Integrating nurse practitioners into primary healthcare to advance health equity through a social justice lens: An integrative review.

AIM: To develop a framework to guide the successful integration of nurse practitioners (NPs) into practice settings and, working from a social justice lens, deliver comprehensive primary healthcare which advances health equity. DESIGN: Integrative review. METHODS: The integrative review was informed by the Whittemore and Knafl's framework and followed the Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines. Quality was assessed using the Johns Hopkins Research Evidence Appraisal Tool. Findings were extracted and thematically analysed using NVivo. A social justice lens informed all phases. DATA SOURCES: Databases, including CINAHL, PubMed, Scopus and Web of Science, were searched for peer-reviewed literature published in English between 2005 and April 2022. RESULTS: Twenty-eight articles were included. Six themes were identified at the individual (micro), local health provider (meso), and national systems and structures (macro) levels of the health sector: (1) autonomy and agency; (2) awareness and visibility; (3) shared vision; (4) leadership; (5) funding and infrastructure; and (6) intentional support and self-care. The evidence-based framework is explicitly focused on the components required to successfully integrate NPs into primary healthcare to advance health equity. CONCLUSION: Integrating NPs into primary healthcare is complex and requires a multilevel approach at macro, meso and micro levels. NPs offer the potential to transform primary healthcare delivery to meet the health needs of local communities. Health workforce and integration policies and strategies are essential if the contribution of NPs is to be realized. The proposed framework offers an opportunity for further research to inform NP integration. IMPACT STATEMENT: Nurse practitioners (NPs) offer the potential to transform primary healthcare services to meet local community health needs and advance health equity. Globally, there is a lack of guidance and health policy to support the integration of the NP workforce. The developed framework provides guidance to successfully integrate NPs to deliver comprehensive primary healthcare grounded in social justice. Integrating NPs into PHC is complex and requires a multilevel approach at macro, meso and micro levels. The framework offers an opportunity for further research to inform NP integration, education and policy. SUMMARY STATEMENT: What problem did the study address: The challenges of integrating nurse practitioners (NPs) into primary healthcare (PHC) are internationally recognized. Attempts to establish NP roles in New Zealand have been ad hoc with limited research, evidence-informed frameworks or policy to guide integration initiatives. Our review builds on existing international literature to understand how NPs are successfully integrated into PHC to advance health equity and provide a guiding framework. What were the main findings: Six themes were identified across individual (micro), local health provider (meso) and national systems and structures (macro) levels as fundamental to NP integration: autonomy and agency; awareness and visibility of the NP and their role; a shared vision for the direction of primary healthcare utilizing NP scope of practice; leadership in all spaces; necessary funding and infrastructure; and intentional support and self-care. Where and on whom will the research have an impact: Given extant health workforce challenges together with persisting health inequities, NPs provide a solution to delivering comprehensive primary healthcare from a social justice lens to promote healthcare access and health equity. The proposed evidence-informed framework provides guidance for successful integration across the health sector, training providers, as well as the NP profession, and is a platform for future research. REPORTING METHOD: This integrative review adhered to the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) method. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

How the Institutional and Policy Context Shapes the Establishment of Nurse Practitioner Roles and Practice in New Zealand's Primary Health Care Sector.

The implementation of the nurse practitioner (NP) workforce in primary health care (PHC) in New Zealand has been slow, despite ongoing concerns over persisting health inequalities and a crisis in the primary care physician workforce. This article, as part of a wider institutional ethnography, draws on the experiences of one NP and two NP candidates, as they struggle to establish and deliver PHC services in areas of high need, rural, and Indigenous Maori communities in New Zealand. Using information gathered initially by interview, we develop an analysis of how the institutional and policy context is shaping their experiences and limiting opportunities for the informants to provide meaningful comprehensive PHC. Their work (time and effort), with various health organizations, was halted with little rationale, and seemingly contrary to New Zealand's strategic direction for PHC stipulated in the Primary Health Care Strategy 2001. The tension between the extant biomedical model, known as primary care, and the broader principles of PHC was evident. Our analysis explored how the perpetuation of the neoliberal health policy environment through a "hands-off" approach from central government and district health boards resulted in a highly fragmented and complex health sector. Ongoing policy and sector perseverance to support privately owned physician-led general practice; a competitive contractual environment; and significant structural health sector changes, all restricted the establishment of NP services. Instead, commitment across the health sector is needed to ensure implementation of the NP workforce as autonomous mainstream providers of comprehensive PHC services.

Austerity, new public management and missed nursing care in Australia and New Zealand.

AIMS: To outline the way the culture of austerity arising from the Global Financial Crisis has been used by Australian and New Zealand governments to maintain and extend healthcare budget cuts, through new public management strategies leading to missed nursing care. BACKGROUND: Ten years on the cost of the Global Financial Crisis continues to be borne by tax payers and those employed by the welfare state, yet analysis shows clearly that it was caused by a failure to adequately regulate markets, particularly the banks and multinational corporations. In health care, one of the impacts is increased workload for nurses leading to missed care. DESIGN/METHODS: Registered Nurses and midwives (n = 7,302) completed the MISSCARE surveys between 2012 - 2015, in four Australian states and New Zealand providing quantitative and qualitative responses. The qualitative comments were analysed using a template analysis approach based on key features of New Public Management. FINDINGS: Sixty-two qualitative responses identified measures in place directly linked to austerity and new public management strategies that impacted on the quality of patient care and nursing work, as well as contributing to missed care. CONCLUSION: Opportunities for resistance may lie outside public and private health organizations in civil society, in the nurse union movements and other health and nursing professional associations.

Prevalence of key care indicators of pressure injuries, incontinence, malnutrition, and falls among older adults living in nursing homes in New Zealand.

Pressure injuries, incontinence, malnutrition, and falls are important indicators of the quality of care in healthcare settings, particularly among older people, but there is limited information on their prevalence in New Zealand (NZ). The aim of this study was to establish the prevalence of these four problems among older people in nursing home facilities. The cross-sectional study was an analysis of data collected on a single day for the 2016 National Care Indicators Programme-New Zealand (NCIP-NZ). The sample included 276 people ages 65 and older who were residents in 13 nursing home facilities in a geographically diverse area of central NZ. Data were analyzed with descriptive statistics. Prevalence rates in these nursing home settings was pressure injuries 8%; urinary incontinence 57%; fecal incontinence 26%; malnutrition 20%, and falls 13%, of which half resulted in injuries. As people age, complex health issues can lead to increasing care dependency and more debilitating and costly health problems. Measuring the prevalence of basic care problems in NZ healthcare organizations and contributing to a NZ database can enable monitoring of the effectiveness of national and international guidelines.

New risks: the intended and unintended effects of mental health reform.

In crisis situations, the authority of the nurse is legitimised by legal powers and professional knowledge. Crisis stakeholders include those who directly use services and their families, and a wide range of health, social service and justice agencies. Alternative strategies such as therapeutic risk taking from the perspective of socially inclusive recovery policy coexist in a sometimes uneasy relationship with mental health legislation. A critical discourse analysis was undertaken to examine mental health policies and guidelines, and we interviewed service users, families, nurses and the police about experiences of accessing services. For those who attempt to access services early in crisis, as is suggested to lead to a better outcome, provision of services and rights appear to be reversed by an attempt to exclude them through practices that screen them out, rather than prioritising a choice in access.

The nurse practitioner role: Solution or servant in improving primary health care service delivery.

In New Zealand, as in many other countries, the demand for health services is escalating as chronic disease, population ageing and health disparities increase. It has been argued that a more comprehensive primary health care approach is needed combining biomedical approaches with a social determinants and social justice based approach. The contemporary development of the nurse practitioner (NP) role in New Zealand (NZ) offers the possibility of taking up a more critical approach to strengthen and extend primary health care services (PHC). Nurse practitioners could simply be utilised to shore up the nature and style of existing primary care (PC) service configurations or, more usefully, they could lead a revolution in traditional approaches towards genuine primary health care delivery.

Evaluation of a diabetes nurse specialist prescribing project.

AIMS AND OBJECTIVES: To evaluate the diabetes nurse specialist prescribing project with the aim of determining whether diabetes nurse specialist prescribing is safe and effective and to inform the implementation and extension of registered nurse prescribing. BACKGROUND: Registered nurses in many countries are able to prescribe medicines, but in New Zealand, prior to the diabetes nurse specialist project, nurse practitioners were the only nurses who could prescribe medicines. New regulations allowed the nurses to prescribe a limited number of prescription medicines. DESIGN: The study was a process and outcome clinical programme evaluation. METHODS: The project took place between April-September 2011 and involved 12 diabetes nurse specialist in four localities. Quantitative data were collected from clinical records maintained by the diabetes nurse specialist for the project (1274 patients and 3402 prescribing events), from surveys with stakeholders (general practitioners, n = 30; team members, n = 19; and patients, n = 89) and audits from patient notes (n = 117) and prescriptions (n = 227), and qualitative data from interviews with project participants (n = 18) and patients (n = 19). All data were analysed descriptively. RESULTS: Diabetes nurse specialist prescribing was determined to be safe, of high quality and appropriate. It brought important benefits to the effectiveness of specialist diabetes services, was acceptable to patients and was supported by the wider healthcare team. CONCLUSIONS: These findings are consistent with the findings reported in the international literature about nurse prescribing in a range of different practice areas. Clarification of the education and competence requirements and resourcing for the ongoing supervision of nurses is recommended if the prescribing model is to be extended. RELEVANCE TO CLINICAL PRACTICE: Diabetes nurse specialist prescribing improved access to medicines by providing a more timely service. Nurses felt more satisfied with their work because they could independently provide a complete episode of care. As novice prescribers, nurses need to be well prepared educationally and have access to supportive clinical supervision.

Nurse perceptions of the Diabetes Get Checked programme.

AIM: The Diabetes Get Checked programme provided a free annual diabetes check to people diagnosed with diabetes. The aim of the present study was to ascertain the impact this programme had on the practice of nurses; identify factors that nurses consider contributed to the success or failure of the programme in their work setting; and to elicit nurses' suggestions for future improved management and outcomes for people with diabetes. METHOD: An observational study utilising an online survey was undertaken. A total of 748 people completed the survey - the majority being nurses. Data were analysed descriptively. RESULTS: The Diabetes Get Checked programme was shown to have had a substantial impact on the practice of nurses, enabling the development of new models of nursing care, improved educational levels among nurses (and doctors), improved confidence in the management of diabetes, and increased satisfaction in their work. Nurses in the study suggested future interventions and programmes designed to support people with diabetes. These include implementation of a multi-disciplinary wrap-around approach, enhanced case management and self-management, implementing direct funding for nurse-led services, and improving population-based approaches such as policy changes and social marketing. DISCUSSION: The study sought nurse's perspectives with regard to a recently terminated programme designed to provide care to people with diabetes. It identified areas that worked well in programme implementation and those that could be improved. These findings provide useful information for funders and planners developing new programmes designed to support people with diabetes.

Perceptions of policy and political leadership in nursing in New Zealand.

This qualitative study was focused on the landscape of nursing policy and political leadership in New Zealand. A volunteer sample (N = 18) of nurse leaders (Fellows of the College of Nurses Aotearoa (NZ) Inc) drawn from across the country was interviewed with respect to issues that affect their interest in participating in political action and policy work. The framework of stages of nursing's political development published by Cohen and colleagues (1996) was used as an interview guide. Respondents were asked to describe their own stage of political development, their perception of the political development of New Zealand nurses and nursing organisations at large, and also their thoughts on what could be done to better position nursing in healthcare policy development. In general, respondents agreed that the major nursing organisations in New Zealand (the College of Nurses-- Aotearoa and New Zealand Nurses Organisation [NZNO]) were moving toward increasing policy sophistication. Qualitative content analysis suggested five themes which, taken together, describe nursing's policy/political development in New Zealand: languaging; succession/legacy planning; Tall Poppies and Queen Bees; "it's a small country"; and speaking with one voice. Although limited by sample size, the information collected provides a beginning focus for discussion that can steer New Zealand nursing activities toward the wider involvement of nurse leaders in healthcare policy work on behalf of the discipline.

Caesarean section in the absence of need: a pathologising paradox for public health?

Caesarean section in the absence of need: a pathologising paradox for public health? This qualitative study explored the discourses constructing women's choice for a caesarean section, in the absence of clinical indication. The research was informed from the theoretical ideas of poststructuralism that presumes people's reality is shaped discursively through the discourses they encounter. A Foucauldian discourse analysis was undertaken of the transcripts of participant's interviews and the texts of both professional and popular media before inductively discerning the prevailing discourses that influence the choice of caesarean in the absence of need. In shaping women's choice in childbirth the discourses of autonomy, convenience and desire alongside fear and risk were identified in the talk and texts of women, childbirth professionals and popular culture. For the purposes of this article we have confined our focus to the findings related to how caesarean is represented in both professional and popular discourse and include feminist discussions around childbirth as an embodied practice. We contend that the discourses of autonomy, desire and risk unite with broader societal discourses to expose a pathologising paradox in which normal bodily performance emerges as abnormal and the abnormal as normal. The trend has implications for both future healthy populations and the equitable distribution of maternity resources.

Employing nurse practitioners in general practice: an exploratory survey of the perspectives of managers.

INTRODUCTION Establishing the nurse practitioner (NP) workforce in New Zealand is a viable solution to health and workforce challenges in primary health care. General practices have been slow to implement NP services. Managers of general practices are central to the employment and development of NP roles. AIM To explore the perspectives of managers on employing NPs in general practice. METHODS An electronic survey was used to collect demographic and numerical data, which were analysed descriptively and analytically using SPSS (version 26). Written answers to open-ended questions were analysed qualitatively. RESULTS In total, 143 managers participated in the survey (response rate 39.7%); 54 (37.8%) worked in practices employing at least one NP. Of respondents, 88.9% (n = 127) agreed or strongly agreed that NPs could enhance continuity of care (89/143, 62.2%), improved access to services and medications (89/143, 62.2%) and filled a gap that added value to health care (97/143, 67.8%). Practices employing NPs had statistically significant higher levels of agreement about the advantages of NPs than practices not employing NPs. Challenges and enablers to employing NPs were themed under organisational environment, NP scope of practice and role, and NP workforce development. DISCUSSION This exploratory study revealed that there is little knowledge about the NP workforce in surveyed general practices. Ongoing work is required to improve knowledge for employing general practices, including dissemination of information about NP education and training, scope and models of care, and ability to generate business income.

Experiences of nursing in older care facilities in New Zealand.

To examine issues related to the working life of registered nurses in residential care for older people in New Zealand, 48 registered nurses completed surveys (n = 28) or participated in discussions (n = 26) regarding their work roles, continuing education and interactions with specialist nurse services when providing care for older people living with chronic illnesses. This nursing workforce is characterised by ageing, relative isolation, reduced confidence and few opportunities for induction of new graduates. Registered nurses reported their struggle to deliver the appropriate quality of care to residents as acuity increases, general practitioner availability decreases and the opportunities for increasing their knowledge and competence remain limited. The provision of nursing services in residential care for older people is an area of growing concern to many Western countries. Nurse practitioners offer opportunities to improve the quality of residential care.

Nursing staff satisfaction with the acute pain service in a surgical ward setting.

Over the last 20 years significant advances in the management of pain have been made. Specifically, establishment during the 1990s of Acute Pain Services (APS) within hospitals both nationally and internationally resulted in improved awareness and management of pain. However there has been little research into staff satisfaction with the service, and no studies have been undertaken at a local hospital level. Nurses play a major role in the assessment and treatment of acute pain; therefore it is useful to determine the level of their satisfaction following introduction of APS. The purpose of the present study was to explore, by means of a survey, the level of nursing staff satisfaction with the APS in a large hospital in New Zealand (NZ). Questionnaires, predominantly quantitative in form, were distributed to 58 nursing staff who worked alongside the APS. Thirty six (62%) responded. The findings showed that while, overall, respondents were very satisfied, or satisfied with the APS, responses to open-ended section of the questionnaire brought to light areas that the researchers see as warranting further attention.

Self-management support? Listening to people with complex co-morbidities.

OBJECTIVES: The study aimed to explore how people with complex, established co-morbidities experience long-term condition care in New Zealand. Despite the original conception as appropriate for people with early stage disease, in New Zealand the self-management approach dominates the care provided to people at all stages of diagnosis with long-term conditions, something reinforced through particular funding mechanisms. METHODS: A multiple case study followed the lives of 16 people with several long-term conditions. Data collection comprised two interviews, four weekly contacts with patients over an 18-month period and an interview with their primary health care clinicians. RESULTS: This paper reveals a cohort of tired, distracted patients struggling to manage their lives in the face of multiple conflicting challenges, with insufficient energy for the level of personal agency required to deal with the self-management approach. DISCUSSION: Participants described aspects of care received, which does meet their needs but sit outside the self-management approach, that resonate with the ideas behind current approaches to palliative care. The potential of an approach to care built upon these ideas is explored as a more compassionate, effective way of meeting the needs of people with advanced, multiple long-term conditions. Further research is warranted to explore the acceptability of such an approach.

A survey of the NP workforce in primary healthcare settings in New Zealand.

AIM: The aim of the survey was to describe the demographics, distribution, clinical settings and employment arrangements of the New Zealand nurse practitioner workforce in primary healthcare settings; and organisational factors limiting their practice. METHOD: An online survey was developed and sent to all NPs in mid-2019. RESULTS: The survey was completed by 160 nurse practitioners who worked in settings broadly defined as primary healthcare (response rate 71.4%). In addition to clinical work, nurse practitioners engaged in teaching and clinical supervision; leadership and management; policy development; locum work; and research; but 14% continued to do at least some work as a registered nurse. One hundred and fifty-one respondents were working clinically and 48% of these worked in more than one clinical setting. General practice-type settings (39%), of which over 40% were very low-cost access practices, and aged residential care (19%) were most commonly identified as the main clinical setting. Others included long-term conditions; mental health and addiction; sexual health/family planning; whanau ora; child/youth health; and various community nursing service roles. Seventy-three percent of nurse practitioners earned less than $120,000 per annum for full-time work; and 60% had $2,000 or less available for professional development. Three quarters had worked in the same setting for at least two years, and 60% intended to stay a further three years. Fourteen percent worked rurally. Employment models, models of care, and access to diagnostics, particularly radiology, were most limiting to their practice. CONCLUSION: The nurse practitioner workforce offers stability and flexibility in working across multiple clinical settings in primary healthcare. They provide the potential solution to the general practitioner workforce shortage by improving access to primary healthcare and reducing health inequalities. As authorised prescribers able to enrol patients, receive capitation payments and claim general medical services, it is timely to facilitate the expansion of the nurse practitioner workforce in New Zealand.

A snapshot of clinical educational experiences for advanced practice nurses worldwide.

Using a convenience sampling, nurse educators representing 10 countries were surveyed to describe required clinical education for advanced practice beyond basic traditional nursing education. This article explores the many factors currently influencing the structure and diversity of these clinical experiences worldwide.