Similarities and differences in general practices with and without nurse practitioners: multiple case study design

Abstract

Abstract Background: New care models are needed for the increasing elderly, chronically ill, and multimorbid population, especially in primary healthcare. Rural regions are particularly affected where bottlenecks in supply provisions and a shortage of health professionals are emerging. To address these challenges, nurse practitioners (NPs) have been introduced in Swiss general practices to improve primary healthcare of chronically ill people. We aimed to explore Swiss primary healthcare delivery for chronically ill people in general practices with and without NPs and identify similarities and differences in these general practices. Methods: We conducted a multiple case study design with interviews, observations, questionnaires, and patient records. The EQUATOR reporting standards for organisational case studies were used. We described the similarities and differences by drawing on Wagner’s Chronic Care Model and applied deductive thematic analysis. We included five general practices located in rural areas in Switzerland. A total of 34 patients and 26 health professionals were included. Each general practice team consisted of general practitioners (GPs), medical practice coordinators (MPCs), medical practice assistants (MPAs), and a NP (in two general practices). Results: Similarities in all five general practices included the presence of specific framework conditions such as the shortage of health professionals or the lack of billing options. By law, the final decisional responsibility lays with the GPs. GPs had trust in the general practice teams. Patients wanted to be perceived as a whole person. Differences included that NPs filled gaps in interfaces with the local community and regarding complex, unstable patient situations. Teams with NPs found themselves in a larger process of change. Conclusions: NPs, MPCs, MPAs, and GPs in Swiss general practices make major contributions to the care of chronically ill patients in local communities. NPs provide additional care to patients at home and in general practices that was previously unavailable; however, adaptation of existing general practice structures to the new healthcare delivery model needs to be explored. The identified similarities and differences can help general practices to conceptualize new roles of health care professionals with different educational backgrounds and restructure the workflow, especially in countries where new roles are emerging.