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

We found that confidence in advanced practice nurses in general practice was established through development activities. Professional development included formal education [22], self-directed learning [23], structured learning pathways [10] and research activities [22]. One study reported that funding of professional activities was an issue [24]. Some nurses were content with their current duties and chose not to participate in further education with a participant stating ‘(we have to) accept that there’s a lot of nurses that don’t want any more responsibility, or they don’t want to extend their roles. They are happy to work within…what they currently do’ [25, p. 3]. Others used the knowledge provided to help them to develop their role further [24, 26]. In some cases, this involved conducting their own development activities within the general practice as part of staff training and mentoring [27‐29] and in the community as part of public health programs [25].

We also found a tension between the need to undertake professional development and the drive to establish independent practice. Some nurse practitioners were adamant that professional status would not result from more education, but from a wider scope of practice [30]. Other advanced practice nurses went so far as to claim that skilling less qualified nurses devalued their own training that, in many cases, had cost them thousands of dollars [9]. It was also noted that a minority of GPs still doubted that advanced practice nurses had sufficient education to complete their role [25].

We found that over time, GPs became satisfied that they could relinquish certain duties and hand over full or partial responsibility for a range of care activities to advanced practice nurses [28, 31]. This included allowing the advanced practice nurse freedom to operate within their scope of practice [24]. Indeed, GPs considered themselves quite peripheral to the advanced practice nurses in the context of diabetes care, who, they argued had more time to educate patients about glycaemic control [9]. This was also the case with cervical screening, a task that many GPs felt uncomfortable about performing [25]. However, McKinlay et al. [10] found that GPs were reluctant to share the care of mental health patients with advanced practice nurses because it was not an effective use of the nurses’ time. Other GPs were happy to hand off care if they did not have to supervise or otherwise support the advanced practice nurse including answering questions [15, 30]. One nurse stated ‘I think they (doctors) are very happy to leave us to our own devices and I think they are sometimes a little bit unhappy…when we…ask them to look at things we are not happy about and that can cause conflict’ [15, p. 891.]

We found that while many GPs were prepared to handover individual tasks, fewer were willing to assign overall case responsibility to the advanced practice nurse. Two studies found that this only occurred when there were established routines and sustainable structures in place [32, 33]. It was accepted that advanced practice nurses were competent in maintaining the flow of patients through the general practice with one GP stating ‘If she thinks someone needs to be seen, and when, and how, I value that. I follow her advice, and if she disagrees with me then she’ll say so’ [23, p. e379]. However, many GPs did not believe that advanced practice nurses were capable of being both autonomous and accountable [33]. This was reflected in the hesitancy of many nurses to assume full responsibility for patient care [30].

We found that trust was an important element in establishing and maintaining confidence in advanced practice nurses in general practice. One study found that trust was the bridge between professional cultures which ultimately benefitted patients [34], while two studies highlighted the importance of medical mentorship in maintaining trust [28, 35]. Diabetic Nurse Educators (DNE) were uniquely placed in this respect because they demonstrated skills regarding insulin initiation and titration that were, in many cases, superior to a GP [35]. The DNE’s relationship with endocrine specialists, allowed GPs to maintain a professional distance that was not replicated with other advanced practice nurses [35]. Another study found that patients needed to see that the DNE carried the authority of, and was trusted by, the GP [36].

Patients also trusted advanced practice nurses who displayed clinical acumen and attitudes by behaving in similar ways to a doctor [23]. Mahomed et al. [8] discovered that patients who had their care needs met were more likely to recognise the level of education, training and experience required to achieve the advanced practice nurse role. A patient in this study stated ‘I presume they’ve all got the same training, they all know what they’re doing and they know what they’ve got to do for me’ [8, p. 2545]. Two studies found that visible and ongoing role development was an essential element of trust [23, 31], while another study found that advanced practice nurses wrestled with the expectation of being both autonomous and a team player with a broad range of professional skills [32].

We found that issues around accountability negatively affected confidence in advanced practice nurses in general practice. One study found that while the scope and responsibility of advanced practice was negotiated locally, there was universal agreement between doctors, nurses and patients that the GP was ultimately accountable for decisions made by the nurse [9]. Main et al. [30] found that many NPs were reluctant to fully utilise prescribing rights because they considered themselves to be nurses first and were uncomfortable with being viewed as elitist and acting like a doctor. A NP in this study stated ‘I’m not sure where the resistance emanates from but there’s possibly resistance from the Nursing and Midwifery Council…I think the argument possibly is around the fact that nursing roles are changing so fast that they don’t want to make an elite group’ [30, p. 483]. Senior nurses working towards NP status were in a similar situation [10].

Many patients appreciated having both a GP and an advanced practice nurse involved in their care [33]. Patients reported that the nurse was more likely to ask about any additional concerns that they may have [36]. Advanced practice nurses were also more willing to share information about themselves which put them at ease [8]. This communication style inspired patient confidence in the advanced practice nurse, however, patients did not resonate with approaches that were censorial or dictatorial [8].

We found that some GPs were reluctant to endorse referrals made by NPs to specialists outside the practice on their behalf [28‐30, 36]. Some specialists refused to recognise the referral at all and berated the responsible GP for allowing the normal protocol to be bypassed [28]. This gave advanced practice nurses the impression that they were trusted within the walls of the general practice, but not in a way that was visible to the outside world [30]. Of note, was an effort by one advanced practice nurse to reclaim stature by declaring that her role was central to the operation of the practice. She stated ‘we’re, you know running the ship, meaning we’re not able to free up time’ [27, p. e320].

One study discovered that despite being supervised by NPs in the initial stages of their training, GP residents were still unclear about the NP’s scope of practice [27]. This uncertainty was also evident in three other studies where more experienced GPs stated that the advanced practice nurse scope of practice was ill-defined and ambiguous [15, 30, 31]. Without a clear understanding of the roles and responsibilities of the advanced practice nurse, some general practitioners lost interest in the position and became disconnected from the advanced practice nurse. This vacuum acted as a boundary between the two areas of practice.

In an attempt to narrow this gap, some GPs resorted to traditionalising their relationship with the nurse [10, 15, 25, 27, 28, 30‐32, 34, 35, 37]. Speed et al. [15] noted incidences of GPs disciplining nurses over the standard of their paperwork. One study reported a case where a GP rationalised role demarcation to who earned the income to pay the nurses [30]. Three studies found that this discordance came down to the initial limited understanding of patients’ needs by the GP [10, 32, 34] which subsequently restricted the capabilities of the advanced practice nurse downstream.

We found that medicalisation of nursing roles was resisted by both nurses and doctors. Some doctors were uncomfortable with nurses making a diagnosis [28] and losing control over treatment decisions [31]. Advanced practice nurses were uneasy with performing time-limited consultations because this reduced the amount of time that they could interact with their patients with one advanced practice nurse stating ‘You are booked solid and you have patient after patient, and when you go back to review they want to talk about all things and you really don’t have time’ [27, p. e320].

Clarification both strengthened and weakened the divide between advanced practice nurses and GPs. Within environments that were micro-managed by the GP, seven studies reported that nurses began to doubt their care decisions and sought clarification for increasingly simple matters [10, 15, 28, 30, 31, 34, 36]. One study reported incidences where overt patient requests were overlooked because of this unnecessary interplay between nurse and doctor [34]. Twelve studies reported the development of protocols as a means of avoiding omissions and explicitly stating what duties advanced practice nurses could perform [9, 10, 15, 25, 27, 28, 31‐36]. This included computer templates preloaded with pertinent patient information [32], drug initiation and titration algorithms [9, 27] and structured care pathways [10]. In one case a nurse stated ‘…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…’ [32, p. 131]. One study reported incidences where GPs believed insulin protocols were only relevant to nurses [31]. Over time, advanced practice nurses lost decision-making skills and felt their status within the practice was devalued [15]. One study found that nurses in this situation preferred to operate within broader policy frameworks [25]. Reassuringly, however, clarification was reported to improve teamwork [30] develop relationships [26] and overcome uncertainty regarding responsibility [31].

Several other behaviours narrowed the gap between GPs and advanced practice nurses. Three studies reported that more experienced GPs were prepared to reform the way care was delivered and expand the role of the advanced practice nurse [25, 28, 32]. One study reported that the ease of implementation was directly correlated with the sustainability of this reorganisation with a GP stating ‘We have to make it easy…we have to make it user friendly’ [32, p. 131]. Another study found that GPs were sceptical of expansion when their own workload pressures increased [31]. One study discovered an interesting tension between DNEs and PNs involving role expansion [35]. In this case, as DNEs became overloaded with additional cases, insulin initiation was delegated to PNs who did not have specialist training and this was viewed as a threat to their status within the practice [35]. Three studies found that nurses had always been trying to expand their roles, citing instances where nurses provided independently organised groups to support patients with chronic illnesses [9, 25, 26]. In another study, patients understood the limitations of care led by advanced practice nurses and realised that they would be referred to a GP if their condition became complicated [8].

Five studies found that advanced practice nurses and GPs appreciated flexibility [15, 23, 27, 28, 37]. This included balancing multiple priorities [23] and informal communications outside of clinical treatment spaces [37]. A nurse in one study stated ‘It’s a real skill in family practice nursing, identifying those red flags of who needs to be seen – that triaging function’ [23, p. e379]. One study found that a lack of flexibility had serious implications for ongoing relationships [15].

In six studies, advanced practice nurses viewed interactions with GPs as opportunities for collaboration [9, 26, 30, 32, 34, 35]. A further six studies reported negotiation during these exchanges [10, 15, 28, 30, 34, 36]. One study reported that the key components of collaborative relationships were shared knowledge, mutual respect and acceptance [35], while another highlighted the importance of mentoring and supportive networks [32]. In one study, a nurse stated ‘…you do work in isolation. As far as I am aware I am the only primary mental health nurse in (the area)…so I’ve tried to make links with a mental health nursing adviser who provides professional oversight…’ [10, p. 229].

Negotiation was not confined to purely clinical interactions between GPs, advanced practice nurses and patients. One study reported that understanding and utilising key power relationships within the practice, particularly involving those with financial control, was an important skill [32]. Another study found that clinical negotiation skills included overstating a patient’s condition to expedite treatment and challenging/counter-challenging [15]. Interestingly, seven studies reported that patients did not recognise interactions between the advanced practice nurse and the GP as professional cooperation [10, 15, 28, 30, 31, 34, 36]. One patient stated ‘she had to get permission from Dr Ken to put me on insulin, but it was her that decided and he had to say yes’ [9, p. 619].

Ten studies reported tensions regarding the cost of advanced practice nurses [9, 10, 24, 25, 30‐34, 37]. Another five studies reported anxieties around recouping this expense [9, 24, 31, 32, 34]. Sixteen studies found that as salaried employees, advanced practice nurses measured their worth to the practice in terms of the extra services they offered and the additional time they could give to their patients [8‐10, 22, 23, 25‐27, 30‐37]. One study found that advanced practice nurses believed that the process of establishing a connection with a patient was time consuming in the beginning but reaped dividends in terms of patient compliance [34]. However, a GP in one study stated ‘the nurses can afford to spend a little bit more time with the patients than we can’[37, p. 140] implying that a GP’s time was more valuable in dollar terms.

Both nurses and patients reported a reluctance to waste a doctor’s time [37]. One study found that GPs were more conscious of the time versus cost considerations of advanced practice nurses than they were of other services within the general practice, including their own [30]. In another study, a GP believed that NPs were a waste of money because they always asked for a second opinion [22]. In another case, a GP proposed a funding model where patients paid an ‘upfront practice payment’ for services provided by an advanced practice nurse [9, p. 353]. Many GPs believed that it was not their role to provide patient education or engage in health promotion and this task was better left to the advanced practice nurse [15, 24‐28, 30, 32, 34, 35, 37]. Some GPs did concede, however, that the advanced practice nurse was an effective means of providing continuity of care to vulnerable patients and many patients suffering chronic illnesses supported this view [8, 9, 24, 25, 28, 30‐32, 34].