All invited participants agreed to participate in the interviews. A total of 27 interviews were conducted, 12 in team-A and 15 in team-B. In addition, 11 NPs participated in the two focus group discussion. Due to the small number of NPs at the GPC, four NPs participated both in the individual interviews and in the focus group discussions (see Table
1). The interviews took, on average, 21 min; the focus groups, on average, 60 min.
Table 1
Participating team members
N Receptionists | 2 | 2 | | 4 |
N Medical assistants | 2 | 3 | | 5 |
N Nurse Practitioners | 2 | 2 | 11 | 15a
|
N General Practitioners | 6 | 8 | | 14 |
Total
|
12
|
15
|
11
| 38 |
Theme 1. Clarity of NP role and regulation of NP practice
Regardless of the team structure, there was a general lack of awareness among GPs about NPs’ scope of practice. The GPC formulated the role of the NP in writing, and provided a list on the intranet of those patients who are excluded from NP care. However, in contrast to the NPs, none of the GPs knew about the document or its exact content. Most GPs believed that NPs are not allowed to see complex patients, but they lacked specific knowledge or had misconceptions about the specifics regarding which patients NPs were unable to see. This is illustrated by a GP from team-A: “I know they don’t treat complex patients, or no abdominal pain… I think I know it.” An NP in the focus group stressed the importance of communicating clearly with GPs regarding the NP scope of practice: “It’s important to be very specific to GPs about what patients we don’t treat. Often they say ‘Oh yeah, I know,’ but turns out they don’t know it at all.”
NPs and medical assistants reported that NPs sometimes treated patients from the excluded patient groups, such as patients younger than one year, when they had the knowledge and expertise to work with these patients. A medical assistant from team-B explained: “The exact scope of the NP is sometimes handled a bit flexibly. NPs might call in patients with, for example, abdominal pain in case it looks like a bladder infection.” Some GPs found it confusing that different NPs treat different patients.
Although legal regulations regarding NP care were not clear for many GPs (e.g. some had the belief they needed to authorise NPs’ drug prescriptions), none of the GPs expressed concerns about legal liability for the NP care. A GP from team-B said: “My knowledge about the role of the NPs is somewhat diluted. Also, some NPs treat different patients than others. I believe I have to authorise NPs’ drug prescriptions as well.” Lastly, most GPs said they did not have prior experience working with NPs in their practice and were uncertain whether they had ever worked with NPs at the GPC before.
Theme 2. Shared caseload and use of skills
In team-A, none of the GPs reported differences in the number of patients and type of patients they treated between teams working in teams with and without NPs. Moreover, although some patients were excluded for NP care, none of the GPs changed his or her professional routine based on the NPs’ scope of practice or in the type of patients he or she cared for. One GP from team-A said: “I started my day with caring for the first patient on the presentation list. I didn’t pay attention to the NP really.”
In team-B, GPs generally stated they had to treat more complex patients compared to working in teams with only GPs. However, there were differences between GPs. One GP from team-B said: “I think the consultations become more intense and difficult; the complaints are more complex.” Another GP from team-B commented; “I think there is not really a difference in the type of patients I treated today, I saw everything.”
In Team-B most GPs said they changed their professional routines by providing care for more complex patients (especially those with abdominal complaints), in order for the NPs to focus on less complex patients. A GP from team-B explained:
If there are two NPs we have to check all patients on the presentation list, not only their urgency level, but also their complaint. If it’s, for example, an ear infection, I take the next patient and leave the ear infection to the NP. Checking who the patients are on the presentation list is less important in shifts with three GPs.
Both NPs, medical assistants and receptionists indicated differences between GPs regarding changing their routines in teams with NPs. An NP from team-B commented: “At times I see GPs treating patients that could have been treated by us, while other patients from the presentation list are waiting. Not every GP is willing to cooperate.” General practitioners who had prior experience working with NPs in their practice during office hours were, in general, more willing and aware of the need to focus on more complex patients. If GPs did not change their routines of selecting patients from the presentation list in team-B, patients had to wait longer periods of time to receive treatment from a GP if their complaint did not fit the predefined NP scope of practice. This was a safety risk, especially for the more urgent patients. This is illustrated by examples provided by several team members:
Some shifts run perfectly, others you think “I wish there was a third GP now.” Especially when there are GPs who pick out patients with skin complaints from the presentation list. You get delay if more patients with abdominal pain show up. (Medical assistant, team-B).
One GP basically picked out all patients. In those cases I have to warn “think about the urgent patients”. There was an incident when an older woman got called in for a consultation, while a more urgent man was waiting to see the doctor. (Receptionist, team-B)
However, support staff indicated that the condition of the patient in the waiting room is more important than the urgency level determined during earlier triage. Therefore, medical assistants sometimes performed an extra triage in the waiting room to indicate those patients who are in urgent need of care.
Nurse practitioners in team-B did not report they treated different numbers or types of patients compared to working in team-A. An NP in team-B said: “I don’t experience any difference, you continue to treat the same complaints and that costs you the same amount of time.” In addition, NPs in team-B said they did not change their professional routines compared to working in team-A.
In both teams, team members indicated that, in general, NPs spend a longer time on consultations than GPs. Nurse practitioners and GPs assumed this is because NPs take a more extensive patient history and document more in the patients’ medical records. A GP from team-B said: “I must say, a patient with, for example, a sore, I finish those consultations within a minute and I feel confident to do that. I think NPs are more careful and still take a full history just to be sure they do their work properly.” An NP in the focus group explained; “I think we are more anxious about making mistakes, due to the vulnerable position of NPs in a relatively new profession. I think we take more extensive histories and physical exams. That might also be influenced by less experience.” Moreover, NPs reported they provide more education and counselling to patients.
Both NPs and medical assistants indicated that NPs ask less often for support from the medical assistant compared to GPs; for example, regarding putting on bandages after suturing: “GPs are used to having medical assistants in their practices that take over a lot of tasks. They ask more easily “do you want to take a look at this?” From my experience, NPs more often complete things themselves.” (Medical assistant, team-B).
Lastly, sharing the same practice ideology was not mentioned by any of the participants. They said during the shift they focus on the patients in their own surgery room and lack insight into the other professionals’ patients and treatments.
Theme 4. Trust and support in NP practice
The role of the NP was well accepted by receptionists and medical assistants in both teams and they had a positive view about the quality of care delivered by NPs. They also had the impression that patients are satisfied with NP care. As a medical assistant in team-B said: “From my personal experience, I don’t care if I have to work with 2 NPs, or one, or with only GPs.” There were, however, differences among GPs in support for the role of the NP. A receptionist in team-B said: “It’s hard to generalise; the one GP is fine with NPs, the other one sees problems immediately. It’s just another point of view.” Most GPs believed NPs are well capable of treating the patients within their scope of practice. Some even considered the NP being more skilled for certain types of patients than GPs. One GP from team-A explained: “I must say, it’s nice to work with NPs, they have a lot of knowledge in their field of practice. I even asked some advice from the NP today about a stoma, that was helpful.” However, some GPs believed care provided by NPs is of less quality compared to the care delivered by GPs, and certain GPs resisted the role of NPs. One GP in team-B said: “I totally disagree that they try to transform nurses into some sort of GP.” Often, these GPs expressed misconceptions about NPs’ education and legislation governing NP scope of practice. None of the GPs worried about becoming deskilled in treating certain complaints. Even though GPs treated more complex patients when there were more NPs part of the team, in both teams, GPs said that most complaints they treated were still of low complexity.