Practice nurse perspectives of role extension including diagnostic work in long term conditions; a qualitative meta-synthesis

Problem

The Five Year Forward View demands that patients receive care from the ‘right care provider’, and describes new roles and expansion of existing roles as crucial in ‘future proofing’ the NHS. Practice Nurses (PNs) are fundamental to delivery of care in long term conditions (LTCs) and future role extension is set to include assessment and diagnosis. Whilst role extension (‘substitution of doctors’ traditional role) is common in primary care in the UK, role boundaries are fundamental to the maintenance of discrete professional identities and extension may be interpreted as boundary encroachment, serving as a barrier to effective integrated care. This synthesis aims to provide a conceptual understanding of potential barriers and facilitators to PN role extension including diagnostic work in LTCs.

Approach

Meta-synthesis of qualitative literature informed by Noblit and Hare’s meta-ethnographic approach. This inductive and interpretive method is well suited to generating models or higher order theories of behaviour and experiences, allowing PN perceptions and experiences to be gathered and interpreted, fostering understanding of the barriers and facilitators to PN role extension in primary care. A systematic search of nine electronic databases using substantive keywords and MeSH headings, formulated through consideration of relevant research. Potentially relevant citations were identified, duplicates removed and titles and abstracts screened according to pre-defined inclusion/exclusion criteria. Full texts of potentially eligible articles were reviewed by two independent researchers. A third reviewer allowed consensus where needed. Rigour, credibility and relevance was assessed using the Critical Appraisal Skills Programme (CASP) criteria for qualitative research.

Findings

Of 3491 potentially articles, 2772 unique papers were identified, with 197 full texts remaining after initial title and abstract screening. Six articles were included in the review (set in primary care in the UK, Australia, Canada, and Germany). Perceptions of the PN extended role were reported in the context of the broad areas of LTC management, interdisciplinary teamwork and sickness certification, and specific conditions such as vestibular rehabilitation and insulin initiation. Whilst PNs recognise the potential for role extension, professional boundaries are unclear and new roles lack clarity, resulting in poor recognition and lack of acceptance of these roles by other healthcare professionals (HCPs) and patients. Emergent themes key to acceptance of extended roles by other HCPs and patients include supportive inter-professional relationships and trust (thereby promoting autonomy), education and competence, and clear role boundaries.

Consequences

If PNs are to adopt diagnostic work in LTCs into their remit, role boundaries must be explicit and consensus amongst HCPs and patients achieved. Results of the review have informed a topic guide for a qualitative study which will further explore PN role extension from the perspective general practice nurses, further enhancing understanding of PN diagnostic work in the care of patients with LTCs.