What Percentage Of Nurse Practitioners Provide Primary Care Services

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

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

BMC Family Practice book 21, Article number:254 (2020) Cite this article

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Abstract

Background

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

Methods

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

Results

Stakeholders predominantly felt the NPSP would not change the status quo of limited practice opportunities and the resulting underutilization of primary care NPs in the province. Participants attributed low levels of NP integration into the chief care arrangement to: 1) financial viability problems that directly impacted NPs, physicians, and primary care networks (PCNs); 2) policy issues related to the NPSP's reliance on PCNs as employers, and a requirement that NPs panel patients; and 3) governance issues in which NPs are non afforded sufficient say-so over their role or how the key concept of 'care team' is defined and operationalized.

Conclusions

In general, stakeholders did non run across the NPSP as a long-term solution for increasing NP integration into the province's primary care system. Policy adjustments that enable NPs to admission funding not simply from inside but as well outside PCNs, and modifications to let greater NP input into how their role is utilized would likely ameliorate the NPSP's ability to reach its goals.

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Background

The integration of nurse practitioners (NPs) into primary care has been viewed equally a solution to shortages of doctors [one], and a tool for improving patient access to care and lowering costs [2]. It has also been suggested that the integration of NPs into community-based care delivery is disquisitional to accomplishing the transformation of primary care into primary wellness care (PHC) [3, 4] - a transformation that has itself been linked to improved intendance, improved outcomes, and lowered costs [5,half dozen,seven,8]. The shift to PHC is one towards prevention, health, health and the successful direction of chronic illness [9,10,11,12,thirteen,14], accomplished through team-based care [15]. 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 [16,17,xviii,xix]. Despite this alignment with transformation principles and much policy enthusiasm, the utilization of NPs in Canadian principal intendance has been inconsistent [17].

To ameliorate understand the factors backside the inconsistent utilization of NPs, this paper presents ane Canadian province'southward contempo and ongoing efforts to increment the integration of NPs into its chief care organisation. We describe the Nurse Practitioner Support Plan (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's primary care environment. The data we nowadays hither provide broader comparative learnings for other jurisdictions contemplating policies to back up greater NP integration into their master care systems.

NPs in Alberta are registered nurses (RNs) that have: worked at to the lowest degree 4500 RN hours; completed a recognized NP educational programme; and passed a standardized exam specific to their practice area [twenty]. Drawing on competencies acquired in their Masters-level, clinically focused education [21] NPs enjoy a wider telescopic of practice than RNs, including the power to: conduct avant-garde health assessments; guild and interpret diagnostic tests; diagnose, care for, and perform avant-garde interventions; prescribe medications; monitor patient outcomes; and refer patients to other professionals as required [22]. Currently all provinces in Canada have legislation regulating the NP scope of exercise [2, 23]. In the province of Alberta, the Health Professions Human action [24] and the Registered Nurses Profession Regulation [25] requires NPs exist registered with the College and Clan 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 beyond Canada, [two] funding and payment reform to support NP integration have proved to exist barriers to practical implementation of the role [26].

The NPSP was not the Alberta government'southward start attempt at increasing NP participation in primary care [27]. In 2012, the province announced an increased role for NPs with the introduction of family unit care clinics [28]. Seen as plush and opposed by some members of the medical customs [29, 30], the family unit care clinic concept did non successfully navigate a modify in political leadership [31, 32]. Simply 3 out of the 140 clinics envisioned were ultimately built [31].

In April 2019, with a delivery to team-based intendance ^{Footnote 2} and its advantages [33] well-articulated in the provincial master care strategy [4], the province sought to increase the relatively low count of NPs in primary care by introducing the NPSP [17]. In Alberta the majority of registered NPs – 72% in 2018 – were employed in acute care or specialty out-patient clinics [17]. In other Provinces the majority of NPs work in chief care and community settings with simply 24% working in hospitals [35]. The NPSP thus aimed to increase the use of NPs in Alberta's principal care arrangement, part of a broader provincial regime priority to improve access, rubber, quality, and continuity of main intendance [17].

The NPSP allows the province's Chief Care Networks (PCNs) to apply for NP-specific funding, with the aim of increasing NP integration into chief intendance. PCNs are intermediary organizations positioned between the regime and the front end lines of primary intendance, and as envisioned by the NPSP, are the master agents for main care NP integration in the province. Originally created in 2003, PCNs are funded by the Regime of Alberta'southward Ministry of Health and formed through a articulation venture system between Alberta Health Services (AHS; the single wellness authority and service provider for the province) and master care physicians who opt-in, signing a contract to become members of a PCN [36].

In Alberta, private physicians are generally independent small-business concern owners, with the province functioning almost exclusively on a Fee-For-Service (FFS) model [37,38,39,forty]. Physicians tin however arrange an alternative compensation method with the authorities if they choose [41]. These compensation options are available to primary care physicians whether they cull to join a PCN or non. As noted above, primary care physicians can opt to bring together a PCN, which generates money for their respective PCN. This per capita funding for the PCN is in addition to the physician's regular compensation. For each patient on a PCN-physician'southward panel, a PCN receives $62 per twelvemonth, with this collective per capita money being used to support locally adapted service delivery and team enhancement, as well every bit pay the PCN's administrative costs. In addition to implementing squad-based care, the PCNs are too responsible for implementing other elements of the Patient Medical Home (PMH) including improved admission, patient panelling, employ of electronic medical records, and quality improvement [four, 42].

The NPSP positions Alberta's PCNs as the primary back up and implementation machinery for achieving NP integration into primary care, as role of a broader western Canadian objective of delivering team-based main care [xv]. In light of the province's relatively depression rate of NP uptake in main care, the NPSP aims to incentivize PCNs to rent more NPs in Alberta and to increase NP integration into chief intendance 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 non only physicians, to create a 'panel' of patients [43]. Where a panel refers to a set of patients attached to a detail provider, a 'roster' refers to a prepare of patients fastened to a group of providers [43]. The funding generated from an NP's PCN-based console of patients (the same $62 per capita) would, unlike with physicians, exist earmarked to embrace that NP'south 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 regime's supplemental superlative-up, paid to the PCN to back up the NP'south annual salary. This supplemental top up is to a maximum of $125,000 [17]. In dissimilarity, if a patient is paneled to a dr., the per capita payments do not reduce the corporeality the government remunerates that physician based on FFS billings. Instead, a physician bills the government the regular amount and the doctor'southward per capita coin is pooled with other PCN doc members' per capita panel funds and made available to the PCN [17]. This financial arrangement, aslope other factors discussed beneath, directly impacts the viability of the NPSP policy aimed at integrating NPs into Alberta'southward primary care system.

Changes in authorities oft innovate differing priorities with existing publicly funded policies either changed or abandoned. Shortly after the introduction of the NPSP, there was a change in Alberta'due south government. However, the integration of NPs into primary care continues to exist a priority, with the new regime promising NP billing reform [44] and continued back up for the NPSP [45]. The urgency of the upshot has been emphasized equally NPs and their scope of practice have one time once again come to the forefront as part of the response to the COVID-19 pandemic and the strains it introduced to the master intendance arrangement [46].

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

• Make prove-based recommendations regarding policy and operational factors that will help meliorate NP integration into PCNs and PCN effectiveness.

Methods

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

Further information is provided in Table 1 beneath.

Tabular array one Participants

Full size table

Recruitment began purposively – with the limited aim of including a diversity of perspectives driving our choices [49] – and so shifted to include snowball sampling of individuals through participant referrals [49, 50]. 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 primary care, and their views on the NPSP. Participants are identified in the following pages with the Roman numerals I to 15. In total, we interviewed xv participants, with this sample composed of different professional backgrounds to ensure potential differences in stance were considered (See Table 1). Over the course of collecting data from this sample, we found 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 past 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 90 min and were both recorded and transcribed. The data was then analyzed with the assistance of NVivo 12 software using an inductive coding approach aimed at rendering an interpretive description of participants views on NP integration into master care generally, and via the PCNs and the NPSP specifically.

Our interpretive description approach allowed us to gain insight not just on areas of commonality, but areas of disagreement amongst participants, and with an eye on providing pragmatic suggestions to meliorate policy in the surface area [51, 52]. SB and ML analysed the information iteratively, expanding, collapsing and merging themes to make it at the final analysis. Nosotros carried out participant checks on the interpretations presented.

This research obtained upstanding blessing 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 resources in Alberta's primary care surroundings. The information from xv participant interviews attributed this low level of NP integration to a lack of independent practice opportunity and minimal job prospects which, in turn, related to: ane) fiscal viability issues that touch both NPs, physicians, and PCNs; ii) 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 chief intendance" (Participant VI). A PCN executive manager described how at that place had been trivial progress in integrating NPs into main care in the preceding decade:

There were very, very few positions exterior of the astute intendance setting. And I think, in some ways still – like 10 years later, at that place hasn't been much progress. (Participant IX).

The lack of available positions was, in the aforementioned participant'southward mind, a disservice to both those undertaking NP training and the taxpayers who subsidize that preparation:

All of those professional [programs] are generally topped up by regime funding in the education stream... I don't remember we were doing NPs a service when they could obtain this education, graduate, and so non have any … positions in the principal care environs [available]. (Participant Nine).

Another participant further elaborated:

[I]t'due south and then sad that this cream of the crop bunch [is] being lost [due] to lack of opportunity... what a brain drain! And they're leaving the province, they're leaving the country … they are leaving the profession. [Due west] lid a waste product of human resources. (Participant I).

The lack of job openings and government-funded brain drain to other jurisdictions was viewed by participants as a result of specific fiscal disincentives that shaped the viability of becoming an NP in the province's primary care system. These financial viability issues impacted all three of the key stakeholders involved in the NPSP: NPs, physicians, and the PCNs.

Fiscal viability: NPs

A range of participants described how the province's physicians have an assortment of options to fund their exercise (FFS, blended capitations, salary). All the same, the majority of family unit physicians in Alberta operate as a private business organization and fund their practice by billing the authorities FFS. In contrast, NPs – both nether the NPSP and prior to its introduction – tin only be funded as employees (Participant I, XIV, XII), relying on physicians or PCNs having available jobs for them. Every bit one participant noted, independent NP practice "isn't supported" by current policy arrangements (Participant Three).

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

[T] he bounty systems are non in place to support independent [NP] practice right now (Participant Six).

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 be paid directly:

I can't get paid by the government to offer those services. [T] he regulatory body and the Health Professions Deed of Alberta allows me to do it, but I cannot become paid [to provide those services] (Participant XI).

Unable to be reimbursed equally independent practitioners, NPs for the most part currently can either cull to bill patients directly for services or rely on beingness hired by PCNs or individual physicians as employees. For those who choose to beak outside the publicly funded system, participants noted that fiscal viability hinges on exploiting a niche for which patients – otherwise accustomed to 'complimentary' main care – are willing to pay out-of-pocket. Without niche practice able to back up private billing, financial viability hinges on condign an employee of an private physician or a PCN. As nosotros will see later, the governance and power issues inherent in seeking employment from physicians and PCNs are seen equally both personally challenging, and detrimental to NPs practicing at their full scope. Beyond these problems, the charge per unit of pay as an employee and lack of culling options to practice was summed upward past one participant as follows:

A lot of registered nurses (RNs) … inquire me, is it worth it? I would say, no. [T]hither's no opportunity [to become a business loan, to neb the government, or go a task.] … [I] f there is opportunity [to get a job], frequently you make less than a senior RN. (Participant XI).

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

If the root cause of depression 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 issue for physicians.

Financial viability: physicians

Nether the province's predominant physician's FFS billing arrangements, physicians are not encouraged to deploy NP employees to evangelize care for which physicians would otherwise be able to neb the government. For a policy-maker participant, the key trouble was a missing mechanism for physicians to recover revenue 'lost' when an NP provided a service:

[I]t's really unclear to family unit physicians how they would use an NP in their practise. At that place'due south not a mechanism for the doctor [and the exercise] to exist compensated for the services that that NP delivers right at present (Participant VI).

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

[I]t's lucrative [for physicians] to come across easy patients because [physicians] become paid fee-for-service. I recall a lot of people in primary care don't want NPs to practice that stuff, because [physicians] think information technology [is] going to affect their bottom line (Participant Ii).

Across presenting a claiming to the depression-effort, high-advantage cases at the centre of current doctor profitability, participants noted that the NPSP did not provide ways to generate acquirement to cover overhead costs. As an NP who ultimately lost their task noted:

I was basically taking up space where if a doctor was in that space, they could bill the government and pay overhead. And the overhead that physicians pay is astronomical (Participant Vii).

Most family physicians in Alberta operate as a private business organization with revenue generated from billing the government for services provided. NPs cannot bill the government for services they provide and do non receive bounty direct from regime. If a physician or a PCN hires an NP, that NP'southward bacon is paid from the physician'southward or PCN's revenue. As such, NPs do non generate revenue from regime to pay overhead. If an NP opened a clinic outside the public system and billed patients directly, the NP would take to pay the same amount of overhead. Even so, with patients accustomed to publicly funded primary care services, and many NPs wanting to operate within the public system, the inability to cover overhead costs similar their dr. colleagues proved problematic for nearly participants.

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

I have to kind of just pop my caput in and say, "Hi! Whatever questions? Let me know..." And that'south a bit ridiculous, but I have to popular my caput in so I can bill for those patients (Participant XV).

This 'whites of the optics' billing arroyo increased revenue to cover the NP's overhead costs and bacon. However, information technology appeared to be an exception to a general rule where most physicians instead viewed NPs as a financial burden to their business.

Financial viability: PCNs

Despite being the focal betoken of the NPSP, the PCNs – as member-driven organizations composed of family physicians – are also disincentivized by the financial realities of integrating NPs. Where the NPSP aims to use per capita revenue generated by the NP's patient panel to pay the NP salary, the PCNs' members tend not to see the value suggestion. In an extension of their individual concern for an employee delivering services they would otherwise be able to nib for, PCN members often see their organization's per capita funds better spent elsewhere. A old PCN administrator noted:

[T] he prevailing conventionalities amongst docs is:

'Nosotros shouldn't be using PCN coin to fund NPs … because nosotros could just [put a doc in that position and] bill FFS [to cover the physician's salary and overhead] and practise what [the NP is] doing and use the [PCN] coin for something else like a chronic disease nurse, a social worker, a pharmacist, [etc.]' (Participant XII).

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

[T] he services that an NP can offer could be offered similarly by a physician and that doctor's compensation would come out of, not the PCN budget, but [the Ministry of Health's budget] (Participant XI).

Alongside these fiscal viability issues for NPs, physicians, and PCNs, participants also identified policy and governance issues that made attractive jobs equally a master 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 merely machinery for funding and implementation.

Requirements for paneling and total scope primary care

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

I don't experience the need to have my ain patient panel. There are other nurse practitioners who want to have their ain patients. So that's just a personal preference (Participant VII).

This sense that the policy's paneling requirement was unnecessarily restrictive was shared by physicians (Participant 15, Participant II). Another NP participant illustrated what they saw as the ineffectiveness of the paneling requirement past making a hypothetical pitch for money to outset up a community-based specialty NP practise:

I'm a nurse practitioner. I have a sub specialization in chronic pain management. There is a high burden of chronic hurting in Calgary and it's under met. The chronic hurting centre has a 2 year waiting list. I want to beginning a clinic that deals with chronic hurting patients. I want to submit a business programme … [and], I want to submit an expression of interest to have funding to be able to do this. But I can't exercise that. Information technology doesn't exist. Even under the [NPSP] I can't do it because the premise is total telescopic, chief care. (Participant 11).

In the hypothetical pitch, even if an NP were able to identify a specific expanse that is underserved past physicians, the NPSP's need for only full spectrum – which is to say fully empanelled – intendance would stop the project moving forward because at that place is no current funding mechanism that would accommodate the participant'south instance. In this mode, the policy's panelling requirement and resulting mandate that NPs integrate past providing full telescopic primary care fails to let 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 choice to submit an awarding for this defended NP funding. Some participants questioned the prerogative this gives to PCNs over whether to consider integrating NPs at all. As one former PCN administrator noted:

If physicians are managing it, it'due south a footling bit like the mice guarding the cheese … Would they really want to requite money to NPs and fund their contest? (Participant XII).

This sense that PCNs should not be the just 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 physician-members view NPs thus has an oversized result on how the NPSP gets implemented, as PCNs are the merely avenue for NPs to qualify for NPSP funding support. As a policy maker noted:

[W]eastward're getting some early indication that [NPs are] also perceived every bit a threat, and therefore the physicians don't want them... (Participant 6).

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

I call back nosotros're a great avenue to support [NP integration]. But I don't necessarily retrieve we are the simply avenue that could (Participant 9).

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

Inappropriate governance

Both NP and non-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), "md-axial" (Participant I) (Participant IX), "led by family physicians" (Participant 14), and "physician-led" (Participant VI).

As 1 NP described information technology, choosing the PCNs to advance NP integration was one in which the government was essentially "asking some other profession – which is physicians - to develop the role of NPs." This was non but seen as "inappropriate", merely meant the NPSP was "flawed by design" because information technology, "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] tin only be an employee of the PCN [non a full member like physicians] … and so you're missing the nursing voice at the table … How you're deployed, where are y'all deployed, how you're utilized. I don't have any control (Participant Eleven).

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 grade of squad-based care. For 1 participant, at that place was a key difference betwixt a squad that was working together collegially, and a team that was built around doing work for physicians. This participant described the difference as being one betwixt:

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

When team was defined collegially, and and then governance hierarchies were flattened, not just NP integration, but reported job and patient satisfaction improved. Under these conditions the employee-NP model was viable from a governance standpoint as much equally it withal suffered from financial challenges. Illustrating this, an NP participant described a catamenia of collegial dr.-NP teamwork at a PCN where they worked:

[West] e chosen it the Dream Team … the patients were really happy … It [was] the best job 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 percent … And so, the medical director [of the PCN] came back, and insisted on a hierarchy. And we all got sort of dispersed, and we weren't allowed to swallow lunch together … And almost everybody either quit or was permit go (Participant I).

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

Nether what this NP saw as an inappropriate governance regime inside their PCN, NPs became mere "helpers to physicians" expected to "fill in where doctors have left holes in intendance," (Participant I).

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

Physicians [in the PCN where I worked] would not let me practice. [They] refused to let me to do … I didn't become information technology. Just then, something [would need] to exist assessed right away and [they would say], "Oh, yous could go do that!" After hours, Fri nights and weekends. [And then information technology was] no problem, but during the week I could not have clinic infinite (Participant 14).

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

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

A PCN ambassador participant noted how deploying NPs later 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 primary intendance:

[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 mode the hierarchical rather than collegial governance enabled by the NPSP'due south choice of the PCNs was seen, past 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 achieve its stated objective of integrating NPs into the province's primary care system. These challenges include governance problems that distribute say-so and funding options unequally; financial disincentives for NPs, physicians, and PCNs; and a small number of highly delimited task opportunities. Each of these represents an opportunity to adapt the policy to be amend calibrated to accomplish its main goal of NP chief care integration.

From the majority of participants' perspectives, perhaps the most problematic attribute of the NPSP'south utilise of the PCNs as mechanisms of integration was that this gave physicians the final say on job availability, remuneration, and termination, also equally how central 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 master care 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 means in which funding and care delivery models that support medical dominance tend to impede collaboration [56]. Our data confirm that NPs are not encouraged to integrate when physicians are granted the authorisation to resolve territorial conflicts over scope of practice in their own favour, or to define whether a team volition be collegial or hierarchical. Equally D'Flirtation et al. [57] accept noted, successful collaboration in healthcare teams is the result of conscientious work at interpersonal, system, and governance levels, not imbalanced relationships. In this sense, the NPSP in its present form, embedded equally it is in the billing and governance structures of the province, is not able to achieve its full potential as a means to increase admission to quality chief care through NP participation.

Across governance every bit an issue of professional autonomy, the NPSP fails to address longstanding financial disincentives that affect NPs themselves, physicians, and the PCNs. It is imperative to consider medico compensation structures in place 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 cull 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 exist employees of "doc-controlled" PCNs. As such, NPs find themselves both unable to open up practices of their own and observe it challenging to generate enough acquirement to cover the overhead they incur as employees. For their part, physicians operating on a FFS basis – which is to say the bulk of primary care practices in the province – detect that NPs, forth with other members of the care team working aslope them, are unable to nib for services that physicians would commonly provide. The inability to bill the government for services rendered by non-physician care team members has been consistently identified equally 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 individual NPs and physicians, at the PCN level the NPSP proposes that PCNs apply the per capita revenue generated past the patients on an NP's panel to cover, or partially comprehend, that NP'southward salary. The challenge here is that this per capita funding is at the center 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 piece of work at the heart of these organizations' mandate. In this sense, deploying a dr. who tin can beak the government FFS, and not an NP who draws down the local budget, is a more sensible option equally a medico frees upwards more PCN money. The NPSP does not adequately address the fact PCNs are financially incentivized to utilize physicians over NPs – a critical point since the determination to utilize NPs, equally the policy is before long written, remains a choice for the PCN to make. If the goal is for long-term NP utilization, rather than a "fill up in" for the curt-term, these fiscal disincentives demand to exist addressed. The sense amid participants was that options beyond PCNs, and options beyond console driven full general practice were central to achieving greater NP integration in the province'due south primary care organization.

Participants fabricated information technology clear that part of the shortcoming of the NPSP was in its failure to anticipate the operational and practical role of NPs as they integrated into principal care. The Program 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 later hours? Or is the role of the NP to partner with a physician and together manage patients? Peradventure the goal was to enable NPs to operate as independent practitioners. These goals do non have to be mutually sectional, but each crave different operational and funding barriers to be addressed for the stated goal to be met. Whatsoever policy that impacts the role of NPs should offer clear definitions of goals and roles of the plan, particularly from the perspective of the finer operational details. In addition, the concerns of existing stakeholders need to be predictable and addressed in a comprehensive manner – pregnant they must be developed with broad clinician and stakeholder consultation. In other words, NPs should, as one participant put it, "have a seat at the table" in providing input to how their role is utilized.

Conclusion

Three major factors are impeding Alberta'southward NPSP from realizing its own objective of increasing NP integration into primary care: ane) financial viability issues in which NPs, physicians, and PCNs are all adversely afflicted; 2) policy issues in which PCNs with competing priorities act as NP employers, and NPs are expected to panel patients in competition with PCN physicians; and 3) governance issues in which NPs are not afforded sufficient authority over their part or how the key concept of 'care team' is divers and operationalized. In its electric current iteration, the NPSP does not appear to be a long-term solution for increasing NP integration into the province's principal care environment. Increased NP integration in chief care likely requires increased funding flexibility that will allow NPs to access funding straight from the government, outside PCNs, with funding options to fit their individual do setting. In addition, future NP policy development should: i) ensure a clear goal for the NP role is established through clinician and stakeholder consultation including NPs themselves; and ii) ensure funding, policy, and governance structures are aligned with this envisioned goal for successful NP integration into diverse primary care do settings.

Availability of data and materials

Recordings and transcripts of interviews are saved but not made public to protect the identity of the participants.

Notes

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

Abbreviations

AMA:

Alberta Medical Association

CARNA:

Higher and Clan of Registered Nurses of Alberta

FFS:

Fee-For-Service

NP:

Nurse Practitioner

NPAA:

Nurse Practitioner Association of Alberta

NPSP:

Nurse Practitioner Support Program

PCN:

Master Care Network

PHC:

Master Health Care

RN:

Registered Nurse

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Acknowledgements

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

Funding

The pb author (SB) completed this work while belongings a Carpenter Medical Corporation (CMC) Health Policy Studentship, with additional back up coming from ML's bookish research stipend.

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Affiliations

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

   Stacey Black, Raad Fadaak & Myles Leslie

Contributions

SB and ML conceived of the study. 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 final analysis. SB led the drafting of the last manuscript, with ML and RF providing disquisitional and substantive feedback. All authors read and approved the final manuscript.

Respective author

Correspondence to Stacey Blackness.

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This research obtained upstanding approval from the Conjoint Faculties Research Ethics Board at the University of Calgary (REB18–1709). Participants provided written consent.

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The authors declare that they have no competing interests.

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Black, S., Fadaak, R. & Leslie, M. Integrating nurse practitioners into primary intendance: policy considerations from a Canadian province. BMC Fam Pract 21, 254 (2020). https://doi.org/x.1186/s12875-020-01318-iii

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• Received: 06 Apr 2020

• Accepted: 15 November 2020

• Published: 04 December 2020

• DOI : https://doi.org/ten.1186/s12875-020-01318-3

Keywords

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

What Percentage Of Nurse Practitioners Provide Primary Care Services,

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