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International Journal of Nursing Practice 2014; 20: 629–635
RESEARCH PAPER
The evolving role of nurses in primary care medical settings Nelly D Oelke PhD Assistant Professor, Faculty of Health and Social Development, School of Nursing, University of British Columbia, Okanagan Campus, Kelowna, British Columbia, Canada Adjunct Faculty, Faculty of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Jeanne Besner PhD Former Director, Health Systems and Workforce Research Unit, Alberta Health Services, Calgary, Alberta, Canada
Rebecca Carter MA Continuous Improvement Leader, Calgary Rural and Highland Primary Care Networks, Calgary, Alberta, Canada
Accepted for publication April 2013 Oelke ND, Besner J, Carter R. International Journal of Nursing Practice 2014; 20: 629–635 The evolving role of nurses in primary care medical settings The role of nurses in primary care is understudied. The purpose of this study was to describe the current registered nurse (RN) role in three Primary Care Networks (PCNs) in western Canada and to identify opportunities for optimal utilization of RNs in these settings. Case study methodology included interviews and document review. Although the RN role evolved during the study, most RNs focused on chronic disease management. Role ambiguity was evident between nurses and with interprofessional team members. Relationships of RNs to other providers, particularly physicians, impacted the enactment of the nursing role. Other barriers to role enactment included physician fee-for-service remuneration, management structures and processes, lack of access to electronic medical records and lack of previous opportunities to apply primary health-care education in the practice setting. Further work is needed to optimize the RN role in primary care to ensure maximum impact for patients, providers and the health system overall. Key words: Canada, nurses’ practice patterns, nurse’s role, primary care, primary health care.
INTRODUCTION Primary health-care redesign continues to be a major focus in Canada to address the issues of ageing populations,1,2 increased chronic disease,3,4 health human Correspondence: Nelly D. Oelke, School of Nursing, Faculty of Health and Social Development, University of British Columbia, Okanagan Campus, 3333 University Way, Kelowna, BC, Canada V1V 1V7. Email: [email protected] Institution where research was conducted: Health Systems and Workforce Research Unit, Alberta Health Services, 10301 Southport Lane SW, Calgary, AB. T2W 1S7. doi:10.1111/ijn.12219
resource shortages5,6 and health-care system sustainability.7,8 In Alberta, Primary Care Networks (PCNs) were implemented as an innovative primary care strategy through a trilateral agreement9 between the Alberta Medical Association, Alberta Health and Wellness, and former regional health authorities, now the single entity of Alberta Health Services. PCN services address five objectives: access to primary care services; management of 24/7 primary care services; prevention, health promotion, chronic disease and complex care; coordination of services across the continuum of care; and facilitation of team-based care.9 Nurses, pharmacists, behavioural health © 2013 Wiley Publishing Asia Pty Ltd
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consultants and social workers are being hired by PCNs to support physicians in providing comprehensive primary care services for their patients. The integration of nurses, particularly registered nurses (RNs), is widespread in Alberta PCNs.
BACKGROUND Health promotion, disease/injury prevention and population health underpin the practice of RNs. The optimal role of the RN includes the assessment of individual, community and population needs, focusing on the social determinants of health; integrating services across the continuum; interprofessional and intersectoral collaboration; and facilitating partnerships with individuals and communities to actively participate in their care.10 Scope of practice is defined as the knowledge, competencies and skills nurses are educated and legislated to perform, reflected in the practice standards of regulatory bodies.11 Overall, little consideration has been given to the practice of RNs in Canadian primary care medical settings except for recent primary health-care redesign initiatives.12 Prior to these initiatives, few RNs (13%) practised in this setting.13 The existing literature, although limited, suggested the RN role was poorly understood and underutilized in primary care. The enactment of the RN role varied significantly,14 and RNs did not typically work to their full scope of practice.12,15,16 Many RNs frequently performed activities, such as clerical work (e.g. booking appointments, tests), stocking supplies, rooming patients and cleaning equipment,12,17,18 not directly related to patient care. Previous research also showed that role ambiguity and physician trust influenced RN role enactment.16 Despite continued role ambiguity and the lack of opportunity for nurses to work to their full scope of practice, research has shown positive outcomes, particularly for patients, through the integration of nurses in primary care settings. A systematic review19 evaluating outcomes of care provided by primary care nurses (e.g. heart disease, depression) found that patients had higher rates of satisfaction, higher rates of compliance with medication and treatment, and increased knowledge of their condition and treatment. Given the limited information on primary care nursing roles in the literature, this research provides important information on current RN role enactment, barriers to working to full scope of practice and opportunities to optimize the RN role. The current role of RNs is © 2013 Wiley Publishing Asia Pty Ltd
described in three PCNs in Alberta, and opportunities for improving the optimal utilization of these nurses in these settings are discussed.
METHODS A case study design was used to examine RN role enactment in three Alberta PCNs. Multiple, embedded, comparative case study methods20 were utilized to guide data collection and analysis, with each PCN representing a distinct case. Embedded within each of the PCNs were additional contextual units of analysis impacting RN role enactment: urban/rural similarities and differences, influence of fee-for-service models, PCN structure and function, physician practice and patient mix. Data collection took place in PCNs in two phases over approximately 1 year. Three Alberta PCNs participated in the study, each one unique in its geographic location, size, programmes and maturity. PCN1 was established in 2006, serving a population of approximately 10 000 people in rural Alberta, including two First Nations communities. PCN1 encompassed 31 physicians and 10 staff (e.g. executive director, nurses, pharmacist, dietitian, midwife, respiratory therapist). Mental health, chronic disease management (CDM) and navigation services involved nurses. The PCN was located in close proximity to physician offices, and a small acute care hospital also existed in the local community. PCN2 was implemented in 2005 in a large urban centre. One hundred physicians from 18 distinct clinics were part of the PCN; 40 other health-care providers (e.g. nurses, dietitians, pharmacists, social workers) were employed to provide services to approximately 105 000 patients. Nursing services included CDM, complex care and maternal health. PCN3, the newest and largest PCN in our study, was implemented in 2007. It consisted of approximately 250 physicians, serving over 250 000 people in a large urban centre. The PCN employed nurses, behavioural health consultants, pharmacists and administrative staff. Programmes offered included nursing, mental health, hospitalist liaison, physiotherapy, pharmacy and population health. In Phase 1, qualitative approaches (interviews and document review of nursing job descriptions) were completed to understand current nursing roles in the participating PCNs. Semistructured interviews21 were conducted with 42 individuals (nurses, other providers, physicians, decision-makers) across the PCNs. The
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631
Table 1 Interview breakdown by PCN PCN PCN1 Phase 1 Phase 2 PCN2 Phase 1 Phase 2 PCN3 Phase 1 Phase 2
Staff†
Patients
12 19
15 8
18 15
0 0
12 14
20 11
†
Due to the overall small numbers of interviews in each of the stakeholder groups, for confidentiality’s sake all non-nursing and nursing interviews are reported as a group. Non-nursing interviews included physicians, other health-care providers such as pharmacists, dietitians, social workers and midwives, administrative staff, and managers.
breakdown of interviews is outlined in Table 1. Participants were recruited through PCN administrators, and maximum variation22 in participants ensured varied perspectives on the current RN role in these settings, role optimization or perceptions of how they could be, barriers and facilitators to optimization, and the impact of the RN role in this setting on patient, provider and systemlevel outcomes. Interviews were completed face to face and were 30–90 min in length. All interviews were audio-recorded, and field notes were taken by the interviewer. Nursing job descriptions were collected for document review in each of the PCNs (n = 12). Mixed methods were employed in Phase 2 and are outlined in Table 2. Given the participatory approach used and the contextual differences of each of the PCNs, data collection varied for each of the PCNs. Qualitative data (e.g. interview transcripts, job descriptions, team meeting notes) were analysed using inductive thematic analyses.23 Data were coded and categorized in NVivo7™ software (QSR International (Americas) Inc., Burlington, MA, USA) to facilitate data management and analysis. Documents (job descriptions) were analysed manually for themes. More specifically, job descriptions were analysed to determine whether what was expected of nurses differed substantially across PCNs, as well as what was occurring in actual practice. Common themes were then identified across all data sources and
recurring patterns explored.24 Constant comparative methods25 were used to ensure continuous comparison of the data. Research procedures followed an iterative process, with one data collection activity and analysis informing future data collection and analysis.24 All quantitative data (e.g. job shadowing, patient surveys, health utilization data) were analysed using spss 13.0TM statistical software (SPSS Inc., Chicago, IL, USA). Descriptive statistics were reported for baseline and follow-up data. The small number of surveys completed by patients and the loss of patients to follow-up prohibited meaningful analysis of patient data.
RESULTS Overall, there was significant evolution of the RN role over the duration of the study. The introduction of RNs in primary care was relatively new, as PCNs were a new service delivery model in Alberta at the time of data collection. For some PCNs, nursing was a recent addition to the complement of services, whereas in others nursing was more established. For the most part, nursing roles focused on the physical needs and physiological disease processes of patients, a majority of whom were receiving care for the management of chronic diseases. To deliver our main chronic disease management areas [is the nurse’s area of responsibility] . . . We see that the majority is diabetes, obesity, and then dyslipidaemia. So really, they pretty much focus on those areas. (PCN stakeholder) Although RNs recognized they could play a major role in promoting the health of the population, they did not feel supported in enacting this aspect of their role. A change of attitudes among physicians, other providers and nurses themselves would be required to help nursing shift from an individual, disease-oriented focus to a more holistic, health-oriented approach. Role ambiguity was evident in all PCNs. There was lack of role clarity between RNs and licensed practical nurses (LPNs)a, between nurses and other healthcare team members, and between RNs and clinic administrative staff. Role ambiguity among RNs and nurse practitioners (NPs) was evident in two of the PCNs, whereas in the other, RNs suggested NPs played a central role in optimizing the utilization of all categories of nurses. The relationship between RNs and physicians varied within and between PCNs. Clearly evident was that the nature of the relationship and the degree of trust between © 2013 Wiley Publishing Asia Pty Ltd
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Table 2 Phase 2 data collection by PCN PCN
Components of Phase 2
Data collection
PCN1/PCN3
Baseline data (understanding of nursing role†, patient data, context)
• • • • • • • • • • • • •
Role optimization initiatives Follow-up data collection
PCN2
Baseline data (in-depth understanding of nursing role, patient data)
Job shadow template Ethnographic field notes for job shadowing, patient contacts Patient surveys (quality of life, perceptions of nursing care) Statistics Canada data on population served Documented activities Team meeting notes Interviews with nurses, physicians, other providers, PCN stakeholders Job shadowing, ethnographic field notes Patient surveys Patient interviews Demographic data from patient database Nursing activity audits Interviews prior to and immediately after patient appointment with nurses to discuss intended care, care actually delivered
†
PCN1 focused on registered nurse (RN) and LPN roles, whereas PCN2 and PCN3 focused only on the RN role. PCN, Primary Care Network
RNs and physicians influenced nursing role enactment. If there was a good relationship between a physician and a nurse, the nurse was encouraged and allowed to do more than if the relationship was not well established or there was limited trust by the physician of the nurse. You need to have a personal understanding; you need to have professional respect and rapport, because when the physician says ‘I need you to do this for me on this particular patient’, that’s the physician’s responsibility if something doesn’t go right. It’s also the physician’s livelihood. This is their practice. It’s their professional identity. A lot riding on the quality of work this other team member provides. And so, there has to be trust in that relationship. (PCN stakeholder) Participants noted an increase in integration with physicians over the study duration, given the time to build relationships. As relationships between nurses and physicians improved, participants perceived more autonomy in enacting their appropriate role. Physicians could choose whether or not to avail themselves of the PCN nursing programme, either formally, by not enrolling to participate, or informally, by not referring patients to the nurse. Awareness and understanding of the nursing role by physicians was also lacking. © 2013 Wiley Publishing Asia Pty Ltd
And hopefully, there will be more utilization of the nurses too. There will be more accountability for the doctors providing us with the patient referrals and the expectation of more followups. . . . I’ve heard from other nurses too that there’s been some real underutilization and just the physicians not being aware of what the role is and how to use them. (PCN nurse) Historically, physicians in primary care settings completed many activities RNs were capable of, but when nurses were introduced by PCNs, physicians were challenged in relinquishing responsibilities to nurses and other providers. They don’t want to take away—they want to do the histories, they want to do the full exams, they want to do the teaching, because they feel like that’s part of their job. (PCN stakeholder) Collaboration and coordination of services in PCNs was initially characterized by fragmentation and duplication. Nurses were not necessarily co-located with other health-care professionals, which, in some instances, presented a barrier to collaboration. Most often, nurses saw patients by referral only, primarily by the physician, as opposed to using a collaborative approach to care. Occasionally, self-referral patients were seen, or patients were
Role of nurses in primary care
referred by another provider. Some increase in collaboration was noted during the study when two PCNs implemented joint appointments between the nurse and other health-care providers (e.g. dietitian). We’re going to see this patient together as a team and we’re going to come up with a set of goals. (PCN nurse) Four barriers to nursing role optimization were described by participants in each of the PCNs. First, the current fee-for-service funding structure impacted nurses’ ability to practice to the full extent of their knowledge and skills. For physicians to receive remuneration for services rendered, patients were required to see the physician prior to receiving other PCN services. This resulted in duplication and RNs not always being able to see patients unless referred by the physician. Second, management structures and processes also inhibited nurses from being able to work to their full scope of practice. Job descriptions and nursing programme guidelines often limited the populations they could work with and the care they were able to provide. Third, electronic medical records (EMRs) caused barriers when they were not accessible to nurses. RNs were unable to access lab results and physician progress notes, and in turn, they were unable to chart in the EMR, limiting their access to and ability to provide up-to-date information on patients. Fourth, participants were concerned about their education and experience not preparing them to work in a primary care setting. The lack of opportunity for nurses to implement their primary health-care education in prior settings left them thinking they were less than adequately prepared for nursing in this setting. Primary care nurses also needed to be flexible, to be able to work in a less structured environment, and to move from more specialized care to a more general approach – often the exact opposite to situations in acute care, where there was a great amount of structure and little room for flexibility in their practice. These barriers presented significant challenges for nurses participating in our study, limiting their ability to optimize their roles within the PCNs under study.
DISCUSSION This research focused on the RN role in primary care medical settings. PCNs were purposefully selected to capture variability in size, geography and length of operation, testing the hypothesis that these might impact
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nursing role enactment. In reality, the size of the PCN and its location did not appear to have a noticeable influence on role enactment. The length of operation did have some influence on role enactment: More established PCNs were characterized by longer-standing, more trusting relationships between providers, positively influencing role optimization and collaborative practice. Additionally, the amount of support provided to RNs by the PCN did impact the ability for RNs to work towards a more optimal role. Over the course of the study, evolution of the RN role in participating PCNs was clear. One PCN moved to a more generalist (i.e. rather than disease or programmespecific) role for its nurses. In that same PCN, physicians initially saw nurses as decreasing their workload by completing tasks (e.g. injections, dressings), but later came to realize the benefit of nurses caring for patients with complex conditions and psychosocial needs. Even so, RNs’ care focused primarily on CDM for patients with one or more chronic conditions at the expense of holistic patient care addressing all the patient’s health needs. Nurses were most often hired to work in PCN programmes (e.g. CDM, diabetes, hypertension) established long before actual nursing staff were hired. Research results showed actual roles were not necessarily well aligned with the optimal role of the nurse. As noted earlier, the key components of the optimal role of the RN are population health, disease/injury prevention and health promotion,10 whereas in this study there was minimal focus on the same. Nursing interventions encompassing the physiological, psychological, social, cultural and/or spiritual should assist patients and families to promote, retain and/or recover their health.26 Considering the needs of communities and populations, in addition to the needs of individuals and families, is another foundational component of the RN role.27 The study was able to increase the awareness of the expected role of RNs, but participants were not confident change would occur in PCNs in the near future given the prevailing focus on physical and medical needs of patients. The lack of differentiation between RN and LPN roles was evident in our study. Although LPN work focused more on tasks as compared with RN work, which one would expect, similar functions were performed frequently by RNs and LPNs. A significant component of the differentiation of RN and LPN roles is the focus of RN practice on the social determinants of health and on health needs at the community and population level in addition © 2013 Wiley Publishing Asia Pty Ltd
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to the assessment of health needs of individuals and families.10 Hence, the focus on disease-oriented care in PCNs contributes to the lack of differentiation between RN and LPN roles; without full enactment of the RN role to include the components above, role ambiguity and underutilization of RNs will persist. Similar findings were also made in acute care settings.28 Apparent in the study was the dependence of role optimization on the relationship between nurses and other providers, in particular physicians. Overall, the RN role was poorly understood by all providers, including RNs themselves. The RN role was delineated by relationships between RNs and physicians, requiring a foundation of trust, as opposed to the needs of patients and communities. Role enactment cannot be based on the relationship between providers, but must be established by the education, knowledge and competencies of the health-care professional. Fragmentation and duplication were evident between nurses and other providers within PCNs. Efforts were being made to remedy duplication of services, and some change was evident over the course of the study. Considering the ambiguity in roles between RNs and other providers, substantial work will still be required to address these issues. Barriers to optimizing the role of RNs in primary care were apparent. Fee-for-service models impact the opportunity for physicians to work as part of an interprofessional team. Current management structures and processes within PCNs were also seen to influence whether nurses were able to work to their full scope of practice. Finally, nurses did not feel their education and prior experience prepared them appropriately to work in this type of setting. Better understanding of these issues is required to facilitate the full integration of RNs in primary care practice. Research results provide several opportunities to improve optimal utilization of RNs. First, a clearly defined vision of the role for nursing in primary care will facilitate an overall direction for nursing in this setting, as well as for all stakeholders. Second, well-defined roles for RNs and other providers (including other nursing providers) will decrease role ambiguity and territorialism. Third, patients should have direct access to RNs to address their needs; hence, the physician fee-for-service remuneration model should be reevaluated to facilitate appropriate direct access to nurses for patients and assist RNs to work autonomously within their scope of practice. © 2013 Wiley Publishing Asia Pty Ltd
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Finally, well-articulated programmes for PCNs based on the needs of the populations they serve with expected outcomes will enhance the clarity and direction of care for nurses and all providers. Nurses have an important role to play in primary care, with the potential to positively impact outcomes. Further work is needed to facilitate the optimization of the RN role in this setting to ensure maximum impact for patients, health-care providers and the health system overall.
ACKNOWLEDGEMENTS Funding for this study was provided by the Canadian Institute for Health Research and Alberta Innovates. We would also like to acknowledge the participation of management, staff and physicians in the three Primary Care Networks in which the study occurred. The authors have no conflicts of interest to declare.
NOTE a
Licensed practical nurses in Alberta are educated in a 2-year programme with a defined scope of practice and specific competencies.29 Education (some only have 1 year of training) and scope of practice vary across provinces in Canada, as does the name of this category of practitioners (e.g. registered practical nurses in Ontario).
REFERENCES 1 Canadian Institute for Health Information. Health care in Canada, 2011: a focus on seniors and aging. 2011. Available from URL: https://secure.cihi.ca/estore/productFamily .htm?locale=en&pf=PFC1677. Accessed 31 May 2012. 2 Conference Board of Canada. How Canada performs: a report card on Canada. 2012. Available from URL: http:// www.conferenceboard.ca/hcp/Details/Health.aspx. Accessed 31 May 2012. 3 World Health Organization. Global status report on noncommunicable diseases 2010. 2011. Available from URL: http://www.who.int/nmh/publications/ ncd_report2010/en/. Accessed 31 May 2012. 4 Health Council of Canada. Helping patients help themselves: are Canadians with chronic conditions getting the support they need to manage their health? Available from URL: http://publications.gc.ca/collections/collection_2011/ ccs-hcc/H173-1-2-2010-eng.pdf. Accessed 13 October 2013. 5 Canadian Nurses Association. Tested solutions for eliminating Canada’s registered nurse shortage. 2009. Available from URL: http://www.nursesunions.ca/sites/default/ files/rn_shortage_report_e.pdf. Accessed 13 October 2013.
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6 World Health Organization. Increasing access to health workers in remote and rural areas through improved retention. 2009. Available from URL: http://www.who.int/ hrh/migration/background_paper.pdf. Accessed 9 August 2011. 7 Health Council of Canada. Progress report 2011: healthcare renewal in Canada. 2011. Available from URL: http:// www.healthcouncilcanada.ca/rpt_det.php?id=165. Accessed 13 October 2013. 8 Morgan MW, Zamora NE, Hindmarsh MF. An inconvenient truth: a sustainable healthcare system requires chronic disease prevention and management transformation. Healthcare Papers 2007; 7: 6–23. 9 Primary Care Initiative. About PCNs. 2010. Available from URL: http://www.albertapci.ca/AboutPCNs/Pages/ default.aspx. Accessed 23 December 2010. 10 College and Association of Registered Nurses of Alberta. Primary Healthcare. Edmonton: College and Association of Registered Nurses of Alberta, 2008. 11 Canadian Nurses Association. Framework for the Practice of Registered Nurses in Canada. 2007. Available from URL: http://www2.cna-aiic.ca/CNA/documents/pdf/ publications/RN_Framework_Practice_2007_e.pdf. Accessed 31 January 2013 12 Allard M, Frego A, Katz A, Halas G. Exploring the role of RNs in family practice residency training programs. The Canadian Nurse 2010; 106: 20–24. 13 Canadian Institute for Health Information. Regulated nurses: Canadian trends, 2004–2008. 2009. Available from URL: http://publications.gc.ca/collections/collection _2009/icis-cihi/H115-48-2008E.pdf. Accessed 13 October 2013. 14 Besner J, Drummond J, Oelke ND, McKim B, Carter R. Optimizing the practice of registered nurses in the context of an interprofessional team in primary care. Calgary: Health Systems and Workforce Research Unit, 2011. 15 Alsaffar A. Family practice: a nursing perspective. Toronto: Ontario Family Practice Nurses, 2005. Available from URL: http://rnao.ca/sites/rnao-ca/files/storage/connect/ interest-groups/917_OFPN_Family_Practice_Nursing _Perspective.pdf. Accessed 13 October 2013. 16 Akeroyd J, Oandasan I, Alsaffar A, Whitehead C, Lingard L. Perceptions of the role of the registered nurse in an urban
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interprofessional academic family practice setting. Canadian Journal of Nursing Leadership 2009; 22: 73–84. Gibson T, Heartfield M. Mentoring for nurses in general practice: An Australian study. Journal of Interprofessional Care 2005; 19: 50–62. Todd C, Howlett M, MacKay M, Lawson B. Family practice/primary health care nurses in Nova Scotia. The Canadian Nurse 2007; 103: 23–27. Keleher H, Parker R, Abdulwadud O, Francis K. Systematic review of the effectiveness of primary care nursing. International Journal of Nursing Practice 2009; 15: 16–24. Yin RK. Case Study Research: Design and Methods. Thousand Oaks, CA, USA: Sage Publications, Inc, 2003; ix-166 p. Kvale S. An Introduction to Qualitative Research Interviewing. Thousand Oaks, CA, USA: Sage Publications, 1996. Polit DE, Hungler BP. Nursing Research, Principles and Methods. Philadelphia: Lippincott, 1999. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA, USA: Sage Publications, 1985. Morse JM, Richards L. README FIRST for A User’s Guide to Qualitative Methods. Thousand Oaks, CA, USA: Sage Publications, 2002. Glasser B, Strauss A. The Discovery of Grounded Theory. Chicago, IL, USA: Aldine Publishing Company, 1967. Royal College of Nurses. Pillars of the community: the RCN’s UK position on the development of the registered nursing workforce in the community. 2010. Available from URL: http://www.rcn.org.uk/__data/assets/pdf_file/ 0007/335473/003843.pdf. Accessed 24 December 2010. College and Association of Registered Nurses of Alberta. Entry-to-Practice Competencies for the Registered Nurse Profession. Edmonton: College and Association of Registered Nurses of Alberta, 2006. White D, Jackson K, Besner J et al. Enhancing nursing role effectiveness through job redesign. 2009. Available from URL: http://www.calgaryhealthregion.ca/hswru/ documents/reports/JobRedesignReportFeb2009.pdf. Accessed 18 July 2010. College of Licensed Practical Nurses of Alberta. Competency Profile for LPNs, 2nd edn. 2009. Available from URL: http://www.clpna.com/wp-content/uploads/2013/02/ doc_AB_LPN_Competency_Profile_2nd%20Edition.pdf. Accessed 13 October 2013.
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International Journal of Nursing Practice 2014; 20: 629–635
RESEARCH PAPER
The evolving role of nurses in primary care medical settings Nelly D Oelke PhD Assistant Professor, Faculty of Health and Social Development, School of Nursing, University of British Columbia, Okanagan Campus, Kelowna, British Columbia, Canada Adjunct Faculty, Faculty of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Jeanne Besner PhD Former Director, Health Systems and Workforce Research Unit, Alberta Health Services, Calgary, Alberta, Canada
Rebecca Carter MA Continuous Improvement Leader, Calgary Rural and Highland Primary Care Networks, Calgary, Alberta, Canada
Accepted for publication April 2013 Oelke ND, Besner J, Carter R. International Journal of Nursing Practice 2014; 20: 629–635 The evolving role of nurses in primary care medical settings The role of nurses in primary care is understudied. The purpose of this study was to describe the current registered nurse (RN) role in three Primary Care Networks (PCNs) in western Canada and to identify opportunities for optimal utilization of RNs in these settings. Case study methodology included interviews and document review. Although the RN role evolved during the study, most RNs focused on chronic disease management. Role ambiguity was evident between nurses and with interprofessional team members. Relationships of RNs to other providers, particularly physicians, impacted the enactment of the nursing role. Other barriers to role enactment included physician fee-for-service remuneration, management structures and processes, lack of access to electronic medical records and lack of previous opportunities to apply primary health-care education in the practice setting. Further work is needed to optimize the RN role in primary care to ensure maximum impact for patients, providers and the health system overall. Key words: Canada, nurses’ practice patterns, nurse’s role, primary care, primary health care.
INTRODUCTION Primary health-care redesign continues to be a major focus in Canada to address the issues of ageing populations,1,2 increased chronic disease,3,4 health human Correspondence: Nelly D. Oelke, School of Nursing, Faculty of Health and Social Development, University of British Columbia, Okanagan Campus, 3333 University Way, Kelowna, BC, Canada V1V 1V7. Email: [email protected] Institution where research was conducted: Health Systems and Workforce Research Unit, Alberta Health Services, 10301 Southport Lane SW, Calgary, AB. T2W 1S7. doi:10.1111/ijn.12219
resource shortages5,6 and health-care system sustainability.7,8 In Alberta, Primary Care Networks (PCNs) were implemented as an innovative primary care strategy through a trilateral agreement9 between the Alberta Medical Association, Alberta Health and Wellness, and former regional health authorities, now the single entity of Alberta Health Services. PCN services address five objectives: access to primary care services; management of 24/7 primary care services; prevention, health promotion, chronic disease and complex care; coordination of services across the continuum of care; and facilitation of team-based care.9 Nurses, pharmacists, behavioural health © 2013 Wiley Publishing Asia Pty Ltd
630
ND Oelke et al.
consultants and social workers are being hired by PCNs to support physicians in providing comprehensive primary care services for their patients. The integration of nurses, particularly registered nurses (RNs), is widespread in Alberta PCNs.
BACKGROUND Health promotion, disease/injury prevention and population health underpin the practice of RNs. The optimal role of the RN includes the assessment of individual, community and population needs, focusing on the social determinants of health; integrating services across the continuum; interprofessional and intersectoral collaboration; and facilitating partnerships with individuals and communities to actively participate in their care.10 Scope of practice is defined as the knowledge, competencies and skills nurses are educated and legislated to perform, reflected in the practice standards of regulatory bodies.11 Overall, little consideration has been given to the practice of RNs in Canadian primary care medical settings except for recent primary health-care redesign initiatives.12 Prior to these initiatives, few RNs (13%) practised in this setting.13 The existing literature, although limited, suggested the RN role was poorly understood and underutilized in primary care. The enactment of the RN role varied significantly,14 and RNs did not typically work to their full scope of practice.12,15,16 Many RNs frequently performed activities, such as clerical work (e.g. booking appointments, tests), stocking supplies, rooming patients and cleaning equipment,12,17,18 not directly related to patient care. Previous research also showed that role ambiguity and physician trust influenced RN role enactment.16 Despite continued role ambiguity and the lack of opportunity for nurses to work to their full scope of practice, research has shown positive outcomes, particularly for patients, through the integration of nurses in primary care settings. A systematic review19 evaluating outcomes of care provided by primary care nurses (e.g. heart disease, depression) found that patients had higher rates of satisfaction, higher rates of compliance with medication and treatment, and increased knowledge of their condition and treatment. Given the limited information on primary care nursing roles in the literature, this research provides important information on current RN role enactment, barriers to working to full scope of practice and opportunities to optimize the RN role. The current role of RNs is © 2013 Wiley Publishing Asia Pty Ltd
described in three PCNs in Alberta, and opportunities for improving the optimal utilization of these nurses in these settings are discussed.
METHODS A case study design was used to examine RN role enactment in three Alberta PCNs. Multiple, embedded, comparative case study methods20 were utilized to guide data collection and analysis, with each PCN representing a distinct case. Embedded within each of the PCNs were additional contextual units of analysis impacting RN role enactment: urban/rural similarities and differences, influence of fee-for-service models, PCN structure and function, physician practice and patient mix. Data collection took place in PCNs in two phases over approximately 1 year. Three Alberta PCNs participated in the study, each one unique in its geographic location, size, programmes and maturity. PCN1 was established in 2006, serving a population of approximately 10 000 people in rural Alberta, including two First Nations communities. PCN1 encompassed 31 physicians and 10 staff (e.g. executive director, nurses, pharmacist, dietitian, midwife, respiratory therapist). Mental health, chronic disease management (CDM) and navigation services involved nurses. The PCN was located in close proximity to physician offices, and a small acute care hospital also existed in the local community. PCN2 was implemented in 2005 in a large urban centre. One hundred physicians from 18 distinct clinics were part of the PCN; 40 other health-care providers (e.g. nurses, dietitians, pharmacists, social workers) were employed to provide services to approximately 105 000 patients. Nursing services included CDM, complex care and maternal health. PCN3, the newest and largest PCN in our study, was implemented in 2007. It consisted of approximately 250 physicians, serving over 250 000 people in a large urban centre. The PCN employed nurses, behavioural health consultants, pharmacists and administrative staff. Programmes offered included nursing, mental health, hospitalist liaison, physiotherapy, pharmacy and population health. In Phase 1, qualitative approaches (interviews and document review of nursing job descriptions) were completed to understand current nursing roles in the participating PCNs. Semistructured interviews21 were conducted with 42 individuals (nurses, other providers, physicians, decision-makers) across the PCNs. The
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Table 1 Interview breakdown by PCN PCN PCN1 Phase 1 Phase 2 PCN2 Phase 1 Phase 2 PCN3 Phase 1 Phase 2
Staff†
Patients
12 19
15 8
18 15
0 0
12 14
20 11
†
Due to the overall small numbers of interviews in each of the stakeholder groups, for confidentiality’s sake all non-nursing and nursing interviews are reported as a group. Non-nursing interviews included physicians, other health-care providers such as pharmacists, dietitians, social workers and midwives, administrative staff, and managers.
breakdown of interviews is outlined in Table 1. Participants were recruited through PCN administrators, and maximum variation22 in participants ensured varied perspectives on the current RN role in these settings, role optimization or perceptions of how they could be, barriers and facilitators to optimization, and the impact of the RN role in this setting on patient, provider and systemlevel outcomes. Interviews were completed face to face and were 30–90 min in length. All interviews were audio-recorded, and field notes were taken by the interviewer. Nursing job descriptions were collected for document review in each of the PCNs (n = 12). Mixed methods were employed in Phase 2 and are outlined in Table 2. Given the participatory approach used and the contextual differences of each of the PCNs, data collection varied for each of the PCNs. Qualitative data (e.g. interview transcripts, job descriptions, team meeting notes) were analysed using inductive thematic analyses.23 Data were coded and categorized in NVivo7™ software (QSR International (Americas) Inc., Burlington, MA, USA) to facilitate data management and analysis. Documents (job descriptions) were analysed manually for themes. More specifically, job descriptions were analysed to determine whether what was expected of nurses differed substantially across PCNs, as well as what was occurring in actual practice. Common themes were then identified across all data sources and
recurring patterns explored.24 Constant comparative methods25 were used to ensure continuous comparison of the data. Research procedures followed an iterative process, with one data collection activity and analysis informing future data collection and analysis.24 All quantitative data (e.g. job shadowing, patient surveys, health utilization data) were analysed using spss 13.0TM statistical software (SPSS Inc., Chicago, IL, USA). Descriptive statistics were reported for baseline and follow-up data. The small number of surveys completed by patients and the loss of patients to follow-up prohibited meaningful analysis of patient data.
RESULTS Overall, there was significant evolution of the RN role over the duration of the study. The introduction of RNs in primary care was relatively new, as PCNs were a new service delivery model in Alberta at the time of data collection. For some PCNs, nursing was a recent addition to the complement of services, whereas in others nursing was more established. For the most part, nursing roles focused on the physical needs and physiological disease processes of patients, a majority of whom were receiving care for the management of chronic diseases. To deliver our main chronic disease management areas [is the nurse’s area of responsibility] . . . We see that the majority is diabetes, obesity, and then dyslipidaemia. So really, they pretty much focus on those areas. (PCN stakeholder) Although RNs recognized they could play a major role in promoting the health of the population, they did not feel supported in enacting this aspect of their role. A change of attitudes among physicians, other providers and nurses themselves would be required to help nursing shift from an individual, disease-oriented focus to a more holistic, health-oriented approach. Role ambiguity was evident in all PCNs. There was lack of role clarity between RNs and licensed practical nurses (LPNs)a, between nurses and other healthcare team members, and between RNs and clinic administrative staff. Role ambiguity among RNs and nurse practitioners (NPs) was evident in two of the PCNs, whereas in the other, RNs suggested NPs played a central role in optimizing the utilization of all categories of nurses. The relationship between RNs and physicians varied within and between PCNs. Clearly evident was that the nature of the relationship and the degree of trust between © 2013 Wiley Publishing Asia Pty Ltd
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Table 2 Phase 2 data collection by PCN PCN
Components of Phase 2
Data collection
PCN1/PCN3
Baseline data (understanding of nursing role†, patient data, context)
• • • • • • • • • • • • •
Role optimization initiatives Follow-up data collection
PCN2
Baseline data (in-depth understanding of nursing role, patient data)
Job shadow template Ethnographic field notes for job shadowing, patient contacts Patient surveys (quality of life, perceptions of nursing care) Statistics Canada data on population served Documented activities Team meeting notes Interviews with nurses, physicians, other providers, PCN stakeholders Job shadowing, ethnographic field notes Patient surveys Patient interviews Demographic data from patient database Nursing activity audits Interviews prior to and immediately after patient appointment with nurses to discuss intended care, care actually delivered
†
PCN1 focused on registered nurse (RN) and LPN roles, whereas PCN2 and PCN3 focused only on the RN role. PCN, Primary Care Network
RNs and physicians influenced nursing role enactment. If there was a good relationship between a physician and a nurse, the nurse was encouraged and allowed to do more than if the relationship was not well established or there was limited trust by the physician of the nurse. You need to have a personal understanding; you need to have professional respect and rapport, because when the physician says ‘I need you to do this for me on this particular patient’, that’s the physician’s responsibility if something doesn’t go right. It’s also the physician’s livelihood. This is their practice. It’s their professional identity. A lot riding on the quality of work this other team member provides. And so, there has to be trust in that relationship. (PCN stakeholder) Participants noted an increase in integration with physicians over the study duration, given the time to build relationships. As relationships between nurses and physicians improved, participants perceived more autonomy in enacting their appropriate role. Physicians could choose whether or not to avail themselves of the PCN nursing programme, either formally, by not enrolling to participate, or informally, by not referring patients to the nurse. Awareness and understanding of the nursing role by physicians was also lacking. © 2013 Wiley Publishing Asia Pty Ltd
And hopefully, there will be more utilization of the nurses too. There will be more accountability for the doctors providing us with the patient referrals and the expectation of more followups. . . . I’ve heard from other nurses too that there’s been some real underutilization and just the physicians not being aware of what the role is and how to use them. (PCN nurse) Historically, physicians in primary care settings completed many activities RNs were capable of, but when nurses were introduced by PCNs, physicians were challenged in relinquishing responsibilities to nurses and other providers. They don’t want to take away—they want to do the histories, they want to do the full exams, they want to do the teaching, because they feel like that’s part of their job. (PCN stakeholder) Collaboration and coordination of services in PCNs was initially characterized by fragmentation and duplication. Nurses were not necessarily co-located with other health-care professionals, which, in some instances, presented a barrier to collaboration. Most often, nurses saw patients by referral only, primarily by the physician, as opposed to using a collaborative approach to care. Occasionally, self-referral patients were seen, or patients were
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referred by another provider. Some increase in collaboration was noted during the study when two PCNs implemented joint appointments between the nurse and other health-care providers (e.g. dietitian). We’re going to see this patient together as a team and we’re going to come up with a set of goals. (PCN nurse) Four barriers to nursing role optimization were described by participants in each of the PCNs. First, the current fee-for-service funding structure impacted nurses’ ability to practice to the full extent of their knowledge and skills. For physicians to receive remuneration for services rendered, patients were required to see the physician prior to receiving other PCN services. This resulted in duplication and RNs not always being able to see patients unless referred by the physician. Second, management structures and processes also inhibited nurses from being able to work to their full scope of practice. Job descriptions and nursing programme guidelines often limited the populations they could work with and the care they were able to provide. Third, electronic medical records (EMRs) caused barriers when they were not accessible to nurses. RNs were unable to access lab results and physician progress notes, and in turn, they were unable to chart in the EMR, limiting their access to and ability to provide up-to-date information on patients. Fourth, participants were concerned about their education and experience not preparing them to work in a primary care setting. The lack of opportunity for nurses to implement their primary health-care education in prior settings left them thinking they were less than adequately prepared for nursing in this setting. Primary care nurses also needed to be flexible, to be able to work in a less structured environment, and to move from more specialized care to a more general approach – often the exact opposite to situations in acute care, where there was a great amount of structure and little room for flexibility in their practice. These barriers presented significant challenges for nurses participating in our study, limiting their ability to optimize their roles within the PCNs under study.
DISCUSSION This research focused on the RN role in primary care medical settings. PCNs were purposefully selected to capture variability in size, geography and length of operation, testing the hypothesis that these might impact
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nursing role enactment. In reality, the size of the PCN and its location did not appear to have a noticeable influence on role enactment. The length of operation did have some influence on role enactment: More established PCNs were characterized by longer-standing, more trusting relationships between providers, positively influencing role optimization and collaborative practice. Additionally, the amount of support provided to RNs by the PCN did impact the ability for RNs to work towards a more optimal role. Over the course of the study, evolution of the RN role in participating PCNs was clear. One PCN moved to a more generalist (i.e. rather than disease or programmespecific) role for its nurses. In that same PCN, physicians initially saw nurses as decreasing their workload by completing tasks (e.g. injections, dressings), but later came to realize the benefit of nurses caring for patients with complex conditions and psychosocial needs. Even so, RNs’ care focused primarily on CDM for patients with one or more chronic conditions at the expense of holistic patient care addressing all the patient’s health needs. Nurses were most often hired to work in PCN programmes (e.g. CDM, diabetes, hypertension) established long before actual nursing staff were hired. Research results showed actual roles were not necessarily well aligned with the optimal role of the nurse. As noted earlier, the key components of the optimal role of the RN are population health, disease/injury prevention and health promotion,10 whereas in this study there was minimal focus on the same. Nursing interventions encompassing the physiological, psychological, social, cultural and/or spiritual should assist patients and families to promote, retain and/or recover their health.26 Considering the needs of communities and populations, in addition to the needs of individuals and families, is another foundational component of the RN role.27 The study was able to increase the awareness of the expected role of RNs, but participants were not confident change would occur in PCNs in the near future given the prevailing focus on physical and medical needs of patients. The lack of differentiation between RN and LPN roles was evident in our study. Although LPN work focused more on tasks as compared with RN work, which one would expect, similar functions were performed frequently by RNs and LPNs. A significant component of the differentiation of RN and LPN roles is the focus of RN practice on the social determinants of health and on health needs at the community and population level in addition © 2013 Wiley Publishing Asia Pty Ltd
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to the assessment of health needs of individuals and families.10 Hence, the focus on disease-oriented care in PCNs contributes to the lack of differentiation between RN and LPN roles; without full enactment of the RN role to include the components above, role ambiguity and underutilization of RNs will persist. Similar findings were also made in acute care settings.28 Apparent in the study was the dependence of role optimization on the relationship between nurses and other providers, in particular physicians. Overall, the RN role was poorly understood by all providers, including RNs themselves. The RN role was delineated by relationships between RNs and physicians, requiring a foundation of trust, as opposed to the needs of patients and communities. Role enactment cannot be based on the relationship between providers, but must be established by the education, knowledge and competencies of the health-care professional. Fragmentation and duplication were evident between nurses and other providers within PCNs. Efforts were being made to remedy duplication of services, and some change was evident over the course of the study. Considering the ambiguity in roles between RNs and other providers, substantial work will still be required to address these issues. Barriers to optimizing the role of RNs in primary care were apparent. Fee-for-service models impact the opportunity for physicians to work as part of an interprofessional team. Current management structures and processes within PCNs were also seen to influence whether nurses were able to work to their full scope of practice. Finally, nurses did not feel their education and prior experience prepared them appropriately to work in this type of setting. Better understanding of these issues is required to facilitate the full integration of RNs in primary care practice. Research results provide several opportunities to improve optimal utilization of RNs. First, a clearly defined vision of the role for nursing in primary care will facilitate an overall direction for nursing in this setting, as well as for all stakeholders. Second, well-defined roles for RNs and other providers (including other nursing providers) will decrease role ambiguity and territorialism. Third, patients should have direct access to RNs to address their needs; hence, the physician fee-for-service remuneration model should be reevaluated to facilitate appropriate direct access to nurses for patients and assist RNs to work autonomously within their scope of practice. © 2013 Wiley Publishing Asia Pty Ltd
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Finally, well-articulated programmes for PCNs based on the needs of the populations they serve with expected outcomes will enhance the clarity and direction of care for nurses and all providers. Nurses have an important role to play in primary care, with the potential to positively impact outcomes. Further work is needed to facilitate the optimization of the RN role in this setting to ensure maximum impact for patients, health-care providers and the health system overall.
ACKNOWLEDGEMENTS Funding for this study was provided by the Canadian Institute for Health Research and Alberta Innovates. We would also like to acknowledge the participation of management, staff and physicians in the three Primary Care Networks in which the study occurred. The authors have no conflicts of interest to declare.
NOTE a
Licensed practical nurses in Alberta are educated in a 2-year programme with a defined scope of practice and specific competencies.29 Education (some only have 1 year of training) and scope of practice vary across provinces in Canada, as does the name of this category of practitioners (e.g. registered practical nurses in Ontario).
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