Scholarly Articles on the Prospect of Family Nurse Practitioners

• Research article
• Open Access
• Published: 04 December 2020

Integrating nurse practitioners into primary care: policy considerations from a Canadian province

BMC Family Practice volume 21, Article number:254 (2020) Cite this commodity

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Abstruse

Background

The integration of nurse practitioners (NPs) into primary intendance health teams has been an object of interest for policy makers seeking to achieve the goals of improving care, increasing admission, and lowering price. The province of Alberta in Canada recently introduced a policy aimed at integrating NPs into existing principal care delivery structures. This qualitative research sought to understand how that policy – the NP Support Program (NPSP) – was viewed past key stakeholders and to describe out policy lessons.

Methods

Fifteen semi-structured interviews with NPs and other stakeholders in Alberta'southward main intendance arrangement were conducted, recorded, transcribed and analyzed using the interpretive description method.

Results

Stakeholders predominantly felt the NPSP would non change the status quo of express practice opportunities and the resulting underutilization of principal care NPs in the province. Participants attributed low levels of NP integration into the primary care system to: one) financial viability issues that directly impacted NPs, physicians, and primary care networks (PCNs); ii) policy issues related to the NPSP's reliance on PCNs as employers, and a requirement that NPs panel patients; and iii) governance bug in which NPs are not afforded sufficient authorization over their role or how the key concept of 'intendance team' is defined and operationalized.

Conclusions

In general, stakeholders did not see the NPSP as a long-term solution for increasing NP integration into the province's primary care system. Policy adjustments that enable NPs to access funding not but from within only besides outside PCNs, and modifications to permit greater NP input into how their function is utilized would likely improve the NPSP's ability to reach its goals.

Peer Review reports

Background

The integration of nurse practitioners (NPs) into principal intendance has been viewed every bit a solution to shortages of doctors [1], and a tool for improving patient access to care and lowering costs [2]. Information technology has also been suggested that the integration of NPs into community-based care delivery is disquisitional to accomplishing the transformation of master care into primary health care (PHC) [3, iv] - a transformation that has itself been linked to improved intendance, improved outcomes, and lowered costs [v,6,7,eight]. The shift to PHC is one towards prevention, health, health and the successful management of chronic disease [9,10,11,12,thirteen,14], accomplished through team-based care [xv]. The integration of NPs into PHC-focused teams, and their integration into healthcare systems more broadly has been advocated for in a range of policy environments, including both Canada and the United States [sixteen,17,xviii,nineteen]. Despite this alignment with transformation principles and much policy enthusiasm, the utilization of NPs in Canadian primary care has been inconsistent [17].

To ameliorate understand the factors behind the inconsistent utilization of NPs, this paper presents ane Canadian province's contempo and ongoing efforts to increment the integration of NPs into its principal care system. We describe the Nurse Practitioner Support Program (NPSP ^{Footnote 1}) in Alberta, Canada, and present qualitative data from interviews with stakeholders. These interviews highlight the challenges to achieving the goals outlined in the NPSP and to NP integration in the province'southward primary intendance environment. The data we present here provide broader comparative learnings for other jurisdictions contemplating policies to support greater NP integration into their primary intendance systems.

NPs in Alberta are registered nurses (RNs) that have: worked at to the lowest degree 4500 RN hours; completed a recognized NP educational plan; and passed a standardized exam specific to their practice surface area [twenty]. Cartoon on competencies acquired in their Masters-level, clinically focused instruction [21] NPs relish a wider scope of do than RNs, including the power to: behave avant-garde health assessments; order and interpret diagnostic tests; diagnose, care for, and perform advanced interventions; prescribe medications; monitor patient outcomes; and refer patients to other professionals every bit required [22]. Currently all provinces in Canada have legislation regulating the NP telescopic of practise [2, 23]. In the province of Alberta, the Health Professions Human action [24] and the Registered Nurses Profession Regulation [25] requires NPs be registered with the College and Association of Registered Nurses of Alberta (CARNA). CARNA requirements govern maintenance of an NP'south license to practice [22]. Despite a regulatory presence in colleges and legislation across Canada, [2] funding and payment reform to support NP integration have proved to be barriers to practical implementation of the office [26].

The NPSP was not the Alberta government's first attempt at increasing NP participation in main care [27]. In 2012, the province announced an increased office for NPs with the introduction of family unit intendance clinics [28]. Seen equally plush and opposed by some members of the medical community [29, 30], the family care clinic concept did not successfully navigate a modify in political leadership [31, 32]. Only 3 out of the 140 clinics envisioned were ultimately built [31].

In April 2019, with a delivery to team-based care ^{Footnote ii} and its advantages [33] well-articulated in the provincial primary care strategy [4], the province sought to increase the relatively low count of NPs in principal care past introducing the NPSP [17]. In Alberta the bulk of registered NPs – 72% in 2018 – were employed in acute intendance or specialty out-patient clinics [17]. In other Provinces the majority of NPs piece of work in chief care and community settings with only 24% working in hospitals [35]. The NPSP thus aimed to increment the utilize of NPs in Alberta'south primary care system, role of a broader provincial government priority to improve admission, safety, quality, and continuity of primary intendance [17].

The NPSP allows the province'southward Main Care Networks (PCNs) to employ for NP-specific funding, with the aim of increasing NP integration into chief care. PCNs are intermediary organizations positioned between the government and the front lines of main care, and every bit envisioned by the NPSP, are the master agents for chief care NP integration in the province. Originally created in 2003, PCNs are funded past the Government of Alberta'southward Ministry of Wellness and formed through a articulation venture arrangement betwixt Alberta Health Services (AHS; the single health authority and service provider for the province) and master care physicians who opt-in, signing a contract to get members of a PCN [36].

In Alberta, individual physicians are mostly independent small-business organisation owners, with the province performance most exclusively on a Fee-For-Service (FFS) model [37,38,39,40]. Physicians can however arrange an alternative compensation method with the government if they choose [41]. These bounty options are bachelor to primary care physicians whether they choose to bring together a PCN or non. As noted to a higher place, primary care physicians tin can opt to join a PCN, which generates coin for their respective PCN. This per capita funding for the PCN is in add-on to the physician's regular compensation. For each patient on a PCN-physician's console, a PCN receives $62 per year, with this commonage per capita money being used to back up locally adapted service delivery and team enhancement, as well equally pay the PCN'south administrative costs. In improver to implementing squad-based intendance, the PCNs are too responsible for implementing other elements of the Patient Medical Home (PMH) including improved access, patient panelling, use of electronic medical records, and quality improvement [four, 42].

The NPSP positions Alberta's PCNs equally the primary support and implementation mechanism for achieving NP integration into primary intendance, every bit part of a broader western Canadian objective of delivering squad-based main care [15]. In light of the province's relatively depression rate of NP uptake in primary intendance, the NPSP aims to incentivize PCNs to hire more NPs in Alberta and to increase NP integration into main care teams and achieve primary healthcare transformation [17].

In order to place NPs within the PCN structure, the NPSP introduced changes to the PCN funding formula allowing NPs, and not only physicians, to create a 'panel' of patients [43]. Where a console refers to a prepare of patients fastened to a detail provider, a 'roster' refers to a set of patients attached to a group of providers [43]. The funding generated from an NP's PCN-based panel of patients (the same $62 per capita) would, different with physicians, be earmarked to embrace that NP's salary. In other words, according to the NPSP, if a patient is paneled to an NP, the $62 per capita payment is routed to that NP's salary which offsets (and decreases) the authorities's supplemental elevation-upward, paid to the PCN to support the NP'south almanac bacon. This supplemental top up is to a maximum of $125,000 [17]. In dissimilarity, if a patient is paneled to a doctor, the per capita payments exercise non reduce the corporeality the government remunerates that physician based on FFS billings. Instead, a doc bills the government the regular amount and the doc'southward per capita money is pooled with other PCN physician members' per capita console funds and fabricated available to the PCN [17]. This fiscal arrangement, alongside other factors discussed below, directly impacts the viability of the NPSP policy aimed at integrating NPs into Alberta's principal intendance organisation.

Changes in government often introduce differing priorities with existing publicly funded policies either changed or abandoned. Shortly later on the introduction of the NPSP, at that place was a alter in Alberta'south regime. However, the integration of NPs into main intendance continues to be a priority, with the new regime promising NP billing reform [44] and continued support for the NPSP [45]. The urgency of the issue has been emphasized as NPs and their scope of do have in one case once more come to the forefront as part of the response to the COVID-19 pandemic and the strains it introduced to the primary care system [46].

This paper draws on qualitative interview data to sympathise NP integration challenges and how a policy like the NPSP is viewed by fundamental stakeholders (NPs, physicians, individuals from nursing and medical professional associations, a patient advancement group representative, a patient, PCN administrators, and government officials). In the context of the NPSP'south introduction and ongoing interest in NP integration, we interviewed a range of stakeholders seeking to understand the factors that might exist limiting the NPSP'due south success and ultimately NP integration into Alberta's chief care environment. Our guiding inquiry questions sought to:

• Identify policy and operational factors that are shaping how Nurse Practitioners (NPs) integrate into Alberta's PCNs.

• Deepen understanding of the effects that current funding policies and incentivization strategies are having on NP participation in primary care.

• Empathise how the policy innovations targeting the integration of NPs into PCNs are perceived past key stakeholders.

• Make evidence-based recommendations regarding policy and operational factors that will aid improve NP integration into PCNs and PCN effectiveness.

Methods

Semi-structured interviews (n = 15) were conducted, recorded, transcribed and analyzed using the interpretive description method. Interpretive clarification is a qualitative, belittling, inductive method of inquiry that focuses on generating practically-applicative knowledge for healthcare issues [47, 48]. We used semi-structured interviews to collect a broad range of perspectives, reflections, and practical knowledge related to the NPSP in Alberta. These interviews were conducted with a range of healthcare providers, conclusion makers/ influencers, and patient advocates.

Further information is provided in Table ane below.

Tabular array 1 Participants

Full size table

Recruitment began purposively – with the express aim of including a variety of perspectives driving our choices [49] – and then shifted to include snowball sampling of individuals through participant referrals [49, l]. We sent out a recruitment email to potential participants and included research objectives and a template of interview questions. The chief focus of the questions involved asking participants for their perception of NP integration in main care, and their views on the NPSP. Participants are identified in the post-obit pages with the Roman numerals I to Xv. In total, we interviewed fifteen participants, with this sample composed of different professional backgrounds to ensure potential differences in stance were considered (See Table one). Over the form of collecting data from this sample, we plant that we had achieved "a realistic range of predictable variance" [51] in the opinions and perspectives that participants were advancing.

The semi-structured interviews were conducted by SB using a guide that was developed iteratively with ML. The guide aimed to depict out rich, nuanced, self-reflective responses from the participants. The interviews ranged in length between 30 to ninety min and were both recorded and transcribed. The data was then analyzed with the aid of NVivo 12 software using an inductive coding approach aimed at rendering an interpretive description of participants views on NP integration into primary care more often than not, and via the PCNs and the NPSP specifically.

Our interpretive description arroyo allowed u.s.a. to proceeds insight not just on areas of commonality, merely areas of disagreement amongst participants, and with an middle on providing pragmatic suggestions to improve policy in the area [51, 52]. SB and ML analysed the information iteratively, expanding, collapsing and merging themes to go far at the last assay. Nosotros carried out participant checks on the interpretations presented.

This research obtained ethical approving from the Conjoint Faculties Research Ideals Board at the University of Calgary (REB18–1709). Participants provided written consent.

Results

Participants described NPs as an underutilized resource in Alberta'due south principal intendance environment. The information from fifteen participant interviews attributed this low level of NP integration to a lack of independent practice opportunity and minimal chore prospects which, in turn, related to: 1) financial viability issues that impact both NPs, physicians, and PCNs; 2) ineffective policy, and 3) issues with governance.

A lack of available jobs

As a policy maker participant noted, Alberta is "… nether-using [NPs] … especially in primary care" (Participant Six). A PCN executive director described how there had been petty progress in integrating NPs into primary intendance in the preceding decade:

There were very, very few positions outside of the acute care setting. And I think, in some ways still – similar x years later, at that place hasn't been much progress. (Participant IX).

The lack of available positions was, in the same participant'due south listen, a disservice to both those undertaking NP preparation and the taxpayers who subsidize that training:

All of those professional [programs] are generally topped upwards past government funding in the pedagogy stream... I don't think we were doing NPs a service when they could obtain this education, graduate, then not have any … positions in the principal care environment [available]. (Participant IX).

Another participant further elaborated:

[I]t's and then sad that this cream of the ingather bunch [is] being lost [due] to lack of opportunity... what a encephalon bleed! And they're leaving the province, they're leaving the state … they are leaving the profession. [W] chapeau a waste of human being resources. (Participant I).

The lack of job openings and authorities-funded brain bleed to other jurisdictions was viewed by participants equally a result of specific financial disincentives that shaped the viability of becoming an NP in the province'south principal care system. These financial viability issues impacted all three of the central stakeholders involved in the NPSP: NPs, physicians, and the PCNs.

Fiscal viability: NPs

A range of participants described how the province'south physicians have an assortment of options to fund their practice (FFS, blended capitations, salary). Even so, the bulk of family physicians in Alberta operate every bit a private business concern and fund their practice by billing the government FFS. In contrast, NPs – both nether the NPSP and prior to its introduction – can simply exist funded equally employees (Participant I, 14, XII), relying on physicians or PCNs having available jobs for them. As one participant noted, independent NP practice "isn't supported" by electric current policy arrangements (Participant III).

A policy maker with 20 years experience suggested this was because:

[T] he compensation systems are non in place to support independent [NP] practice right now (Participant Half-dozen).

This lack of funding options was emphasized past another participant – an NP – who explained how, despite being trained and given authority under legislation to provide certain healthcare services, NPs cannot exist paid directly:

I can't go paid by the authorities to offer those services. [T] he regulatory body and the Health Professions Act of Alberta allows me to practise information technology, but I cannot become paid [to provide those services] (Participant XI).

Unable to be reimbursed every bit independent practitioners, NPs for the most part currently tin can either choose to pecker patients directly for services or rely on being hired past PCNs or private physicians as employees. For those who choose to bill outside the publicly funded organisation, participants noted that fiscal viability hinges on exploiting a niche for which patients – otherwise accustomed to 'free' master care – are willing to pay out-of-pocket. Without niche practice able to support private billing, fiscal viability hinges on becoming an employee of an individual doctor or a PCN. Equally nosotros will meet later, the governance and power bug inherent in seeking employment from physicians and PCNs are seen every bit both personally challenging, and detrimental to NPs practicing at their full scope. Beyond these bug, the charge per unit of pay as an employee and lack of alternative options to exercise was summed up by ane participant as follows:

A lot of registered nurses (RNs) … ask me, is it worth it? I would say, no. [T]hither's no opportunity [to get a business concern loan, to beak the government, or get a job.] … [I] f at that place is opportunity [to get a job], oftentimes you brand less than a senior RN. (Participant Eleven).

A recent report reviewing the province'southward health system agreed with this participant's betoken, emphasizing the financial disincentive RNs take to have the further education, training, and testing involved to get an NP [53].

If the root cause of low levels of NP integration is tied, from the perspective of NPs, to a lack of billing options and poor financial incentives, financial viability was also an effect for physicians.

Financial viability: physicians

Under the province'southward predominant medico's FFS billing arrangements, physicians are non encouraged to deploy NP employees to evangelize intendance for which physicians would otherwise be able to pecker the regime. For a policy-maker participant, the key problem was a missing mechanism for physicians to recover revenue 'lost' when an NP provided a service:

[I]t'southward actually unclear to family unit physicians how they would utilize an NP in their do. At that place's not a mechanism for the physician [and the practice] to be compensated for the services that that NP delivers correct now (Participant 6).

A md participant described the disincentive of losing revenue to an NP employee in starker terms:

[I]t's lucrative [for physicians] to see piece of cake patients because [physicians] get paid fee-for-service. I think a lot of people in primary care don't want NPs to practice that stuff, considering [physicians] think it [is] going to bear upon their bottom line (Participant II).

Beyond presenting a claiming to the depression-endeavour, high-reward cases at the heart of current physician profitability, participants noted that the NPSP did non provide ways to generate revenue to embrace overhead costs. As an NP who ultimately lost their chore noted:

I was basically taking up space where if a physician was in that infinite, they could pecker the government and pay overhead. And the overhead that physicians pay is astronomical (Participant VII).

About family unit physicians in Alberta operate as a private business organisation with acquirement generated from billing the government for services provided. NPs cannot bill the government for services they provide and practise not receive compensation directly from government. If a doctor or a PCN hires an NP, that NP's salary is paid from the physician's or PCN's revenue. As such, NPs do not generate revenue from government to pay overhead. If an NP opened a clinic outside the public system and billed patients directly, the NP would accept to pay the same amount of overhead. However, with patients accustomed to publicly funded primary care services, and many NPs wanting to operate within the public organisation, the inability to comprehend overhead costs like their physician colleagues proved problematic for most participants.

One physician participant noted a workaround unremarkably referred to as the 'whites of the eyes' billing. This arroyo involves the physician entering a consulting room where the NP is finishing an appointment just long enough for brief interaction with the patient. By doing so, this allows the physician employer to bill for the service delivered by the NP employee. Equally described by the physician:

I accept to kind of just popular my head in and say, "Hullo! Any questions? Let me know..." And that'due south a bit ridiculous, but I take to pop my head in so I can pecker for those patients (Participant 15).

This 'whites of the eyes' billing approach increased acquirement to embrace the NP's overhead costs and bacon. Nevertheless, it appeared to be an exception to a general rule where most physicians instead viewed NPs as a financial brunt to their business.

Financial viability: PCNs

Despite beingness the focal betoken of the NPSP, the PCNs – as member-driven organizations composed of family unit physicians – are also disincentivized past the fiscal realities of integrating NPs. Where the NPSP aims to utilize per capita acquirement generated past the NP's patient panel to pay the NP salary, the PCNs' members tend not to see the value proffer. In an extension of their private business organization for an employee delivering services they would otherwise be able to nib for, PCN members oftentimes see their organization's per capita funds amend spent elsewhere. A former PCN administrator noted:

[T] he prevailing conventionalities among docs is:

'We shouldn't be using PCN coin to fund NPs … because we could just [put a medico in that position and] neb FFS [to cover the medico's bacon and overhead] and do what [the NP is] doing and employ the [PCN] money for something else similar a chronic disease nurse, a social worker, a chemist, [etc.]' (Participant XII).

Beyond being unpopular amongst fellow member-physicians, NP employees are a claiming for the PCNs themselves given that they come out of the intermediary organization'south bottom line. As some other participant noted, from the PCN's perspective:

[T] he services that an NP tin can offer could be offered similarly by a physician and that physician'due south compensation would come out of, non the PCN upkeep, merely [the Ministry building of Health's budget] (Participant XI).

Alongside these financial viability problems for NPs, physicians, and PCNs, participants also identified policy and governance issues that made attractive jobs as a principal care NP rare.

Ineffective policy

Participants took issue with specific aspects of the NPSP, focusing on the policy's paneling requirement and its use of the PCNs as its only mechanism for funding and implementation.

Requirements for paneling and full scope primary care

While some participants were pleased that the NPSP allowed NPs to panel patients, others were less interested. As 1 NP participant noted:

I don't feel the need to have my own patient panel. At that place are other nurse practitioners who want to have their own patients. So that's just a personal preference (Participant 7).

This sense that the policy's paneling requirement was unnecessarily restrictive was shared by physicians (Participant Xv, Participant Ii). Another NP participant illustrated what they saw every bit the ineffectiveness of the paneling requirement past making a hypothetical pitch for money to showtime up a community-based specialty NP practice:

I'm a nurse practitioner. I take a sub specialization in chronic pain direction. In that location is a high burden of chronic pain in Calgary and it's nether met. The chronic hurting center has a ii year waiting list. I want to start a clinic that deals with chronic pain patients. I want to submit a concern plan … [and], I want to submit an expression of interest to have funding to be able to do this. Just I can't do that. It doesn't exist. Even nether the [NPSP] I can't do it because the premise is full scope, main intendance. (Participant 11).

In the hypothetical pitch, fifty-fifty if an NP were able to identify a specific area that is underserved by physicians, the NPSP's demand for only total spectrum – which is to say fully empanelled – care would stop the project moving forrad considering there is no electric current funding machinery that would accommodate the participant'south example. In this way, the policy'due south panelling requirement and resulting mandate that NPs integrate by providing total scope primary care fails to allow flexibility for NP integration based both on the needs of the community and practitioner preferences.

Funding and implementation through the PCNs

Under the terms of the NPSP, a PCN - and only a PCN - has the option to submit an application for this dedicated NP funding. Some participants questioned the prerogative this gives to PCNs over whether to consider integrating NPs at all. As i former PCN ambassador noted:

If physicians are managing it, it's a petty bit like the mice guarding the cheese … Would they really want to give money to NPs and fund their competition? (Participant XII).

This sense that PCNs should not exist the simply avenue for NP funding and integration and options beyond PCNs are necessary were widely shared by other participants (Participants I, III, XI, Xiv).

How a given PCN and its PCN medico-members view NPs thus has an oversized result on how the NPSP gets implemented, as PCNs are the only avenue for NPs to authorize for NPSP funding support. As a policy maker noted:

[W]east're getting some early indication that [NPs are] too perceived as a threat, and therefore the physicians don't want them... (Participant Half-dozen).

Even a PCN ambassador participant that was very supportive of NP integration into PCNs emphasized that the PCNs ought not to be the but implementation mechanism:

I think we're a smashing avenue to back up [NP integration]. Simply I don't necessarily think we are the only avenue that could (Participant IX).

Using PCNs as the exclusive avenue for primary care NP integration was considered a major limitation by many participants. Beyond the need for options, there were deep concerns about the governance and authority structures that are embedded in the PCNs, and their touch on NP integration into Alberta's main intendance environment.

Inappropriate governance

Both NP and not-NP participants believed that positioning the PCNs as the sole implementation mechanism for the NPSP was highly problematic. Their concerns centered on the fact that PCNs were "controlled by physicians" (Participant III), "physician-centric" (Participant I) (Participant Nine), "led past family unit physicians" (Participant XIV), and "physician-led" (Participant VI).

As i NP described it, choosing the PCNs to advance NP integration was 1 in which the government was essentially "asking another profession – which is physicians - to develop the role of NPs." This was non merely seen as "inappropriate", merely meant the NPSP was "flawed past blueprint" because it, "leaves the decision to physicians to integrate [NPs]; how to integrate them; where to integrate them" (Participant Eleven).

Further elaborating, the NP emphasized the power imbalance that comes with being an employee rather than a member of a PCN:

[NPs] can only be an employee of the PCN [not a full fellow member like physicians] … and so you're missing the nursing vocalism at the table … How you're deployed, where are you deployed, how y'all're utilized. I don't take any command (Participant Xi).

This loss of input and control was felt keenly by most NP participants. For them, the NPSP supports an inappropriate form of governance and dysfunctional form of team-based intendance. For one participant, there was a key difference between a team that was working together collegially, and a team that was congenital around doing work for physicians. This participant described the departure as beingness one between:

People who are willing to piece of work actually in a team – [and people who] want a team to work for them. Completely unlike (Participant I).

When team was defined collegially, and then governance hierarchies were flattened, non merely NP integration, but reported job and patient satisfaction improved. Under these conditions the employee-NP model was viable from a governance standpoint as much as it still suffered from financial challenges. Illustrating this, an NP participant described a menstruum of collegial physician-NP teamwork at a PCN where they worked:

[W] e chosen information technology the Dream Squad … the patients were really happy … It [was] the best task of my whole life … And we co-referred, nosotros shared, we had hallway consults – it was incredibly dynamic. The patients got what they want [ed] … our job satisfaction was like a hundred per centum … And then, the medical director [of the PCN] came dorsum, and insisted on a hierarchy. And we all got sort of dispersed, and we weren't immune to eat dejeuner together … And about everybody either quit or was let go (Participant I).

Where anxieties virtually overlapping scopes of practice and expertise, as well as financial viability, had briefly been set bated, they returned with the medical director who had the authorization to re-impose onetime hierarchies. With these hierarchies came a revised definition of team. Equally a concept it shifted away from a collegial levelling and towards treating employee NPs every bit tools for greater physician productivity. As the social distinctions between the professions were reasserted, and the governance of NPs by physicians became the reality, the two groups no longer ate lunch in the same physical spaces and morale suffered.

Under what this NP saw every bit an inappropriate governance regime within their PCN, NPs became mere "helpers to physicians" expected to "fill in where doctors have left holes in care," (Participant I).

Another NP described how their role as a PCN employee had been to fill up in for physicians when physicians were unavailable or during times when the physicians preferred not to work. They described how:

Physicians [in the PCN where I worked] would non let me exercise. [They] refused to allow me to exercise … I didn't get it. But then, something [would need] to exist assessed right away and [they would say], "Oh, you could get do that!" After hours, Friday nights and weekends. [Then information technology was] no problem, but during the calendar week I could not take clinic infinite (Participant Xiv).

From the perspective of a participant working for both a PCN and the provincial medical clan, this employer-employee relationship along with its governance implications, was appropriate.

[I] f we don't have doctors that will piece of work until eight:00 PM and NPs are willing to fill in to meet those primary care needs … [That is] TOTALLY [acceptable]. Absolutely use [the NPs] in that capacity. But for the twenty-four hour period to solar day, similar the 8-to-five work of the doc when we take so many physicians, information technology wouldn't make sense to me that yous use the NP in the same way (Participant Xiii).

A PCN administrator participant noted how deploying NPs after hours and to fill in when and where doctors were unavailable or uninterested in working was ultimately at odds with the NPSPs goal for comprehensive chief care:

[If an NP is] just providing access in terms of evenings and weekends, you tin can't necessarily be at that place to provide that comprehensive intendance (Participant IX).

In this way the hierarchical rather than collegial governance enabled by the NPSP'south option of the PCNs was seen, by some participants, as working against the policy's central goals.

Discussion

Alberta's NPSP faces a number of critical challenges that impede its ability to accomplish its stated objective of integrating NPs into the province'southward primary intendance system. These challenges include governance issues that distribute dominance and funding options unequally; financial disincentives for NPs, physicians, and PCNs; and a modest number of highly delimited chore opportunities. Each of these represents an opportunity to arrange the policy to be meliorate calibrated to attain its main goal of NP principal care integration.

From the majority of participants' perspectives, perhaps the most problematic attribute of the NPSP'south use of the PCNs as mechanisms of integration was that this gave physicians the final say on job availability, remuneration, and termination, as well as how key ideas like 'care squad' are operationalized. In this sense, our interviews highlighted governance impediments to NP integration similar to those identified elsewhere [54], with other policy and legislative arrangements described as major barriers to effective integration [55]. Whether NPs are to be employees or independent providers, for primary intendance integration to succeed, governance arrangements that see them collaborating with - rather than subordinate to physicians - are probable a pre-requisite. Here we are drawing on the observations of others who have noted the ways in which funding and care delivery models that support medical dominance tend to impede collaboration [56]. Our information confirm that NPs are non encouraged to integrate when physicians are granted the authority to resolve territorial conflicts over telescopic of practise in their own favour, or to define whether a team will be collegial or hierarchical. Every bit D'Amour et al. [57] have noted, successful collaboration in healthcare teams is the result of careful work at interpersonal, organisation, and governance levels, non imbalanced relationships. In this sense, the NPSP in its present course, embedded equally it is in the billing and governance structures of the province, is non able to reach its full potential as a means to increase admission to quality primary care through NP participation.

Beyond governance every bit an effect of professional autonomy, the NPSP fails to address longstanding financial disincentives that bear upon NPs themselves, physicians, and the PCNs. It is imperative to consider doctor compensation structures in identify where NPs are attempting to integrate. Family physicians in Alberta are able to directly access public funding by billing the government FFS [58], or if they choose through an annualized, sessional or composite capitation agreements with the government [41]. In contrast, the NPSP affords none of these options to NPs and instead requires them to be employees of "medico-controlled" PCNs. Equally such, NPs detect themselves both unable to open practices of their ain and notice it challenging to generate enough revenue to encompass the overhead they incur as employees. For their part, physicians operating on a FFS basis – which is to say the majority of primary care practices in the province – find that NPs, forth with other members of the care squad working alongside them, are unable to bill for services that physicians would normally provide. The disability to beak the regime for services rendered by not-physician care team members has been consistently identified as an impediment to integrating non-physicians into FFS practices [26, 59]. Indeed, it has been identified as restricting NP integration specifically [54, 56, 60,61,62,63].

If these are the disincentives for private NPs and physicians, at the PCN level the NPSP proposes that PCNs apply the per capita revenue generated by the patients on an NP's panel to cover, or partially cover, that NP's bacon. The claiming here is that this per capita funding is at the centre of the PCNs' financial model. Redirecting per capita payments – the PCNs' only source of revenue – towards NP salaries is a redirection away from other care initiatives and practice support work at the heart of these organizations' mandate. In this sense, deploying a physician who can bill the government FFS, and not an NP who draws downwards the local upkeep, is a more than sensible pick every bit a doctor frees up more PCN money. The NPSP does not adequately address the fact PCNs are financially incentivized to apply physicians over NPs – a disquisitional point since the determination to use NPs, as the policy is shortly written, remains a choice for the PCN to make. If the goal is for long-term NP utilization, rather than a "fill in" for the curt-term, these fiscal disincentives need to be addressed. The sense amongst participants was that options beyond PCNs, and options across console driven general practice were central to achieving greater NP integration in the province's principal care system.

Participants fabricated it articulate that office of the shortcoming of the NPSP was in its failure to conceptualize the operational and practical role of NPs as they integrated into main care. The Programme does not provide clarity regarding the roles and positioning of NPs in the primary care system: is the objective to add NP jobs, where the NP acts as a supplement to physicians in certain geographical areas, with certain patient population, or after hours? Or is the function of the NP to partner with a physician and together manage patients? Perhaps the goal was to enable NPs to operate as independent practitioners. These goals practice non have to be mutually exclusive, simply each require unlike operational and funding barriers to be addressed for the stated goal to be met. Any policy that impacts the role of NPs should offering articulate definitions of goals and roles of the program, peculiarly from the perspective of the finer operational details. In improver, the concerns of existing stakeholders demand to be anticipated and addressed in a comprehensive style – significant they must be developed with broad clinician and stakeholder consultation. In other words, NPs should, as one participant put it, "accept a seat at the table" in providing input to how their role is utilized.

Conclusion

3 major factors are impeding Alberta's NPSP from realizing its ain objective of increasing NP integration into primary care: 1) financial viability issues in which NPs, physicians, and PCNs are all adversely affected; 2) policy bug in which PCNs with competing priorities act as NP employers, and NPs are expected to panel patients in contest with PCN physicians; and 3) governance issues in which NPs are not afforded sufficient authority over their function or how the key concept of 'intendance team' is defined and operationalized. In its electric current iteration, the NPSP does non appear to be a long-term solution for increasing NP integration into the province's chief care environs. Increased NP integration in main care likely requires increased funding flexibility that volition allow NPs to access funding directly from the government, outside PCNs, with funding options to fit their individual practice setting. In addition, time to come NP policy evolution should: 1) ensure a clear goal for the NP role is established through clinician and stakeholder consultation including NPs themselves; and 2) ensure funding, policy, and governance structures are aligned with this envisioned goal for successful NP integration into various main intendance practice settings.

Availability of data and materials

Recordings and transcripts of interviews are saved but non made public to protect the identity of the participants.

Notes

2. Team-based intendance involves the collaboration of a multidisciplinary team of healthcare professionals such as physicians, nurses, nurse practitioners (NPs), dietitians, pharmacists, social workers, and mental health professionals [34]

Abbreviations

AMA:

Alberta Medical Association

CARNA:

College and Association of Registered Nurses of Alberta

FFS:

Fee-For-Service

NP:

Nurse Practitioner

NPAA:

Nurse Practitioner Clan of Alberta

NPSP:

Nurse Practitioner Support Program

PCN:

Chief Care Network

PHC:

Primary Health Care

RN:

Registered Nurse

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Acknowledgements

The authors wish to thank Dr. Travis Carpenter and Dr. Jennifer Zwicker for their support, encouragement, and feedback during the analysis and drafting of this paper. We would also like to thank all the participants who generously volunteered their time, knowledge, and insights to contribute to this research.

Funding

The lead author (SB) completed this work while holding a Carpenter Medical Corporation (CMC) Health Policy Studentship, with additional support coming from ML'due south bookish research stipend.

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Affiliations

1. The School of Public Policy, Academy of Calgary, Calgary, Alberta, Canada

   Stacey Blackness, Raad Fadaak & Myles Leslie

Contributions

SB and ML conceived of the written report. SB conducted all policy analysis, interviews and conducted initial Interpretive Description coding of the interview transcripts. ML reviewed policy and transcripts and the results of SB's initial coding, with both authors contributing to the concluding analysis. SB led the drafting of the last manuscript, with ML and RF providing critical and substantive feedback. All authors read and approved the concluding manuscript.

Respective author

Correspondence to Stacey Black.

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Blackness, S., Fadaak, R. & Leslie, Yard. Integrating nurse practitioners into primary care: policy considerations from a Canadian province. BMC Fam Pract 21, 254 (2020). https://doi.org/10.1186/s12875-020-01318-3

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• Received: 06 April 2020

• Accustomed: xv November 2020

• Published: 04 December 2020

• DOI : https://doi.org/10.1186/s12875-020-01318-3

Keywords

• Nurse practitioners
• Main care
• Policy
• Funding
• Role
• Integration
• Collaboration

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