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.

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.

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.

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.

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.

Establishing the nurse practitioner workforce in rural New Zealand: barriers and facilitators.

INTRODUCTION The health sector is facing considerable challenges to meet the health needs of rural communities. Nurse practitioners (NPs) deliver primary health care (PHC) services similar to general practitioner (GP) services, within a health equity and social justice paradigm. Despite GP workforce deficits, New Zealand has been slow to effectively utilise NPs. AIM From a larger study exploring the establishment of NP services, this paper reports on the barriers and facilitators to becoming a NP in rural PHC. METHODS Overall, 13 NPs and 4 NP candidates participated in individual or group interviews. Participants were employed in a variety of PHC settings from six district health boards across New Zealand. Using a scaffold map constructed to show the stages of the pathway from nurse to NP, data were analysed to identify experiences and events that facilitated or were barriers to progress. RESULTS Experiences varied considerably between participants. Commitment to the development of the NP role in their local areas, including support, advanced clinical opportunities, supervision, funding and NP job opportunities, were critical to progression and success. Existing GP shortages and the desire to improve health outcomes for communities drove nurses to become NPs. DISCUSSION Implementation of the NP workforce across New Zealand remains ad hoc and inconsistent. While there are pockets of great progress, overall, the health sector has failed to embrace the contribution that NPs can make to PHC service delivery. A national approach is required to develop the NP workforce as a mainstream PHC provider.

The complexity of food for people with multiple long-term health conditions.

INTRODUCTION The prevalence of long-term health conditions (LTCs) continues to increase and it is normal for people to have several. Lifestyle is a core feature of the self-management support given to people with LTCs, yet it seems to fail to meet their needs. From a larger study exploring the experiences of this group, this paper reports on the role of food and mealtimes, and the effect of the nutritional advice on the lives of people with several LTCs. METHODS The experiences of 16 people with several advanced LTCs were explored using multiple qualitative case studies. Over an 18-month period, contact with participants included monthly conversations, two longer, semi-structured interviews and one interview with their primary care clinicians. The data were analysed inductively using thematic analysis. RESULTS There was profound social, psychological and cultural significance of food to the participants. These aspects of food were then described using the Whare Tapa Wha model of health. The approach to food and nutrition participants experienced in health care was closely associated with conventional weight management. They found this advice largely irrelevant and therefore ineffective. DISCUSSION The pressure people with several LTCs experience during clinical encounters has perverse effects on wellbeing and reinforces an overall sense of failure. This research challenges the assumption that all people have the will, agency and income to follow the advice they receive about nutrition and exercise. Considering people's needs using the Whare Tapa Wha model of health offers clinicians a framework to re-conceptualise the core features of self-management support and provide realistic, compassionate care that will optimise the quality of life for people with multiple LTCs.

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.

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.

Patients' experience and understanding of E-portals in rural general practice: an ethnographic exploration.

AIM This exploratory qualitative study provides insight into E-portal use in rural primary care. INTRODUCTION As of February 2017, almost 300,000 New Zealanders were using E-portals, offered in over 455 general practices. Patient portals are intended to give patients convenient and secure electronic access to their health information and increase their ability to manage their own health care. Early patient experience of E-portal use in New Zealand has not yet been studied. METHODS Thirty-three patients from three rural general practice sites were interviewed between December 2015 and June 2016. Eleven patients were not using a portal. Data were analysed using ethnograph and comparative analysis between two researchers. RESULTS Four major themes emerged from the data: (i) technology acceptance, (ii) activation to full engagement with E-portals, (iii) benefits and concerns, and (iv) the impact of rural contextual understandings for these 33 patients. DISCUSSION Portal use in New Zealand is in its infancy, but signs suggest that New Zealanders are ready and enthusiastic adopters of such technology. Engagement levels are variable and it is too soon to fully explore the impact of E-portals on the general practice culture, provider relationships and the degree to which portals increase personal self-efficacy in relation to health care.

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.

Measuring care alignment in general practice consultations for people with long-term conditions: an exploratory study.

INTRODUCTION Chronic care Model (CCM) aims to make the care of people with long term conditions (LTC) planned, proactive and patient-centred. The patient assessment of chronic care (PACIC) and our recently developed modified PACIC (MPACIC) allow patient and provider views to be compared. AIM To explore the use of measures of care provision and receipt in primary care long-term conditions management and to assess congruity between patient and provider views of support. METHODS For this observational self-report study, 13 pairs of matched patient and provider dyads (patient/general practitioner and patient/practice nurse) were recruited from general practice. Patients with long-term conditions were asked to rate the support provided by their general practitioner and practice nurse, separately, using the PACIC instrument, a measure of care processes. The modified version for providers (MPACIC) was similarly administered, with GPs and PNs (herein referred to as practitioners) rating the care specifically provided to the 13 patients. Aggregated scores were compared and a case study example was used. RESULTS For 67% of ratings, patients and practitioners agreed (0 or 1 category difference) on the frequency of self-management support provision. Some disagreement was found for 19% of ratings, and considerable disagreement was found for 15%. The strongest agreement was found with Delivery System Design and the least with Goal Setting. Generally, there was little difference between patient/doctor and patient/nurse agreement. DISCUSSION Agreement between patients and practitioners regarding the level of self-management support received and provided was relatively high. This study demonstrates ways the PACIC and MPACIC can be used together to measure patient/practitioner agreement about long-term condition care provision.

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.