Abstract
Objective To describe and compare well-child care (WCC) in Australia, the Netherlands, and the United Kingdom (UK), focusing on the role of nurses and their interactions with other primary care providers in order to derive relevant lessons for Canada’s interprofessional primary care teams.
Data sources Ovid MEDLINE, EMBASE, and CINAHL were searched broadly using the search terms well child care, nursing role, and delivery of care and other synonymous terms. In addition, Google Scholar was used to search for gray literature, and reference mining revealed a few other relevant articles.
Study selection The original search identified 929 articles. The inclusion criteria were the following: relevant to WCC delivery; focuses on Canada, the Netherlands, the UK, Australia, or an international comparison; describes care of healthy term infants; describes care provided in the community; and describes the role of the nurse in WCC delivery. An abstract review followed by full-text review condensed the search to 25 selected articles.
Synthesis Selected articles varied in method and scope; thus, a narrative synthesis was generated using thematic analysis. In Australia, the Netherlands, and the UK, many WCC tasks are performed by trained public health nurses in a separate but parallel system to family medicine, with interaction between nurses and FPs varying greatly among countries. In general, nurses’ roles in WCC remained in the preventive care and screening domains, including monitoring development, providing health education, and supporting parents. The 3 overarching themes that were identified were around professional development and education, integration of care and interprofessional collaboration, and the nurses’ role in an evolving health system.
Conclusion International examples, given Canada’s primary care reforms, suggest it is time to examine greater role sharing in WCC between nurses and FPs in interdisciplinary primary care teams.
In Canada, well-child care (WCC) is routinely provided by FPs, pediatricians, and, increasingly, nurse practitioners.1,2 Other developed countries have different arrangements for WCC, and there is debate in the literature about how to provide the most effective and efficient WCC.3–6 Various WCC systems exist, dividing and distributing the activities of WCC between physicians and nurses, and across the public health and primary care systems. Over the past decade, many Canadian provinces have adopted novel models of primary care delivery, such as creating interprofessional primary care teams.7 Further, there has been growing attention in Canada to improving the links between the public health and primary care systems.8
Although WCC has not attracted the same public attention as many other aspects of primary care have over the past decade, there is nonetheless concern across the country about the capacity of existing providers to meet the demand for WCC.1,9–11 As the health system seeks to improve outcomes and efficiency, WCC needs to be considered in light of the evolving models of primary care delivery across Canada, specifically paying attention to health professionals’ scopes of practice and the concept of task delegation. This systematic review compared diverse models of WCC in the high-performing primary care systems of the United Kingdom (UK), Australia, and the Netherlands. Although there are many other nations with strong primary care systems, these countries were chosen specifically, as they have long-standing, well established systems of nurse-provided WCC. In addition, in these countries, as in Canada, most people are cared for by FPs or GPs—in contrast to more specialty-driven health care systems such as those of other European nations and the United States.4 This review focused specifically on the role of registered nurses (RNs) in providing WCC and their interactions with FPs in an attempt to derive relevant models or lessons for Canada’s growing number of interprofessional primary care teams, as well as for more traditional family practices that include physicians and RNs only.
METHODS
This study conducted a systematic review of the literature using thematic analysis to produce a qualitative synthesis of the findings, as described by Bearman and Dawson.12 The Bruyère Research Institute Ethics Review Board exempted this study from the need for ethics approval.
Data sources
We searched the Ovid MEDLINE and EMBASE databases, as well as the nursing and allied health database CINAHL. For feasibility purposes, the search was restricted to English, French, or Dutch articles from 1994 to 2016 and used a combination of text words and subject headings that included variations on the key words well child care, nursing role, and delivery of care. The literature was searched using varying combinations and synonyms of the search terms until the search captured most key articles retrieved in preliminary searches (929 articles). Using the inclusion criteria listed in Box 1, a title review and an abstract review were conducted successively. Additional articles were sought through reference mining and searching Google Scholar using the same search terms to find more information on WCC in our chosen countries. Full-text review was completed for 56 articles (Figure 1). The data extraction template, which was developed based on the goals of the study and a preliminary review of the literature by the team, was pilot-tested by all team members with 3 articles to ensure agreement in interpretation and application of the tool, and double data extraction was completed independently by 2 team members (J.T., J.V.) for a randomly selected 14% (8 out of 56) of the articles for quality assurance.13 As we were collecting descriptive data, not quantitative data, our focus was on ensuring appropriate interpretation of studies and proper application of the extraction template. Near-complete agreement was achieved with no important differences in data or coding, so each remaining article was reviewed by the same author (J.V.). The 2 other team members (S.J., J.T.) reviewed all the extracted data for completeness and accuracy and any perceived discrepancies were discussed with reference to the original source until all 3 reviewers reached consensus. The included studies were heterogeneous in their methodologies, thus the validity of the studies was not assessed.
Inclusion and exclusion criteria
Inclusion criteria
Relevant to WCC delivery
Focus is on Canada, the Netherlands, the UK, Australia, or an international comparison
Describes care of healthy term infants
Describes care provided in the community
Describes the role of the nurse in WCC delivery
Exclusion criteria
Specific focus on a different country (eg, US)
Focus on telehealth or group WCC
Focus on nurse practitioners
UK—United Kingdom, US—United States, WCC—well-child care.
Article selection
WCC—well-child care.
SYNTHESIS
The literature review produced an array of article types. Nineteen articles were primary research studies, largely qualitative studies exploring nurses’ and other professionals’ perspectives on WCC delivery approaches, with only 1 article reporting on a large controlled before-and-after trial of nurse-provided WCC. Four articles were literature or scoping reviews, and 2 articles were discussion papers. By far most of the selected articles focused on Australia. Of the 25 articles included, 17 were Australian, 3 were from the UK, 1 was from the Netherlands, and the other 4 included 2 international comparisons (including Canada), 1 review of Canadian and American literature, and 1 Canadian publication describing experiences in the Netherlands. A detailed description of the reviewed studies, including the main outcomes and conclusions, can be found in Table 1.4,14–37
Description of studies and reviews examining the role of RNs in the provision of WCC
In both the UK and Australia, public health nurses (RNs) with special training provide WCC, either independently or working out of FPs’ offices (referred to as practice nurses). In the Netherlands, there is a long-standing tradition of child health doctors and RNs working as a team in growth and development clinics (consultatie-bureaus), which are separate from FPs’ practices, and where visits alternate between the nurse and the doctor.35 A recent feasibility study from the Netherlands, however, compared care provided in this traditional way to WCC provided exclusively by nurses (for children aged 2 months to 3 years) and found that the care was comparable, except that parents perceived a lack of continuity of care from nursing-only care.34 Interestingly, based on this study, the Dutch WCC system is changing to this model of nurse-only WCC (S.J. Benjamins, H.F. van Stel, verbal communication, February 2016) for a large region that includes about 30 000 children.
Our analysis identified a range of WCC activities carried out by nurses, including preventive care and screening, monitoring development, and providing health education and support to parents. Across the literature from each country, 3 recurrent themes emerged: the importance of professional development (PD) and education for nurse WCC delivery, integration of care and interprofessional collaboration, and the changes in nurses’ roles within evolving health systems.
Professional development and education
The extent of PD and training offered to nurses, and the effect that an increase in educational opportunity can have on the success of nurse-provided WCC,29 was frequently raised in intervention study discussions, review papers, and policy discussions. Educational opportunities described in the studies ranged from nurses completing a single skills-development session to formal postgraduate certificates or degrees, with general agreement that an increase in nurses’ training beyond their basic competencies is an important feature in effective WCC interventions.22,36 In the Dutch intervention study, the study nurses were offered a 5-day course in WCC and examination skills, and also received coaching from child health physicians for 4 more months, with gradual task delegation; the physicians received a 1-day coaching workshop.34
When asked their opinions about the necessity of PD, nurses frequently highlighted the need for more PD opportunities.16,23,27,29,32 This included wanting more training around specific skills such as obesity prevention and domestic violence screening24,26,27 or, more broadly, requiring ongoing education in order to keep up with current evidence-based practices.16 Although most studies reported nurses being interested in further training opportunities, barriers to the implementation of ongoing PD were also described in some studies, with time constraints being the most prominent challenge, as nurses are busy with high workloads alongside external commitments.19,29
Integration of care and interprofessional collaboration
Many of the studies described the level of interaction between nurses and FPs providing WCC, with numerous studies finding a disconnect between providers. A 2006 international comparison of WCC found that “most countries seem to assign little value to coordination between different care providers.”4 Although often lacking in practice, the benefits of and desire for a multidisciplinary approach to WCC were repeatedly raised.23 Benefits such as facilitated referrals and improved capacity to manage conditions such as postpartum depression were thought to arise from either a co-located multidisciplinary team or increased familiarity between nurses and FPs.16,21
The same 2006 comparison described Australia as having little coordination between maternal-child health nurses and FPs, whereas in England there was greater coordination when home visitors (the RNs who provide WCC in the UK) were attached to the FP’s office.4 In both countries, co-location of nurses and FPs was described as enabling stronger relationships between nurses and FPs in WCC delivery. In the UK, home visitors increasingly work from FP premises, and in Australia, the role of the nurse working within general practice is also expanding.23,25,29,31
Nurses’ role in an evolving health system
The concept of the dynamic nature of the nursing role was prevalent throughout the literature. In papers from the UK, a common theme was a shift from universal to targeted nurse-provided child health services, mainly to focus on children and families with higher needs.33,38 In addition to nurses focusing more on higher-needs families, the role was also described as expanding to include more tasks.18,26 Child health nurses in Australia saw their role broadening owing to the “abolishment of other health and support agencies,”23 and practice nurses in Australia were beginning to take on preventive pediatric care through opportunities such as the Healthy Kids Check.27,29 A recurrent theme when discussing the evolution of the nurse’s role was the importance of nursing input on change15,16,33 and how the lack thereof can hinder successful implementation of new practices.
The provision of psychosocial support for families was increasingly a key aspect of WCC provided by nurses.16,17,23,28,34 In interviews with child and family health nurses in Australia, this shift was described as “a change in focus from that of the baby to the entire family with an increase in the psychosocial effects on family functioning and health.”19 One report suggested this shift is because there is an overall decrease in available social resources and nurses are filling in to support children and families.22
DISCUSSION
This literature review revealed diverse and illustrative practices in WCC in several countries with well developed primary care systems, similar to those in Canada. The Netherlands, the UK, and Australia all have dedicated systems for WCC, where RNs with some specialty training perform most of the WCC tasks. In Canada, although few nurses provide WCC independently, RNs receive teaching on most of the components of WCC during their training, and enrichment in primary care nursing is available.39 Canadian health care providers could learn a number of things from their international colleagues in the field of WCC, not by completely overhauling our system to match that of the studied countries, but rather by recognizing the opportunity to adapt our system to enable and allow RNs to perform WCC in the primary care setting. Literature about work force issues in primary care points to a growing trend of nurses taking on tasks previously completed by physicians to increase capacity and maximize efficiency, and WCC in Canada seems to be a field perfectly poised to undergo task delegation.34,40 The recurrent themes emerging from this review, including the ongoing need for nurse PD to adapt to new roles, the need for collaborative and integrated practice between nurses and FPs providing WCC, and the context of evolving health systems, should inform any potential delegation of the provision of WCC from physicians to nurses.
Many FPs already work with nurses in their delivery of primary care and could consider delegating or sharing WCC with these nurses. The repeated concerns over strong relationships between nurses and FPs for optimal care highlight that a high degree of collaboration would be most effective. Canada’s interprofessional primary care teams already have features in place that are likely to improve working relationships between FPs and practice nurses—namely co-location of the 2 professions, often with other health care professionals delivering primary care, as well as shared communication systems. Finally, collaborative arrangement between nurses and FPs in delivering WCC must recognize the importance of continuity of care for children and their families, reported as a finding in the before-and-after study in the Netherlands showing comparable care but parent dissatisfaction with a lack of continuity.34
Nurses’ roles in WCC are evolving—to both focus more on higher-needs patients and place greater emphasis on psychosocial care—in the context of larger system trends, also seen in Canada. In the Netherlands, for example, the standard basic “basket of services” offered to children as part of routine WCC has recently undergone a “demedicalization” shift, aiming to increase the focus on and engagement with social resources.41 Similarly, in the UK, the standard WCC has been shifting to place greater emphasis on resources for social support for more vulnerable children.38,42 The trend across countries of distributing WCC resources according to need might reflect diminishing medical resources for WCC, as needs within the health system increase elsewhere, particularly to meet the needs of an aging population. However, pressures from rising costs and searches for greater efficiency in delivering care can create opportunities to reconsider the way care is delivered and to maximize the scopes of practice of all health professionals delivering care. Moreover, the growing role of nurses in providing psychosocial care as part of WCC might also reflect an increased recognition of the health effects and long-term costs of psychosocial determinants of health on the lives of infants and young children.
Limitations
Our literature search had several limitations. As echoed in an Australian policy paper,6 very few articles specifically focus on the provision of WCC, and only 1 recent article described outcomes of WCC compared with different methods of care delivery. Moreover, there were no articles that focused exclusively on the Canadian context. We limited ourselves to 4 countries with similar health care systems, but future searches might review additional countries, and papers written in different languages, to see if innovative WCC practices might be relevant or transferable to the Canadian system. Last, this field of pediatric care remains relatively unaddressed in the literature, so the number of articles was small and they used diverse methods and were of variable quality.
Conclusion
This paper describes initial findings in a burgeoning field. Common themes, which clearly link to health system trends in Canada, were identified. These include the function of interprofessional teams and maximizing scopes of practices of all team members for greater efficiency. International examples suggest Canadian FPs could give RNs the opportunity to provide WCC, while maintaining a therapeutic relationship with the family, if the providers work together in the same location and share the same medical records. More rigorous study and reporting of outcomes should be done to guide reform efforts of WCC in the Canadian primary care system.
Notes
Editor’s key points
The role of nurses in the provision of well-child care (WCC) remains relatively unexplored in the literature. As the health system seeks to improve outcomes and efficiency, WCC needs to be considered in light of the evolving models of primary care delivery across Canada, specifically paying attention to health professionals’ scopes of practice and the concept of task delegation.
This systematic review describes findings from Australia, the United Kingdom, and the Netherlands that might be relevant for the Canadian system. Professional development, the functioning of interprofessional teams, and maximizing the scopes of practices of all team members for greater efficiency are key elements.
International examples suggest Canadian FPs could enable registered nurses to provide WCC, while maintaining a therapeutic relationship with the family, if the providers work together in the same location and share the same medical records. More rigorous study and reporting of outcomes should be done to guide reform of WCC in the Canadian primary care system.
Points de repère du rédacteur
Il existe relativement peu d’études sur le rôle de l’infirmière dans la prestation de soins préventifs aux jeunes enfants (SPJE). Comme le système de santé cherche à améliorer son efficacité et les résultats de ses interventions, les SPJE doivent tenir compte des récents changements dans les modèles canadiens de prestation de soins primaires, en portant une particulière à l’ensemble des responsabilités des différents professionnels de la santé et au concept de délégation des tâches.
Cette revue systématique décrit des d’études effectuées en Australie, au Royaume-Uni et aux Pays-Bas, dont les résultats pourraient s’appliquer au système canadien. Parmi les principaux éléments susceptibles d’améliorer l’efficacité du système, mentionnons l’amélioration des compétences professionnelles, le fonctionnement des équipes interprofessionnelles et la maximisation des champs de pratique de tous les membres de l’équipe.
Certaines initiatives à l’échelle internationale donnent à croire que les MF canadiens pourraient permettre à des infirmières diplômées de prodiguer des SPJE, tout en maintenant une relation thérapeutique avec la famille, lorsque les prestataires de soins travaillent ensemble au même endroit et ont accès aux mêmes dossiers médicaux. Des études et des rapports sur les résultats plus rigoureux devront être effectués afin d’orienter une réforme des SPJE au sein du système canadien de soins primaires.
Footnotes
Contributors
All authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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