‘Thinking outside the box’: advanced geriatric nursing in primary health care in Scandinavia

The postmodern era is characterized by longer life expectancy. Nevertheless, growing old does not necessarily mean living more years in good health [1]. Older people are frequent users of primary health care (PHC) services [2, 3]. A decrease in patient satisfaction among older persons has been noted, and criticism has been voiced, mainly regarding limited accessibility and continuity of care in PHC [2, 4]. Thus, it is suggested that new, innovative models of PHC delivery for older people are developed.

In many countries, a shift of tasks from physicians to nurse practitioners (NPs) has been one strategy to alleviate shortages of staff in PHC. In countries with a long history of the NP role, such as Canada, USA, Australia, Holland and the United Kingdom, NPs are authorized to work at a high level of advanced practice, including advanced health assessments, ordering tests and medical treatment for minor illnesses. In some countries, NPs also have authority to issue prescriptions [5, 6]. Studies indicate that nurse-led care has a positive effect on patient satisfaction, and has led to reduced hospital and/or nursing home admissions and mortality [7‐9]. In addition, NPs in ambulatory care could lower mean health services costs per consultation [10]. However, as the results from previous research are not conclusive, larger and more rigorous research in the field is required [c.f. [9, 10].

In the North of Europe, the NP role was introduced more recently. Sweden was the first country to offer a NP master degree program in 2003, followed by Finland in 2005 [11]. However, task shifting to NPs is still limited. In the North of Europe, Finland is the only Nordic country where NPs, with limited prescription rights, are authorised to work at high levels of advanced practice in PHC [6]. Nevertheless, studies indicate that NPs in PHC can constitute a resource to increase access to care and enhance continuity [7, 8, 12]. Development of the role is though restricted by limited independence and lack of an explicit definition of the NP role, as well as demarcation in relation to responsibility and roles among colleagues [8]. Anyhow, top-level managers and politicians in Scandinavia have anticipated that nursing competence on an advanced level will be needed to meet older persons’ complex needs [13, 14]. Nevertheless, research on advanced practice nursing in the care of older people from a Nordic perspective is scarce. The aim of this study was to explore the feasibility of introducing geriatric nurse practitioners (GNSs) in primary health care (PHC) in Scandinavia, from multiprofessional and older persons’ perspectives. The research questions were:

Data analysis resulted in nine categories and twenty-one sub-categories organised in three domains corresponding to the research questions (Table 3).

The aim of this study was to explore the feasibility of implementing GNPs in PHC in Scandinavia. Feasibility says something about the likelihood of being able to do something, the practicality of a proposed plan, and can be understood as an evaluation and analysis of the potential of a proposed intervention [19]. The interviews reveal that there are common challenges in health services assigned for the older population in Scandinavia, challenges that also are present internationally [20, 21]. Looking into the results, it seems feasible that the envisioned GNP scope of practice correspond to current challenges in health services assigned for the older population. Notwithstanding, there are factors influencing the implementation of the GNP role that should be considered.

Doubts regarding the implementation of the GNP role were expressed in the results. Making advanced assessments, diagnosing and initiating treatment, including prescriptive authority could solve some practical problems, but at the same time there were concerns about this part of the GNP role (see also [12, 22]). In addition, the legislative rights for nurses to prescribe medication on an advanced level in Scandinavia are limited [6, 8]. To utilize the GNP competence fully, as in many other countries [6], policymakers need to initiate regulatory reforms to sanction independent advanced practice nursing roles.

It was not stated that GNPs should replace physicians, but to complement the team (see also [22]). GNPs need to be able to consult physicians if necessary [7, 12, 23]. If successful, GNPs could take on a linking role, promoting teamwork and cooperation within and between different professions and organizations [22, 23, 25]. The implementation of GNPs could further favour continuity in care as the GNPs would have the prerequisites of meeting the older people in their homes, having a case management role and with the foundation in a caring perspective contributing to creating the groundwork for holism and ‘home as a health promotive context’ (cf. [23, 24, 26, 27]). It should also be mentioned that the establishment of GNP positions offers a clinical career opportunity for nurses, entailing greater authority and responsibility, and development of personal competencies [22], a possibility that may attract nurses and also tackle the lack of competence in the field (cf. [13, 28, 29]).

In any event, to succeed there is a need to develop standardized definitions, a clear conception of the GNP role and scope of practice, and a minimum education level [22, 23, 30]. Here the Nordic NP model [11] that emphasises advanced clinical skills and a synthesis of curing and caring, can make a valuable contribution. The model is understood to align with the results of this study, describing the potential role and responsibilities transferable to meet the problems in care of older persons, and serving as a framework for implementing GNP positions in PHC.

To succeed with the implementation of GNP roles it is further implied that there is a need of openness to reorganisations. In line with previous research [31], the leaders are said to be in a critical position to influence the success of organizational change. The leaders must guide, motivate, support and communicate, and use various leadership styles to bring about actual change. It is not just a question about introducing a new routine, but about establishing a cultural change in patterns, values and attitudes [32, 33].

The results suggest that it would be feasible to introduce GNPs in PHC as a mean to address the current challenges, in line with previous research (e.g. [9, 10, 24]). However, it would be naïve to believe in that the implementation of the GNP role in the health care system would solve every problem. If other interventions are not carried out, it is for example probable that older persons still will report lack of social support, there will still be organisational challenges devoted to split authorities, and even though GNPs could reduce the lack of competent staff, there will still be a need for physicians, preferably geriatricians. Nonetheless, the health care system will need to evolve to respond to patient desires and needs, including social and medical care provided by non-physicians like GNPs. Older adults reporting loneliness and other psychosocial factors, in combination with medical problems, cannot rely solely on medicine.

There are several methodological concerns to be considered in this study. The interviews were performed by students with limited experience in performing qualitative research. Nonetheless, they had long work experience as nurses, including long experience in interviewing patients in their daily work. The students were prepared and supervised in performing research interviews before the data collection begun, and were in in close contact with the supervisors, who have considerable experience in qualitative research, during the data collection. The interview guide was developed in cooperation with the supervisors.

Another limitation was that the interviews were performed in different countries with different languages and cultures, and deficient language skills and cultural understanding may have affected the results. Consequently, the interviews and the results were discussed several times in the student and research groups to strengthen credibility. It is further considered a strength that different professionals were interviewed, and that older persons also were included. However, numbers of representatives from each country was small. Nonetheless, the results suggest that there are similar challenges in health services for the aged in Scandinavia. Further, there seems the be an overall consensus on the envisioned GNP role and scope of practice including factors that may influence the implementation of this advanced practice nursing role. No prominent deviation in responses between countries, nor between groups of respondents could be found. However, all group of respondents were not representing all sub-categories, i.e. the older persons did not mention organisational challenges.

It seems feasible that the GNP role and scope of practice broadly correspond to current challenges in health services assigned for the older population in the Scandinavian countries. Notwithstanding, there are factors influencing the implementation of the GNP role that should be considered. It is of importance to clarify the NP competence level, the role and authorities and responsibilities, as well as to prove the necessity to stimulate openness to reorganisation before implementation. Furthermore, policymakers have to initiate regulatory reforms to sanction advanced practice nursing. Only then, the full competence of the GNP can be applied and used in its full scope of practice.