Role dimensions of practice nurses and interest in introducing advanced nurse practitioners in general practice in Ireland

Abstract Background Internationally many countries have implemented strategies to enhance primary care, to strengthen their health systems to cope with an aging population, the rise of chronic conditions, and increased costs. Primary care has the potential to address these challenges, however, general practitioners are increasingly struggling to meet patient demand resulting from a growing and aging population. Expanding the role of general practice nurses to advanced nurse practitioner (ANP) level has worked internationally and could equally be a solution to the Irish context. However, their current role must first be established as well as their level of interest in becoming an ANP. Aim To explore the role of general practice nurses and their interest in becoming an ANP. Design A survey design. Method A purposeful sample of general practice nurses (n = 40) was undertaken between April and June 2019. Data were analyzed using the Statistical Package for Social Science (SPSS V 25.0; IBM). Results General practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, respiratory and cardiovascular issues. Just over half of the respondents were not interested in becoming an ANP. Their perceived challenges associated with the implementation of the role include a lack of support from general practitioners, a lack of resources, insurance issues, and a lack of understanding of the role. Challenges were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources. Conclusion General practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses to advanced practice level. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.


| INTRODUCTION
In 2018, the Astana declaration 1 reaffirmed the global commitment to strengthening primary healthcare as it was seen as inclusive, effective, and efficient way to enhance people's physical, mental health, and social well-being. Primary care teams, commonly led by general practitioners (GPs), provide comprehensive family and communityoriented medical care. Primary care systems worldwide are being challenged by an aging population, an increasing number of chronic diseases, and economic constraints while expected to respond to increasing demands for services. 2 Fundamental to the provision of high-quality primary care is the general practice nurse who typically provides a wide range of services. This higher demand for health care services necessitates a cultural shift from specialist hospital-centric care models to community-led person-centered integrated care and, in many countries, advanced nurse practitioners (ANPs) are emerging as a potential solution for these challenges. 3

| Background
The essential feature of general practice nursing is employment within a general practice setting working alongside a GP. In Ireland, the Sláintecare policy 4 supports the reorientation of healthcare out of the hospital setting and into the community delivered at the lowest level of complexity, appropriate to the individuals' needs. Sláintecare policy has highlighted the burden on service demands associated with chronic disease and its management has been described as suboptimal, fragmented, and siloed. Around 3005 GPs provide care to Ireland's population of 5-m people. 5 It is suggested by Homeniuk and Collins 6 that GPs undertake approximately 25 consultations daily. Yet only half of the country's GP practices are operating to full capacity and have identified that they cannot take on new patients because of working part-time, staff shortages, and lack of holiday cover. In Ireland, GPs are self-employed under a variety of individual contracts with the Health Service Executive for the provision of services to either exclusively public patients, or private patients or to a public-private mix. 7 Although there is mounting evidence of the positive impact of nurses on patient outcomes, 8 there is resistance to enhancing the role.
In Ireland, the general practice nurse, is employed privately by the GP and the current salary subsidy is provided by the tax payer via the Primary Care Reimbursement Service of between €31-38K and the GP pays the indemnity cover. A comparison of the educational requirements, years of experience, and indicators of competency are provided in Table 1. The difference in the competence exercised by each individual is demonstrated in the implementation of the scope of practice.
A practical example illustrating the role of a staff nurse and an ANP in rheumatology is highlighted in Table 2. Table 2 shows that the advanced practitioner level moves beyond developing knowledge of the pathology to teaching interprofessional colleagues, from communicating information to patients to discussing treatment options thus moving from a competency to a capability model.

| The role of ANPs in primary care
Reviews on the effectiveness of nurse-led clinics in primary care found that such models of care delivery improved patient satisfaction, reduced hospital admission, and mortality rates. 12 A recent review concluded that nurse-led care for common minor health conditions was as effective and less costly than GP Care. 13 A Cochrane review suggests that task shifting from doctors to nurses is a useful strategy to improve access, efficiency, and quality of primary care. 14 Primary care services led by nurses in advanced practice have demonstrated to be as safe and effective as those led by physicians 15 and providing improved access for people with minor health problems. 16 A recent economic evaluation of ANPs versus GP's in treating common conditions found that direct costs of nurse practitioner consultations were significantly less than those of GP consultations. 17 Yet, according to van der Biezen et al., 18 improvement in quality of care and the ability to offer technical care were important driving factors for GPs to employ ANPs. Moreover, the bespoke employee arrangements give rise to a lack of standardization of the activities of general practice nurses, and this is compounded by the absence of a national standardized preparation for this role. In addition, the way in which general practice is organisationally structured and the hierarchical position of the general practice nurse limits opportunities for knowledge sharing. 19 These are important considerations in the context of implementing professional practice standards for practice nursing. 20 There is also a lack of promotion and continuing professional development opportunities for practice nursing and general practice nurses can experience a strong sense of professional isolation in comparison to nurses employed in the public sector. Indeed, While and Webley-Brown 21 describe nurses in general practice feeling undervalued and dissatisfied with working conditions. When this is added to negative power relations resulting for their status as employees, gender issues and the part-time nature of the role, the unique challenges of general practice nurses' role and the importance of adequate role preparation become clear. The rising health care costs, and physician shortages increase demand for a review of the services provided by the GPs and particular consideration for the employment of ANPs. 3 In Ireland, a recent reform of GP and service development agreement was concluded 22,23 with emphasis on chronic disease management. While there is mention of practice nurses there is no mention of ANPs.
Consideration is currently being given to the development of advanced clinical practitioners which, according to Ljungbeck and Sjogren Foss 24 allows more time for the doctors to see people. In Ireland, this proposed new role in primary care is known as a community paramedic who will work "collaboratively with other partners in health to bring the right care to the right patient in a home setting." 25 (p. 2) The idea is these practitioners will work autonomously under the guidance of the GP. It would seem that an opportunity is wasted and effectiveness and efficiency are to be ignored by developing a new role in primary care rather than employing more general practice nurses and upskilling them to ANP, which is known to have a positive impact on patient outcomes.
For many medical consultants, both the role and the scope of practice of the ANP are unclear. 26 This is also true in relation to understanding the role and scope of practice of general practice nurses, where little is known about the ways in which they are deployed within each practice. 27 Indeed, many GPs and general practice nurses themselves do not have a clear understanding of the role or the scope of practice with few distinguishing tasks from roles. 28,29 Therefore, the complexity of the general practice nursing role can remain hidden, and they can be an unsung hero of the team. 21 In addition, Jakimowicz et al., 30 found that experienced GPs do not think nurses are autonomous and many general practice nurses articulated their role as an assistant to the GP rather than as an independent professional responsible for their own clinical practice. Moreover, some GPs can mistakenly assume that they are responsible for everything that transpires within the practice which can give the impression that general practice nurses are relieved of any accountability arising from their own decisions. 30 Securing the future of general practice nursing requires a willingness to do things differently building on examples of approaches already undertaken to develop ANP services in acute care. However, before this can take place the current role of general practice nurses must first be established. The aim of this study was to address this gap.

| METHODOLOGY
A survey method was used. Formal qualifications as a nurse responsible for general care shall provide evidence that the professional is able to apply: "(a) competence to independently diagnose the nursing care required using current theoretical and clinical knowledge and to plan, organize and implement nursing care when treating patients; (b) competence to work together effectively with other actors in the health sector, including participation in the practical training of health; (c) competence to assist individuals, families, and groups towards healthy lifestyles and self-care; (d) competence to independently initiate life-preserving immediate measures and to carry out measures in crises and disaster situations; (e) competence to independently give advice to, instruct and support persons needing care and their attachment figures; (f) competence to independently assure the quality of, and to evaluate, nursing care; (g) competence to comprehensively communicate professionally and to cooperate with members of other professions in the health sector; (h) competence to analyze the care quality to improve his own professional practice as a nurse responsible for general care." 10 p. 14 All competencies encompass six domains of practice The competencies for the ANP build on the competencies achieved/ acquired to register as a nurse with the Nursing and Midwifery Board of Ireland in each of the 6 practice domains. A specific standard is set for each domain to: 1. Apply ethically sound solutions to complex issues related to individuals and populations 2. Utilize advanced knowledge, skills, and abilities to engage in senior clinical decision making 3. Actively contribute to the professional body of knowledge related to his/her area of advanced practice 4. Negotiate and advocate with other health professionals to ensure the beliefs, rights, and wishes of the person are respected 5. Manage risk to those who access the service through collaborative risk assessments and promotion of a safe environment 6. Lead in multidisciplinary team planning for transition across the continuum of care

| Survey instrument
The survey contained 40 nursing activities using the preprepared list of practice nursing activities guided by previous research. 11,31 These activities related to dealing with patients and families, chronic disease management, prescribing, providing advice, and other activities. Demographic details were also collected. Respondents were only required to indicate a "yes" or "no" if they undertake the activity.
Respondents were also asked about the types of continuous pro-

| Ethical considerations
Permission for the study was received from the university (Approval no. LS-19-28-XXX). Return of the completed questionnaire was accepted as informed consent. T A B L E 2 The role of a staff nurse and an advanced nurse practitioner in rheumatology 9   Demographic details and registration status of participants are presented in Table 3.

| Dimensions of the role
General practice nurses appear to have an agenda in relation to chronic disease management in relation to wound care, respiratory and cardiovascular issues such as raised blood pressure which were at the top end of selected activities as seen from Table 4.  Table 5 indicates respondents' interest in becoming an ANP in general practice.

| Interest in becoming ANPs
All respondents (n = 19) answered this question. The mean score was 5.1 (SD = 3.6, range: 1-10 with just over half of participants (52.6%, n = 10) giving a response of between 1 and 4, indicating that they were not interested in becoming an ANP in general practice. As seen in Figure 1, general practice nurses with more years of experience appear to be less likely to be interested in becoming ANPs: r = −0.527, r 2 = 0.278, p = 0.025. Figure 1 indicates the level of interest scale is from 1 to 10 on the left side and suggests there may be a short peaking of interest after 15 years postregistration experience, it seems that this interest declines thereafter. However, caution must be exercised due to the sample size.

| Contribution and challenges that an ANP role would bring to general practice
When asked about the perceived contribution that an ANP would bring to the practice the following comments were proffered by nine respondents. One said it "would be very beneficial.   Table 6.
T A B L E 4 List of role activities undertaken by practice nurses in order of frequency Challenges that an ANP might encounter range from time constraints to resistance and lack of support from the GP to a lack of resources, to insurance issues, a lack of understanding of the role,

| Introducing ANP to general practice
Just under half of the sample were interested in becoming an ANP and, while based on a small sample size it appears, respondents with more years of experience were less interested in becoming an ANP.
This may be reflective of the age group and experience level of the respondents and this finding also relates to previous research 38 [47][48][49][50][51][52][53] and the positive impacts of ANPs on patient outcomes, 8 the potential to advance the role of general practice nurses remains unexplored. In the main, the identified challenges to implementation of the ANP role included the lack of adequate resources and a lack of shared understanding of the role. This lack of understanding of the ANP role has been previously identified. 28,30,54 Moreover, it can act as a barrier to implementation of more expanded roles 55 and, in the context of the current study, these findings may contribute to an explanation of the semi-strong interest in becoming an ANP in general practice. GP recruitment is unlikely to provide enough GPs to meet the everincreasing demand in the near future, so it is imperative that more general practice nurses are employed and that they have the option of up-skilling to address the workload. 39

| Study limitations
Some bias which may have arisen due to a small sample size and the study being conducted in just one geographical health area. Therefore, the robustness of the findings must be tempered with these limitations. Moreover, the survey instrument consisted of a list of tasks without any indication of the actual nursing roles associated with the task itself. The task list reveals what the nurses do but not their opinion and confidence to work in an advanced role or any issues with power imbalance in a GP setting. Reliability of the survey was not undertaken, and this may have resulted in the nursing aspect of the role largely remaining hidden in favor of more easily observed tasks taken from the literature. Our study is also prone to selfreporting bias and recruitment bias since respondents reported on their own activities and achievements and respondents were selected from the membership of one professional nursing organization.
Nevertheless, this study gives an understanding of the current di-

| Implications for clinical practice
Enabling general practice nurses to work to their full scope of practice will help mitigate future workforce shortages and improve patient access to care. Introducing the role of ANP to general practice can be realized by providing bespoke educational opportunities for existing practice nurses to upskill or by attracting suitably prepared ANPs to work in general practice.

| Implications for future research
Research is required to further explore the barriers to implementation of the ANP role in general practice beyond what is indicated in this study and how GPs can support the implementation of APNs in primary care settings. It would also be worthwhile to examine the level of confidence of general practice nurses to work in an advanced practice role.

| CONCLUSION
Data from this study has shown that general practice nurses engage in nursing activities appropriate to chronic disease management which may be at the ANP level. Furthermore, they have insight into the potential contribution of ANPs and anticipate resistance to the role from GPs. With greater knowledge and understanding of the scope of practice and the role of ANP, resistance to the implementation of the role could be managed and their contribution to patient care manifest. Therefore general practice nurses and GPs, should be enabled to fully capitalize on the contributions of ANPs to provide a mechanism for the provision of integrated care and to ensure increased access to healthcare resulting in overall health service improvement. Establishing a primary care-specific career pathway for ANPs in general practice is essential as they are an essential component of the primary healthcare team and are necessary for the development of the specialty.