Nurse practitioner caseload in primary health care: Scoping review

Unlocking potential: a qualitative exploration guiding the implementation and evaluation of professional role substitution models in healthcare

BACKGROUND

As role substitution models gain prominence in healthcare, understanding the factors shaping their effectiveness is paramount. This study aimed to investigate factors that impact the implementation and performance evaluation of professional role substitution models in healthcare, with a focus on understanding the variables that determine their success or failure in adoption, execution, continuity, and outcomes.

METHODS

The exploratory qualitative study used semi-structured interviews with key opinion leaders, decision makers, facilitators, recipients, and frontline implementers, who had influence and involvement in the implementation of professional role substitution models. Data analysis was guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Between November 2022 and April 2023, 39 stakeholders were interviewed. Factors influencing implementation and evaluation of allied health professional role substitution models of care aligned with the five core CFIR domains (innovation, outer setting, inner setting, individuals, implementation process) and outcome domain incorporating implementation and innovation outcomes. The six themes identified within these CFIR domains were, respectively; i) Examining the dynamics of innovation catalysts, evidence, advantages, and disadvantages; ii) Navigating the complex landscape of external factors that influence implementation and evaluation; iii) Impact of internal structural, political, and cultural contexts; iv) The roles and contributions of individuals in the process; v) Essential phases and strategies for effective implementation; and vi) The assessment of outcomes derived from allied health professional role substitution models.

CONCLUSIONS

The study highlights the complex interplay of contextual and individual factors that influence the implementation and performance evaluation of professional role substitution models. It emphasises the need for collaboration among diverse stakeholders to navigate the challenges and leverage the opportunities presented by expanded healthcare roles. Understanding these multifaceted factors can contribute to the development of an empowered workforce and a healthcare system that is more efficient, effective, safe, and sustainable, ultimately benefiting patients.

The Nurse Practitioner Role in Complex Malignant Hematology: A Qualitative Descriptive Study

OBJECTIVES

Internationally, there is limited evidence about the role and impact of nurse practitioners (NPs) in complex malignant hematology (CMH). In one Canadian CMH program, NPs have existed for 20 years but not been evaluated. This study aimed to understand stakeholder perceptions of CMH NP role structures, processes, and outcomes and the extent to which the role meets patient and health service needs.

METHODS

A qualitative descriptive study was conducted, guided by the PEPPA-Plus framework. Purposive sampling was used to recruit stakeholders who participated in focus groups and interviews. Content analysis was used to analyze the data.

RESULTS

Participants included patients (n = 8) and healthcare professionals (n = 27). Themes about structures related to evolution of the CMH Program, model of care, and need for strategic vision. Process themes related to provision of accessible, comprehensive, and holistic care and NP workload. Positive and negative outcomes and lack of outcome measurement were identified.

CONCLUSION

Structures related to patient and NP characteristics, organizational change, staffing, and how NP work is organized impacts on NP role implementation and outcomes. Organizational structures can be strengthened to improve the model of care and NP role implementation and workload. Value-added NP contributions related to providing comprehensive care with attention to safety and social determinants of health. Research is needed to evaluate NP role outcomes in CMH.

IMPLICATIONS FOR NURSING PRACTICE

The results can inform role design and organization policies and strategies to promote the recruitment, retention, and optimization of NP roles in CMH settings. Priorities for future research are also identified.

Burnout, job satisfaction, and turnover intention among primary care nurse practitioners with their own patient panels

BACKGROUND

Nurse practitioners (NPs) can enhance NP care and improve access to care by autonomously managing their patient panels. Yet, its impact on workforce outcomes such as burnout, job satisfaction, and turnover intention remains unexplored.

PURPOSE

To estimate the impact of NP panel management on workforce outcomes.

METHODS

Structural equation modeling was conducted using survey data from 1,244 primary care NPs. NP panel management was categorized into co-managing patients with other providers, both co-managing and autonomously managing, and fully autonomous management.

DISCUSSION

Fully autonomous management led to more burnout than co-managing (B = 0.089, bias-corrected 95% bootstrap confidence interval [0.028, 0.151]). Work hours partially (27%) mediated this relationship. This findings indicate that greater autonomy in panel management among NPs may lead to increased burnout, partially due to longer work hours.

CONCLUSION

Interventions to reduce work hours could help NPs deliver quality care without burnout.

"Low-value" glycemic outcomes among older adults with diabetes cared for by primary care nurse practitioners or physicians: A retrospective cohort study

BACKGROUND

"Low-value" healthcare is care without benefit to patients. Overly intensive glycemic control (i.e., HgbA1C < 7 %) can cause harm to patients at high risk of hypoglycemia, particularly among older adults with co-morbidities. It is unknown whether overly intensive glycemic control differs among patients with diabetes and at high-risk of hypoglycemia cared for by primary care nurse practitioners versus physicians.

OBJECTIVE

This study examined patients with diabetes at high risk of hypoglycemia receiving primary care between Jan 2010 and Jan 2012, comparing patients reassigned to nurse practitioners to those reassigned to physicians after their previous physician separated from practice in an integrated United States health system.

DESIGN

This was a retrospective cohort study. Study outcomes were collected at two years after reassignment to a new primary care provider. Outcomes were predicted probabilities of HgbA1C < 7 % using two-stage residual inclusion instrumental variable models, controlling for baseline confounders.

SETTING

Primary care clinics within the United States Veterans Health Administration.

PARTICIPANTS

38,543 patients with diabetes at increased risk for hypoglycemia (age ≥ 65 years with renal disease, dementia, or cognitive impairment), who had their primary care physician leave the Veterans Health Administration and who were reassigned to a new primary care provider in the following year.

RESULTS

Cohort patients were on average 76 years and 99 % men. Of these, 33,700 were reassigned to physicians and 4843 to nurse practitioners. After two years with their new provider, in adjusted models, patients reassigned to nurse practitioners had a -20.4 percentage-point [95 % CI -37.9 to -2.8] lower probability of two-year HgbA1C < 7 %.

CONCLUSIONS

Aligned with prior studies on care quality, rates of overly intensive glycemic control may be appropriately lower among older patients with diabetes at high-risk of hypoglycemia, cared for by nurse practitioners than physicians.

TWEETABLE ABSTRACT

Primary care nurse practitioners deliver equivalent or better rates of low-value diabetes care for older patients, compared to physicians.

The workplace culture in addiction psychiatry in Finland as described by healthcare personnel

Purpose

The purpose of this study is to describe the workplace culture and factors associated with it from the viewpoint of the personnel providing care to patients with dual diagnosis.

Design/methodology/approach

Data were collected from six organizations using an electronic survey in 2019. The respondents (n = 75) worked in addiction psychiatry in specialized health care and provided care to patients. The data were statistically analyzed.

Findings

Workplace culture was evaluated as positive. Stress was experienced occasionally (Md = 2.58, Q1 = 1.96, Q3 = 3.03), job satisfaction levels were moderate (Md = 4.83, Q1 = 4.28, Q3 = 5.44) and the practice environment was evaluated as neutral (Md = 4.46, Q1 = 4.00, Q3 = 5.04). Gender, age in years, employment relationship, work time, staffing, number of patients and the participants’ experience in health care and experience in their current workplace had statistically significant associations with workplace culture.

Originality/value

In Finland, there have been attempts to reform service structures that also influence mental health and substance addiction services. Workplace culture is one approach to promote service development. Yet, there has been no research on workplace culture in the context of the care of patients with dual diagnosis. The results of this study bring knowledge about how health-care personnel perceives stress, job satisfaction and their practice environment in addiction psychiatry, which can be used to further develop services and workplace culture.

Engagement of nurse practitioners in primary health care in northern British Columbia: a mixed-methods study

BACKGROUND

Nurse practitioners (NPs) have been regulated primary care providers in British Columbia since 2005; however, many practices and contributions of NPs, especially those in northern or rural regions, remain unarticulated in primary health care. The objective of this study was to evaluate NP practices in the context of providing primary health care in northern BC.

METHODS

This was a qualitative-dominant mixed-methods study. We recruited NP participants working in northern BC; recruitment and data collection occurred between April and June 2018. Participants completed the validated 28-item Primary Health Care Engagement (PHCE) Scale to assess their perceptions of their workplace with 8 attributes of primary health care (quality improvement, community participation, patient-centred care, accessibility, intersectoral team, interdisciplinary collaboration, continuity and population orientation). We also interviewed NPs about their everyday practice. Transcribed data from the interviews were analyzed interpretively.

RESULTS

In total, 13 of 30 (43%) eligible NPs participated in the survey and interview. The PHCE Scale results showed that all NPs perceived their workplaces to be highly engaged in patient-centred care, but none reported their workplaces as accessible. Interview data were organized into 5 headings which described how NPs see patients who are medically and socially complex, address inequities in access, practice collaboratively, address local service gaps and improve patient abilities to access care.

INTERPRETATION

In interprofessional primary health care teams, NPs are key members and attend to both direct patient care and broader social conditions affecting health. Nurse practitioners can help accelerate advancements to deliver responsive community-based primary health care.

Perspectives of Quebec Primary Health Care Nurse Practitioners on Their Role and Challenges in Chronic Disease Management: A Qualitative Study

BACKGROUND

Primary health care nurse practitioners (PHCNPs) can play a key role in chronic disease management. However, little is known about the challenges they face.

PURPOSE

The study aimed to describe PHCNPs' perspectives on their role for patients with chronic health conditions, the barriers they face, and facilitating factors.

METHODS

A qualitative descriptive exploratory study was conducted with 24 PHCNPs in the Canadian province of Quebec.

RESULTS

PHCNPs believe that they are in an optimal position to address the needs of patients with chronic health conditions, especially in providing self-management support. However, PHCNPs reported feeling pressured to practice according to a biomedical model and to constantly defend their role in chronic disease management. They feel that they are frequently being diverted from their role to compensate for the lack of family doctors. PHCNPs made concrete recommendations to optimize their autonomous practice and quality of care: promoting strong interprofessional communication skills, genuine mentoring relationships between PHCNPs and partner physicians, managers upholding the full scope of PHCNPs' practice, and a more flexible legislative framework.

CONCLUSIONS

The original conception of PHCNPs as health professionals with unique characteristics is at stake. The factors that should be targeted to support the autonomy of PHCNPs were identified.

An Evidence-Based Checklist for Improving Scoping Review Quality

A scoping review aims to systematically explore and map the research available from a wide range of sources. The objective of this study was to produce a scoping review checklist to guide future scoping studies to enable rigorous review and critique of phenomena of interest. The methods used included a review of literature, expert consensus group meetings, a modified Delphi survey and, finally, verification against recent scoping study examples. Results showed that the checklist was able to identify key elements of scoping reviews. The 22-item Scoping Review Checklist (SRC), which includes two optional stakeholder consultation items, has been developed using rigorous recommended approaches. The checklist can be used to guide the conduct and critique of scoping studies.

Developing Community-Based Primary Health Care for Complex and Vulnerable Populations in the Vancouver Coastal Health Region: HealthConnection Clinic

INTRODUCTION

Designing, delivering, and evaluating high-performing primary health care services for complex and vulnerable subpopulations are challenging endeavors. However, there is a relative paucity of research evidence available to support such work.

OBJECTIVE

To provide a case study using HealthConnection Clinic, a public primary care center located in Metropolitan Vancouver's North Shore.

METHODS

Developmental evaluation approach operationalizing the 10 Building Blocks of High-Performing Primary Care framework using qualitative and quantitative methods.

RESULTS

The clinic provided valuable insights to policymakers and researchers related to development of the Building Blocks' foundational elements, particularly engaged leadership, empanelment, and data-driven improvement. The study highlighted the key enablers, achievements, challenges, and barriers related to operationalizing each Building Block. The Building Blocks were a useful heuristic that enabled the development and evaluation of primary care for complex subpopulations. Particularly salient from a Canadian policy perspective was the demonstration that system integration was possible when highly engaged leaders from a Regional Health Authority and a Division of Family Practice shared a common vision and purpose. HealthConnection Clinic's entrepreneurial spirit has enabled the development of innovative, evidence-based tools such as the AMPS complexity assessment tool (attachment, medical conditions, psychological/mental health/addictions challenges, and socioeconomic status), designed to identify and assess biopsychosocial complexity and needs. The study also highlighted the importance of incorporating community orientation and equity into developmental work.

CONCLUSION

The study demonstrates how the Building Blocks approach can be adapted to operationalize high-performing primary care standards in settings serving complex and vulnerable populations.

Nurse practitioners as primary care providers with their own patient panels and organizational structures: A cross-sectional study

BACKGROUND

Health care systems globally are facing challenges of meeting the growing demand for primary care services due to a shortage of primary care physicians. Policy makers and administrators are searching for solutions to increase the primary care capacity. The effective utilization of nurse practitioners (NPs) has been proposed as a solution. However, organizations utilize NPs in variable capacities. In some settings, NPs serve as primary care providers delivering ongoing continuous care to their patients, referred to as patient panels, whereas in other settings they deliver episodic care. Little is known about why organizations deploy NPs differently.

OBJECTIVES

Investigate the NP role in care delivery-primary care providers with the own patient panels or delivering episodic care-within their organizations and understand how work environments affect their role.

DESIGN

A cross-sectional survey design was used to collect data from primary care NPs.

SETTINGS

The study was conducted in one state in the United States (Massachusetts). Data from 163 primary care organizations was obtained, which employed between one to 12 NPs.

PARTICIPANTS

807 NPs recruited from the Massachusetts Provider Database received mail surveys; 314 completed and returned the survey, yielding a response rate of 40%.

METHODS

The survey contained measures of NP role in care delivery and work environment. NP role was measured by an item asking NPs to report if they deliver ongoing continuous care to their patient panel or if they do not have patient panel. The work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). The multilevel Cox regression models investigated the influence of organization-level work environment on NP role in care delivery.

RESULTS

About 45% of NPs served as primary care providers with their own patient panel. Organization-level Independent Practice and Support subscale, an NP-PCOCQ subscale, had a significant positive effect on NP role (risk ratio=2.33; 95% CI: 1.06-5.13); with a one unit increase on this subscale, the incidence of the NPs serving as primary care providers with their own patient panel doubled.

CONCLUSIONS

NPs can help meet the increasing demand for primary care by taking responsibilities as primary care providers, and organizations can assign NPs their own patient panels. Supporting NP independent practice within organizations promotes NP role as primary care providers. Policy and organizational change focused on promoting NP work environments so NPs can practice as primary care providers can be an effective strategy to increase the primary care capacity.

Implementation of integrated geriatric care at a German hospital: a case study to understand when and why beneficial outcomes can be achieved

BACKGROUND

Many health systems have implemented integrated care as an alternative approach to health care delivery that is more appropriate for patients with complex, long-term needs. The objective of this article was to analyse the implementation of integrated care at a German geriatric hospital and explore whether the use of a "context-mechanisms-outcomes"-based model provides insights into when and why beneficial outcomes can be achieved.

METHODS

We conducted 15 semi-structured interviews with health professionals employed at the hospital. The data were qualitatively analysed using a "context-mechanisms-outcomes"-based model. Specifically, mechanisms were defined as the different components of the integrated care intervention and categorised according to Wagner's Chronic Care Model (CCM). Context was understood as the setting in which the mechanisms are brought into practice and described by the barriers and facilitators encountered in the implementation process. These were categorised according to the six levels of Grol and Wensing's Implementation Model (IM): innovation, individual professional, patient, social context, organisational context and economic and political context. Outcomes were defined as the effects triggered by mechanisms and context, and categorised according to the six dimensions of quality of care as defined by the World Health Organization, namely effectiveness, efficiency, accessibility, patient-centeredness, equity and safety.

RESULTS

The integrated care intervention consisted of three main components: a specific reimbursement system ("early complex geriatric rehabilitation"), multidisciplinary cooperation, and comprehensive geriatric assessments. The inflexibility of the reimbursement system regarding the obligatory number of treatment sessions contributed to over-, under- and misuse of services. Multidisciplinary cooperation was impeded by a high workload, which contributed to waste in workflows. The comprehensive geriatric assessments were complemented with information provided by family members, which contributed to decreased likelihood of adverse events.

CONCLUSIONS

We recommend an increased focus on trying to understand how intervention components interact with context factors and, combined, lead to positive and/or negative outcomes.