Background
Primary care services play a crucial role in providing care to healthy children and adolescents and in coordinating care for pediatric patients who need multidisciplinary support [
1,
2]. To strengthen the capacity of the primary pediatric health care model, it is paramount to ensure those resources and services that today continue to be mainly a prerogative of hospitals in several countries [
3‐
5]. In particular, in Italy, a universalistic approach based on a highly-valued community healthcare service has become a concrete reality since the National Healthcare Plan was implemented between 2003 and 2005. One of its objectives is to promote the community as the primary venue for social and healthcare services and health governance. However, considerable efforts are required to ensure integrated and high quality primary care for children throughout the country.
In many countries, like the United Kingdom, Ireland, Portugal, Sweden, and Norway, general practitioners also care for children [
6]. In contrast, Italy, like other European countries such as France, Belgium, or Germany, has a combined system where pediatricians care for younger children [
7]. In Italy, pediatric primary care is provided by pediatricians, whose services are free of charge for every child from birth until the age of 14 years, and, if affected by severe conditions, also up to the age of 16 years [
8,
9]. Pediatricians working in primary care, known as ‘family pediatricians’ in Italy [
10‐
12], play a key role in the prevention, treatment, and rehabilitation of every child/adolescent, as well as providing health education and health promotion, with a focus on children’s physical, mental, relational, and cognitive development [
13]. They work according to an arrangement made with the Italian public service through a private-public partnership, which involves solo practices or associative forms such as pediatric group practices, associations, and networks. Their offices are open all day during weekdays [
11] and, if necessary, they make house calls. To meet healthcare needs on a 24/7 basis, primary care services are organized as integrated systems, where pediatricians are one of the main pillars.
In recent years, Italian regulations have emphasized the importance for health professionals to provide integrated and multidisciplinary care to children in the community by working together to ensure holistic care also in the primary care setting [
14,
15]. An integrated care approach at the community level could improve health outcomes especially for children with chronic conditions and reduce readmission rates [
16]. For example, nurses in integrated pediatric primary care services can take part in child health surveillance programs, as also shown by experiences in other countries [
17].
While the role of pediatric nurses is well-established within hospital settings, in several countries worldwide more should be done to expand the scope of nursing in the community setting [
18‐
20], where often an overly medical view of primary care prevails [
21]. For example, a survey showed that nurses are present in pediatric primary care settings in about 64% of the European countries [
6]. Although pediatric nurses play a key role in managing children’s conditions and enhancing symptom- and disease-management skills for the entire family in hospitals [
22,
23], they are not always involved in providing this type of care in the community [
24,
25]. In adult care, the contribution of family nurses has been increasingly recognized as extremely valuable, cost-effective, and well-accepted [
26,
27]. This is desirable also for pediatric primary care, where nurses need to closely collaborate with pediatricians to promote the health of children and their families, especially when dealing with complex cases and treatments [
10,
28].
With the support of pediatric nurses, pediatricians could further improve the care of the whole family and facilitate care transitions [
29]. The family nursing role in the pediatric context is innovative and could include several activities, such as the assessment of family needs, and planning and coordinating integrated care pathways, while promoting the empowerment of the entire family [
30]. In line with the family-centered approach, family nurses establish a partnership of trust with the family to achieve more positive outcomes for children in the community [
31]. All the nursing activities concerning disease management should be performed in collaboration with the pediatrician and consistently with the operational procedures and protocols of the pediatrician’s office.
Since the current organization of pediatric primary care in Italy does not mandate the presence of a pediatric nurse in all the pediatricians’ offices, the majority do not have a pediatric nurse [
32]. Therefore, it is important to understand how pediatricians could work in close collaboration with pediatric nurses to provide more effective primary care in the community. For example, pediatric nurses could practice collaboratively with pediatricians in their office to foster prevention, education, continuity of care for children with chronic conditions, while reducing inappropriate access to the accident and emergency department [
33].
To involve primary care pediatricians in identifying which activities pediatric nurses could perform at their office, a pilot study was previously conducted to describe the pediatricians’ opinions [
34]. However, considered the total number of pediatricians in Italy, the sample of those who participated in the previous pilot study was small (
n = 178) and the questionnaire had so many items that a large number of respondents did not complete it. Therefore, we conducted a similar study, but this time at a national level, to describe the opinions of all the pediatricians working in primary care in Italy regarding the usefulness of several nursing activities that pediatric nurses could perform in their offices.
Discussion
This study investigated the opinions of Italian primary care pediatricians about the usefulness of several nursing activities that pediatric nurses could perform in their offices. In line with the pilot study [
34], participants had a positive opinion of having a pediatric nurse in their office and rated ‘very useful’ most of the suggested activities. This is promising in light of the crucial role that pediatric nurses could play in the community setting not only in Italy [
40] but in any other country [
41,
42].
‘Healthcare education’ was the area of nursing practice that was rated as the most useful one, in line with the pilot study [
34]. This may reflect the great importance given to patient and family education in the community setting [
43,
44] and the high consideration for nurses’ educational competencies worldwide [
45,
46]. Pediatric nurses could perform many educational activities in the community to support the pediatricians in empowering children/adolescents and their parents in terms of health promotion, risk-prevention, disease management, and improved adherence to treatment. For example, education about how to manage medical devices was rated as the most useful one, in line with the needs of patients with chronic diseases [
47‐
49]. Moreover, the pediatrician’s office is one of the main settings in the community where parents of healthy children refer to [
9]. Therefore, nurses could play an important role in promoting healthy lifestyles in this setting [
10] and also contribute to the system’s effort to create multidisciplinary teams to promote holistic health for children [
50].
The second area rated as the most useful one was ‘Disease prevention’, whereas in the pilot study this was ‘Care for healthy, sick or disabled children/adolescents’ [
34]. This may be due to pediatricians’ increased awareness of the role nurses play in disease prevention, such as vaccination. Although not every pediatrician provides mandatory and recommended vaccinations based on regional agreements, nurses’ collaboration in vaccination was rated as one of the most important activities. Nurses’ immunization activities under the responsibility of primary care pediatricians include cooperation in advocating for mandatory vaccines [
51], storage of the medication, parent and child education about the procedure, and performing the vaccination. In particular, those who could administer vaccines rated the role of nurses as more useful for this crucial service, which often requires teamwork to be widely performed [
52,
53]. Operational support for the pediatrician and the educational role for families about crucial aspects of vaccination, such as the complex issue of vaccine hesitancy, may explain this finding [
54]. Besides, only a few Italian Regions already had local agreements that supported collaboration with a pediatric nurse in the primary care pediatrician’s office. This may be due to the difficult sustainability of a pediatric nurse in their office, which was expressed by some participants in the qualitative findings. In the future, the issue of providing major support to implement collaboration with nurses in the pediatrician’s office would deserve further discussion.
Compared to the pilot study [
34], participants considered less useful the area ‘Care for healthy, sick or disabled children/adolescents’, and, in particular, the nurse’s role in caring for sick children at home was rated as secondary. In Italy, it is possible that in the future, with the support of appropriate organizational processes and instruments (e.g. protocols, e-health, measurement scales), pediatric nurses working in primary care will play a major role in caring for children at home [
55]. Also area 4 ‘Coordination and organizational activities’ was considered secondary, as it obtained the lowest score, while area 3 ‘Disease prevention’ obtained the lowest score in the pilot study [
34]. This may indicate that participants recognized the uniqueness of nursing competence and training rather than considering them only for assistance with their medical itinerary or with administrative issues. However, some organizational activities were considered to be quite useful, especially by those who already had a nurse in their office and appreciated the support from a health professional that mainly performs healthcare, educational, and prevention activities. With regard to collaboration, those who already had a secretary in their office rated nursing clinical, educational, and prevention activities as more useful. We could assume that the experience of collaborating with others in the primary care office may facilitate collaboration with nurses and foster a better opinion about nursing activities. Therefore, implementing and maintaining a good pediatrician-nurse collaboration is key to providing high-quality comprehensive care and to reciprocally appreciate each other’s professional value [
56].
The regression analysis showed other interesting associations. On the one hand, the younger pediatricians had a better opinion about the importance of conducting educational activities. Therefore, younger pediatricians may be more willing to collaborate with nurses in educational activities, given the increasing importance of education for patient care and the potential of nurses in this key role [
44,
57]. On the other hand, a longer working experience predicted a poorer opinion of the nursing clinical and organizational activities. This may be the result of their adjustment to being used to working alone for many years. In addition, working in small towns was found to predict a better opinion of nurses’ clinical, educational, and organizational activities. Probably in small towns pediatricians become even more important for patients in the community, because in these places it is often more difficult to reach hospitals or other health services. Therefore, they may value more the need to collaborate with a pediatric nurse in their office.
Overall, qualitative findings showed that pediatricians recognize the need for the specific professional education of pediatric nurses in providing nursing care to children in their office. This type of education should be provided both academically and through continuing education. Shared education and clinical placements were suggested, as pediatricians were interested in working together with pediatric nurses who are well prepared to work in their office. Nursing knowledge and theory development should be better linked to practice-relevant actions [
58] so that pediatric nurses develop a specialized understanding of the needs of sick children and their families [
59]. This should be taken into consideration to inform undergraduate and postgraduate education curricula for pediatric nurses.
Limitations
The findings of this study should be interpreted in light of few limitations. Given that there are a total of 7656 pediatricians working in primary care in Italy [
35], 9.2% of them participated in this study (12.4% of potential participants, who were the 5700 pediatricians registered with the Italian Federation of Pediatricians [
36]). Thereby, the sample cannot be considered representative of the entire population of pediatricians working in primary care in Italy. Moreover, self-selection bias may have occurred [
60], as differences in the scores between those who completed and those who did not complete the entire survey were significant. This might indicate that participants with a better opinion of the nursing activities in the pediatrician’s office may have selected themselves by completing the whole survey [
61,
62]. In addition, we did not investigate what knowledge and understanding the pediatricians had of the competencies, skills, and responsibilities of pediatric nurses. This may have affected the validity of the results. Future studies should also investigate the opinions of pediatric nurses as well as parents about the need for nursing activities in primary health care. Another limitation is that primary care in Italy is connected to the National Healthcare System, but the main providers are the Regional services, with several differences across Regions. We also recognize that the peculiarity of the Italian health care system limits the generalizability of the findings.
Acknowledgements
We thank Dr. Massimiliano Raponi, MD, MS, Medical Director at Bambino Gesù Children’s Hospital, for supporting this study within the Clinical-Technological Innovation Research Area of which he is in charge; Dr. Paolo Biasci, MD, MS, President of Italian Federation of Pediatric Physicians, for his interest in the topic of this research and his contribution to the dissemination of the online survey among family pediatricians; Dr. Barbara Mangiacavalli, RN, MSN, President of the National Federation of Nursing Professions Orders, for the useful suggestions regarding the presentation letter of the questionnaire; the Registered Nurses Elvira Vanelli and Federica Graziosi for their collaboration in the development of the original questionnaire; Dr. Valerio Ghezzi, psychologist, PhD, for the statistical support in reducing the items of the original questionnaire; Dr. Marta Luisa Ciofi Degli Atti, MD, MS, chief of the Epidemiology Unit of the Bambino Gesù Children’s Hospital, for her valuable suggestions and support during the study; the Engineers Matteo Ritrovato and Martina Andellini of the Health Technology Assessment Unit, Bambino Gesù Children’s Hospital, IRCCS, for developing Fig.
1; Dr. Giuliana D’Elpidio, PedRN, MSN, Director of the School of pediatric nursing ‘Pierluigi Frassati’, Tor Vergata University, for her continued support on this topic; the pediatricians, nurses, and families who helped to validate the short version of the questionnaire; the primary care pediatricians who completed the questionnaire.
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