable ACPs to realise their full potential in primary care in the UK.

Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis

BACKGROUND

Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles.

OBJECTIVES

(1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review.

SEARCH METHODS

We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed.

SELECTION CRITERIA

We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively.

DATA COLLECTION AND ANALYSIS

We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness.

MAIN RESULTS

We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses.

AUTHORS' CONCLUSIONS

Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.

Challenges faced by Canadian primary health care nurse practitioners in chronic disease management: A qualitative study among key informants

BACKGROUND AND PURPOSE

The increasing prevalence of chronic diseases is driving health care systems to rethink their operations. Despite numerous studies supporting the advantages of primary health care nurse practitioners (PHCNPs) in chronic disease management, implementing practices that fully use the skills of these practitioners seems impeded in the Canadian province of Québec. This study explores the views of leaders involved in primary health care regarding the contributions PHCNPs can make in chronic disease management and the challenges they face in doing so.

METHODS

Through semistructured interviews, an exploratory descriptive qualitative study was conducted with 20 key informants across Québec who hold a variety of professional positions connected to PHCNPs.

CONCLUSIONS

Primary health care nurse practitioners were perceived to be able to improve self-management support for chronic diseases. In reality, however, PHCNPs are mainly devoting their time to clientele in acute care, and current regulations governing their practices limit their involvement in chronic disease management.

IMPLICATIONS FOR PRACTICE

Integrating PHCNPs offers a unique opportunity for health care settings to redefine the roles of family physicians and registered nurses and to restructure practices toward a chronic disease-oriented system. A clinical manager should be designated to monitor this restructuring process and ensure its success.

Knowledge and attitudes of primary care physicians toward the nurse practitioner role in the Kingdom of Bahrain

PURPOSE

The Kingdom of Bahrain is facing a number of challenges, including an escalating cost of health services, increasing incidence of chronic diseases, and shortage of primary care physicians (PCPs). Introducing the nurse practitioner (NP) specialty in the primary care setting is one way to meet these challenges. The purpose of this quasi-experimental study was to examine the knowledge and attitudes of PCPs about the NP role prior to and following an educational intervention.

DATA SOURCES

The modified Northern Emergency Nurse Practitioner Staff Survey was used to measure the PCPs' attitudes and knowledge. A total of 90 PCPs completed the pretest and posttest.

CONCLUSIONS

The study findings showed that PCPs had poor understanding of the NP role. Their knowledge and attitudes changed significantly after the educational intervention. Also, posttest data indicated a positive correlation between knowledge and attitudes toward the NP role.

IMPLICATIONS FOR PRACTICE

More educational preparation and orientation to the NP role for PCPs and other healthcare professionals are needed before the implementation of the role in the primary care setting in Bahrain. There is a need for the role to be clearly defined prior to implementation to help gain understanding and acceptance.

Does team-based primary health care improve patients' perception of outcomes? Evidence from the 2007-08 Canadian Survey of Experiences with Primary Health

BACKGROUND

Team-based practice in primary care has been advocated for improved access, quality, effectiveness, and cost-efficiency of primary health care services, but there is limited empirical evidence supporting it.

OBJECTIVE

To examine the impact of team-based practice on patients' perception of several process and outcome indicators from patients' perspective.

DATA AND METHODS

Micro data from the 2007-08 Canadian Survey of Experiences with Primary Health Care conducted by Statistics Canada were utilized. Regression techniques and propensity score matching method were used to examine the impact of team-based primary care on several process and outcome indicators of primary care.

RESULTS

The estimated average treatment effect of team-based care was positively significant and robust for access to after-hours care, quality of care, confidence in the system, overall coordination of care, and patient centeredness. Although the estimated average treatment effects for the two dimensions of follow-up coordination, continuity of care, health promotion and disease prevention initiatives, and utilization of physician and nurse services were statistically significant, sensitivity test results showed that these results were unreliable.

CONCLUSIONS

Team-based primary care improves patients' perception of process and outcome indicators in the area of access to after-hours care, quality of care, confidence in the system, overall coordination and patient centeredness. Future research needs to establish the causal link between team-based primary care and health outcomes of patients.

Advanced practice nurses' scope of practice: a qualitative study of advanced clinical competencies

AIM

To describe and explore Advanced Practice Nurses' clinical competencies and how these are expressed in clinical practice.

BACKGROUND

Discussion concerning advanced clinical practice has been ongoing in the USA since the 1960s and in the UK since the late 1980s. Approximately 24 countries, excluding the USA, have implemented the role of Advance Practice Nurse (APN). In the Nordic countries, especially Sweden and Finland, APNs have been introduced in some organizations but their competency domains have not yet been clearly defined.

THEORETICAL FRAMEWORK

The study's theoretical framework emanates from Aristotle's three-dimensional view of knowledge that is epistêmê, technê, and phronesis.

METHODS

Between October 2005 and January 2006, focus group interviews of Clinical Nurse Specialists who provide expert functions in pediatric, internal medicine, and surgical units (n = 26) and APN students (n = 8) were conducted. The data material was analyzed using inductive content analysis.

FINDINGS

Grouped into five main themes, the study results indicate that APNs possess advanced level clinical competencies in: (A) assessment of patients' caring needs and nursing care activities, (B) the caring relationship, (C) multi-professional teamwork, (D) development of competence and nursing care, and (E) leadership in a learning and caring culture.

CONCLUSION

Clinical competencies consist of advanced skills, which typify an expanding role that offers new possibilities for holistic patient care practice. APNs' scope of practice is characterized by responsibility and competence in making autonomous judgments based on expanded clinical competence. On an advanced level, clinical competence consists not merely of advanced skills for assessing and meeting the needs of patients but also the creation of safe and trustful relationships with patients and collaboration with colleagues. APNs can realize advanced skills in their actions through their manner of knowing, doing, and being.

What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review

OBJECTIVES

To review and draw together the existing research evidence to assess the impact of advanced primary care nursing roles, particularly first contact nursing roles, for patients, nurses themselves and their colleagues in order to highlight salient issues for policy, practice and research.

BACKGROUND

Internationally, nurses' roles continue to expand in response to doctor shortages and policy drives to provide effective and efficient health services. A body of research exists from which to evaluate the impact of advanced nursing roles on various dimensions of healthcare delivery and organisation.

DESIGN AND DATA SOURCES

Medline, CINAHL, Applied Social Sciences Index and Abstracts, British Nursing Index, Cochrane Library, EMBASE, National Research Register, and PsycINFO databases were searched, including relevant websites. Studies were included if published in English and relevant to the primary/community care setting. Of a total of 211 papers identified, 88 were of relevance and included in the review.

RESULTS

Nurses working in many advanced primary care roles such as acute/minor illness, minor injury and long-term conditions provide safe and effective care, and patient satisfaction is generally high. Many factors influence patient satisfaction with, and access to, such services but are little understood. Evidence on cost-effectiveness, efficiency and impact on other health care professionals is inconclusive though research suggests the introduction of extended roles can create uncertainty and intra-/inter-professional tensions.

CONCLUSIONS

Evidence is of variable quality, often ignoring potentially important effect mediators such as the experience and educational level of advanced nurses, the effect of service 'maturation', organisational characteristics and differing patient preferences. The complex range of factors that influence patient satisfaction, access and outcomes of care need further investigation. Recent UK developments in nurse prescribing and the introduction of a national post-registration competency framework may improve working relations and patient understanding and experience of advanced nursing roles in primary care.