A systematic review of experiences of advanced practice nursing in general practice

Abstract

BackgroundDespite efforts to achieve conceptual clarity, advanced practice nursing continues to reside in a liminal space, unable to secure ongoing recognition as a viable means of healthcare delivery. This is particularly evident in general practice where advanced practice role development is more fluid and generally less supported by the hierarchical structures evident in the hospital system. This review synthesises published qualitative studies reporting experiences of advanced practice nursing in general practice. The panoramic view provided by patients, nurses and doctors within this novel context, offers a fresh perspective on why advanced practice nurses have struggled to gain acceptance within the healthcare milieu.MethodsWe conducted a systematic review of qualitative studies that explored the experiences of patients, nurses and doctors who had contact with advanced practice nurses working in general practice. Published work from 1990 to June 2016 was located using CINAHL and PubMed. The full text of relevant studies was retrieved after reading the title and abstract. Critical appraisal was undertaken and the findings of included studies were analysed using the constant comparative method. Emergent codes were collapsed into sub-themes and themes.ResultsTwenty articles reporting the experiences of 486 participants were included. We identified one major theme: legitimacy; and three sub-themes: (1) establishing and maintaining confidence in the advanced practice nurse, (2) strengthening and weakening boundaries between general practitioners and advanced practice nurses and (3) establishing and maintaining the value of advanced practice nursing.ConclusionsWe set out to describe experiences of advanced practice nursing in general practice. We discovered that general practitioners and patients continue to have concerns around responsibility, trust and accountability. Additionally, advanced practice nurses struggle to negotiate and clarify scopes of practice while general practitioners have trouble justifying the costs associated with advanced practice nursing roles. Therefore, much work remains to establish and maintain the legitimacy of advanced practice nursing in general practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s12912-016-0198-7) contains supplementary material, which is available to authorized users.

Metaphors of Interdisciplinary Collaboration to Overcome the Theory-Practice Gap when Transitioning from RN to Advanced Practice Nurses

“…GPs were found to question if APNs have sufficient education to be autonomous and accountable [9]. Some GPs were reluctant to endorse referrals made by APNs to specialists outside the practice; some specialists refused to recognize these referrals, berating the GPs for bypassing the normal protocol [10]. Only once GPs are satisfied they can relinquish certain duties and care activities to APNs can the APNs have freedom to operate within their scope of practice [11].…”

“…This unnecessary interplay between nurse and physician resulted in incidences of overt client requests being overlooked [16]. Other studies reported the development of protocols as a means of avoiding omissions and explicitly delimiting the APN"s duties [7], [8], [10]- [17]. One nurse expressed that "it was tick the boxes, spit out the care plan, spit out the health assessment… We are not dealing with the patient as a holistic person" [16].…”

“…Disagreement on the place of the APN in the general practice milieu and how to best utilize this model of care was reported [12]- [13], [15], [17], [21]- [22]. Whereas physicians may enjoy handing over what they perceive to be mundane duties, tensions regarding the cost of APNs and anxieties around recouping this expense were evident [10], [16]. APNs reported being in a constant battle to be recognised professionally by their colleagues and clients [8], [12], [14]- [17], [20]- [22] and also by other nursing staff [7].…”

“…APNs have struggled to maintain a caseload commensurate with their training [12]. They have measured their worth to the practice in terms of the extra attention they could give their clients [10], [18], [19]. According to one physician, APNs were "a waste of money" because they always asked for a second opinion [18].…”

“…Yet, clients did not recognize the interactions between the APN and GP as professional cooperation. For instance, one client stated "she [APN] had to get permission from Dr. Ken to put me on insulin, but it was her that decided and he had to say yes" [10].…”