A process-based framework to guide nurse practitioners ...

Integrating Nurse Practitioners into primary care teams is a process that involves significant challenges. To be successful, nurse ... Skiptomaincontent Advertisement SearchallBMCarticles Search DownloadPDF Researcharticle OpenAccess Published:27February2015 Aprocess-basedframeworktoguidenursepractitionersintegrationintoprimaryhealthcareteams:resultsfromalogicanalysis DamienContandriopoulos1,AstridBrousselle2,Carl-ArdyDubois1,MélaniePerroux1,Marie-DominiqueBeaulieu3,IsabelleBrault1,KelleyKilpatrick1,DanielleD’Amour1&EstherSansgter-Gormley4  BMCHealthServicesResearch volume 15,Article number: 78(2015) Citethisarticle 12kAccesses 40Citations 13Altmetric Metricsdetails AbstractBackgroundIntegratingNursePractitionersintoprimarycareteamsisaprocessthatinvolvessignificantchallenges.Tobesuccessful,nursepractitionerintegrationintoprimarycareteamsrequires,amongotherthings,aredefinitionofprofessionalboundaries,inparticularthoseofmedicineandnursing,acoherentmodelofinter-andintra-professionalcollaboration,andteam-basedworkprocessesthatmakethebestuseofthesubsidiarityprinciple.Therehavebeennumerousstudiesonnursepractitionerintegration,andtheliteratureprovidesacomprehensivelistofbarriersto,andfacilitatorsof,integration.However,thisliteratureismuchlessprolificindiscussingtheoperationallevelimplicationsofthosebarriersandfacilitatorsandinofferingpracticalrecommendations.MethodsInthecontextofalarge-scaleresearchprojectontheintroductionofnursepractitionersinQuebec(Canada)wereliedonalogic-analysisapproachbased,ontheonehandonarealistreviewoftheliteratureand,ontheotherhand,onqualitativecase-studiesin6primaryhealthcareteamsinruralandurbanareaofQuebec.ResultsFivecorethemesthatneedtobetakenintoaccountwhenintegratingnursepractitionersintoprimarycareteamswereidentified.Thosethemesare:planning,roledefinition,practicemodel,collaboration,andteamsupport.Thepresentpaperhastwoobjectives:topresentthemethodsusedtodevelopthethemes,andtodiscussanintegrativemodelofnursepractitionerintegrationsupportcenteredaroundthesethemes.ConclusionItconcludeswithadiscussionofhowthisframeworkcontributestoexistingknowledgeandsomeideasforfutureavenuesofstudy. PeerReviewreports BackgroundMajorchallengesfordevelopedcountries’healthsystemsinthenextdecadesincludepervasivehealthinequalities;limitationsinhealthservicesaccessibility,carecomprehensiveness,andcontinuity,especiallyinprimarycare;demographicshifts;technologicaldevelopments;andfiscalconstraints[1-7].Thepressingnatureofthesechallengesshouldnot,however,obscurethefactthat,attheprogrammaticlevel,thereisstrongevidenceoneffectiveinterventionpaths.Amongthose,increasedrelianceonprimarycareoverspecializedhospital-basedcareandagreaterrolefornursesandothernon-physicianprofessionalsinprimarycareteamsareofparticularimportancetosimultaneouslyimproveefficiencyandaccessibility[8-12].Inthisgeneralcontext,thecurrentarticleisfocusedononespecificobjective,whichistoprovideevidence-based,practicaladvicetosupporttheeffectiveintegrationofprimarycarenursepractitioners(NP)intocaredeliverysystems.Wehavepursuedthisobjectiveusinganoriginalresearchstrategycombiningresultsfromlogicandimplementationanalyses[13].ThereisalargebodyofevidencesuggestingthatincreasedrelianceonNPshasthepotentialtoimproveaccessibilityofprimarycareserviceswhilecontrollingexpenditures[8,14-20].However,integratingNPsintoprimarycareteamshasprovenchallenginginpractice[8,19,21,22].Thereisabundantliteratureanalyzingtheunderlyingcausesofthosechallenges,butoperationalliteratureonthesolutionstoovercomethemisconsiderablymorelimited.ContextIn2010,Quebec’sgovernmentannounceditwouldsupportNPpracticeandfundtheintegrationof500primarycareNPsoverthenextdecade.Themainobjectiveputforwardwastoimproveaccessibility[23].Thisdecisionwasthestartingpointforalarge-scaleresearchprojectfocusedonsupportingprimarycareteamsthatintegratedNPsastheywentthroughtheprocessofrethinkingcaredeliverymodels,processes,androles.ThemajorityofhealthcareservicesinQuebecarefundedthroughaBeveridgeanpublicinsurancesystem.EssentialCare,whetherofferedinpubliclyownedinstitutionsorinprivatemedicalclinics,isusuallyfreeatthepointofservice.TheMinistryofHealthandSocialServices(MSSS)fundsservicesthroughpublictaxationandhasadirectresponsibilityintheoverallgovernanceofthehealthcaredeliverysystem.Whenthegovernmentdecidedtoadd500NPstothehealthcaresystem,theMSSShadacentralroleindrafting,implementing,andsupervisinga“deploymentplan”thatwouldreachthebroaderpolicyobjectiveofimprovingaccessibilitytoprimarycareservices.Forexample,studentsinNPmaster’sprogramsareofferedagenerousbursarypackagebytheMSSStosupporttheirstudiesandprofessionaltravelexpensesinexchangeforacommitmenttoworkatleastthreeyearsinalocationapprovedbytheMinistry.InQuebec,primarycareNPsareregisterednurseswhohavesuccessfullycompletedamaster’s-level,university-based,NPprogram.Uponemploymenttheyarerequiredtoworkincollaborationwithatleastonephysician,withwhomtheysigna“partnershipagreement”.NPshavethelegalandregulatoryauthority,incollaborationwithaphysician,toassess,diagnoseandtreatpatientsforacutecommonillnessesandinjuries,managechronicdiseases,providepregnancycareupto32weeksofgestation,andengageinhealthandwellnesspromotion.Theyorderandinterpretdiagnostictests,prescribedrugs(basedonaformulary)andperformspecificprocedureswithintheirlegislatedscopeofpractice[24].Uponcompletionoftheireducationalprograms,andpriortoregistration,NPgraduatesareaccordedtherighttopracticeundermedicalsupervisionas“candidates”andhavetwoyearstopassthecertificationexamjointlydraftedbythenursingandmedicalprofessionalboards.NPsareexpectedtoprovideprimarycareinpublicorganizationsprovidingprimarycareandsocialservices(CLSCs);hospital-basedfamilymedicineunits(UMFs),whichtrainmedicalresidentsinfamilymedicine;andfamilymedicinegroups(GMFs).GMFsareprivatemedicalclinicswherepublichospitalscoverthesalaryandbenefitsofnursingstaff(bothRNsandNPs)inexchangeforclinicsprovidingextendedopeninghoursandincreasedcarecontinuity.MethodsInthispaperwereportonfindingobtainedfromanoriginalresearchstrategycombiningresultsfromlogicandimplementationanalyses[13].ThelogicdatawerederivedfrompublishedliteratureandimplementationdatawerederivedfromcasestudiesconductedbytheresearchteaminQuebec(Canada).Therecommendationspresentedherearebasedonacombinedlogicandimplementationanalysis.Bothevaluationapproachesaimtoassessthepotentialvalueofagivenintervention,buteachhasadifferentfocus.Ononehand,“Logicanalysisisanevaluationthatallowsustotesttheplausibilityofaprogram’stheoryusingavailablescientificknowledge—eitherscientificevidenceorexpertknowledge”[25].Implementationanalysis,ontheotherhand,reliesmostlyonempiricalobservationstoidentifyfactorsthatactuallyenhanceorimpedetheimplementationoftheinterventionortheproductionofitseffects[26].CombiningthesetwoevaluationapproachesallowedustobuildacomprehensiveunderstandingoffactorsandcontextualcharacteristicspotentiallyinfluencingNPimplementation,whichinturnmadeitpossibletoprovideevidence-basedadvicetooptimizeimplementationandmaximizeNPs’effectiveness.Furthermore,implementationanalysiswashelpfulinidentifyingwhichdeterminantsofimplementationeffectivenessweremoreimportantthanothersasdeploymentofNPswasbeingplannedandphased-in.Attheoperationallevel,theresearchteamfirstconductedalogicanalysisofQuebec’sNPdeploymentplanandofNPpracticepatterns,mostlybasedonarealistreviewoftheliteratureandonexpertadvice.Wethenconductedanimplementationanalysisusingacasestudyresearchdesign(n = 6cases)inthreehealthregionsofQuebec.TheevidencederivedfromboththelogicandimplementationanalyseswasthencombinedintopracticaladvicepertainingtofivecorethemesthatstructuretheNPintegrationprocess.Figure 1belowrepresentsphasesoftheresearchprocessschematically.Figure1 Researchprocess. FullsizeimageLogicanalysisFirstwebeganwithalogicanalysiswhichisathree-stepapproach[25,27]consistingofbuildingalogicmodel,developingtheconceptualframework,andevaluatingprogramtheory.Tobuildthelogicmodel,weconsultedavailabledocumentsproducedbytheMinistry,regionalboards,professionalorganizationsandexpertsfromtheMSSSwhoweredirectlyinvolvedintheNPimplementationplaninQuebec.Wethenreviewedtheavailablepublishedevidencethroughamethodinspiredbytherealistreviewapproach[28-31].UsingthelogicmodeloftheMSSS’NPimplementationplanweestablishedasastartingpoint,weiterativelybuilt,fromtheliterature,aconceptualmodelofthebestpracticesandsupportingconditionsforNPintegrationintoprimarycareteams.GiventhecomplexityofNPimplementation,purelykeyword-basedsearchsyntaxeswereunlikelytoprovidesatisfactoryresults[28,31-34].Asastartingpoint,wechoseinsteadtoconductamanualsearchintheAdvanced-PracticeNursing(APN)LiteratureDatabase[35],inwhichallthescientificliteraturepublishedonadvancedpracticenursingbetween2000and2009hadbeensystematicallycompiled.Weextractedthe3,674referencesidentifiedasrelevanttoadvanced-practicenursingintheAPNdatabaseandmanuallyassessedtheirrelevanceforthepurposeofourstudybasedontitlesandabstracts.Atotalof159articleswereretainedforfurtherreview.Toberetained,documentshadtoaddressNPimplementationinprimaryhealthcareteams,practicemodels,orintegrationprocesses.Twomembersoftheresearchteamindependentlyassessedtheretainedarticlesforrelevance.Nextdocumentsweresummarizedusinganabstractiontoolandgivenarelevancescoreandascientificvalidityscore,bothrangingfrom1to3.Therelevancescorerangedfrom1fordocumentsofferingaminorormarginalcontributiontotheunderstandingofthephenomenastudiedto3fordocumentsprovidingdetailedinsightsdirectlyfocusedonthosephenomena.Thevalidityscorerangedfrom1foraneditorialopinionorsignificantlyflawedresearchto3foranarticlepresentingresultsfromarobustandwell-conductedmethod.Foreditorialtypematerialwithnodiscernableevidencebase,reviewersalsohadtheoptionofremovingthearticlefromthedatabase(scoreof0).Onlydocumentswithacombinedscore(relevanceandvalidity)of4orhigher,43articleswereretainedasprimarysourcesforanalysis.Atthetimeofconductingthereview,theAPNLiteratureDatabasewaslimitedtoliteraturepublishedbetween2000and2009.Toincludepublicationsafter2009,wereproducedthesearchsyntaxusedtocompiletheAPNLiteratureDatabasetoidentifyarticlespublishedbetween2010and2012.Weappliedthesamesortingmethodstothissecondcorpusofarticlesandretained53articlesforfulltextualanalysis.Ofthese,15wereaddedtothe43documentsselectedinthefirstphase.Altogether58documentswereselectedforin-depthanalysis.Thedocuments,bothpeer-reviewedarticlesandresearchreports,weretheniterativelyread,oftenseveraltimes,andanalyzedtobuildapreliminaryconceptualmodelaccordingtotherealistreviewapproach[28,31,34,36].ThemodelwasfocusedonstructuringavailableevidencetosupportNPintegration.Fromtheliterature,fivemajorthemeswereinductivelyidentifiedastheconceptualmodel’scoreelements:1)planningtheintegration,2)roledefinition,3)patientmanagement,4)collaboration,and5)supporttotheteam.Foreachtheme,weproducedafirstsummaryoftheinformationcollectedintheliteraturereview.Atthispoint,theinterdisciplinaryexpertiseoftheresearchteam(whichincludedregisterednurses,NPs,physicians,andexpertsinorganizationaltheoryandhealthadministration)wasappliedtoidentifynewdocumentsonanadhocbasis.Thedraftsummaryforeachthemewasthenusedastheanalyticalframeworkfortheimplementationanalysis.ImplementationanalysisTheseconddatasource,uponwhichtheadviceprovidedhereisbased,comesfromanimplementationanalysisusingsixqualitativecasestudies.EachcasewasdefinedasaclinicalteamintowhichoneormoreNPshadbeenintegratedinQuebec.WeidentifiedpotentialcasesincollaborationwithMSSSandwiththeRegionalHealthandSocialServicesAgencies(ASSS)involved.Caseswereselectedbasedontwocriteria.First,caseshadtoinvolveteamswhoseNPintegrationwasseenassuccessfulbytheMSSSortheASSS,inordertoidentifyandanalyzesuccessfulintegrationmodels.Second,toimprovetheexternalvalidityofthefindings[37-39]wedeliberatelysoughtmaximumvariationintermsofenvironment(rural,suburban,urban),organizationalsetting(privatelyownedclinics,community-basedpubliclyownedclinics,andhospital-basedprimarycareteams),andstageofNPintegration.Table 1belowprovidesadditionalinformationonthecharacteristicsofeachcasestudysite.Table1 Locationandteamcompositionforeachcasestudysite FullsizetableFindingsfromthecasestudiesarebasedon34semi-structuredinterviewsconductedwithmembersoftheclinicalteamsandotherkeyactorsaswellasonanalysisofavailabledocumentation.Ineachsetting,researchersskilledininterviewingconductedinterviewswiththemainstakeholdersinvolvedintheNPintegrationintotheprimarycareteam,suchastheNP,thephysicianpartner,andtheChiefNursingOfficerofthelocalhospital,andmostofthenursesandtheadministrativestaffofeachoftheprimarycareteams.Allinformantsgaveinformedconsent,andbestpracticesfortheethicalconductofresearchwerefollowed.Theprojectwasapprovedandsupervisedbytheresearchethicscommitteesofallinstitutionsinvolved.Eachofthesixcaseswasundertheresponsibilityofoneteammember,whoproducedanarrativecasesummarypercase,structuredaroundthefivethemesidentifiedintheliteraturereview.Thosesummarieswerediscussedinresearchteammeetings,andcross-caseinsightswereidentified.Inasecondstep,weproducedfivenarrativetheme-basedcross-analysesofthecasestosynthesizethecontributionofempiricalcase-studyevidenceaccordingtoeachofthefivepreviouslyidentifiedthemes.CombinedanalysisAftercompletingtheimplementationanalysis,werevisedthesummariesconstructedduringthelogicanalysisphasetoincorporateempiricalknowledgederivedfromthecasestudies.Ultimately,theevidencefromthelogicanalysisandtheimplementationanalysiswasintegratedintoonesingletheme-basednarrative,andthespecificexpertiseofeachteammemberwasmobilizedinthatprocess.Theobjectivesofusingtwodifferentapproachestoanalysiswere:1)tobeabletocross-validateandcomparetheevidencederivedfromtheliteraturetopracticesidentifiedinourcasestudiesand;2)toassesstheapplicabilityandusefulnessoftheliterature-basedadviceinreal-worldcontextsanddeterminewhichofthefactorsidentifiedintheliteratureweremostimportantinsupportingtheimplementationofprimarycareNPs;and3)tobetterappraiseimplementationdynamicsandunderstandhowfactorsareintertwinedduringtheimplementationprocess.Threeimportantpointsshouldbemaderegardingthefinalintegrationofthematerial.First,ourfocuswastoofferpracticaladvice.Muchoftheliteratureisstructuredaroundidentifyingbarriersandfacilitators[8,40-44]butofferslittletosupportteams’improvement.Itmightalsobeworthstressingherethatintegrationisaprocess,andthusadynamicphenomenon,whereasalistofbarriersandfacilitatorsisaverystaticanalyticalframework.Second,weaimedforasinglesetoftheme-basedrecommendationsforallteammembers,whetherNPs,RNs,MDs,administrators,orsupportstaff.Whatisyourthirdpoint?ResultsAsdescribedintheMethodologysectionabove,unlessotherwisespecified,thefindingsprovidedherecomefromtheintegrationofevidencefromthelogicanalysisandimplementationanalysiscomponentsofthestudyandarestructuredaroundthefivethemesidentified.PlanningtointegrateanNP:anopportunityforclinicalteamsThefirstelementinsuccessfullyintegratinganNPintoaprimarycareteamisadvanceplanning.Althoughthismayseemobvious,ourdatasuggestinadequateplanningisalltoocommon[21,22,45].Thefirststepintheplanningprocessistoreflectontheintendedpracticemodelindiscussionsamongallthedifferentactorsinvolved(physicians,nurses,managers,andothermembersoftheteam).Acomprehensiveplandevelopedcollectivelybyallteammembersisakeyfactorinimplementinganeffectiveandsatisfactorypracticemodel.Inpracticalterms,itisthusimportanttotakeintoaccountthetimeandenergythisprocesswillrequirefromtheclinicalteamandtheconsequenttimeline[46].OuranalysissuggeststhereareoftenpreconceivednotionsaboutthenatureofNPs’trainingandpractice[47].ItisalsoimportantnottounderestimatethedistancebetweenmakingadministrativeandregulatoryinformationaboutNPs’roleandscopeofpracticeavailableandensuringthatallteammembersareawareofthisinformation.Preparationisamatternotonlyofmakinginformationavailablebutalsooftransformingavailableinformationintopracticalknowledge[48-50].Morebroadly,thearrivalofanNPshouldbeseenasanopportunitytoreflectonthecurrentpracticemodel’sstrengthsandweaknessesandtoestablishasharedvisionofthedesiredfuturepracticemodel.Thisreflectionshouldcovercertainfundamentalconsiderations,suchasfitbetweenpatients’needsandappropriateresponse,solutionstoimprovethepracticemodelandroleofeachprofessionalintheteam[21,51-55].Oncethepracticemodelisdefined,thebroaddimensionsoftheNP’sroleandexpectedcontributionshouldbediscussed.TheNP’sactualroleneedstobediscussedduringthehiringprocessanddeterminedincollaborationwiththeNPhired;however,bydefiningbroaddimensionsbeforehand,theteamwillbeabletoassesswhethertheirexpectationsarerealisticandconsistentwiththeregulatoryandadministrativeframeworkgoverningNPpractice.Ateam-generateddefinitionalsoprovidesausefultoolforcandidateinterviews.ItwillalsobeimportanttotakeintoaccountthelevelofexperienceoftheNPhiredandthepotentialevolutionofthatperson’spracticewithgrowingexperienceandabilities.Allavailableevidencesuggeststhefirstyearofpracticeaftergraduationisoneoftransition[42,45,46,56,57].Ourdatasuggestthatakeyoperationalfactoristoformallydesignateapersontobeinchargeofthepracticalstepsoftheintegrationprocess,includingsettingupcommunicationstrategiestoensureeffectiveinformationtransmissionwithinandoutsidetheteam[45,58].Finally,throughouttheprocess,itisimportanttobothconceiveofandpresentthearrivalofanNPasanopportunityforthewholeteamtoimprovebyreflectingonhowthingsarecurrentlydone,identifyingareasforpracticeimprovement,andcreatingavisionfortheentireteam’sfuturepractice.RoledefinitionandconsensusbuildingTheimportanceofappropriatelyandcoherentlydefiningtheNP’sroleandscopeofpracticeis,byfar,thepointmostoftenmadeintheliteratureonobstaclestocollaborationortoNPintegration[40,59-62].Theresultsfromourcombinedanalysisshowthat,evenwhenallclinicalteammemberssharethedesiretodevelopacollaborativepractice,misunderstandingsandconflictsaroundrolesarefrequentandsignificantbarrierstoNPintegrationandpractice.WhentheNP’srolesetiswell-defined,thereisconsensusabouthowpatientmanagementresponsibilitiesaredistributed,eachteammember’sskills,andscopeofpractice,aswellasdifferencesandsimilaritiesofroles[63].Overall,thereissolidevidencetosupporttheneedforteamconsensusonroledefinition.However,evidencetosupportmoreinstrumentalrecommendationsonhowtocreatesuchaconsensusinsideinterdisciplinarycareteamsismuchweaker.Theoptimallevelofroleformalization,inparticular,isopentodebate.Thelevelofformalizationdescribestheextenttowhicheachperson’sroleisdefined,inmoreorlessdetail,inwrittendocuments.Some[51,56]suggestthattheroledefinitionprocessshouldresultineachperson’srolebeingformalizedinwriting.However,wehavefoundnostrongempiricalevidencetosupporttheconclusionthatroleformalizationisthesoleorbestwaytosupportconsensusaroundroledefinitions.Onehypothesisderivedfromourstudyisthattheoptimallevelofformalizationisafunctionofteamsizeandthatlargerteamsmayrequiregreaterformalization.Inanycase,roleformalizationshouldbesufficientlyflexibleandmalleabletoallowteammembers’practicestoevolve[64,65].Excessiveroleformalizationthatattemptstosetdowninwritingeverypossiblesituationandallinterventionsisprobablycounterproductivetocollaboration[65,66].Notwithstandingthelevelofformalization,acentralelementintheprocessofdefiningtheNP’sroleis,infact,therecognitionthattheprocesscannotbelimitedtotheNP’srole.CoherentlydefiningtheNP’sroleandpracticalscopeofpracticeinvolvesrethinkingeveryone’srolez[53,67,68]).Failuretodosoislikelytoproduceroleoverlaps,redundancies,andfrustrations.Sibbald,LaurantandScott[69]proposedausefultypologyfordefiningprimarycarerolesusingfourlogics: enhancement,whichinvolveswideningthefieldofpracticeorthecompetenciesofaprofessionalgroup; substitution,whichinvolvesreplacingonetypeofprofessionalbyanotherintheprovisionofcertainservices; delegation,whichinvolvesallowingasubordinateprofessionaltoprovideextendedservices,butunderthesupervisionofanothertypeofprofessional; innovation,whichinvolvesestablishingnewtypesofservicesorcreatingnewprofessionalroles. Theselogicsarenotmutuallyexclusivebutcanserveasguidepostsforthinkingabouttheprocessofredefiningrolesinateam.Asageneralrule,roledefinitionshouldenableallteammembersto: practicetothefullscopeoftheircapacities;. contributeefficientlyandeffectivelytopatientmanagementaccordingtoeachprofessional’sexpertise. developtheirownexpertiseandcapacitiesandfacilitatethisdevelopmentprocess. Atthepracticallevel,anessentialfactorintheroledefinitionprocessistheidentificationofoneormoreprojectchampionsintheorganization,suchaschiefnursingofficersornurseconsultants,whowillhelpensurethefullscopeoftheNP’spracticeisrespected.Itisalsohelpfultorepeatperiodicallytheinteractiveprocessofdiscussingteammembers’roles,asthoseevolveovertime.SeveralpatientcaremodelsbutnosimplerecipeThepracticemodelforNPsinQuebec,asdescribedinofficialdocumentsandregulations[70-77],isoneinwhichNPsandtheirphysicianpartnerslookafterpatients’needscollectively.Inpracticethisgeneralprinciplecantaketwodifferentforms:the“jointmodel”andthe“consultativemodel”[21,51].AmodelisconsideredjointwhentheNPandthephysicianpartnerfollowthesamepanelofpatients.Insuchamodel,bothprofessionalsmayseethesamepatientsatdifferentpointsintheirtreatment.Conversely,amodelisconsideredconsultativewhentheNPandthephysicianpartnereachfollowadifferentpanelofpatientsandthephysicianisconsultedasneeded.Inthatmodel,mostpatientsfollowedbytheNPneverseethephysicianexceptfortheoccasionalspecificneed.Followingtheevidencederivedfromtheliterature,weusedthreedimensionstoassessthesuitabilityofpatientcaremodels:grouppractice,interdisciplinarypractice,andcollaborativepractice[67,78-82].Grouppracticeischaracterizedbyteammembers’sharingofresourcesandresponsibilities.Ininterdisciplinarypractice,thepatientmanagementmodelisbasedonpoolingthecomplementaryexpertiseofthevariousprofessionals.Lastly,wedescribeascollaborativethecommunicationandtask-sharingprocessesthatoptimizeefficiencyandqualityofcare.Acoherentdefinitionofthepracticemodelisacrucialdeterminantofthequalityofinterprofessionalcollaborationandofthecapacitytoestablishoperationaldefinitionsofeachteammember’srole.Thereisalsocredibleevidencetosuggestthecoherentdefinitionofapatientcaremodelisanimportantdeterminantofjobsatisfactioninprimarycareinterdisciplinaryteams[83].Threegeneralobservationsemergedfromourimplementationanalysisregardingthepatientcaremodelsimplemented.First,themodelsimplementedbytheteamsweregenerallynottheresultofanexplicitchoice.Theyseemedrathertohaveemergedthroughtrialanderror.Second,ourdatashowthat,inpractice,themodelsimplementedweregenerallyhybridsofthetwotypespresentedhere.Severalregulatoryfactors,suchasproceduresforenrollingpatientswithphysiciansorclinics,hadadetermininginfluenceonthepatientcaremodelscreated.Lastly,inthecasesanalyzed,consultativemanagementfiguredmuchmorefrequentlythanjointmanagement.ThiscouldbetheresultofabetterfitbetweentheconsultativemanagementmodelandstructuralcharacteristicsofQuebec’shealthcaresystem.Itmightalsohavetodowithmanyprimarycarephysicians’limitedexperienceofworkingcollaborativelyorfromhowphysiciansexpecttopracticewithotherphysicians.Overallourresultsdonotallowustosuggestthatonepatientcaremodelisinherentlybetterthantheothers.Itislikelythatamodelthatworkswellinonesettingmaybeinappropriateinanother.Ontheotherhand,thereisconvergentevidencetosupportthenotionthatitistheoverallcoherenceofthemodelthatmatters[55].Ifthepatientmanagementmodelisincompatiblewiththetypesofclientelefollowed,withtheteam’scompositionandcollaborationprocess,orwiththeNP’slevelofexperience,itsoperationwillbebothdysfunctionalandfrustrating[9,84].ExamplesofdysfunctionsobservedincludeddifficultiesinassemblingasufficientpatientpanelfortheNPs,oranon-functioningconsultativemodelduetooverlystringentinterpretationofproceduresfortheNPs’practice;suchdysfunctionsweresymptomsthatthemodelsneededtobereviewedandadapted[47].Thereappeartobethreedeterminingfactorstoconsiderinchoosingapatientmanagementmodel:clientelecharacteristics,physicians’andNPs’experienceandpreferences,andnumberofphysicianpartners.ThenatureandcomplexityoftheclientelefollowedmustbeconsistentwithlegislativeandregulatoryframeworksforNPs’scopeofpractice,includingtherangeofdiagnostictestsanddrugstheycanprescribe,andproceduresforreferringtospecialists[85,86].TeamsthatoptforaconsultativepatientmanagementmodelneedtoestablishparametersregardingthecharacteristicsofpatientsfollowedbytheNPsothattheNPisabletomeetmostofthosepatients’healthneeds[9].Itisalsoimportanttounderstandthatthisimpliesapotentialincreaseintheaveragecomplexityofthepatientsfollowedbythephysiciansintheteam.Thedatafromourcasestudiessuggestthatphysicianscaringformorecomplexpatientscouldimpacttheamountoftimerequiredforthepatientvisitand,inafee-for-servicescheme,physicians’revenues.AsfarasNP’sexperienceandpreferencesareconcerned,thereisconvincingevidencethattheirfirstyearofpracticeisoneoftransitioningtowardfullyoccupyingtheirscopeofpracticeanddevelopingautonomy.ItisthusimportantthatthepatientmanagementmodelbeallowedtoevolveovertimeastheNPgainsexperienceandconfidence.Aswell,somewhatakintothegreatvariabilityseeningeneralphysicians’practiceprofiles,thepreferencesandskillsofboththeNPandthephysicianpartnershouldplayaroleindevelopingpatientcaremodels.Hereagain,itappearsimportanttokeeptheseparametersopenandtobereadytoredefinethemovertime.ThethirdelementtoconsideristhenumberofdifferentphysicianpartnerswithwhomtheNPwillneedtocollaborate[55].WhiletheliteratureisnotspecificontheoptimalnumberofphysicianpartnersperNP,thedifficultiesencounteredinourcasessuggestthattheoptimalnumberofphysicianpartnersisprobablybetweentwoandfour.Havingonlyonephysicianpartnerresultsinlogisticalchallengeswhenthatphysicianisabsent.Conversely,themorephysicianpartnersthereare,themoreadaptationisrequiredfromtheNP,asbondsoftrustarebuiltupslowlyanddifferentlyfromonepersontoanother.Collaboration:atoolforoptimalpatientcareThefourththemethatneedstobetakenintoaccountbyinterprofessionalprimarycareteams,whethertheyincludeNPsornot,isthatofcollaborationprocesses.Thisisthefocusofahugebodyofliterature,whichwewillnottrytosummarizehere.However,itisworthrememberingthatgoodcollaborativerelationshipsamongprofessionalsfosterapositiveworkclimateandhelptooptimizequalityofcareandpatientmanagement[87-89].Theextensiveliteratureoncollaborationsuggestsdeterminantscanbeorganizedintothreelevels:interpersonal,whichincludeselementssuchasconfidence,attitudes,andcommunicationskills;organizational,whichencompassesleadership,egalitarianrelationships,communication,coordination,androleclarification;andsystemic,whichreferstoregulatoryenvironments,funding,andremuneration,aswellaseducationalframeworks[89,90].Atthepracticallevel,threeelementsseemtostandoutasparticularlyimportant.First,itisimportanttoidentifyleaders,bothmanagersandclinicians,towhomteammemberscanturnforsupporttosettledifferences,resolveproblems,orprovidehelpinsituationswherecommunicationisproblematic[46].Second,developingcollaborationamongclinicians,whetherinter-orintraprofessional,requirestime,inparticularformutualtrusttodevelop.Forthistrusttobebuilt,newNPsneedtodemonstratetheircompetenceinmanagingpatients.AlthoughmuchoftheliteraturefocusesonrelationsbetweenphysiciansandNPs,collaborationbetweenNPsandnursecliniciansisalsoakeyissue.Ourempiricaldatashowaperiodofadjustmentisrequiredduringwhichnursescangettoknoweachotherandtalkabouttheirvisionsandrespectiveresponsibilities,buildinguptheircollaborativerelationshipovertime.Timealsoneedstobeallocatedtogiveteammembersopportunitiestotalkaboutvaluesandtheirvisionoftheroleandhowitcancontributetoserviceprovision[21,46,63,67].Spaceisalsoastrategicelementincollaboration.Professionalsneedspaceinwhichtobeabletomeetandtalktogetherbothformallyandinformally.Finally,collaborativepracticedoesnotalwaysemergespontaneously[21,88,91].Theliteratureontrainingforphysician–NPcollaborationidentifiedinourreviewrecommendsavarietyoflearningstrategies,suchascasediscussions,scenariobuilding,anddiscussionsaroundclinicalandorganizationalissues[8,55,56,67,88-90,92,93].OurimplementationanalysisdatasuggestthatNPsgreatlyappreciatedactivitiesinvolvingjointtrainingorclinicalcasediscussionsandconsideredthemtobeteam-buildingactivitiestoconstructajointpractice.Focusingdiscussionsonqualityofcareandemphasizingapatient-centeredapproacharealsogoodwaystofosterproductiveteamdiscussions.SupportingteamsintegratinganNPProfessionals’capacitytodevelopeffectiveandsatisfactoryclinicalpracticesdependsprimarilyontheenergy,openness,andmutualtrustofthecliniciansthemselves.Yetitisimportantnottounderestimatethekeyrolesofmanagers,nursingandmedicaldirectors,andadministrativeassistantsinsupportingpracticeanditsdevelopment[58,64,94].OurstudyidentifiedthreecomplementaryspheresofactivityneededtoadequatelysupportprimarycareteamsintegratingNPs:clinical-levelsupport,team-levelsupport,andleadershipandsystemicsupport.Clinical-levelsupportThedatafromourimplementationanalysiscoincidewithfindingsfromexperiencesinotherprovincesandcountriesshowingthatsomeNPsarenotabletofullyexploittheirrolesduetoissuesrelatedtodrugprescribing,diagnostictesting,andreceivingconsultationreportsfromspecialistphysicians[8,21,51,86,95,96].Theseproblemsaresometimescausedbyadministrativefailuresandsometimesbytheoppositionofcertainprofessionals.SupportprovidedtoNPsatboththeclinicalandsystemiclevelsisessentialtosmoothoutthesedifficulties[89,91,97].NPsalsoneedtobeabletodeveloptheirclinicaljudgmentanddecisionalautonomyandapplytheseinpractice.Thesearecompetenciesthatdevelopovertimeanddependonthequalityofinterprofessionalcollaborationandthecomprehensivenessofthepatientcaremodel[21,88,91,98,99].Likewise,accesstocontinuingeducationisanimportantfactorindevelopinggoodclinicalpractice,notonlyforNPs,butalsoforphysiciansandotherprofessionals[63].Thelackofavailabilityofspecifictraining,difficultiesinbeingliberatedfromwork,anddistancetotraininglocationswereidentifiedassignificantobstaclesinthisregard.InthosesettingswheretheNPs’scopeofpracticewasmostextensiveandwheretheirroledefinitionwasevolvingpositively,severaldeterminingfactorswereobserved:jointmeetingsamongmanagers,nursingormedicaldirectors,andpartnerphysicians;asharedvisionoftheNP’srole;mobilizationofthecareteammembers’complementaryexpertise;andcollaborativeworkwithnurseclinicians.TheNPs’prescribingauthorityanddecisionalautonomywerealsodiscussedandclarifiedbythewholeteam,includingthemedicalteam.SupportfortheteamThereissolidevidencethatstrongleadershipandconsistentsupporttoprimarycareteamsfostertheemergenceofaneffectivepatientmanagementmodel[21,40,64].Ourcasesshowedgreatvariabilityintheadministrativestructuresinplaceandinthepersonsmobilized(e.g.clinicmanagers;headnurse;licensedpracticalnurses;physicianclinicmanager;manager,etc.).Onlyrarelywerethereclearlinesofauthoritydelineatingtheresponsibilitiesofmanagersatdifferenthierarchicallevels.Organizationaltheorysuggeststhatthecharacteristicsofprimarycareteams(smallprofessionalgroups,veryautonomousparticipants,decentralizedpowerintermsofoperations)favorinformalfunctioningandstructuresthatarenotveryhierarchical[66,100].Thistypeofstructureproducesgoodresultswhenthereisaconsensualvisionoftheorganization’sgoalsandvaluesbutcarriestheinherentriskthatnoonewouldfeelaccountableforresolvingproblems.Therethusneedstobepositiveleadershipfromoneormorekeypersonswhohavestronglegitimacyandaclearsenseofpurpose.Effectivecommunicationmechanismsareakeyfactorinencouragingtheemergenceandmaintenanceofasharedvisionoftheteam’sobjectivesandvalues[45,58].Communicationmustbebalancedbetweenformalandinformalopportunitiesforexchange.Similarly,abalanceisrequired—dependingonthepersons,subject,andcontextinvolved—betweendirectcommunications(suchasdiscussionsbetweentwoprofessionalstoimproveasuboptimalworkpractice)andindirectcommunications(suchastransmittingsuggestionsforimprovementtothepersoninchargeofaspecificaspect)[56,58,90].Inanychangeprocess,itisnormalthattensionsanddifferencesinpreferenceswouldarisebetweenteammembers.Insomecases,tensionsarebestresolvedbyface-to-facediscussion.Resolvingdisagreementsdirectlywithintheteamispartoftheprocessofcreatingteamdynamics.Evenso,itisessentialtobeabletoconsultaneutralthirdpartywhennecessary,someonepreparedtotakeonaboundary-spanningrolebetweenthemedicalandnursingdisciplines.Hereagain,thereisnosolidevidenceforanyspecificoperationalization,butseveralcredibledatasourcesintheliteraturesuggesttheprincipleitselfisimportant.Thispersonwhohasthelegitimacy,capacity,andmotivationtotakeonthisrolewillberesponsibleforpreservinganoverallvisionofalltheworkprocesses[58].SystemicsupportBeyondtheirinternalfunctioning,primarycareteamsarealsopartoflargerhealthcaresystems.Assuch,theoperationsofprimarycareteamsarealsostructuredbytheenvironmentsinwhichtheypractice,withregardtosuchthingsasbillingpolicies,enrolmentofnewpatients,orreferralsfortestsorspecializedservices.Aswithanyotherpracticechange,introducinganNPentailsadjustmentsandcommunicationsbetweentheprimarycareteamanditsexternalenvironment[85].However,theNProleisstillevolving,andpartofthatroleisplayedoutattheinterfacebetweenmedicineandnursing.Tofulfilltheirresponsibilities,NPsmustbeabletorelyoncollaborationfromotheractorsintheexternalenvironment(specialistphysicians,diagnosticservices,pharmacists).Itisthereforeimportantthatclinicalteamsbegiventhesystemicsupportneededtoidentifyappropriatesolutionsandtoensureproblemsareresolved[14,88,91].Fulfillingthismandatetakestimeandagoodknowledgeofthelocalenvironment.Thisiswhy,inpractice,thefunctionsofdirectsupervisionandsystemicsupportmayneedtobesharedamongthelocalleaders[58].Finally,whileitisusefultodividethediscussiononsupportforpracticeintothreesphereshere,itisalsoimportanttoremembertheyareinterdependentand,inpractice,necessarilyintegrated.DiscussionandconclusionTheresultsofourlogicandimplementationanalysessuggesttheexistingliteratureonNPintegrationcouldbeimprovedintwoways.First,takenasawholeitistoooftenintradisciplinary,offeringanalysisandadvicethatistootargetedtooneprofessionalgroup.Yet,bydefinition,integratingNPsintoprimarycareteamsisaninterprofessionalendeavor.Second,whiletheliteratureoffersmuchconvergingdescriptiveevidenceregardingbarrierstoandfacilitatorsofNPintegration[8],itismuchlesshelpfulintermsofpracticallyorientedadvice.Whenpracticaladviceisfound,itisoftenstructuredasastep-basedlinearmodel.However,inourviewsuchlinearmodelsarevulnerabletothebroaderweaknessesoflinearplanningstrategies[101,102].IntegratingNPsintoprimarycareteamsislikelytobeadynamic,complex,andmessyprocess.Inreallife,manyelementsoftenneedtobetackledsimultaneously;itmightmakesensetobacktracktofindandfixsomethingthatwasnotdonerightinthefirstplace,anditisimpossibletodrawalinebetweenwhatconstitutesintegrationandwhatarenormalactivities.ThisisnottosaythatNPintegrationoughttobeconceivedasasomethingtobeimprovised,butratherthatitisaprocessforwhichthebestadvicemaynotbestep-based,asiselegantlyconveyedintheoften-quotedwordsofD.D.Eisenhower,“InpreparingforbattleIhavealwaysfoundthatplansareuseless,butplanningisindispensable.”Thetheme-basedprocessual[101,103]perspectiveputforwardinthisarticlecanalsobelinkedwithaparticularperspectiveofroletheory.Inoppositiontothedominantfunctionalistviewthatfocusesonhowaroleisexternallydefined,thispaperisalignedwiththeenactment,interactionistperspective.Fromthisperspective,rolesaredynamic,contextdependent,processual,andinteractional.Theanalyticalfocusshouldthusbeontheeverydayandlocalprocessesthroughwhichrolesareconstructed,negotiated,learned,enacted,andperformed.Suchaviewisincompatiblewithcookbook-typelinearadvice.Intheend,whatoughttobedonewillalwaysbedependentonmanycontingentfactors.Webelievethefivethemesdelineatedherecanprovidefruitfulstartingpointsforclinicalteamsstrivingtodevelopeffectivemodelsforintegratingnewroles.EthicsThisstudyhasbeenapprovedbytheethicscommitteesoftheComitéd’éthiquedelarecherchedel’AgencedeSantéetdesServicesSociauxdeMontréalandbytheComitéd’éthiquedelarecherchéensantédel’UniversitédeMontréal. 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GoogleScholar  DownloadreferencesAcknowledgmentThisresearchwassupportedbyajointCanadianInstitutesforHealthResearch(CIHR)andMinistryofHealthandSocialServicesofQuébecgrant(Grantnumber:238537).D.Contandriopoulos,A.Brousselle,C.-A.DuboisandK.Kilpatrickalsoreceivesalaryawardsfromthefondsderechercheduquébec–Santé(FRQ-S).A.BrousselleholdsaCanadaResearchChair.AuthorinformationAffiliationsFacultyofNursing,UniversityofMontreal,C.P.6128succ.Centre-Ville,Montréal,Québec,H3C3J7,CanadaDamienContandriopoulos, Carl-ArdyDubois, MélaniePerroux, IsabelleBrault, KelleyKilpatrick & DanielleD’AmourDepartmentofCommunityHealthSciences,UniversityofSherbrooke,150,placeCharles-LeMoyne,Bureau200,Longueuil,Québec,J4K0A8,CanadaAstridBrousselleDepartmentofFamilyMedicineandEmergencyMedicine,UniversityofMontreal,PavillonRoger-Gaudry,2900,boulÉdouardMontpetit,Montréal,Québec,H3T1J4,CanadaMarie-DominiqueBeaulieuSchoolofNursing,UniversityofVictoria,POBox1700STNCSC,Victoria,BC,V8W2Y2,CanadaEstherSansgter-GormleyAuthorsDamienContandriopoulosViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarAstridBrousselleViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarCarl-ArdyDuboisViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarMélaniePerrouxViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarMarie-DominiqueBeaulieuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarIsabelleBraultViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarKelleyKilpatrickViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarDanielleD’AmourViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarEstherSansgter-GormleyViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarCorrespondingauthorCorrespondenceto MélaniePerroux.AdditionalinformationCompetinginterestTheauthorsdeclarethattheyhavenocompetinginterests.Authors’contributionsDCconceivedofthestudy,drawnitsdesignandcoordination,carriedoutthestudy,foundthecaseandcollecteddataof2ofthemanddraftedandreviewthemanuscript.ABparticipatedinthedesignofthestudyandreviewedthemanuscript.CADparticipatedinthedesignofthestudy,collecteddataforonecaseandhelpedtoreviewthemanuscript.MPcoordinatedandparticipatedinthedataanalysesanddraftedthemanuscript.MDBparticipatedinthedesignofthestudy,helpedtoanalyzethedataandreviewedthemanuscript.IBparticipatedinthedesignofthestudy,collecteddataforonecaseandhelpedtoreviewthemanuscript.KKparticipatedinthedesignofthestudy,collecteddataforonecaseandhelpedtoreviewthemanuscript.DDparticipatedinthedesignofthestudy,collecteddataforonecaseandhelpedtoreviewthemanuscript.ESGreviewedthemanuscript.Allauthorsreadandapprovedthefinalmanuscript.Rightsandpermissions OpenAccess ThisarticleislicensedunderaCreativeCommonsAttribution4.0InternationalLicense,whichpermitsuse,sharing,adaptation,distributionandreproductioninanymediumorformat,aslongasyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinktotheCreativeCommonslicence,andindicateifchangesweremade. 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BMCHealthServRes15,78(2015).https://doi.org/10.1186/s12913-015-0731-5DownloadcitationReceived:02July2014Accepted:06February2015Published:27February2015DOI:https://doi.org/10.1186/s12913-015-0731-5SharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative KeywordsCollaborationDeliveryofhealthcareIntegratingprocessLogicevaluationNursepractitionersPracticemodelPrimaryhealthcareRoledefinitionTeamsupport DownloadPDF Advertisement BMCHealthServicesResearch ISSN:1472-6963 Contactus Submissionenquiries:[email protected] Generalenquiries:[email protected]