A systematic review of experiences of advanced practice nursing in general practice

Implementation of a nurse practitioner service in a rural setting: a qualitative analysis of healthcare practitioners' experiences

BACKGROUND

Nurse Practitioners work independently and collaboratively within multidisciplinary teams to fill unmet service delivery needs. Despite strong evidence of the benefits of the nurse practitioner service model, organisational support for nurse practitioners varies in terms of resources and support from leadership and other healthcare professionals.

AIMS

The study aimed to explore healthcare practitioners' experiences of implementation of a NP service in a rural setting.

METHODS

Semi-structured interviews were conducted with ten healthcare practitioners to investigate their perspectives of a recently implemented NP service. Data were analysed inductively using thematic analysis.

FINDINGS

Themes emerged related to facilitating collaborative practice, person-centred continuity of care and positive health outcomes for the community. Challenges and limitations related to operational role clarity, scopes of practice and leadership.

CONCLUSION

Healthcare practitioners were mostly satisfied with the service however challenges caused tension. Change management principles provide a framework to strengthen the effective clinical alignment of the service.

Nurse-led clinical activity in kidney transplantation care in Spain: A cross-sectional observational study

OBJECTIVES

To explore the presence of specialist outpatient nursing activity in care for kidney transplant recipients in Spain and to determine the level of competence development of this activity according to the Advanced Practice Nurse model.

DESIGN

Descriptive, cross-sectional study.

PARTICIPANTS AND MEASUREMENTS

All outpatient nurses specialising in renal transplantation in the 39 transplant hospitals in Spain were included. To fulfil the study objectives, an ad hoc questionnaire and the 'Advanced Practice Nurse Role Definition Instrument (IDREPA)' were administered to assess the nurses' level of competence development.

RESULTS

Of the facilities included in the study, 25 (64.1%) had posttransplant nursing activity, 13 (33.3%) had pretransplant nursing activity and 11 (28.2%) had nursing activity involving kidney donor candidates. Twenty-seven specialist nurse's offices were identified. The results of the IDREPA reflect the presence of advanced practice in the domains of 'expert care planning' and 'comprehensive care'. Three (11.1%) nurses met all criteria for advanced nursing practice.

CONCLUSION

The results on specialised outpatient nursing activity at the 39 transplantation facilities in Spain indicate a low presence of this type of activity, with an even lower presence of advanced practice nurses.

IMPLICATIONS FOR CLINICAL PRACTICE

Management teams should consider investing in the quality of care provided by advanced nurse practice to ensure that suitable treatment is provided and better clinical outcomes are obtained.

Developing a career and education framework for advanced clinical practice in midwifery

INTRODUCTION

This study outlines the nature of Advanced Clinical Practice in Midwifery (ACPiM), reporting on a stakeholder analysis as part of a national project to develop a career framework for advanced practice in midwifery on behalf of the National Health Service (NHS) in England.

METHODS

Between June and July 2022, 31 advanced practice midwives were recruited across England within the NHS settings. Convenience sampling was used to identify midwives working as advanced practitioners, and those pursuing this career route. Focus group and one-to-one interviews were conducted, recorded, and transcribed. These stakeholder data were then analyzed using a reflexive thematic approach.

RESULTS

ACP midwives were active across many professional settings. The findings resulted in three themes: Midwifery autonomy, Desire for progression, and Avenues of support. Midwifery autonomy highlighted a midwifery desire to utilize specialist skills and expert decision-making to provide holistic care directly to women and families. Desire for progression highlighted that, regardless of career stage, midwives aspired to advance their practice requiring a range of pathways to fulfil career satisfaction and meet local population health needs. Avenues of support discussed the barriers and facilitators to progression, highlighting the need for service vision, a multi-disciplinary approach to facilitate support for individuals, and strong midwifery leadership.

CONCLUSIONS

Although the ACPiM role is desired by maternity institutions and organizations, midwives remain unclear about how to achieve this position, and employers remain unsure of how an ACPiM could transform services. If midwives are to successfully achieve ACPiM status, organizational support is needed to facilitate individuals drive for career progression, resulting in a strengthened workforce and improved patient experience.

Professional identity work of nurse practitioners and family physicians in primary care in Quebec and Ontario - a study protocol

BACKGROUND

Solo medical practices in primary healthcare delivery have been abandoned in favor of interdisciplinary teamwork in most Western countries. Dynamics in interdisciplinary teams might however be particularly difficult when two or more autonomous health professionals develop similar roles at the practice level. This is the case of family physicians (FPs) and nurse practitioners (NPs), due to the fact that the latter might accomplish not only the traditional role proper to a nurse, but also several medical activities such as requesting diagnostic exams and prescribing medical treatments. The tensions that this overlap might generate and their implications in regard of the development of professional identities, and consequently of the quality of health care delivered, have been suggested, but rarely examined empirically. The goal of this study is to examine identity work, i.e., the processes of (re)construction of professional identities, of NPs and FPs working together in primary care interdisciplinary teams.

METHODS

A longitudinal, interpretive, and comparative multiple (n = 2) case study is proposed. Identity work theory in organizations is adopted as theoretical perspective. Cases are urban primary care multidisciplinary teams from two different Canadian provinces: Quebec and Ontario. Participants are NPs, FPs, managers, and patients. Data gathering involves audio-diaries, individual semi-structured and focus group interviews, observations, and archival material. Narrative and metaphor techniques are adopted for analyzing data collected. Within- and cross-case analysis will be performed.

DISCUSSION

For practice, the results of this investigation will: (a) be instrumental for clinicians, primary care managers, and policy decision-makers responsible for the implementation of interdisciplinary teamwork in primary healthcare delivery to improve decision-making processes and primary care team performance over time; (b) inform continuing interdisciplinary professional development educational initiatives that support competency in health professionals' identity construction in interdisciplinary primary care organizations. For research, the project will contribute to enriching theory about identity construction dynamics in health professions, both in the fields of health services and primary care education research.

Exploring Frontline Shelter Staff Perspectives on the Healthcare Needs of Clients Experiencing Homelessness

PURPOSE

To examine healthcare service development needs for persons experiencing homelessness from the perspective of frontline staff at a homeless shelter in Montreal, Quebec.

DESIGN

Qualitative descriptive design.

METHODS

Purposive sampling, semi-structured interviews with frontline shelter staff (n = 8), and thematic analysis.

FINDINGS

Themes included: 1) Challenges meeting healthcare service needs in a shelter environment. 2) Visions for improving healthcare services while accounting for health issues and barriers to care. 3) Participants' own knowledge gaps around health and healthcare services.

CONCLUSIONS

Future research should emphasize this group's crucial role in homelessness healthcare services development.

Perceptions of general practitioners towards the services provided by advanced practice nurses: a cross-sectional survey in France

BACKGROUND

New healthcare professions are emerging due to scarce medical resources. The appearance of a new healthcare profession, advanced practice nurses (APNs), has raised questions about how general practitioners interrelate with them as primary care providers. The objective of this study was to explore the perceptions general practitioners have towards the services rendered by APNs to patients, to general practice and the role they play in the healthcare system.

METHODS

A survey-based, cross-sectional study was conducted throughout the Grand Est region of France which covers 57,333km2 and has a population of approximately 5,562,651. The survey was compiled using pre-existing questionnaires and was carried out from July to September 2022 via email. Variables collected were rate of acceptability and socio-demographic characteristics.

RESULTS

In total, 251 responses were included. The mean age of general practitioners was 41.7 years, most were women (58.2%) and worked in rural areas of the region (53.8%). Over 80% of respondents practiced in group structures (defined as either multi-professional health centers (n = 61) or in group practices (n = 143)). Most respondents (94.0%) were familiar with the APN profession and did not consider that APNs improved access to care (55.8%, percent of responders with score ≤ 3/10). Moreover, most did not believe that APNs were useful as a primary care provider for patients (61.8%). However, being a member of a territorialized healthcare community, known as Communautés Professionnelles Territoriales de Santé (CPTS), was associated with a positive appraisal of APNs' services (OR = 2.116, 95%CI: 1.223 to 3.712; p = 0.007).

CONCLUSIONS

Encouraging shared and networked practice within a healthcare community may promote a positive perception of new actors. Further studies need to be conducted to show whether the integration of APNs into healthcare networks improves quality of care.

Perception, perceived scope, and potential barriers towards developing nurse practitioners cadre among health care providers and beneficiaries: A pilot study from Northern India

BACKGROUND

The role of nurse practitioner (NP) emerged in early 1965 when general practitioners began working with nurses. Evidence across the world highlights the benefits achieved by the NP role. The Indian Nursing Council (INC) implemented a country-wide NP in critical care (NPCC) program with the approval of the ministry of health and family welfare (MoHFW) in 2017. The NP role is in its infancy in India. Hence, there is a need to assess the perception among beneficiaries and healthcare personnel. This study was conducted to assess the perception, perceived scope, and potential barriers for developing the role of NPs in India among beneficiaries and healthcare providers.

MATERIAL AND METHODS

A descriptive, cross-sectional pilot study was conducted at AIIMS Rishikesh, Uttarakhand, India, among 205 participants (84 beneficiaries, 78 nurses, and 43 physicians) using a proportionate stratified random sampling technique. Likert scales and socio-demographic sheets were used to assess the perception, perceived scope of practice, and potential barriers in developing a NP cadre in India. Descriptive and inferential statistics were used for analyzing data.

RESULTS

The mean age of beneficiaries was 37.98, nurses was 27.58, and physicians was 28.13 years, respectively. 121 (61%) of participants were highly favored, and 77 (38%) were in favor of developing NP cadre in India. They considered it to be necessary, feasible, and acceptable in India. The feasibility and necessity of the perception domain were highly significant (P < 0.001 and P < 0.003, respectively). Nurses (mean ± SD: 35.36 ± 3.55) considered that NPs could have a wide range of practice followed by beneficiaries (mean ± SD: 38.17 ± 3.68) than physicians (mean ± SD: 34.75 ± 5.95). Lack of awareness, the nonexistence of cadre structure, lack of acceptance of the role of physicians, and lack of clear policy were the key potential barriers to develop an NP cadre in India.

CONCLUSIONS

In this study, participants had favorable views on employing NPs in India; thus, this role will improve healthcare access for beneficiaries. NPs can carry out a wide range of practices.However, a lack of awareness, no cadre structure, and a lack of a clear policy may hinder the development of the NP cadre in India.

[Intention to Delegate Clinical Practice of Medical Specialists in Accordance with the Enactment of the Scope of Practice for Advanced Practice Nurses]

PURPOSE

This study aimed to investigate the nationwide intention to delegate clinical practice of medical specialists in accordance with the enactment of the scope of practice for advanced practice nurses (APNs).

METHODS

Data were collected from October to December 2021 using Google Surveys. In total, 147 medical specialists from 12 provinces responded to the survey. The survey questionnaire was categorized into four legislative draft duties, according to the scope of practice (a total of 41 tasks): Twenty-nine tasks on treatments, injects, etc., performed under the guidance of a physician and other activities necessary for medical treatment (treatment domain); two tasks on collaboration and coordination; six tasks on education, counseling, and quality improvement; four regarding other necessary tasks. Participants were asked whether they were willing to delegate the tasks to APN.

RESULTS

The intention to delegate tasks to APN was higher for non-invasive tasks such as blood sampling (97.3%) or simple dressing (96.6%). Invasive tasks such as endotracheal tube insertion (10.2%), sampling: bone marrow biopsy &amp; aspiration (23.8%) showed low intention to delegate in the treatment domain. Participants who were older, male, and had more work careers with APN, showed a higher intention to delegate tasks.

CONCLUSION

To prevent confusion in the clinical setting, a clear agreement on the scope of APN practice as APN delegated by physicians should be established. Based on this study, legal practices that APN can perform legally should be established.

Introducing Advanced Paramedics into the rural general practice team in Ireland – general practitioners attitudes

Introduction

As Ireland's population increases and chronic disease becomes more prevalent, demand on limited general practice services will increase. Nursing roles within general practice are now considered to be standard, yet alternative allied health professional roles are under explored within an Irish context. Allied health personnel such as Advanced Paramedics (APs) may have the capability to provide support to general practice.

Aim

To explore General Practitioners’ (GPs) attitudes and opinions of integrating Advanced Paramedics (APs) into rural general practice in Ireland.

Methods

A sequential explanatory mixed methodology was adopted. A questionnaire was designed and distributed to a purposeful sample of GPs attending a rural conference followed by semi-structured interviews. Data was recorded and transcribed verbatim and thematically analysed.

Results

In total n = 27 GPs responded to the survey and n = 13 GPs were interviewed. The majority of GPs were familiar with APs and were receptive to the concept of closely collaborating with APs within a variety of settings including out-of-hours services, home visits, nursing homes and even roles within the general practice surgery.

Conclusion

General Practitioner and Advanced Paramedic clinical practice dovetail within many facets of primary care and emergency care. GPs recognise that current rural models are unsustainable and realise the potential of integrating APs into the general practice team to help support and sustain the future of rural general practice services in Ireland. These interviews provided an exclusive, detailed insight into the world of general practice in Ireland that has not been previously documented in this way.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01740-9.

[Transfer of Physicians' Tasks to Nurses in the Care of People with Dementia]

THE AIM OF THE STUDY

A transfer of medical activities to nurses and thus the redistribution of tasks has been discussed for almost 15 years. A legal base for model projects has been enacted. However, clearly defined tasks for substitution are still lacking. The aim of this study was to solicit opinions of general practitioners, nurses, people with dementia (PwD) and their relatives about the possibility of a large number of specific General practitioner (GP) tasks being performed by nurses in outpatient dementia care.

METHODS

A mixed-methods study with a sequential in-depth design was conducted. The analysis presented here refers to the quantitative survey of the four participant groups. 865 participants were asked about the acceptance of substitution of assessments, primary and follow-up prescriptions, health monitoring measures and other activities currently performed by physicians.

RESULTS

Across all groups of subjects, the highest level of approval for substitution was achieved for the assessment of mobility restrictions, everyday competencies, nutritional abnormalities, prescription of transportation, nursing aids, home nursing services and drawing of blood samples. Among PwD and relatives, the level of acceptance for substitution was very high. 88% of the PwD and relatives indicated that many activities can be substituted while the general practitioner remained their first point of contact. More GPs (63.2%) than nurses (56.7%) would accept the substitution.

CONCLUSION

The results indicate that a large number of GPs, nurses, patients and their relatives welcome substitution. However, PwD and relatives have a significantly more positive attitude towards substitution.

The advanced practitioners' perspective. Exploring the decision-making process between musculoskeletal advanced practitioners and their patients: An interpretive phenomenological study

INTRODUCTION

Advanced practice roles for allied health professionals continue to expand and provide key services within pathways of care for patients with musculoskeletal conditions. Despite the extensive utilisation of these roles and previously reported high patient satisfaction, little is understood about how these practitioners interact with their patients and the factors that influence decision-making conversations.

STUDY

A qualitative study utilised Interpretive Phenomenological Analysis (IPA) to explore the decision-making process occurring between Advanced Practitioners (APs) and their patients in a musculoskeletal service. AP data were collected through focus groups and analysed using IPA methodology.

CONCLUSIONS

Advanced practice decision-making is a complex process and APs exhibit a range of styles, from paternalistic to shared decision-making. APs may have a personal preference, but exhibit the ability to flex between styles in consultations. Multiple themes emerged from the data that influenced the decision-making process, including AP staff understanding the importance of patient expectations and the complex factors that influence patient interactions. It is important that clinicians have an awareness of the multiple factors that contribute to the decision-making process.

Role dimensions of practice nurses and interest in introducing advanced nurse practitioners in general practice in Ireland

Background

Internationally many countries have implemented strategies to enhance primary care, to strengthen their health systems to cope with an aging population, the rise of chronic conditions, and increased costs. Primary care has the potential to address these challenges, however, general practitioners are increasingly struggling to meet patient demand resulting from a growing and aging population. Expanding the role of general practice nurses to advanced nurse practitioner (ANP) level has worked internationally and could equally be a solution to the Irish context. However, their current role must first be established as well as their level of interest in becoming an ANP.

Aim

To explore the role of general practice nurses and their interest in becoming an ANP.

Design

A survey design.

Method

A purposeful sample of general practice nurses (n = 40) was undertaken between April and June 2019. Data were analyzed using the Statistical Package for Social Science (SPSS V 25.0; IBM).

Results

General practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, respiratory and cardiovascular issues. Just over half of the respondents were not interested in becoming an ANP. Their perceived challenges associated with the implementation of the role include a lack of support from general practitioners, a lack of resources, insurance issues, and a lack of understanding of the role. Challenges were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources.

Conclusion

General practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses to advanced practice level. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.

Temper the Specialist Nurses Heterogeneity in the Interest of Quality Practice and Mobility—18 EU Countries Study

Background: The position of the specialist nurse profession varies across the European Union. Action is required to address the challenges to promote mobility and the contribution of specialist nurses to quality of care. The purpose of the study is to identify the interfaces of the specialist nurse profession across the European Union. Methods: A mixed method study was conducted in October 2019 and total of 40 answers from 18 different European Union countries were selected using a purposive sampling method. Results: The participants had completed various Bologna degree cycles and 57.2% had followed a specific educational programme to become a specialist nurse. More professional autonomy was acquired by 81.9% participants. Conclusion: A striving for homogeneity in the interpretation of the specialist nurses role and competencies is needed to achieve better quality of care provision and facilitate their mobility around the European Union. The lack of recognition identified in this study should encourage nurse managers to consider specialist nurse roles with the aim of capitalizing on the advanced care and expertise that specialist nurses provide. These results are an opportunity to improve the specialist nurses profession with an ultimate impact on management practices of streamlined, cost-effective clinical services.

Core competencies for the training of advanced practice nurses in oncology: a Delphi study

ABSTRACT Objective: To map out and validate the core competencies for the training of advanced practice nurses in oncology. Methods: Exploratory-descriptive research with a quantitative approach using the Delphi technique. Initially, a matrix composed of six domains outlining 112 core competencies of the clinical nurse specialist in oncology was elaborated. The Likert scale was used to measure the degree of agreement. Data collection took place through the Google Forms® platform from February to May 2021. Data were compiled and analyzed based on expert suggestions and literature. Results: 100 competencies achieved consensus (agreement level above 85.7%) in the first round; 13 new competencies were proposed by expert members; and 125 were validated during the Delphi technique. Conclusion: The mapping and validation of core competencies will allow the development of new training models aimed at advanced practice in oncology and future educational harmonization.

[Advanced practice nursing: representations of actors in this new model]

INTRODUCTION

Advanced practice nursing (APN) became legally established in France in 2018. Acquiring competences in the medical domain, an advanced practice nurse (APN) will follow willing patients referred by a physician. An assessment of this innovation's impact in the organization of French health care will be submitted to the French parliament in 2021. This research study was carried out to collect data with the intention of supporting the implementation of this model and constituting the starting point for the model's monitoring over time.

PURPOSE OF RESEARCH

To explore different actors' representations of the advanced practice nursing model pertaining to stabilized chronic diseases' management in primary health care, in the PACA (Provence-Alpes-Côte d'Azur region). Actors involved include patients, general practitioners, nurses and advanced practice nursing students.

RESULTS

In this prospective qualitative study based on grounded theory, 58 semi-structured individual interviews were conducted. Participants showed heterogeneous representations of the APN's role. They expressed vagueness about the model and pointed out the need for better communication to facilitate its integration. The monitoring of care plans, the home health care, the therapeutic education and prevention were identified as needs in which the APN could participate. Under-medicalized areas were suggested as suitable to its implementation. The main fear was the changes of the distribution of professional tasks with the risk of competition with other established positions. The APN's integration was perceived as easier in healthcare establishments as the roles seems well-defined there with less identity confusion between the various actors, unlike in the private ambulatory care sector. Collaboration among health actors was mentioned as a condition for the success of the APN model. A cautious attitude was noted and a need for a run-in period emerged, first APN being considered as precursors.

CONCLUSIONS

Mobilization of health actors is a criterion for successful integration of APN, therefore an awareness policy seems necessary. Training of health professionals in their curricula or in continuing education would make it possible to develop collaborative skills necessary for APN's integration.

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.

[Experiences of Advanced Practice Nurses with a clinical postgraduate education program in the context of their professional development]

Experiences of Advanced Practice Nurses with a clinical postgraduate education program in the context of their professional development Abstract. Background: The Diploma of Advanced Studies in Advanced Nursing Practice (DAS ANP-plus), which has been offered at the University of Basel since 2012, is a clinically oriented postgraduate education program for the still poorly established professional group of the Advanced Practice Nurse (APN). The acquisition of clinical skills plays a central role in the professional biography and for the APN's work in patient healthcare. Aim: The qualitative study aims to explore the experiences of APNs during and after a clinically oriented postgraduate education program in Switzerland and what significant changes they experienced in their professional practice. Methods: Reflexive thematic analysis with a constructivist orientation was used. With fourteen APNs, guided interviews were conducted and analyzed considering the professional biography. Results: "Pursuing the vision for a better care" is the constitutive theme. The graduates all seem to be driven by a strong vision: from striving to know more, to implementing the concept of Advanced Nursing Practice, to initiating changes in the healthcare system. The vision is shaped by three themes: "the challenges of gaining a foothold as an APN" before the program, "gaining security by strengthening clinical skills" during the program and on longer terms "breaking new ground in the healthcare system with allies". Conclusions: The DAS ANP-plus increases the clinical skills of APNs within clinical supervision plays an important role.

The emerging role of the advanced practice epilepsy nurse: A comparative study between two countries

AIMS AND OBJECTIVES

The aim of the study was to compare advanced practice in epilepsy nurses in Spain and United Kingdom, identifying differences in the domains of standard advanced practice.

BACKGROUND

Europe has recently faced the challenge of providing high-quality care for patients with epilepsy, a disease that generates many health demands. In some countries, such as the United Kingdom, advanced practice nursing is well established and could serve as a guide for implantation in countries where it is still in development, as is the case of Spain.

DESIGN

A multicentre cross-sectional descriptive cohort study compared differences in the roles of advanced practice nurses in Spain and the United Kingdom.

METHODS

The Advanced Practice Role Delineation Tool and its validated Spanish version were administered using an online questionnaire in a cohort of advanced practice epilepsy nurses in both countries. A convenience sample was recruited between January to December 2019. The study complied with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

RESULTS

Most United Kingdom nurses in our sample came from community environments, in contrast to Spanish nurses who worked in hospital. All domains analysed in the survey had significantly higher scores in the United Kingdom than in the Spanish cohort, especially in the research and leadership domains.

CONCLUSIONS

The advanced practice role in Spain is underdeveloped compared with the United Kingdom. Differences in the settings of advanced roles in epilepsy nurses may be explained by greater community practice in the United Kingdom and differences in organisational and health systems.

RELEVANCE TO CLINICAL PRACTICE

Our study showed the need to implement specific policies to develop advance practice nurse roles in Spain to improve the quality of care of patients with epilepsy.

Identifying goals, roles and tasks of extended scope physiotherapy in Dutch primary care- an exploratory, qualitative multi-step study

BACKGROUND

Rising healthcare costs, an increasing general practitioner shortage and an aging population have made healthcare organization transformation a priority. To meet these challenges, traditional roles of non-medical members have been reconsidered. Within the domain of physiotherapy, there has been significant interest in Extended Scope Physiotherapy (ESP). Although studies have focused on the perceptions of different stakeholders in relation to ESP, there is a large variety in the interpretation of ESP.

AIM

To identify a paradigm of ESP incorporating goals, roles and tasks, to provide a consistent approach for the implementation of ESP in primary care.

METHODS

An exploratory, qualitative multi-step design was used containing a scoping review, focus groups and semi-structured interviews. The study population consisted of patients, physiotherapists, general practitioners and indirect stakeholders such as lecturers, health insurers and policymakers related to primary care physiotherapy. The main topics discussed in the focus groups and semi-structured interviews were the goals, skills and roles affiliated with ESP. The 'framework' method, developed by Ritchie & Spencer, was used as analytical approach to refine the framework.

RESULTS

Two focus groups and twelve semi-structured interviews were conducted to explore stakeholder perspectives on ESP in Dutch primary care. A total of 11 physiotherapists, six general practitioners, five patients and four indirect stakeholders participated in the study. There was a lot of support for 'decreasing healthcare costs', 'tackling increased health demand' and 'improving healthcare effectiveness' as main goals of ESP. The most agreement was reached on 'triaging', 'referring to specialists' and 'ordering diagnostic imaging' as tasks fitting for ESP. Most stakeholders also supported 'working in a multidisciplinary team', 'working as a consultant' and 'an ESP role separated from a physiotherapist role' as roles of ESP.

CONCLUSIONS

Based on the scoping review, focus groups and interviews with direct and indirect stakeholders, it appears that there is sufficient support for ESP in the Netherlands. This study provides a clear presentation of how ESP can be conceptualized in primary care. A pilot focused on determining the feasibility of ESP in Dutch primary care will be the next step.

Attitudes towards advanced nursing roles in primary dementia care - Results of an observational study in Germany

AIMS

To demonstrate the attitudes of general practitioners (GPs), nurses, persons with dementia, and caregiver towards suitable tasks and qualification needs for and the acceptance and impact of advanced nursing roles in German dementia primary care.

DESIGN

Observational study using a questionnaire survey with 225 GPs, 232 nurses, 211 persons with dementia, and 197 caregivers, conducted between December 2017-August 2018.

METHODS

A questionnaire was generated that includes specific assessment, prescription, and monitoring tasks of advanced nursing roles in dementia primary care as well as qualification requirements for and the acceptance and the impact of advanced nursing roles. Data were analysed using descriptive statistics. Group differences were assessed using the Fisher's exact test.

RESULTS

Advanced nursing roles were highly appreciated across all groups. Assessment and monitoring tasks were rated as highly suitable, and prescription authorities as moderately suitable. Nurses felt less confident in assessment and monitoring, but more confident in prescribing as practitioners expected. Patients and caregivers would appreciate a takeover of tasks by nurses; nurses and practitioners preferred a delegation. A dementia-specific qualification was rated as best suitable for advanced nursing roles, followed by 'no specific qualification' if medical tasks that only can be carried out by practitioners were delegated and an academic degree if tasks were substituted. Advanced nursing roles were rated as beneficial, strengthening the confidence in nursing care and improving the cooperation between professionals and the treatment. Practitioners assumed that advanced nursing roles would improve job satisfaction of nurses, which was not confirmed by nurses.

CONCLUSION

There is an extended consensus towards the enlargement of advanced nursing roles, represented by high endorsement, acceptance, and willingness to reorganize tasks.

IMPACT

Results debunk the common notion that German practitioners would be reluctant towards advanced nursing roles and a takeover of current practitioner tasks, supporting the implementation of advanced nursing roles in Germany.

Patients' experiences with the advanced practice nurse role in Swiss family practices: a qualitative study

Background

Considering shortages of general practitioners (GP) and strategies for improving the quality of health care provision, many countries have implemented interprofessional care models with advanced practice nurses (APN). International evidence suggests that APN care results in high patient satisfaction. In Switzerland, the role is still new, and the patient perspective has not yet been researched. Our aim was therefore to explore patients’ experiences with the APN role in Swiss family practices.

Methods

We conducted 22 semi-structured interviews in four different family practices with patients aged 18 to 97 suffering from minor acute to multiple chronic diseases, and who had at least one consultation with an APN. All interviews were audiotaped, transcribed verbatim, and analysed using qualitative content analysis.

Results

The analysis resulted in five themes: Despite the unfamiliarity, all patients were willing to be consulted by an APN because it was recommended by their GP (1); after several encounters, most participants perceived differences between the APN and the GP consultation in terms of the length and style of the consultations as well as the complexity of their tasks (2); the interviewees emphasised coaching, guidance, care coordination, and GP-assisting tasks as APN core competencies and attributed the characteristics empathetic, trustworthy, and competent to the APN role (3); most patients especially valued home visits and the holistic approach of the APNs, but they also noticed that in certain cases GP supervision was required (4); and due to the close collaboration between the APN and the GP, patients felt safe, well cared for and experienced improvements in physical and psychological well-being as well as in daily activities (5).

Conclusion

Our results suggested that patients value the APNs’ competencies, despite their initial lack of role knowledge. Trust in the GP seemed to be the most important factor for patients’ receptiveness toward the APN role. Overall, patients perceived an added value due to the enlargement of the scope of practice offered by APNs. The patient perspective might provide valuable insights for further APN role implementation in Swiss family practices.

Japanese nurse practitioners' legal liability ambiguity regarding their medical practice: a qualitative study

BACKGROUND

Nurse practitioners' role is always expanding. The Japanese Nurse Practitioner (JNP) system was initiated in 2015 to shift some aspects of doctors' work to various other healthcare professionals, including nurses. JNPs' fulfillment of their roles was shown to have a certain degree of efficacy and provide positive outcomes for patients (e.g., shortening hospitalization period). Nurse practitioners are considered legally liable for their medical practices because they are performed on doctors' behalf; however, in real life, there is ambiguity regarding such practice. It is necessary to clarify nurse practitioners' legal liability in order to ensure the safety of their medical practice and protect them in medical procedures performed on physicians' behalf. This study aimed to clarify how JNPs understand their own legal liability in medical practice.

METHODS

A qualitative, inductive research design was adopted to record participants' opinions. The survey was conducted from October 2017 to February 2018. Participants were nurses working as JNPs at general hospitals in eastern Japan. We recruited participants via snowball sampling.

RESULTS

With regard to JNPs' legal liability in their medical practice, three themes understanding were observed: "determining whether the JNP has the ability to perform the assigned medical procedure," "exercising caution when performing medical procedures on a doctor's behalf" and "an urge to follow up with appropriate medical practice until the end of care."

CONCLUSIONS

We demonstrated that JNPs recognized their own legal liability in medical practice. They had to protect themselves because their legal position was ambiguous. Furthermore, JNPs accepted that diagnosis and drug prescription could be performed on behalf of doctors if trusting relationships had been previously established.

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.

Characterising the evidence base for advanced clinical practice in the UK: a scoping review protocol

INTRODUCTION

A global health workforce crisis, coupled with ageing populations, wars and the rise of non-communicable diseases is prompting all countries to consider the optimal skill mix within their health workforce. The development of advanced clinical practice (ACP) roles for existing non-medical cadres is one potential strategy that is being pursued. In the UK, National Health Service (NHS) workforce transformation programmes are actively promoting the development of ACP roles across a wide range of non-medical professions. These efforts are currently hampered by a high level of variation in ACP role development, deployment, nomenclature, definition, governance and educational preparation across the professions and across different settings. This scoping review aims to support a more consistent approach to workforce development in the UK, by identifying and mapping the current evidence base underpinning multiprofessional advanced level practice in the UK from a workforce, clinical, service and patient perspective.

METHODS AND ANALYSIS

This scoping review is registered with the Open Science Framework (https://osf.io/tzpe5). The review will follow Joanna Briggs Institute guidance and involves a multidisciplinary and multiprofessional team, including a public representative. A wide range of electronic databases and grey literature sources will be searched from 2005 to the present. The review will include primary data from any relevant research, audit or evaluation studies. All review steps will involve two or more reviewers. Data extraction, charting and summary will be guided by a template derived from an established framework used internationally to evaluate ACP (the Participatory Evidence-Informed Patient-Centred Process-Plus framework).

DISSEMINATION

The review will produce important new information on existing activity, outcomes, implementation challenges and key areas for future research around ACP in the UK, which, in the context of global workforce transformations, will be of international, as well as local, significance. The findings will be disseminated through professional and NHS bodies, employer organisations, conferences and research papers.

Integration of nurses in general practice: A thematic synthesis of the perspectives of general practitioners, practice nurses and patients living with chronic illness

AIMS AND OBJECTIVES

To explore the views of general practitioners, practice nurses and patients on interprofessional collaboration in general practice and to understand to what extent the nurse-doctor relationship meets their needs and expectations.

BACKGROUND

To address future challenges of primary health care, there is a need for integrated interprofessional collaboration care systems with a patient-centred focus. Worldwide, there is an integration of nurses in general practice. However, in a transitioning Belgian context little is known about the perspectives of three key stakeholder groups.

DESIGN

The results of four qualitative descriptive primary studies were triangulated and a secondary analysis resulted in a thematic synthesis within a pragmatic research paradigm.

METHODS

Primary data were collected through individual, semi-structured interviews with 7 general practitioners, 19 practice nurses and 21 patients living with chronic illness in 26 primary care centres with different nurse integration levels. We conducted a secondary analysis for the thematic synthesis of the different stakeholders' perspectives. This study was reported in accordance with the COREQ checklist.

RESULTS

Four overarching themes were found as follows: vision and mission at general practice level, patient-centred care, practice nurse role development and interprofessional collaboration. Interprofessional collaboration within general practice ensures better response to patient needs. Evolution of the practice nurse role to autonomous decision-making can be facilitated by clear vision and mission, team communication, complementarity of responsibilities and trust-based professional relationships.

CONCLUSIONS

The key for patient-centred care in a well-organised practice is a clear vision and mission and well-defined task description for interprofessional collaboration. General practice is urging for systematic guidance for the sustainable integration of a practice nurse.

RELEVANCE TO CLINICAL PRACTICE

Our study highlights opportunities and challenges to nurse integration in general practice from key stakeholders' perspectives, which can inform other transitioning contexts.

Advanced practice nurses' and general practitioners' first experiences with introducing the advanced practice nurse role to Swiss primary care: a qualitative study

BACKGROUND

Primary care is facing a multimorbid, ageing population and a lack of general practitioners (GPs), especially in rural areas. In many countries, advanced practice nurses (APNs) may be a potential solution for these challenges. Switzerland, however, is in the early stages of APN role development with a handful of pilot projects that are unresearched. Our aim was to explore the experiences of APNs and GPs involved in introducing the APN role to Swiss primary care.

METHODS

We organised two focus group discussions with APNs (n = 9) engaged in primary care across German-speaking Switzerland and individual interviews with APNs (n = 2) and GPs (n = 4) from two pilot projects in remote areas. Data analysis followed an exploratory hybrid approach of thematic analysis and was guided by the PEPPA Plus framework.

RESULTS

The analysis resulted in five main themes: The participants considered themselves pioneers developing a new model in primary care, seeking to shape and improve future health care ((1) pioneering spirit). Both nurses and doctors agreed on the additional value of the APN role, a role seen as having more time for and a different approach to patient care, bringing higher quality of care and flexibility to the practice ((2) added value from the APN role). Participants also emphasized the importance of asking for advice when unsure about diagnostic steps or appropriate treatment ((3) awareness of limited knowledge and skills). The main barriers identified included the impression that Swiss doctors have little knowledge about nurses in advanced roles ((4) GP's lack of knowledge regarding the APN role), and that further regulations will be important to foster role clarity and accountability ((5) political and legal obstacles in introducing the APN role).

CONCLUSIONS

The early phase of introducing APNs to Swiss primary care is characterised by heterogeneous, small-scale projects of pioneering GPs and APNs recognising the added value and limits of APNs despite a lack of governance and knowledge regarding the APN role among GPs. Experiences gained from ongoing projects provide elements of good practice for political discussions and regulations.

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.

A review of the development and current status of wound ostomy continence nurses in the mainland of China

Wound ostomy continence nurses (WOC nurses), developed as an important part of clinical nurse specialists play an indispensable role in the management of ostomy, all kinds of chronic wounds and incontinent dermatitis. However, there exists a gap compared with developed countries and regions. This paper provides an overview of WOC nurses in China including origin and development, training and accreditation system, roles, values and management, in order to provide references for the development of WOC nurses in China.

Advanced nurse practitioners in municipal healthcare as a way to meet the growing healthcare needs of the frail elderly: a qualitative interview study with managers, doctors and specialist nurses

Background

The number of frail elderly people with complex nursing and medical care needs is increasing, and consequently, the healthcare burden. The implementation of Advanced Nurse Practitioners globally has been shown to make healthcare more effective and increase patient safety, continuity of care and access to care. In Sweden, research about Advanced Nurse Practitioners is limited. Thus, this study aimed to investigate the opinions of managers, doctors and nurses in primary care and municipal healthcare about the role of ANPs in municipal healthcare as a way to meet the increasing healthcare needs of the frail elderly.

Methods

Managers, doctors and specialist nurses in primary care and municipal healthcare adopted a qualitative, descriptive design through 12 semi-structured interviews. The data were analysed using content analysis.

Results

The participants expressed both opportunities as well as challenges with Advanced Nurse Practitioners in municipal healthcare. This role considered to satisfy frail elderly people’s healthcare needs and making the healthcare more effective as the doctors would have more time for other patients. The challenges mainly consist of doubts from the managers whether the nurses would be motivated to pursue further education to become an Advanced Nurse Practitioner if the role becomes a reality. The doctors were unsure if the nurses would consider taking the responsibility the role would imply.

Conclusions

Advanced Nurse Practitioner is considered to be a valuable resource not only for the frail elderly but also for the nurses in the municipal healthcare and for the doctors in primary care as they probably would make healthcare more effective. They might be a way to meet the increasing healthcare needs of frail elderly, however there are also challenges to overcome before they can become a reality in a Swedish healthcare context. Consequently, this role deserves further investigation.

Electronic supplementary material

The online version of this article (10.1186/s12912-017-0258-7) contains supplementary material, which is available to authorized users.