Nurse practitioner integration: Qualitative experiences of the change management process

Put on the sidelines of palliative care: a qualitative study of important barriers to GPs' participation in palliative care and guideline implementation in Norway

BACKGROUND

Demographic changes, the evolvement of modern medicine and new treatments for severe diseases, increase the need for palliative care services. Palliative care includes all patients with life-limiting conditions, irrespective of diagnosis. In Norway, palliative care rests on a decentralised model where patient care can be delivered close to the patient's home, and the Norwegian guideline for palliative care describes a model of care resting on extensive collaboration. Previous research suggests that this guideline is not well implemented among general practitioners (GPs). In this study, we aim to investigate barriers to GPs' participation in palliative care and implementation of the guideline.

METHODS

We interviewed 25 GPs in four focus groups guided by a semi-structured interview guide. The interviews were recorded and transcribed verbatim. Data were analysed qualitatively with reflexive thematic analysis.

RESULTS

We identified four main themes as barriers to GPs' participation in palliative care and to implementation of the guideline: (1) different established local cultures and practices of palliative care, (2) discontinuity of the GP-patient relationship, (3) unclear clinical handover and information gaps and (4) a mismatch between the guideline and everyday general practice.

CONCLUSION

Significant structural and individual barriers to GPs' participation in palliative care exist, which hamper the implementation of the guideline. GPs should be involved as stakeholders when guidelines involving them are created. Introduction of new professionals in primary care needs to be actively managed to avoid inappropriate collaborative practices. Continuity of the GP-patient relationship must be maintained throughout severe illness and at end-of-life.

Expanding urological services into regional Australia and reducing interhospital transfers: how the nurse practitioner can help

BACKGROUND

A visiting urology service has been in existence at Hamilton Base Hospital, Western Victoria, over the past 25 years, serving an unmet need. A Urology Nurse Practitioner (UNP) provides the care and management of urology patients working in close association with visiting urologists. We aim to assess the impact of the UNP's role in the delivery of regional urological care.

METHODS

A retrospective analysis of medical records identified all clinical interventions by the UNP between January 2016 and December 2019. Each encounter was graded according to a clinical severity scale from grade 1 to 5 and assessed for UNP management of patients and the prevention of interhospital transfers.

RESULTS

One hundred eighty-four patients with 654 individual assessments were identified for inclusion and classified according to the adapted clinical severity scale. Most interventions for category 3 and 4 patients related to major bleeding, catheter difficulties, and haemodynamic instability. A total of 19 patients whose urological issues would typically require interhospital transfer were able to be managed locally.

CONCLUSIONS

Transferring an acute patient from a regional to a tertiary hospital for specialist care is often necessary but not ideal for the patient and their family. The presence of a dedicated UNP in a regional centre is important for patient care and has an important role in preventing unnecessary transfers. This is a vital component of a visiting urological service to a rural community.

Nurse Practitioners in a Canadian Pediatric Rehabilitation Hospital: A Description of Roles and Scope of Practice

The nurse practitioner role is strongly suited to meet the needs of children with complex developmental conditions in pediatric rehabilitation settings as they have a unique combination of clinical expertise. To meet the increasing demands in a large Canadian pediatric rehabilitation hospital, the NP role was implemented in several clinical program settings to improve access to care. This paper describes the contributions of NPs to nine specialized inpatient and outpatient programs in NP-led, collaborative NP and physician or interagency care team models of practice. The initial challenges of role implementation and implications for NP practice, research and leadership are discussed.

Facilitators and barriers to the transition from registered nurse to nurse practitioner in Canada

BACKGROUND

Understanding factors that affect integration of NPs is likely to address barriers and provide reform strategies that shape a cost-effective, sustainable, accessible, and efficient health care system. There are a limited number of current and high-quality studies examining the transition process of registered nurses (RNs) to nurse practitioners (NPs), especially in Canada.

PURPOSE

To explore the experiences of RNs transitioning to NPs in Canada.

METHODOLOGY

Thematic analysis of audio-recorded semi-structured interviews was conducted to explore the experiences of 17 RNs as they transitioned to NPs. A purposive sampling of 17 participants was completed in 2022.

RESULTS

Six main themes emerged from analysis of 17 interviews. The content of themes varied according to NPs' years of experience and the NP school they attended.

CONCLUSIONS

Peer support and mentorship programs were facilitators in the transition from RN to NP. Conversely, shortcomings in education, financial stressors, and the lack of NP role definition were seen as barriers. Legislation and regulations supportive of NPs, diverse and comprehensive education, and improved availability of mentorship programs may strengthen transition facilitators and help NPs overcome related barriers.

IMPLICATIONS

Legislation and regulations supportive of the NP role are needed, focusing on defining the NP role and establishing an independent and consistent remuneration structure for NPs. A more in-depth and diversified educational curriculum is needed, with increased support from faculty and educators and continual encouragement of initiation and perpetuation of peer support. A mentorship program is beneficial to reduce transition shock from the role of the RN to the NP.

Nurse practitioner in Swedish municipal elderly care: A Delphi study of challenges and opportunities

INTRODUCTION

Worldwide, countries are struggling with strained healthcare systems, especially due to the growing number of frail elderly. Developing the role of nurse practitioner in the care of the frail elderly is therefore of interest to make the care chain more efficient. In Sweden, the role is in an early development phase, but more research is needed.

AIM

The aim was to investigate how stakeholders at the national level express the challenges and opportunities of the evolving nurse practitioner role in Swedish municipal elderly care.

METHOD

A Delphi survey technique with three rounds of electronic questionnaires was used. Twenty-seven experts responded to the first questionnaire, containing two open questions; what opportunities respectively challenges do you see in developing and implementing the nurse practitioner role in municipal elderly care? The following questionnaires consisted of statements to rate using a four-grade Likert scale, and 20 and 17 responded to the second and third, respectively. The first round was analysed using content analysis, and the other two with descriptive statistics.

RESULTS

Thirty-four statements about challenges and opportunities related to the nurse practitioner role in municipal elderly care were identified and rated as important.

CONCLUSION

The findings provide knowledge that can contribute to discussions and decisions to refine the nurse practitioner role in Swedish municipal elderly care. The nurse practitioner role may contribute with much-needed competence to the elderly care. However, it is important to consider the challenges that need to be overcome before the development of the role. To solve this, it is necessary to have clear national guidelines concerning issues of education, title protection and the mandate and authority of the NP role.

Nurse practitioner integration: Conceptual development to enhance application in policy and research

BACKGROUND

Nurse practitioners (NPs) have been introduced across the world to improve care quality and solve provider shortages. Realizing these benefits relies on their successful integration into health care systems. Although NP integration has been discussed extensively, the concept is defined inconsistently. Literature, therefore, cannot be synthesized to create policy recommendations for management and policymakers to plan for and advance NP integration.

OBJECTIVES

To describe and define NP integration and enhance its applicability in research and policy.

DATA SOURCES

A modified Walker and Avant concept analysis was used to develop a conceptual model of NP integration. Data were extracted and synthesized from 78 sources referencing the concept.

CONCLUSIONS

Nurse practitioner integration was operationally defined as the multilevel process of incorporating NPs into the health care system so that NPs can practice to their full scope, education, and training and contribute to patient, system, and population needs. The attributes of NP integration are: 1) achievable goal; 2) process; 3) introduction of the role; 4) incorporation into organizational care models; 5) challenging traditional ideologies; 6) ability to function; 7) provide high-quality care; and 8) improve outcomes, sustainability, and health system transformation. Seventeen facilitators/barriers affecting NP integration were identified. Three health care system levels at which integration occurs were identified- macro , meso , and micro .

IMPLICATIONS FOR PRACTICE

Findings will inform managers, policymakers, and stakeholders about NP integration to aid in planning and policy development. Results can be used to inform research on barriers and facilitators to NP integration.

Systemic barriers and facilitators to the transition of registered nurse to nurse practitioner in Canada: A scoping review

BACKGROUND

The scope of practice of nurse practitioners (NPs) is expanding, and an increasing number of registered nurses (RNs) are advancing their careers to become NPs. Nurse practitioners are prepared to improve access to high-quality care and enhance care standards. The barriers and facilitators in the transition of RNs to NPs have been seldom studied in the Canadian context.

OBJECTIVE

To conduct a scoping review to identify systemic barriers and facilitators affecting Canadian RN experience in transitioning to independent practice as NPs.

DATA SOURCES

Four electronic databases were searched for primary studies, and several search engines were used to retrieve gray literature. Keywords included NP, transition, novice, Canada, barriers, obstacles, facilitators, and their variations. Eligible studies are those published from the inception of each respective database to 2021.

CONCLUSIONS

Four research studies and one report in the gray literature were located. Three themes were identified from the literature review, including inconsistencies in education and the need for mentors, need for legislation supportive of NP practice, and inconsistent remuneration structures for NPs.

IMPLICATIONS FOR PRACTICE

Addressing systemic barriers and employing systemic facilitators are likely to facilitate the transition of RNs to NPs. The lack of primary evidence to explore the factors that affect the transition process from an RN to an NP in Canada indicates that further research must be done. Findings from the future research are likely to furnish a better understanding of the transition process so that the integration of new NPs into the health care system can be achieved efficiently.

A survey of nurse practitioner perceptions of integration into acute care organisations across one region in Ireland

Aim

The purpose of the study was to explore nurse practitioner perceptions of integration practices in acute hospitals across one health care region in Ireland.

Background

A recent Department of Health National policy towards developing a critical mass of nurse practitioners was implemented across Ireland. Successful integration of nurse practitioner roles is integral to the success of the service and sustainability of the roles for the long term.

Method

An electronic survey was circulated to a convenience sample of 85 nurse practitioners across a single, acute health care region in Ireland.

Results

Sixty‐six (78%) of nurse practitioners participated. A standardized governance structure was reported by 24 (36%) participants. Thirty‐two (48%) participants expressed their job description clearly defined their role. Consultant physicians were identified as the most supportive stakeholder by participants.

Conclusions

This research identifies that nurse practitioner integration is not currently structured. A framework to support nurse practitioner integration is required to ensure ongoing support for the role. This research identifies that integration is not currently optimized.

Implications for Nursing Management

Failure to successfully integrate the nurse practitioner role risks the long‐term sustainability of the role and is a missed opportunity to demonstrate the success of advanced clinical leadership to health care.

A translational research framework for nurse practitioners

AIMS

This study aims to explore a proposed translational research continuum for nurse practitioners.

BACKGROUND

Nurse practitioners are acknowledged as clinical leaders responsible for transforming health care delivery. It is important that nurse practitioners contribute to health care knowledge using scientific processes for the implementation of evidence-based practice and evaluation of outcomes of interventions for their patient groups.

EVALUATION

This paper provides a review of translational research literature including implementation science to align nurse practitioner activities to a modified translational research framework.

KEY ISSUES

A translational research framework has the potential to strengthen nursing research in the nurse practitioner role. Adapting an accepted translational research continuum for nurse practitioners places the clinical nursing leaders in an equitable research position with all health care professionals.

IMPLICATIONS FOR NURSING MANAGEMENT

The translational research continuum provides nursing management with a structure to benchmark nursing research. The continuum applies a modern research framework to support research engagement for the nurse practitioner role.

An integrative review to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes

AIMS

This study aimed to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes.

BACKGROUND

Changing health-care delivery is synonymous with the nurse practitioner role. The literature is critical of the lack of research by nurse practitioners, reporting the effects of a change to health-care delivery.

DESIGN

This study used a systematic integrative review by using Torraco's approach.

DATA SOURCES

Databases Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Web of Science and SCOPUS were searched for peer-reviewed publications from 2000 to 2019.

REVIEW METHODS

A systematic approach was used to screen and analyse the literature. Inclusion/exclusion criteria were applied, and quality appraisal was undertaken by two reviewers.

RESULTS

Eighteen articles were selected. The research projects were across the community and acute care settings. Research methodologies varied including preintervention and postintervention studies, evaluation of quality improvement projects, randomized controlled trial and descriptive studies. Multiple data collection tools were used. Two major themes were identified including evidence-based practice champions and improved patient outcomes.

CONCLUSION

The nurse practitioner role is pertinent toward improving evidence-based practice in clinical settings. Positive patient outcomes and praise for clinical leadership are evident in the literature. Research by nurse practitioners to date has focused on individual services.

New understanding of primary health care nurse practitioner role optimisation: the dynamic relationship between the context and work meaning

BACKGROUND

Optimising health professionals' contribution is an essential step in effective and efficient health human resources utilisation. However, despite the considerable efforts made to implement advanced practice nursing roles, including those in primary care settings (PHCNP), the optimisation of these roles remains variable. In this investigation, we report on the subjective work experience of a group of PHCNPs in the province of Quebec (Canada).

METHODS

We used Giddens' structuration theory to guide our study given its' facilitation of the understanding of the dynamic between structural constraints and actors' actions. Using a qualitative descriptive study design, and specifically both individual and focus group interviews, we conducted our investigation within three health care regions in Quebec during 2016-2017.

RESULTS

Forty-one PHCNPs participated. Their descriptions of their experience fell into two general categories. The first of these, their perception of others' inadequate understanding and valuing of their role, included the influence of certain work conditions, perceived restrictions on professional autonomy and the feeling of being caught between two professional paradigms. The second category, the PHCNPs' sense of engagement in their work, included perspectives associated with the specific conditions in which their work is situated, for example, the fragility of the role depending on the particular clinic/s in which they work or on the individuals with whom they work. This fragility was also linked with certain health care reforms that had been implemented in Quebec (e.g., legislation requiring greater physician productivity).

CONCLUSION

Several new insights emerged, for example, the sense of role fragility being experienced by PHCNPs. The findings suggest an overarching link between the work context, the meaning attributed by PHCNPs to their work and their engagement. The optimisation of their role at the patient care level appears to be influenced by elements at the organisational and health system context levels. It appears that role optimisation must include the establishment of work environments and congruent health context structures that favour the implementation and deployment of new professional roles, work engagement, effective collaboration in interprofessional teams, and opportunities to exercise agency. Further research is necessary to evaluate initiatives that endeavour to achieve these objectives.