Primary care nurse practitioners and the interface with secondary care: a qualitative study of referral practice

In the United Kingdom nurse practitioners are assuming responsibilities traditionally considered to be within the domain of general practitioners. Important amongst these is the referral of patients to medical consultants in secondary care, a responsibility commonly associated with the general practitioner's role as 'gatekeeper' to health care. This paper describes a study designed to identify issues raised by the challenge that a developing nursing role presents to interprofessional working at the interface between primary and secondary care. When invited to comment, study participants (nurse practitioners, nurse educators, medical consultants and general practice registrars) related nursing referrals to issues associated with professional boundary changes, namely: teamwork, regulation of practice, communication, professional conflict and professional relationships. This paper discusses the views of primary and secondary care practitioners about who should take responsibility for the referral of patients in the light of concerns raised about professional competence and accountability. Individual nurse practitioners and their colleagues have found pragmatic ways to manage their work however, although UK government policy supports development of advanced clinical nursing, there remains much work to be done to provide the professional and legal infrastructure to support the role.     

Primary health care nurse practitioners in Canada

Canada, like many countries, is in the midst of primary health care reform. A key priority is to improve access to primary health care, especially in remote communities and areas with physician shortages. As a result, there is an increased emphasis on the integration of primary health care nurse practitioners. As of March 2006, legislation exists in all provinces and two territories in Canada that allows nurse practitioners (NPs) to implement their expanded nursing role. In this paper, we will briefly review the historical development of the NP role in Canada and situate it in the international context; describe the NP role, supply of NPs in the country, and the settings in which they work; propose an NP practice model framework; summarize facilitators and barriers to NP role implementation in primary health care delivery; and outline strategies to address the barriers.     

Shifting patterns of practice: nurse practitioners in a managed care environment

The purpose of this qualitative study was to uncover patterns across nurse practitioner (NP) experiences that contribute to understanding their perceptions of managed care, how it affects daily practice, and how NPs respond to a changing managed care workplace. In-depth interviews were conducted with 14 NPs representing primary care, specialty, and independent practices. Over an 18-month period, data collection and analysis occurred simultaneously using standard methods of purposive sampling, constant comparison, memoing, and member checks. This study illuminates the tension NPs experience between a business and a professional ethic and the strategies they use to reconcile this difference with core nursing values. Type of setting, workplace dynamics, and length of time in practice contributed to variation in NP perspectives.     

Critical care nurse practitioners and clinical nurse specialists interface patterns with computer-based decision support systems

PURPOSE: The purposes of this review are to examine the types of clinical decision support systems in use and to identify patterns of how critical care advanced practice nurses (APNs) have integrated these systems into their nursing care patient management practices. The decision-making process itself is analyzed with a focus on how automated systems attempt to capture and reflect human decisional processes in critical care nursing, including how systems actually organize and process information to create outcome estimations based on patient clinical indicators and prognosis logarithms. Characteristics of APN clinicians and implications of these characteristics on decision system use, based on the body of decision system user research, are introduced. DATA SOURCES: A review of the Medline, Ovid, CINAHL, and PubMed literature databases was conducted using "clinical decision support systems,"computerized clinical decision making," and "APNs"; an examination of components of several major clinical decision systems was also undertaken. CONCLUSIONS: Use patterns among APNs and other clinicians appear to vary; there is a need for original research to examine how APNs actually use these systems in their practices in critical care settings. Because APNs are increasingly responsible for admission to, and transfer from, critical care settings, more understanding is needed on how they interact with this technology and how they see automated decision systems impacting their practices. IMPLICATIONS FOR PRACTICE: APNs who practice in critical care settings vary significantly in how they use the clinical decision systems that are in operation in their practice settings. These APNs must have an understanding of their use patterns with these systems and should critically assess whether their patient care decision making is affected by the technology.     

Clinical practice characteristics of gerontological nurse practitioners: a national study

PURPOSE: To determine the clinical practice characteristics of gerontological nurse practitioners (GNPs) in the United States and ascertain whether length of employment, geographic region of practice, work setting, and educational preparation influence GNPs' delivery of advanced clinical services and clinical procedures. DATA SOURCES: The Gerontological Nurse Practitioner Practice Profile was mailed to a stratified random sample of 1000 GNPs certified by the American Nurses Credentialing Center. CONCLUSIONS: Despite the growing demands for GNPs, of the 472 GNPs who responded to the survey, only half were working full-time as a GNP. Although the role was established over 30 years ago, 56% of the respondents indicated that they were the first GNP in the position. There was a statistically significant positive relationship between being the first GNP in his or her practice and the percent of primarily medical advanced clinical services performed. GNPs who worked in multiple clinical setting performed more advanced clinical services and medical procedures than GNPs who only worked in one setting. IMPLICATIONS FOR PRACTICE: This study provides insight into the complex practice characteristics of GNPs. GNPs are combining the nursing skills so necessary to care for older adults with advanced clinical services and clinical procedures deemed medical acts. Various factors influence how GNPs practice, including geographic location, type of practice, and whether the GNP was the first person to be employed as a nurse practitioner at the practice.     

Measuring practice patterns among acute care nurse practitioners

OBJECTIVE: This initiative was designed to develop a reliable instrument to measure the activities of acute care nurse practitioners (ACNPs). A sound, standardized method for measuring ACNP productivity will assist nursing leaders and administrators to demonstrate the effectiveness and productivity of ACNPs in and across institutions and systems. BACKGROUND DATA: Current research on ACNPs uses many different methodologies and research designs, and fails to provide standard definitions to measure practice patterns, making it difficult to generalize across settings. METHODS: Advisory groups from 2 New York academic health science centers developed a survey that covered the demographic, educational, and employment characteristics of ACNPs, and a 20-item classification of advanced practice nursing activities. Sixty-one ACNPs completed surveys, a 58% response rate. RESULTS: The survey found strong similarities at both institutions. ACNPs spend most of their time in 5 activities involving direct care and 4 activities within indirect care. Strong Cronbach alphas confirmed that the instrument was reliable. CONCLUSIONS/IMPLICATIONS: The availability of a reliable instrument for measuring ACNP practice patterns provides administrators with a powerful tool to demonstrate the contributions of their ACNPs. In addition, a standardized method for data collection can contribute to healthcare workforce policy discussions.     

Facilitating safe care: a qualitative study of Iranian nurse leaders

Aim The purpose of this study was to explore and describe how nurse leaders facilitate safe care from the perspectives of both nurses and nurse leaders. Background The health-care system’s success in improving patient safety pivots on nursing leadership. However, there is a lack of knowledge in the international literature about how nurse leaders facilitate provision of safe care and reaching the goal of a safe health-care system. Method A qualitative design using a content analysis approach was applied for data gathering and analysis. In this study, 20 nurses (16 nurses and four head nurses) working in a referral teaching hospital in Tehran, Iran, were recruited through purposive sampling. Semi-structured interviews and 10 hours of structured observations were conducted to collect data. Results The data analysis resulted in three main themes: ‘providing environmental prerequisites for safe nursing practice’, ‘uniting and integrating health-care providers’, and ‘creating an atmosphere of safe care’. Conclusion The results indicate that to facilitate providing safe care, nurse leaders should improve nurses’ working conditions, develop the nurses’ practical competencies, assign duties to nurses according to their skills and capabilities, administer appropriate supervision, improve health-care providers’ professional relationships and encourage their collaboration, empower nurses and reward their safe practice. Implications for nursing management Approaching the challenge of patient safety requires the health-care system to combine its efforts and strategies with nursing leadership in its vital role of facilitating safe care and improving patient safety.     

Involvement of general practitioners in palliative cancer care: a qualitative study

Purpose

General practitioners play an important role in palliative care for cancer patients. The intensity of care and its medical complexity make palliative care a demanding task for general practitioners. This study explored general practitioners' perceptions of their involvement in palliative cancer care and the constraints they confront.

Methods

We conducted semi-structured interviews with 13 German general practitioners. Recruitment occurred by means of purposeful sampling to secure maximum heterogeneity. The interviews were electronically recorded, transcribed, and then analyzed using qualitative content analysis according to Mayring.

Results

A number of themes were identified. General practitioners describe being intensely involved in the final phase of their patients' lives. When providing home-based end-of-life care to cancer patients, general practitioners become aware of the limitations in their medical skills and knowledge and their ability to provide round-the-clock care. They find it helpful and satisfying to collaborate with trusted care providers and seek to cooperate with specialized palliative care services for outpatients.

Conclusions

The substantial involvement of general practitioners in end-of-life care for cancer patients pushes them to their limits because of the major time commitment required, and the need for special skills for which they have received no training. It will be a challenge to provide general practitioners with the structural and personal support they need to provide home-based palliative care for their cancer patients at end of life.     

Integration of spirituality into health care practice by nurse practitioners

Although conceptualizations of mind, body, and spirit are ancient, spiritual aspects have not been readily integrated into health care. Western medicine's mechanistic model, with its "fix-broken-parts" paradigm, focuses on the physical body, with occasional consideration given to emotional and mental aspects. One's view of self in relation to a Supreme Being, and one's existence and purpose for life is central to health at all levels, e.g., spiritual, physical, emotional, and cognitive. The purpose of this article is to describe the role that nurse practitioners can and should take with patients and their families in integrating spirituality into health care practice.     

From competence to capability: a study of nurse practitioners in clinical practice

Aims and objectives. This research aimed to understand the level and scope of practice of the nurse practitioner in Australia and New Zealand further using a capability framework. Background. The original study, from which the present paper was developed, sought to identify competency standards for the extended role of the nurse practitioner in Australia and New Zealand. In doing so the researchers became aware that while competencies described many of the characteristics of the nurse practitioner they did not manage to tell the whole story. In a search of the literature, the concept of capability appeared to provide a potentially useful construct to describe the attributes of the nurse practitioner that went beyond competence. Design. A secondary analysis of data obtained from interviews with nurse practitioners working in Australia and New Zealand was undertaken. These data had previously been obtained in a study to identify nurse practitioner competencies. The analysis described in this paper investigated whether or not the components of capability would adequately explain the characteristics of the nurse practitioner. Methods. Fifteen nurse practitioners were interviewed from Australia and New Zealand. A secondary (deductive) analysis of interview data using capability as a theoretical framework was conducted. Results. The analysis showed that capability and its dimensions is a useful model for describing the advanced level attributes of nurse practitioners. Thus, nurse practitioners described elements of their practice that involved: using their competences in novel and complex situations as well as the familiar; being creative and innovative; knowing how to learn; having a high level of self‐efficacy; and working well in teams. Conclusions. This study suggests that both competence and capability need to be considered in understanding the complex role of the nurse practitioner. Relevance to clinical practice. The dimensions of capability need to be considered in the education and evaluation of nurse practitioners.     

The specialist palliative care nurse: a qualitative study of the patients' perspective

BACKGROUND: Relatively little is known about patients' perceptions of the work and role of the specialist palliative care nurse. Understanding the patients' perspective can help to evaluate services, improve quality of care, and identify misunderstandings. OBJECTIVES: To explore the experiences of those who said that they had a 'terminal illness', focusing on patients' perceptions of the work and role of these nurses. DESIGN: Qualitative study with narrative interviews. SETTING: England and Wales. PARTICIPANTS: Forty-one people recruited through those working in hospices, community nurses, general practitioners, support groups, a national newspaper, and a conference on palliative care. Twenty-five people talked about the work of specialist palliative care nurses. METHOD: Interviews were fully transcribed; followed by a thematic analysis with constant comparison. RESULTS: Patients valued the nurses' work, particularly their advice on practical matters, information given about their disease, emotional support, advice on symptoms, and help with communication. They were glad that help was readily available. However, some patients who had been referred to the service did not realise that specialist palliative care nurses may be involved at a relatively early stage in a person's illness, and sometimes felt distressed by an early referral. One woman felt she had not had the emotional support she needed and another knew of women who had been upset because these nurses had discussed topics such as place of death 'too early'. However, people recognised the difficulties nurses faced in their work. CONCLUSIONS: Although our study differs from other studies, particularly in the way people were recruited, our findings support previous studies that have shown that specialist palliative care nurses are highly valued by those who have a terminal illness. It is important for people to understand that these nurses may be involved from the time of diagnosis and that roles have changed.     

Managed care organizations' arrangements with nurse practitioners: a Connecticut perspective

Executives in more than 50% of managed care organizations (MCOs) in New York and Connecticut were interviewed for information on the roles, participation, and listing of NPs as primary care providers. MCO executives are highly satisfied with their primary care provider NPs, particularly in women's health and geriatrics, secondary to spending more time teaching and explaining procedures than physicians. Among both health care professionals and the general public there is an overall lack of current knowledge and/or confusion about NPs and their practice. Eighty-two percent of executives in MCOs thought their organization should encourage the use of NPs as primary care providers. Beginning in the early 1960s, advanced practice nursing has shown steady growth. Research has found that NPs provide cost-effective, quality-driven patient care (Brown & Grimes, 1995; Cohen & Juszczak, 1997; Frampton & Wall, 1994; Hardy & Evans, 1995). Many thought health care reform would lead to an expansion of advanced practice nurses (APNs) and other nonphysician providers as primary care providers (Aiken & Salmon, 1994). Funding for and enrollment in graduate nursing programs rose nationwide (American Association of Colleges of Nursing, 1996). Anecdotal reports indicated that NPs were not included in MCO primary care provider panels. The purpose of this study was to explore MCO arrangements with nurse practitioners and the factors that influence them.     

Illuminating the clinical nurse specialist role of advanced practice nursing: a qualitative study

As the advanced practice nursing initiative in Canada gains momentum, effort is being directed towards clarifying and defining advanced practice roles. A qualitative study was undertaken to increase understanding of the clinical nurse specialist role of advanced practice. Sixteen nurses who worked in advanced practice roles, organizing and providing healthcare for children with complex health needs and their families across the continuum of care, participated in in-depth conversations about the nature of their practice, the knowledge that informs it and the factors that influence it. Findings suggest that clinical nurse specialists have a unique role in the organization and delivery of healthcare for specialized populations with complex health needs in their dual focus on the system level of healthcare and on population health needs. Initiatives directed to children and families within the study participants' specialties included program development, consultation and educational outreach and the development of clinical guidelines and policies. Although the nurses described their practice as focusing both on individual children and families and on the population of children and families within their specialty, it is at the population level that they see their greatest potential for contributing to the delivery of high-quality, cost-effective healthcare.     

Patients' and practice nurses' perceptions of secondary preventive care for established ischaemic heart disease: a qualitative study

A significant proportion of patients with established ischaemic heart disease remain unrecognized in general practice and those who are receiving treatment are experiencing sub-optimal care. The provision of coronary prevention by practice nurses may be an important strategy to improve the quality of this care, and this is feasible and effective. This study explored what occurred during patients' initial assessment for secondary prevention of ischaemic heart disease with a practice nurse and investigated patients' and practice nurses' views ofnurse-led clinics in primary care. Nurses were effective in history taking and offering reassurance and dietary advice, yet were less confident in discussing patients' understandings of heart disease and related medication. Practice nurse-led coronary preventive care is acceptable to both nurses and patients. Further practice nurse education is required in heart disease, cardiac medications and skills necessary for exploring and challenging patients' understandings of these issues.