Hiring a nurse practitioner: What's in it for the physician?

Ophthalmic nurse practitioner assessment of glaucoma: evaluating agreement within an initiative to enhance capacity in glaucoma clinics

AIMS

A local service evaluation was conducted in order to compare clinical assessment measures and management decisions between an ophthalmic nurse practitioner and a reference standard glaucoma consultant, for patients referred into secondary care with suspected Chronic Open Angle Glaucoma or Ocular Hypertension.

METHODS

One hundred patients were selected. A clinical pathway incorporating the assessment methods recommended by National Institute for Health and Care Excellence (NICE) Glaucoma update 2017 (NG81) was delivered by a single ophthalmic nurse practitioner and the reference standard glaucoma consultant. Clinical findings and outcomes were recorded, with both practitioners being masked to each other's findings. Agreement was determined employing Cohen's kappa, measuring inter-rater agreement allowing for chance agreement.

RESULTS

Agreement was observed as follows: Visual field assessment (kappa k = 0.806, 95% CI 0.661-0.951); Optical Coherence Tomography evaluation (kappa k = 0.648, 95% CI 0.507-0.798); C:D Ratio assessment (Cronbach's alpha α = 0.96, 95% CI 0.88-0.94); Diagnosis (kappa k = 0.874, 95% CI 0.818-0.914); and Treatment planning (kappa κ = 0.844, 95% CI 0.733-0.955). In three cases the nurse practitioner judged the optic nerve to appear normal, where the reference standard examiner detected glaucoma and commenced treatment.

CONCLUSION

This service evaluation demonstrates how an ophthalmic nurse practitioner with appropriate theoretical knowledge and practical training, can develop skills to reach a high level of agreement in patient assessment and management for those patients with suspected glaucoma. Within the limitations of a single centre and single practitioner evaluation, our findings provide evidence that this model of capacity expansion ought to merit wider consideration in secondary care glaucoma services.

Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review

BACKGROUND

General practitioner (GP) shortages and increasing demand for care led to the introduction of nurse practitioners (NPs) to primary care. Many concepts for task sharing among health professionals feature complexity. The aim of this narrative review was to examine how complexity is used as a factor for task allocation between GPs and NPs.

METHODS

According to the PRISMA statement, PubMed and CINAHL were searched systematically, and eligibility criteria were applied to detect literature concerning GPs and NPs in primary care and complexity in the context of task allocation. Relevant information was extracted, and a narrative analysis was performed.

RESULTS

Thirty-seven studies from seven countries were included, comprising quantitative, qualitative, and mixed methods. Complexity was used to describe patients, their needs, and health professionals' tasks. The understanding of the use of complexity as a factor for task allocation between NPs and GPs was based on the patient population (specific vs. unspecific), the setting (specific vs. unspecific), the numbers of health professionals involved (two vs. more than two), and the NP role (distinct model of care vs. no model). Despite similarities in these areas, the tasks which NPs perform range from providing minor to complex care. However, there is a slight trend towards NPs treating socially complex patients and GPs focusing on medically complex cases.

CONCLUSION

Complexity as a concept is prominent in primary care but remains broad and inconsistent as a factor for task allocation between NPs and GPs. This review can be used as a point of reference when practitioners are seeking methods for task allocation in a collaborative primary care setting.

Collaboration in teams with nurse practitioners and general practitioners during out-of-hours and implications for patient care; a qualitative study

BACKGROUND

Increasingly, nurse practitioners (NPs) are deployed in teams along with general practitioners (GPs) to help meet the demand for out-of-hours care. The purpose of this study was to explore factors influencing collaboration between GPs and NPs in teams working out-of-hours.

METHODS

A descriptive qualitative study was done using a total of 27 semi-structured interviews and two focus group discussions. Data was collected between June, 2014 and October, 2015 at an out-of-hours primary care organisation in the Netherlands. Overall, 38 health professionals (GPs, NPs, and support staff) participated in the study. The interviews were audio-taped and transcribed verbatim. Two researchers conducted an inductive content analysis, involving the identification of relevant items in a first phase and clustering into themes in a second phase.

RESULTS

The following four themes emerged from the data: clarity of NP role and regulation, shared caseload and use of skills, communication concerning professional roles, trust and support in NP practice. Main factors influencing collaboration between GPs and NPs included a lack of knowledge regarding the NPs' scope of practice and regulations governing NP role; differences in teams in sharing caseload and using each other's skills effectively; varying support of GPs for the NP role; and limited communication between GPs and NPs regarding professional roles during the shift. Lack of collaboration was perceived to result in an increased risk of delay for patients who needed treatment from a GP, especially in teams with more NPs. Collaboration was not perceived to improve over time as teams varied across shifts.

CONCLUSION

In out-of-hours primary care teams constantly change and team members are often unfamiliar with each other or other's competences. In this environment, knowledge and communication about team members' roles is continuously at stake. Especially in teams with more NPs, team members need to use each other's skills to deliver care to all patients on time.

Towards an optimal composition of general practitioners and nurse practitioners in out-of-hours primary care teams: a quasi-experimental study

OBJECTIVES

To gain insights into the ability of general practitioners (GPs) and nurse practitioners (NPs) to meet patient demands in out-of-hours primary care by comparing the outcomes of teams with different ratios of practitioners.

DESIGN

Quasi-experimental study.

SETTING

A GP cooperative (GPC) in the Netherlands.

INTERVENTION

Team 2 (1 NP, 3 GPs) and team 3 (2 NPs, 2 GPs) were compared with team 1 (4 GPs). Each team covered 35 weekend days.

PARTICIPANTS

All 9503 patients who were scheduled for a consultation at the GPC through a nurse triage system.

OUTCOME MEASURES

The primary outcome was the total number of consultations per provider for weekend cover between 10:00 and 18:00 hours. Secondary outcomes concerned the numbers of patients outside the NPs' scope of practice, patient safety, resource use, direct healthcare costs and GPs' performance.

RESULTS

The mean number of consultations per shift was lower in teams with NPs (team 1: 93.9, team 3: 87.1; p<0.001). The mean proportion of patients outside NPs' scope of practice per hour was 9.0% (SD 6.7), and the highest value in any hour was 40%. The proportion of patients who did not receive treatment within the targeted time period was higher in teams with NPs (team 2, 5.2%; team 3, 8.3%) compared with GPs only (team 1 3.5%) (p<0.01). Team 3 referred more patients to the emergency department (14.7%) compared with team 1 (12.0%; p=0.028). In teams with NPs, GPs more often treated urgent patients (team 1: 13.2%, team 2: 16.3%, team 3: 21.4%; p<0.01) and patients with digestive complaints (team 1: 11.1%, team 2: 11.8%, team 3: 16.7%; p<0.01).

CONCLUSIONS

Primary healthcare teams with a ratio of up to two GPs and two NPs provided sufficient capacity to provide care to all patients during weekend cover. Areas of concern are the number of consultations, delay in patient care and referrals to the emergency department.

TRIAL REGISTRATION

NCT02407847.

Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: a qualitative study

BACKGROUND

Due to the increasing demand on primary care, it is not only debated whether there are enough general practitioners (GPs) to comply with these demands but also whether specific tasks can be performed by other care providers. Although changing the workforce skill mix care by employing Physician Assistants (PAs) and Nurse Practitioners (NPs) has proven to be both effective and safe, the implementation of those professionals differs widely between and within countries. To support policy making regarding PAs/NPs in primary care, the aim of this study is to provide insight into factors influencing the decision of GPs and managers to train and employ a PA/NP within their organisation.

METHODS

A qualitative study was conducted in 2014 in which 7 managers of out-of-hours primary care services and 32 GPs who owned a general practice were interviewed. Three main topic areas were covered in the interviews: the decision-making process in the organisation, considerations and arguments to train and employ a PA/NP, and the tasks and responsibilities of a PA/NP.

RESULTS

Employment of PAs/NPs in out-of-hours services was intended to substitute care for minor ailments in order to decrease GPs' caseload or to increase service capacity. Mangers formulated long-term planning and role definitions when changing workforce skill mix. Lastly, out-of-hours services experienced difficulties with creating team support among their members regarding the employment of PAs/NPs. In general practices during office hours, GPs indented both substitution and supplementation for minor ailments and/or target populations through changing the skill mix. Supplementation was aimed at improving quality of care and extending the range of services to patients. The decision-making in general practices was accompanied with little planning and role definition. The willingness to employ PAs/NPs was highly influenced by an employees' motivation to start the master's programme and GPs' prior experience with PAs/NPs. Knowledge about the PA/NP profession and legislations was often lacking.

CONCLUSIONS

Role standardisations, long-term political planning and support from professional associations are needed to support policy makers in implementing skill mix in primary care.

The NPs Role of Assessing and Intervening with Older Adult Drivers

As the silver tsunami continues, assessing and intervening with older adult drivers are becoming an essential aspect of the comprehensive geriatric exam. The current lack of time efficient clinical guidelines is a concern and barrier for NPs. The purpose of this study was to identify strategies currently used by NPs. The critical incident technique was used to obtain data from a convenience sample of NPs. A total of 89 incidents were collected. The perspective of the NP can provide important information for developing clinical guidelines to promote individual and community safety.

Substitution of general practitioners by nurse practitioners in out-of-hours primary care: a quasi-experimental study

AIM

To provide insight into the impact of substituting general practitioners with nurse practitioners in out-of-hours services on: (1) the number of patients; and (2) general practitioners' caseload (patient characteristics, urgency levels, types of complaints).

BACKGROUND

General practitioners' workload during out-of-hours care is high, and the number of hours they work out-of-hours has increased, which raises concerns about maintaining quality of care. One response to these challenges is shifting care to nurse practitioners.

DESIGN

Quasi-experimental study comparing differences between and within out-of-hours teams: experimental, one nurse practitioner and four general practitioners; control, five general practitioners.

METHODS

Data of 12,092 patients from one general practitioners cooperative were extracted from medical records between April 2011 and July 2012.

RESULTS

The number of patients was similar in the two study arms. In the experimental arm, the nurse practitioner saw on average 16·3% of the patients and each general practitioner on average 20·9% of the patients. General practitioners treated more older patients; higher urgency levels; and digestive, cardiovascular and neurological complaints. Nurse practitioners treated more patients with skin and respiratory complaints. Substitution did not lead to a meaningful increase of general practitioners' caseload.

CONCLUSION

The results show that nurse practitioners can make a valuable contribution to patient care during out-of-hours. The patients managed and care provided by them is roughly the same as general practitioners. In areas with a shortage of general practitioners, administrators could consider employing nurses who are competent to independently treat patients with a broad range of complaints to offer timely care to patients with acute problems.

A patient - centered approach to addressing physical activity in older adults: motivational interviewing

Regular physical activity reduces the burden of chronic diseases in older adults, but the majority of this population is relatively sedentary. Individuals considering a change in behavior, such as increasing exercise, often experience a mental state of ambivalence, which can lead to inaction. Ambivalence is resistant to traditional counseling methods used in medical settings, such as patient education. Motivational interviewing (MI) is a conversational style that has been shown to help overcome ambivalence by guiding patients to voice their personal reasons for change. Nurse practitioners are uniquely positioned to use MI with older adults to address ambivalence toward increasing physical activity.