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Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: a realist evaluation case study

Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: a realist evaluation case study
Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: a realist evaluation case study

Objectives This study aimed to gain insight into how substitution of elderly care physicians (ECPs) by nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs) in nursing homes is modelled in different contexts and what model in what context contributes to perceived quality of healthcare. Second, this study aimed to provide insight into elements that contribute to an optimal model of substitution of ECPs by NPs, PAs or RNs. 

Design A multiple-case study was conducted that draws on realist evaluation principles. 

Setting Seven nursing homes in the Netherlands 

Participants The primary participants were NPs (n=3), PAs (n=2) and RNs (n=2), working in seven different nursing homes and secondary participants were included; ECPs (n=15), medical doctors (MDs) (n=2), managing directors/managers/supervisors (n=11), nursing team members (n=33) and residents/relatives (n=78). 

Data collection Data collection consisted of: (1) observations of the NP/PA/RN and an ECP/MD, (2) interviews with all participants, (3) questionnaires filled out by the NP/PA/RN, ECPs/MDs and managing directors/managers and (4) collecting internal policy documents. 

Results An optimal model of substitution of ECPs seems to be one in which the professional substitutes for the ECP largely autonomously, well-balanced collaboration occurs between the ECP and the substitute, and quality of healthcare is maintained. This model was seen in two NP cases and one PA case. Elements that enabled NPs and PAs to work according to this optimal model were among others: collaborating with the ECP based on trust; being proactive, decisive and communicative and being empowered by organisational leaders to work as an independent professional. 

Conclusions Collaboration based on trust between the ECP and the NP or PA is a key element of successful substitution of ECPs. NPs, PAs and RNs in nursing homes may all be valuable in their own unique way, matching their profession, education and competences.

nurse practitioner, nursing homes, physician assistant, realist evaluation, skill mix change
2044-6055
1-12
Lovink, Marleen Hermien
46bb61db-0e11-4da3-8e49-1ecd5bdf33e2
Laurant, Miranda G.H.
d6b4e83a-0fed-46a4-9738-e11b9150a5e8
Van Vught, Anneke Jah A.H.
a6e9b861-dc4f-46b9-ae9d-baa8cee3febb
Maassen, Irma
6ba7feb5-9974-4ec2-8fa7-469305df118c
Schoonhoven, Lisette
46a2705b-c657-409b-b9da-329d5b1b02de
Persoon, Anke
c4be7b8e-8f71-486c-bdc0-f984c8e3cfcc
Koopmans, Raymond T.C.M.
3df55d8d-a5cb-4353-80ff-87fdfbba5ab5
Lovink, Marleen Hermien
46bb61db-0e11-4da3-8e49-1ecd5bdf33e2
Laurant, Miranda G.H.
d6b4e83a-0fed-46a4-9738-e11b9150a5e8
Van Vught, Anneke Jah A.H.
a6e9b861-dc4f-46b9-ae9d-baa8cee3febb
Maassen, Irma
6ba7feb5-9974-4ec2-8fa7-469305df118c
Schoonhoven, Lisette
46a2705b-c657-409b-b9da-329d5b1b02de
Persoon, Anke
c4be7b8e-8f71-486c-bdc0-f984c8e3cfcc
Koopmans, Raymond T.C.M.
3df55d8d-a5cb-4353-80ff-87fdfbba5ab5

Lovink, Marleen Hermien, Laurant, Miranda G.H., Van Vught, Anneke Jah A.H., Maassen, Irma, Schoonhoven, Lisette, Persoon, Anke and Koopmans, Raymond T.C.M. (2019) Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: a realist evaluation case study. BMJ Open, 9 (5), 1-12, [e028169]. (doi:10.1136/bmjopen-2018-028169). (In Press)

Record type: Article

Abstract

Objectives This study aimed to gain insight into how substitution of elderly care physicians (ECPs) by nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs) in nursing homes is modelled in different contexts and what model in what context contributes to perceived quality of healthcare. Second, this study aimed to provide insight into elements that contribute to an optimal model of substitution of ECPs by NPs, PAs or RNs. 

Design A multiple-case study was conducted that draws on realist evaluation principles. 

Setting Seven nursing homes in the Netherlands 

Participants The primary participants were NPs (n=3), PAs (n=2) and RNs (n=2), working in seven different nursing homes and secondary participants were included; ECPs (n=15), medical doctors (MDs) (n=2), managing directors/managers/supervisors (n=11), nursing team members (n=33) and residents/relatives (n=78). 

Data collection Data collection consisted of: (1) observations of the NP/PA/RN and an ECP/MD, (2) interviews with all participants, (3) questionnaires filled out by the NP/PA/RN, ECPs/MDs and managing directors/managers and (4) collecting internal policy documents. 

Results An optimal model of substitution of ECPs seems to be one in which the professional substitutes for the ECP largely autonomously, well-balanced collaboration occurs between the ECP and the substitute, and quality of healthcare is maintained. This model was seen in two NP cases and one PA case. Elements that enabled NPs and PAs to work according to this optimal model were among others: collaborating with the ECP based on trust; being proactive, decisive and communicative and being empowered by organisational leaders to work as an independent professional. 

Conclusions Collaboration based on trust between the ECP and the NP or PA is a key element of successful substitution of ECPs. NPs, PAs and RNs in nursing homes may all be valuable in their own unique way, matching their profession, education and competences.

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Accepted/In Press date: 1 April 2019
Keywords: nurse practitioner, nursing homes, physician assistant, realist evaluation, skill mix change

Identifiers

Local EPrints ID: 433320
URI: http://eprints.soton.ac.uk/id/eprint/433320
ISSN: 2044-6055
PURE UUID: 1494535c-bf86-4708-a87d-be381a682919
ORCID for Lisette Schoonhoven: ORCID iD orcid.org/0000-0002-7129-3766

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Date deposited: 14 Aug 2019 16:30
Last modified: 07 Oct 2020 02:00

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Contributors

Author: Marleen Hermien Lovink
Author: Miranda G.H. Laurant
Author: Anneke Jah A.H. Van Vught
Author: Irma Maassen
Author: Anke Persoon
Author: Raymond T.C.M. Koopmans

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