Planning to integrate a phcnp: an opportunity for clinical teams

Integrating a primary health care nurse practitioner (PHCNP) into a primary care team requires planning by the setting and some reflection on the intended practice model. A comprehensive plan developed collectively by all team members is a key factor in implementing an effective and satisfactory practice model.
Integrating a PHCNP into a clinical team should be the end result of a process of reflection and discussion among the different professionals and actors involved (physicians, nurses and other members of the team, managers, etc.). Because of this, it is important to take into account the time and energy this process will require from the clinical team and the consequent timeline.

Even though the process requires an investment of time, the arrival of a PHCNP is an opportunity to reflect on how things are currently done, identify areas for practice improvement and create a vision for the entire team’s future practice. According to the Commonwealth Fund’s recent survey of primary care physicians on health policies, most believe there is currently a problem of accessibility in primary care services, and this view is widely shared by the public. Integrating a PHCNP into the primary care team is one way to improve this accessibility..

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Source et validity of these recommendations

The information presented here comes from two sources: 1) the results of a systematic review of the scientific literature on advanced nursing practice in primary care, and 2) the results of six case studies of settings that have integrated PHCNPs in three health regions of Quebec. Details of the methodologies used for each of these two research efforts are presented in the Methodology section. The analyses of the data produced in each of these two components were used to inform each other reciprocally. Thus, the data from the scientific literature were analyzed in relation to the various models of integrating PHCNP practice found in Quebec, while the empirical data were interpreted based on themes identified in the literature.
In the literature there are many studies that have analyzed the deployment of primary health care nurse practitioners in other provinces and countries. Likewise, there are solid and credible data confirming the importance of comprehensively preparing the setting into which the PHCNP is being introduced. However, only a very few studies offer insights useful for determining the procedures and stages of good preparation of settings.

What to consider when planning to integrate a PHCNP into the team
Both the scientific literature and the data collected in our studies suggest there are often preconceived notions about the nature of PHCNPs’ training and practice. Teams on the ground often have little factual information about administrative and regulatory dimensions and on PHCNPs’ practice models. Data from the empirical case studies show that many physician partners had only very superficial knowledge about PHCNPs’ autonomous field of practice before a PHCNP was introduced into their setting. Likewise, clinical teams often still do not know very much about the nature of PHCNP training and the particular aspects of the trainee’s status, or the process of obtaining the right to practice, when required.
As such, when planning to add a PHCNP to the team, the main recommendation is very simple: take the time to provide team members with reliable information on these matters. Yet even so, teams are still often incompletely or inadequately prepared. In these cases, it helps to compile the most relevant documents already developed (see the Documents section (in French only)).

More broadly, the arrival of a PHCNP provides an opportunity to reflect on current practices, their strengths and weaknesses, and to establish a shared vision of the preferred practice models. This reflection should cover certain fundamental considerations:

  • What are patients’ needs in terms of care and service provision?
  • Is the current practice model an appropriate response to those needs?
  • Are the members of the care team satisfied with the current practice model, and what improvements would they like to see?
  • What practice model is the care team aiming to create?
  • What would be the PHCNP’s place and role in that envisioned practice model?
  • How would integrating a PHCNP into the current practice model improve the response to patients’ needs?
  • Is the role envisioned for the PHCNP consistent with the regulatory and administrative framework of PHCNP practice, the experience of the person being hired, and the nature of PHCNP practice?
  • How will integrating a PHCNP into the team affect the work of the other team members?

The answers to these questions will determine the broad strokes of the practice model to be put in place and help guide the process of integrating the PHCNP. There are also other resources that can be used to support teams in their reflections at this stage (see the other information sheets as well as the Documents section (in French only) ). The detailed description of the PHCNP’s role should be produced in collaboration with the person hired; however, by defining the broad dimensions of the practice model beforehand, the team will be able to assess whether their expectations are realistic and consistent with the regulatory and administrative framework governing PHCNP practice. It will also provide a useful tool for candidate interviews.

It is also important when planning the integration to take into account the level of experience of the person who will be hired as the PHCNP and the changing nature of that person’s practice. The data indicate that the first year of practice after graduation is one of transition. In this regard, it may be helpful to keep in mind that there is a significant difference between the practicums of PHCNPs and the residencies of family physicians, especially in terms of length of time spent in training. It is important to take this into account when planning the integration. Each Canadian province has its own regulations, but it can happen that some PHCNPs might not yet have passed their certification or might have only a provisional license when hired, and if so, this needs to be clearly understood by the team.

Some practical suggestions for planning the integration of a PHCNP
Here are a few practical suggestions to facilitate the planning process:

  • Designate the people who will be in charge of the different steps of the integration process, and establish a schedule and procedures to be followed
  • Organize one or more meetings of the clinical team members (physicians, nurses, other professionals) and, when applicable, administrative staff (reception, appointment desk, human resources, etc.) to discuss the questions identified above and to develop a practice model.
  • Become familiar with the regulatory and administrative frameworks governing PHCNP practice.
  • Develop a brief description of the core principles of the intended practice model and of the PHCNP’s role in this model. This description will be useful both for internal communications and for recruitment.
  • Set up a communications strategy to ensure all team members are informed about the impending arrival of the PHCNP.
  • Develop a plan for orienting and supporting the PHCNP during the first weeks on the job.
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For more information:

Canadian Nurse Practitioner, I. (2006). Implementation and Evaluation Toolkit for Nurse Practitioners in Canada (pp. 1-84). Ottawa, ON: Canadian Nurses Association.

DiCenso, A., & Matthews, S. (2005). Report on the Integration of Primary Health Care Nurse Practitioners into the Province of Ontario. Toronto, ON: Ministry of Health and Long Term Care. (Download)

Bryant-Lukosius, D., & DiCenso, A. (2004). A framework for the introduction and evaluation of advance prectice nursing roles. Journal of Advanced Nursing, 48(5), 530-540. (Download)

Way, D., Jones, L., & Busing, N. (2000). Implementation Strategies: “Collaboration in Primary Care – Family Doctors & Nurse Practitioners Delivering Shared Care" (pp. 1-12). Toronto, ON: Ontario College of Family Physicians.

Tarrant, F., & Associates. (2005). Practice Component: Literature review report. Supports, Barriers, and Impediments to Practice. Ottawa, ON: Canadian Nurses Association; Canadian Nurse Practitioner Initiative.

Citing this document Project (2014). Information sheet on planning the integration. Planning to integrate a PHCNP: an opportunity for clinical teams. Montreal, march 2014.

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CarefuL preparation of the nurse practitioner's integration into the team fosters the development pf everyone's effective collaborative practices