Advanced practice nursing

Study design

We used a qualitative research case study design,¹⁹ which is appropriate for the exploration of a phenomenon within its context. In our investigation, the cases were 3 health care regions (Capitale-Nationale, Bas-Saint-Laurent, Laurentides) owing to their distinguishing characteristics (eg, population, services, administrative structures) and diverse conditions in which the PHCNP role was being implemented.

Study setting, sample, and recruitment

Our investigation was carried out during 2016 and 2017 across a range of demographic (eg, urban, semiurban, rural) and administrative (centre local de services communautaires, groupes de médecine de famille, groupes de médecine de famille universitaires, groupes de médecine de famille–clinique réseau Québec) structures.

To participate in the study, the family physicians were required to have worked in collaboration with at least 1 PHCNP for a minimum of 6 months. To recruit physicians, we were assisted by regional directors of general medicine, who agreed to forward information about the project by e-mail to the family physicians. We also used the snowball²⁰ approach, whereby physicians encouraged other physicians to participate in the study.

In total, 16 physicians participated in individual or focus group interviews; 2 physicians participated in both formats. Physicians from all 4 administrative structures participated. Several physicians had collaborated with more than 1 PHCNP, up to a maximum of 6 PHCNPs.

We created 2 advisory committees to support the rigour of our study by providing advice regarding recruitment, data collection, and analysis (Table 1).

This research project received ethics approval from the Research Ethics Committee of the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale.

Data collection

The individual interviews (average 1.25 hours’ duration) were conducted either face-to-face or by Skype, as requested by the participants. The semistructured interview guide comprised open-ended questions that elicited a description of the work milieu and the characteristics of the catchment area in which the services were being provided; the evolution of physicians’ role and their overall professional practice; the effects on professional autonomy; and previous experiences of interprofessional collaboration and the supports necessary for optimal collaboration. The focus group interviews (average 1.5 hours’ duration) were carried out following the initial analysis of the individual interview data, with the objective of validating these initial findings but also of pursuing some of these findings in greater depth. For example, we sought to better understand how the collaboration with the PHCNPs affected physicians’ perspectives regarding their own role and the meaning of their work. With the participants’ consent, both the individual and focus group interviews were audiorecorded.

Data analysis

The audiorecorded interviews were transcribed and anonymized. A comprehensive summary of each individual interview was prepared; these summaries were structured according to the interview guide elements and the themes that emerged. Subsequently, a matrix was constructed to organize the global themes as they emerged; this information constituted the first level of analysis.²¹ We used this information to develop the interview guide for the focus groups. The focus group interview data were coded using NVivo software and organized in a matrix to reveal the subjective experience of the participants and the actions that they recommended. Over the course of the investigation, the emerging findings were presented to the members of the Strategic Committee and the Work Committee. These members’ questions and reflections were used to clarify the analysis of the data.

Nature of follow-up possible with patients

Collaborating with PHCNPs has an important influence upon the nature of physicians’ follow-up with some patients. The traditional model, in which family physicians were often the sole or primary providers of care over the patient’s lifetime, appears to be evolving. Several physicians reported that their specific role is tending to be squeezed between the respective roles of PHCNPs and other specialist physicians. These changes not only influence the specific tasks performed by family physicians but also these professionals’ overall way of thinking about their practice in family medicine. Health promotion, a holistic long-term perspective of patients, continuity of care through a single provider of services, and the possibility of establishing a long-term relationship with patients are important elements of family physicians’ professional identity that play an important role in the meaning that they attribute to their work. Some physicians expressed strong misgivings about the dilution of these dimensions of their practice in the face of the redefinition of their role within the collaboration with PHCNPs. They sometimes wondered about the evolution of their profession and what would become of family medicine.

Sharing the scope of practice

Collaborating with PHCNPs raises questions for family physicians specifically where there is some potential role overlap. Physicians question their accountability for the care provided to patients by other professionals. In part because in Quebec patients are only registered in the physician’s name, several physicians expressed unease, believing that they were accountable for all care provided. Even if this interpretation of their legal accountability is not necessarily accurate given PHCNPs’ own clearly defined accountability obligations for the services they provide, the physicians’ misgivings were not only linked with their legislative understanding but also with an overall sense of ethical accountability; in essence, they feel a strong sense of responsibility for the overall quality of the care provided to the patients on their list. Collaboration with PHCNPs similarly raised concerns about physicians’ definition of their professional autonomy, in that the joint management of the same patients might imply a certain loss of overall control regarding the services provided.

Patient profile

For many physicians, collaboration with PHCNPs has meant that their own case load has included more medically complex patients (eg, individuals with comorbidities or undiagnosed conditions), with the less medically vulnerable patients being directed toward the PHCNPs. This situation has tended to evolve family medicine toward a more specialized practice in which the physicians primarily treat patients who require their exclusive expertise. The physicians expressed divergent perspectives about this situation. Some individuals were comfortable with this evolution, believing that it made sense for them to be concentrating on treating cases that clearly required their competencies, as well as seeing it as a recognition of the important and distinct role of family medicine. However, other individuals expressed reservations, believing that it was contributing to making their already demanding practice even more so. Being able to include some more straightforward patients in their case load permitted them to better balance their workload. These latter comments were situated within the context of overall concerns about the highly demanding nature of their practice as family physicians, in which they were endeavouring to provide high-quality services while maintaining a satisfying professional and personal life (eg, avoiding burnout). In a related vein, the fact that the patients being followed by the PHCNPs are registered on the physician’s list could also be anxiety provoking given the potential considerable implications for the physician’s case load should the PHCNP be away on parental or sick leave.

New positive work experiences

Despite the challenges identified, many physicians also identified various positive outcomes that have emerged from their collaboration with PHCNPs—for example, the teaching role that they have needed to play with their PHCNP collaborators. Some physicians also noted the improvement in their practice because of their access to the up-to-date knowledge of their PHCNP partners and a related harmonization of quality practices in the clinic. Also mentioned by some individuals was a better, and highly satisfying, use of their expertise. In a point highlighted by many participants, working with a PHCNP helped to decrease the isolation that sometimes characterizes family physicians’ practice—for example, by holding discussions about clinical questions and sharing responsibility for patients’ care. Thus, for many physicians, collaboration with PHCNPs was associated with new sources of satisfaction that enriched their subjective experience of work, including the meaning attributed to this work. This collaboration also could lead to tangible changes, for example, in managing their case load, which in turn could help them to have a better work-life balance.

Some physicians remarked that this effective collaboration evolves over time. This process can require a substantial investment of time and energy at the start; however, once this new way of working becomes more established, there are clear rewards that tend to outweigh the difficulties.

Limitations

The generalizability of our conclusions might be limited by our focus on family physicians’ experiences in one jurisdiction (Quebec). Nevertheless, the broad trends to which these experiences appear to be linked (eg, increased productivity pressures) suggest that our findings might have broader applicability.²⁹ The comprehensive nature of the individual and focus group interviews that were conducted, as well as the ongoing validation of the findings carried out with the 2 committees over the course of the research, lead us to feel confident that we have accurately understood some important trends despite the limited number of interviews in a single jurisdiction.