Collaborative practice in health systems change: the Nova Scotia experience with the Strengthening Primary Care Initiative

Recently attention has been focussed on the significance of primary care to the Canadian healthcare system. Nova Scotia. Like other provinces, is seeking ways to improve the healthcare that it provides within a financially constrained publicly funded system. The Strengthening Primary Care Initiative in Nova Scotia (SPCI) was a primary care demonstration project to evaluate specific goals related to primary care. Although the provincial government conceived the SPCI, the approach to its planning and implementation was participatory and consultative. Funded through the federal Health Transition Fund (HTF) (Health Canada 2002) and the government of Nova Scotia, the SPCI involved changes in four communities over a three-year period (2000-2002). These changes included the introduction of a primary healthcare nurse practitioner in collaborative practice with one or more family physicians; remuneration of the family physician(s) with methods other than a solely fee-for-service (FFS) arrangement; and the introduction and utilization of a computerized patient medical record. The SPCI was committed to a consultative process with stakeholders, and this gave rise to several challenges. Initially there was disagreement on the requirement for nurse practitioners at each of the demonstration sites. The Minister of Health confirmed that a nurse practitioner was a required component at each demonstration site. Differences in perspectives on the role of allied health professionals in the SPCI were encountered, and the significance of the role pharmacists have in primary care was not fully appreciated until after the SPCI had started. At the time the SPCI began there was no legislation for nurse practitioners in Nova Scotia; therefore, an approval mechanism for nurse practitioner practice was authorized through the provincial regulatory bodies for nursing and medicine. Malpractice and liability issues, particularly on the part of providers who had never worked with nurse practitioners before, were an initial concern. Recruitment of nurse practitioners into the three rural sites mirrored the difficulties with recruitment of healthcare providers encountered in other parts of rural Canada. The authors discuss their perspectives on the challenges related to interdisciplinary collaboration in health systems change that were encountered during the planning and implementation of the SPCI. Although nurse practitioner Legislation has existed in Ontario and Newfoundland and Labrador for several years, many provinces are grappling with the challenges associated with the introduction of nurse practitioners and collaborative practice. This paper conveys the experience of one province and will be of interest to administrators, educators and practitioners elsewhere in Canada who are engaged in primary healthcare renewal.     

Nurse practitioners in Ontario primary healthcare: Referral patterns and collaboration with other healthcare professionals

The purpose of this study is to examine referrals of nurse practitioners providing primary healthcare (PHC NPs) to better understand how PHC NPs collaborate with other healthcare professionals and contribute to interprofessional care. The analysis is based on the data from a survey of 378 PHC NPs registered in Ontario, Canada in 2008. Overall, 69% of PHC NPs made referrals to family physicians (FPs) and 67% of PHC NPs received referrals from FPs. Almost 50% of PHC NPs had bidirectional referrals between them and FPs. Eighty-nine percent of PHC NPs made referrals to specialist physicians. Bidirectional referrals between PHC NPs and social workers and mental health workers were common in family health teams and community health centers. Patterns of referrals (bidirectional, unidirectional and no referrals) between PHC NPs and FPs, social workers, mental and allied health workers in various practice settings indicate development of collaborative relationships between PHC NPs and other healthcare professionals and reflect the influence of practice models on delivery of interprofessional care. These findings are discussed in light of the development of NPs' role and integration of PHC NPs in the Ontario healthcare system. Implications for policy changes and future research are also suggested.     

Nurse practitioners in Ontario primary healthcare: referral patterns and collaboration with other healthcare professionals

The purpose of this study is to examine referrals of nurse practitioners providing primary healthcare (PHC NPs) to better understand how PHC NPs collaborate with other healthcare professionals and contribute to interprofessional care. The analysis is based on the data from a survey of 378 PHC NPs registered in Ontario, Canada in 2008. Overall, 69% of PHC NPs made referrals to family physicians (FPs) and 67% of PHC NPs received referrals from FPs. Almost 50% of PHC NPs had bidirectional referrals between them and FPs. Eighty-nine percent of PHC NPs made referrals to specialist physicians. Bidirectional referrals between PHC NPs and social workers and mental health workers were common in family health teams and community health centers. Patterns of referrals (bidirectional, unidirectional and no referrals) between PHC NPs and FPs, social workers, mental and allied health workers in various practice settings indicate development of collaborative relationships between PHC NPs and other healthcare professionals and reflect the influence of practice models on delivery of interprofessional care. These findings are discussed in light of the development of NPs' role and integration of PHC NPs in the Ontario healthcare system. Implications for policy changes and future research are also suggested.     

The experience of role transition in acute care nurse practitioners in Taiwan under the collaborative practice model

The role of the acute care nurse practitioner in Taiwan has changed significantly since the 1990s due in significant part to a shortage of interns and resident physicians in acute care settings. The first year of professional practice represents an important transitional year during which new professionals develop their competency to provide high-quality care to hospitalized patients. As the actual experience of individuals undergoing this transitional process into their new role has yet to be fully explored, this research studied and categorized the experiences of acute care nurse practitioners during their first year of role transition under the collaborative model of practice. We used a qualitative inquiry method with in-depth interviews to investigate the relevant experiences of 10 acute care nurse practitioners working at a medical center in Taiwan. Results show that the experience of expert nurses in their transition to acute care nurse practitioners passed through three phases during the first year under the collaborative practice model. These phases include the role ambiguity, role acquisition, and role implementation phases. Each phase contained a set of sub-themes which describe the multiple dimensions of this experience. This study highlights the experiences, stresses and accomplishments of acute care nurse practitioners during their initial year of advanced practice.     

The Acute Care Nurse Practitioner in Collaborative Practice

Nurse-physician relationships remain, for the most part, hierarchical in nature. A hierarchical structure allows the person at the top, most notably the physician, the highest level of authority and power for decision making. Other health care providers are delegated various tasks related to the medical plan of care. One role of nonmedical health care providers, including nurses, is to support the medical plan of care and increase the productivity of physicians. Medical centers have house staff, usually interns and residents, who work collaboratively with the attending physicians in care delivery. At one medical center, a shortage of medical house staff for internal medicine prompted the development and evaluation of an alternative service. The alternative service utilized master prepared, certified nurse practitioners on a nonteaching service to provide care for selected types of medical patients. Physicians consulted with nurse practitioners, but retained decision-making authority concerning patient admission to the service. This paper describes the development and evaluation of an alternative service based on a collaborative practice model and the role of nurse practitioners working under such a model. Discussion includes suggestions for process guideline development for organizations that want to improve collaborative practice relationships between unit nursing staff, nurse practitioners, and physicians.     

Components Necessary in a Successful Nurse Practitioner-Physician Collaborative Practice

In recent years, collaborative practice has gained much attention from nurse practitioners in primary health care settings. This is because many nurse practitioners feel that nurse practitioners and physicians can complement each other's roles. Together, they can provide more comprehensive, quality primary health care than either profession can provide by itself. Nurse practitioners and physicians working together to care for a common group of patients may have varying degrees of collaboration in their practice. This article discusses some elements and components necessary to maximize the quality and extent of collaboration.     

Effective collaboration: the key to better healthcare

Timely access to primary healthcare is becoming increasingly difficult for many Canadians. In a healthcare system created for managing acute illness and communicable disease, the complex care that millions of Canadians with chronic illnesses require is not being appropriately managed. The answer is not more healthcare dollars; it's better use of the funding already allocated. The key to delivering accessible, comprehensive and cost-effective care is effective collaboration among health professionals. The nurse practitioner role offers a unique skill set, incorporating health promotion and disease prevention into primary healthcare, complementing the roles of a variety of other health professionals. In spite of increasing interest and commitment to collaboration, numerous barriers remain. Perceived competition, leadership struggles and confusion about the role have hindered collaboration between nurse practitioners and physicians. Increased interest in interprofessional education has given rise to improved awareness and respect for the knowledge of other disciplines, raising hopes that fostering interdisciplinary working relationships will result in better client care. Nurse practitioners must take the lead in increasing the visibility of their role, improving public understanding and fostering collaborative relationships with other health professionals in order to provide the most effective care for Canadians.     

What Do Faculty Physicians Know About Nurse Practitioner Practice?

Collaboration between physicians and nurse practitioners (NPs) has been identified as a critical component of effective co-managed care delivery models. Interprofessional knowledge and perceptions impact collaboration, yet little is known about faculty physicians’ knowledge of NP scope of practice or perceptions of NP competencies. The purpose of this study was to explore the knowledge and perceptions of a large group of West Coast faculty physicians pertaining to the NP practice. The intent is that the findings will spark interprofessional conversations throughout the country that will lead to improved collaborative care delivery models.     

List of contributors

Strategies have been proposed to facilitate collaboration between conventional health care providers in primary care. However, little is known if these are transferable to CAM health care providers. We designed a qualitative study to articulate a conceptual model to advance the interprofessional collaboration between physicians and chiropractors within community-based primary care in Ontario, Canada. Data obtained from 16 key informants and eight focus groups, with a range of professionals including chiropractors, physicians and academia as well as patients, informed the development our framework. The framework included processed-based factors that clustered under three categories: communication, practice parameters, and service delivery; presumed necessary to address challenges and optimize benefits of collaboration. The development of this framework may help understand and promote interprofessional collaborative practice and contribute to the understanding of how CAM may participate in mainstream healthcare.     

Tertiary Nurse Practitioners

Tertiary nurse practitioners are proposed to meet the specialized health care needs of complex patients. Societal changes, increasing numbers of medically vulnerable people and increased costs of health care demand innovative responses to health care delivery. Nurse practitioners' effectiveness in primary care settings supports their introduction into acute care settings. Nurse practitioners are involved in tertiary care in response to a need for the delivery of care to patients with specialized needs. The evolution of the tertiary nurse practitioner role pre-dated the response of educational institutions to provide appropriate preparation for practitioners in tertiary care. Curricular imperatives and policy issues that will influence professional practice of the tertiary nurse practitioner are discussed .     

Culture Care Theory: a proposed practice theory guide for nurse practitioners in primary care settings

Leininger's Theory of Culture Care Diversity and Universality is presented as a foundational basis for the educational preparation, primary care contextual practice, and outcomes-focused research endeavours of advanced practice nursing. Discussion emphasises the value of care and caring as the essence of advanced practice nursing through the use of three modes of care, use of the Sunrise and other enablers, and the ethnonursing method. Education, research, practice, and key concepts of the theory are connected as essential components toward the provision of culturally congruent care to meet the healthcare needs of diverse individuals, families, groups, and communities by family nurse practitioners.     

Perceptions of physicians, nurses, and respiratory therapists about the role of acute care nurse practitioners.

BACKGROUND: Information about the contributions of acute care nurse practitioners to medical management teams in critical care settings is limited. OBJECTIVE: To examine contributions of acute care nurse practitioners to medical management of critically ill patients from the perspectives of 3 disciplines: medicine, respiratory care, and nursing. METHODS: Attending physicians, respiratory therapists, and nurses in 2 intensive care units were asked to list 3 advantages and 3 disadvantages of collaborative care provided by acute care nurse practitioners. Qualitative methods (coding/constant comparative analysis) were used to identify common themes and subthemes. Overall response rate was 35% (from 69% for attending physicians to 26% for nurses). RESULTS: Responses were grouped into 4 main themes: accessibility, competence/knowledge, care coordination/communication, and system issues. Acute care nurse practitioners were valued for their accessibility, expertise in routine daily management of patients, and ability to meet patient/family needs, especially for "long-stay" patients. Also, they were respected for their commitment to providing quality care and for their communication skills, exemplified through teaching of nursing staff, patient/family involvement, and fluency in weaning protocols. Physicians valued acute care nurse practitioners' continuity of care, patient/family focus, and commitment. Nurses valued their accessibility, commitment, and patient/family focus. Respiratory therapists valued their accessibility, commitment, and consistency in implementing weaning protocols. CONCLUSION: Responses reflected unique advantages of acute care nurse practitioners as members of medical management teams in critical care settings. Despite perceptions of the acute care nurse practitioner's role as medically oriented, the themes reflect a clear nursing focus.     

A nurse practitioner model of practice in the neonatal intensive care unit

PURPOSE: The purpose of this study was to describe the practice of the nurse practitioner (NP) in the neonatal intensive care unit (NICU) in an attempt to define an advanced practice nursing model that is unique to NP practice in the NICU. DESIGN: This qualitative research used an ethnographic case study design to answer the research question: 'What is the practice model of nurse practitioners working in the NICU?' METHODS: Seven nurse practitioners working in five level II/III NICUs in Massachusetts and Rhode Island were interviewed and observed in practice. Audiotaped interviews using open-ended questions and field notes from participant observations were analyzed for patterns of behavior. RESULTS: These nurse practitioners practiced within a model of advanced practice nursing that emphasized health, holism, and caring within the highly technological and medical NICU environment. CLINICAL IMPLICATIONS: A model of NP practice in the NICU is emerging and needs further development and testing. Nurse educators and administrators must find ways to support the nursing model in the advanced practice nursing role in the NICU. Nurse practitioners need to be more active in promoting a clearer understanding of their practice and contributions to the NICU care delivery team.     

Emergency Physicians' Attitudes Toward the Emergency Nurse Practitioner Role: Validation Versus Rejection

A qualitative grounded theory approach was used in this study, which examined the attitudes of a group of emergency physicians toward collaborative practice with emergency nurse practitioners. Interviews were conducted with five physicians who were not currently working with nurse practitioners. Responses were coded, and a substantive theory model of dependent collaboration emerged. The physicians supported the emergency nurse practitioner role on the grounds that it be supervised in the traditional fashion by the physician. Concerns regarding education, trust, liability, and capability were identified. Deficits in knowledge regarding training and the role/function of nurse practitioners were also identified.     

Collaboration between pharmacists,physicians and nurse practitioners: A qualitative investigation of working relationships in the inpatient medical setting

While collaborative, team-based care has the potential to improve medication use and reduce adverse drug events and cost, less attention is paid to understanding the processes of well functioning teams. This paper presents the findings from key informant interviews and reflective journaling from pharmacists, physicians and nurse practitioners participating in a multicentre, controlled clinical trial of team-based pharmacist care in hospitalized medical patients. A phenomenological approach guided the data analysis and content analysis was the primary tool for unitizing, categorizing and identifying emerging themes. Pharmacists experienced highs (developing trusting relationships and making positive contributions to patient care) and lows (struggling with documentation and workload) during integration into the medical care team. From the perspective of the participating pharmacists, nurse practitioners and physicians, the integration of pharmacists into the teams was felt to have facilitated positive patient outcomes by improving team drug-therapy decision-making, continuity of care and patient safety. Additionally, the study increased the awareness of all team members' potential roles so that pharmacists, nurses and physicians could play a part in and benefit from working together as a team. Focussed attention on how practice is structured, team process and ongoing support would enable successful implementation of team-based care in a larger context. (ClinicalTrials.gov number, NCT00351676)     

A Classic Manuscript Reprinted in Celebration of 25 Years of Progress

From July 1971, to July 1972, in a large suburban Ontario practice of two family physicians, a randomized controlled trial was conducted to assess the effects of substituting nurse practitioners for physicians in primary-care practice. Before and after the trial, the health status of patients who received conventional care from family physicians was compared with the status of those who received care mainly from nurse practitioners. Both groups of patients had a similar mortality experience, and no differences were found in in physical functional capacity, social function or emotional function. The quality of care rendered to the two groups seemed similar, as assessed by a quantitative "indicator-condition" approach. Satisfaction was high among both patients and professional personnel. Although cost effective from society's point of view, the new method of primary care was not financially profitable to doctors because of current restrictions on reimbursement for the nurse-practitioner services.