An investigation of the international literature on nurse practitioner private practice models

Integrating nurse practitioners into primary care: policy considerations from a Canadian province

Background

The integration of nurse practitioners (NPs) into primary care health teams has been an object of interest for policy makers seeking to achieve the goals of improving care, increasing access, and lowering cost. The province of Alberta in Canada recently introduced a policy aimed at integrating NPs into existing primary care delivery structures. This qualitative research sought to understand how that policy – the NP Support Program (NPSP) – was viewed by key stakeholders and to draw out policy lessons.

Methods

Fifteen semi-structured interviews with NPs and other stakeholders in Alberta’s primary care system were conducted, recorded, transcribed and analyzed using the interpretive description method.

Results

Stakeholders predominantly felt the NPSP would not change the status quo of limited practice opportunities and the resulting underutilization of primary care NPs in the province. Participants attributed low levels of NP integration into the primary care system to: 1) financial viability issues that directly impacted NPs, physicians, and primary care networks (PCNs); 2) policy issues related to the NPSP’s reliance on PCNs as employers, and a requirement that NPs panel patients; and 3) governance issues in which NPs are not afforded sufficient authority over their role or how the key concept of ‘care team’ is defined and operationalized.

Conclusions

In general, stakeholders did not see the NPSP as a long-term solution for increasing NP integration into the province’s primary care system. Policy adjustments that enable NPs to access funding not only from within but also outside PCNs, and modifications to allow greater NP input into how their role is utilized would likely improve the NPSP’s ability to reach its goals.

Advocating for Washington state ARNP payment parity

Workforce and reimbursement data were collected from a 2018 survey of Washington state advanced registered nurse practitioners (ARNPs). Survey results will be used to improve workforce planning and advocate for payment parity legislation requiring health plans to pay ARNPs the same as physicians for the same service.

The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review

BACKGROUND

The conditions that stimulated the implementation of Advanced Practice Nursing programmes all over the world have long been ignored in sub-Saharan Africa.

OBJECTIVE

This study sought to explore the essence, opportunities and threats to the implementation of an Advanced Practice Nursing (Child Health Nurse Practitioner) programmes in sub-Saharan Africa.

METHODS

A scoping review was conducted and findings reviewed by a multinational multidisciplinary health experts' team through a Delphi study.

RESULTS

Children are the majority of the 70-90% of the sub-Saharan African population who reside in the rural areas where access to timely, quality and cost-effective healthcare is poor. The Child Health Nurse Practitioner programme offers an opportunity to provide quality, timely and cost-effective healthcare to sub-Saharan Africa children. Limited resources, opposition from the medical profession, poor nursing governance and lack of context-specific Advanced Practice Nursing benchmark programmes constitute threats to the programme.

CONCLUSION

The sub-Saharan Africa context provides opportunities that the nursing profession can harness to surmount such threats. Nursing governance structures, however, need to advocate for government and other stakeholders' support for the Child Health Nursing Practitioner programme.

Systematic review addressing nurse practitioner reimbursement policy: Part one of a four-part series on critical topics identified by the 2015 nurse practitioner research agenda

BACKGROUND AND PURPOSE

The growth and sustainability of nurse practitioners (NPs) requires transparent, fair and equitable reimbursement policies. Complicating this issue is variation in reimbursement policy within and across federal, state, and other payers. Even with explicit regulations, there remain questions on how reimbursement policies are covertly operationalized in practice. This systematic review aims to identify knowledge gaps related to reimbursement policy issues and outlines recommendations for further research.

METHODS

Eight major databases were searched using terms including "nurse practitioner," "reimbursement," "policy," and "research," limited to the United States and inclusive of December 2006-September 2017. Articles meeting the inclusion criteria were analyzed for themes and gaps.

CONCLUSION

The final review includes 17 articles identifying themes including state-determined Medicaid reimbursement and scope of practice legislation shapes NP clinical practice; NPs as identified primary care providers: credentialing and contracting; reimbursement parity; and "incident to" billing. Moreover, there is evidence of discriminatory policies that disadvantage NPs and limit their access to patients, direct billing, and direct reimbursement.

IMPLICATIONS FOR PRACTICE

Future research needs to focus on outcomes of discriminatory, as well as supportive, reimbursement policies in organizations, and their influence on patient access and quality care.

Entrepreneurship and Nursing: integrative review

ABSTRACT Objective: To identify the knowledge produced on business entrepreneurship in Nursing. Method: Integrative literature review in the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, SCOPUS, Web of Science, PubMed, Medline, Latin American and Caribbean Literature in Health Sciences (LILACS), Nursing Database (BDENF), Index Psychology and National Information Center of Medical Sciences of Cuba (CUMED). We included available studies in their totality in the period from 2007 to 2017. Results: 22 articles were included. The categories that emerged from the study are the following: Concepts of entrepreneurship in nursing, Profile of the entrepreneur nurse, Business Diversity, Business Management, Barriers to business entrepreneurship in nursing, Support to entrepreneurial nurses and Entrepreneurship in Nursing Undergraduate. Conclusion: There is a need to prepare nurses with adequate skills to increase the capacity to integrate into the labor market and to improve their own well-being and that of society.

Privately practising nurse practitioners' provision of care subsidised through the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme in Australia: results from a national survey

Objective Since legislative changes in 2010, certain health care services provided by privately practising nurse practitioners (PPNPs) in Australia have been eligible for reimbursement under the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). The aim of the present study was to describe survey results relating to the care provided by PPNPs subsidised through the MBS and PBS. Methods PPNPs in Australia were invited to complete an electronic survey exploring their practice activities. Quantitative data were analysed using descriptive statistics and 95% confidence intervals were calculated for percentages where relevant. Free text data were analysed using thematic analysis. Results Seventy-three PPNPs completed the survey. The most common form of payment reported (34%; n=25) was payment by direct fee for service (MBS rebate only, also known as bulk billing). Seventy-five per cent of participants (n=55) identified that there were aspects of care delivery not adequately described and compensated by the current nurse practitioner (NP) MBS item numbers. 87.7% (n=64) reported having a PBS prescriber authorisation number. Themes identified within the free text data that related to the constraints of the MBS and PBS included ‘duplication of services’ and ‘level of reimbursement’. Conclusion The findings of the present study suggest that PPNPs are providing subsidised care through the MBS and PBS. The PPNPs in the present study reported challenges with the current structure and breadth of the NP MBS and PBS items, which restrict them from providing complete episodes of patient care. What is known about the topic? Since the introduction of legislative changes in 2010, services provided by PPNPs in Australia have been eligible for subsidisation through the MBS and PBS. What does this paper add? This paper provides data on PPNPs’ provision of care subsidised through the MBS and PBS. What are the implications for practitioners? Eligibility to provide care subsidised through the MBS and PBS has enabled the establishment of PPNP services. The current breadth and structure of the NP MBS and PBS item numbers have restricted the capacity of PPNPs to provide complete episodes of patient care.

"It's about fitting in with the organisation": A qualitative study of employers of nurse practitioners

AIMS AND OBJECTIVES

To explore the views of employers about the value nurse practitioners (NPs) add to health services, enablers and barriers to employing NPs, and intentions to employ NPs or expand NP services in the future.

BACKGROUND

Research on Australian NPs has focused on NPs' experiences or patient-related factors like waiting times. Few studies have explored NP roles from the perspective of employers. Australian NPs employed by the private sector are eligible for reimbursement by the national health insurance scheme (Medicare Australia), potentially generating revenue for employers and broadening their career opportunities. We aimed to explore private sector employers' views on the barriers and facilitators to employing NPs and to identify factors affecting NP employability.

DESIGN

A qualitative descriptive exploratory study.

METHOD

Employers of NPs from 23 private and nonprofit health services in Western Australia were interviewed. Inductive content analysis was used to explore the data.

RESULTS

Enablers to employing an NP included enhanced customer service and improved health outcomes. Barriers to employing an NP included lack of financial benefit and inadequate experience or qualifications. Employers also identified future directions for NP employability, such as filling a gap that added value to the health service.

CONCLUSIONS

Employers wanted NPs to work towards a shared vision of patient care that aligned with organisational needs.

RELEVANCE TO CLINICAL PRACTICE

Findings can inform NP education and workforce planning to optimally meet employer and patient health needs.

Practice activities of privately-practicing nurse practitioners: Results from an Australian survey

To facilitate expansion of privately-practicing nurse practitioners in community and primary care settings, a legislative amendment in 2010 made privately-practicing nurse practitioners eligible to provide services subsidised through the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. To evaluate their practice activities, a national survey of privately-practicing nurse practitioners in Australia was conducted, and data analysed using descriptive statistics and thematic analysis (n = 73). As part of their role, 96% (n = 70) participants reported undertaking direct patient care, 95% (n = 69) patient education and health promotion, 95% (n = 69) prescribed medications, 92% (n = 67) referred patients for diagnostic investigations, and 88% (n = 64) reported making a diagnosis. Over 50% of participants saw up to 15 patients daily, and 80% (n = 58) treated the same patients on a regular basis. Of the participants, 59% (n = 43) perceived that they worked to their full scope of practice. The mainstay of privately-practicing nurse practitioner services is provision of direct patient care in community and primary healthcare settings, suggesting they have emerging potential in addressing the ever-increasing demand for healthcare in Australia.

Collaborative arrangements and privately practising nurse practitioners in Australia: results from a national survey

Objective Since the introduction of legislative changes in 2010, services provided by privately practising nurse practitioners (PPNPs) in Australia have been eligible for subsidisation through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). To provide eligible services, PPNPs must collaborate formally with a medical practitioner or an entity that employs medical practitioners. This paper provides data from a national survey on these collaborative arrangements in Australia. The aim of the study was to evaluate the impact of PPNP services on patient access to care in Australia. Methods PPNPs in Australia were invited to complete an electronic survey. Quantitative data were analysed using descriptive statistics, whereas qualitative data were analysed using thematic analysis. Seventy-three surveys were completed. Results Ninety-three per cent of participants reported having a collaborative arrangement in place. Frequency of communication ranged from daily (27%) to never (1%). Participants reported that collaborative arrangements facilitate learning, patient care and offer support to PPNPs. However, for some PPNPs, organising a formal collaborative arrangement is demanding because it is dependent on the availability and willingness of medical practitioners and the open interpretation of the arrangement. Only 19% of participants believed that collaborative arrangements should be a prerequisite for PPNPs to access the MBS and PBS. Conclusion Although there are benefits to collaborative arrangements, there is also concern from PPNPs that mandating such arrangements through legislation presents a barrier to establishing PPNP services and potentially reduces patient access to care. Collaboration with medical practitioners is intrinsic to nursing practice. Thus, legislating for collaborative arrangements is unnecessary, because it makes the normal abnormal. What is known about the topic? To access the MBS and PBS, PPNPs are required by law to have a collaborative arrangement with a medical practitioner or entity that employs medical practitioners. To date, the effects of these collaborative arrangements on PPNP services in Australia have not been known. What does the paper add? This paper provides unique data from a national survey on collaborative arrangements between PPNPs and medical practitioners in Australia. What are the implications for practitioners? Although there are benefits to collaborative arrangements, there is also concern that mandating such arrangements presents a barrier to establishing PPNP services and potentially reduces patient access to care.

Experiences of nurse practitioners and medical practitioners working in collaborative practice models in primary healthcare in Australia - a multiple case study using mixed methods

Background

In 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models.

Methods

A multiple case study of five primary healthcare sites was undertaken, applying mixed methods research. Six nurse practitioners, 13 medical practitioners and three practice managers participated in the study. Data were collected through direct observations, documents and semi-structured interviews as well as questionnaires including validated scales to measure the level of collaboration, satisfaction with collaboration and beliefs in the benefits of collaboration. Thematic analysis was undertaken for qualitative data from interviews, observations and documents, followed by deductive analysis whereby thematic categories were compared to two theoretical models of collaboration. Questionnaire responses were summarised using descriptive statistics.

Results

Using the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners’ and medical practitioners’ adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals.

Conclusions

Findings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions. However, strategic support from healthcare reform decision-makers is needed to strengthen nurse practitioner positions and ensure the sustainability of collaborative practice models in primary healthcare.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0503-2) contains supplementary material, which is available to authorized users.