Marleen Lovink

Worldwide as well as in the Netherlands, the population is aging. As a result of the aging population and the fact that the chance of developing a chronic disease increases with increasing age, it is expected that the number of older people with a chronic illness and multimorbidity will rise. At the same time many older people wish to grow old in their own home. In the Netherlands, as in other developed countries, governance-reforms are implemented to shift care from hospitals and long-term care facilities to the community. These reforms and the growing number of older people, increases the demand on both primary healthcare and on nursing home care to provide suitable care. However, relatively few medical students are interested in healthcare for older people. To face the challenges that come along with the growing number of older people, reforms and shortage of physicians, nurse practitioners (NPs), physician assistants (PAs) and registered nurses (RNs) were introduced as general practitioners (GPs) and elderly care physicians (ECPs) substitutes. Substitution for physicians means expanding the breadth of a job by providing the same services as the physician, while the new provider is responsible for his own work. The new provider is qualified to work autonomously. In order to enable care providers, managers and policy makers to make informed decisions about substituting physicians with NPs, PAs or RNs in healthcare for older people there is a need for evidence concerning the impact and organization of substitution.

The central aim of this thesis is to provide insight into the impact of substituting physicians with NPs, PAs or RNs in healthcare for older people and how it can be organized.

Chapter 2 presents the study protocol of a systematic literature review that evaluated the effect of physician substitution in primary healthcare for older people and long-term care facilities and described facilitators and barriers to the implementation of physician substitution. The review used Cochrane methods. The following databases were searched from January 1995–August 2015 for original research studies that quantitatively compared care provided by a physician to the same care provided by an NP, PA or nurse: PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL, and Web of Science. Study selection, data extraction, and quality appraisal were conducted independently by two reviewers. Outcomes collected were: patient outcomes, process of care outcomes, care provider outcomes, resource use outcomes, costs and descriptions of the implementation. Data synthesis consisted of a narrative.

Chapter 3 describes the results of the systematic literature review. In total, 11,340 records were found of which 12 studies were included. Two studies used a randomized controlled design (RCT) and ten studies used other comparative designs. Year of publication varied from 1997 to 2015. Most studies were conducted in the USA, followed by one study from Canada, Sweden and Japan. Seven studies took place in long-term care facilities. In five of these studies, the care provider was an NP, in one a PA and in one study both an NP and a PA were deployed. The other five studies were performed in primary healthcare settings. In three of these studies, the care provider was an NP, in one a nurse and in one study both an NP and a PA were deployed. Two of the ten studies using another comparative design had low methodological quality and were excluded from analysis of the effect of substitution. The following outcomes were reported: 1) patient outcomes, such as quality of life mortality and HbA1c; 2) process of care outcomes, such as quality indicators scores and percentage prevention performance; and 3) resource use outcomes, such as medication and number of hospital admissions. None of the included studies reported on care provider outcomes, such as workload and job satisfaction. The evidence of the two RCTs showed no effect on approximately half of the outcomes and a positive effect on the other half of the outcomes. Results of eight other comparative study designs pointed towards the same direction, with the exception that two studies showed an increase in the number of acute unplanned visits in case of substitution. No studies reported on care provider outcomes and evidence about costs was too limited to draw conclusions. The implementation was influenced by factors on a societal, organizational and individual level.

Chapter 4 presents a qualitative study that describes how skill mix change is organized in daily practice, what influences it and what the effects are of introducing NPs, PAs or RNs into primary healthcare for older people. In total, 34 care providers working in primary healthcare in the Netherlands were interviewed: GPs (n=9), NPs (n=10), PAs (n=5) and RNs (n=10). Five focus groups and 14 individual interviews were conducted. Analysis consisted of open coding, creating categories and abstraction. NPs, PAs and RNs took care of a range of different patient populations. Only a small part of their job focused on older people living at home. PAs were employed at the general practice, whereas NPs and RNs were employed at community nursing services as well. The tasks that NPs, PAs and RNs performed and their responsibilities in healthcare for older people differed between, as well as within, professions. A clear vision on primary healthcare for older people, including the organization of proactive healthcare, and the role of each professional appeared to be lacking. Skill mix change was also influenced by a lack of team performance, a lack of collaboration, trust and acceptance of each other’s expertise among NPs, PAs, RNs and GPs, and unfamiliarity of older people and family with NPs, PAs and RNs. Nevertheless, interviewees considered NPs, PAs and RNs an added value, and it was stated that the role of the GP changed with the introduction of NPs, PAs or RNs.

Chapter 5 presents a qualitative study that aimed to describe the ways in which skill mix change is organized through introduction of NPs, PAs, or RNs in nursing homes, what factors influence it, and the perceived effects. Four mono-disciplinary focus groups and one multi-disciplinary focus group were conducted with in total 32 care providers: ECPs (n=9), NPs (n=10), PAs (n=6) and RNs (n=7). Analysis consisted of open coding, creating categories and abstraction. Variation in tasks and responsibilities was found. All NPs, PAs and RNs worked at unit level, although some also work at the organizational level with a special area of expertise. PAs took over a broad range of (complex) tasks from ECPs. Among the NPs there was a range of responsibilities, from only performing tasks according to protocols to performing more complex tasks. The RNs prepared work for ECPs and supported them. There was also variation in how NPs, PAs or RNs collaborated with ECPs. Despite this variation interviewees reported increased quality of healthcare, patient-centeredness, and support for care teams and a more coordinating role for ECPs. Skill mix change in nursing homes appeared to be influenced by a lack of a vision on skill mix change, lack of acceptance of NPs, PAs, and RNs by other providers, older people and family, personal factors of the providers involved, and confusion about the legal consequences of substituting responsibilities.

Chapter 6 presents the study protocol of a multiple-case study that draws upon realist evaluation principles. This study aimed to gain insight into how physician substitution in nursing homes is modeled and whether it contributes to perceived quality of healthcare. Second, this study aimed to provide insight into the elements of physician substitution that contribute to quality of healthcare. In the protocol the initial theory is presented and describes three mechanisms: 1) Based on their education and previous experience, NPs, PAs, and RNs are able to substitute for ECPs largely autonomously; 2a) Physician substitution is always a collaboration between the NP, PA, or RN and the ECP; 2b) The role of the ECP changes due to the collaboration with the NP, PA, or RN; and 3) NPs, PAs and RNs have a different way of working and they perform additional tasks compared to ECPs. In order to refine this theory, seven cases were selected based on maximum variation sampling. The primary participants were NPs, PAs and RNs. ECPs, medical doctors (MDs), managing directors/managers/supervisors, nursing team members, and residents/relatives were included as secondary participants. Data collection consisted of observations, interviews, questionnaires, and analysis of internal policy documents. At completion of each case a single-case analyses was carried out followed by a cross-case analysis at the end of the study.

Chapter 7 describes the results of the multiple-case study. The seven cases comprised three NPs, two PAs and two RNs (i.e. practice nurses). An optimal model of substitution of ECPs seems to be one in which the professional substitutes for the ECP largely autonomously, a well-balanced collaboration occurs between the ECP and the substitute, and quality of healthcare is maintained. This model was seen in two NP cases and one PA case. Elements that enabled NPs and PAs to work according to this optimal model were among others: collaborating with the ECP based on trust; being proactive, decisive, and communicative; and being empowered by organizational leaders to work as an independent professional. A successful collaboration between the NP or PAs and the ECP decreased the medical tasks of the ECP and contributed to more time for additional tasks, such as a multidisciplinary meeting with primary care professionals. The RNs did not substitute for the ECPs/MDs autonomously in the medical domain with maintenance of quality of healthcare. Nonetheless, in these cases the ECPs/MDs performed fewer tasks on the border between the medical and the nursing domain, for example wound care, due to their collaboration with a RN. In addition, the results showed that NPs, PAs, and RNs may all contribute to perceived quality of healthcare in their own unique way.

Finally, Chapter 8 provides an overall discussion of the main findings of the thesis. Also the methodological reflections, implications for practice and policy and the recommendations for education and future research are described. This thesis shows that NPs and PAs in healthcare for older people are able to substitute GPs or ECPs largely autonomously with at least maintenance of quality of healthcare. RNs are able to prepare work for physicians and to support them. The results of our research also show that overuse, in RN cases, and underuse, in NP and PA cases of competences existed because of unfamiliarity among the professionals themselves, other professionals, managers and policy makers. They were unfamiliar with job content and qualifications of NPs, PAs and RNs and with the legal frameworks of substituting responsibilities. NPs, PAs and RNs all have their own unique added value as they contribute to quality of healthcare, provide person centered care and strengthen the care team. Substituting physicians with NPs, PA or RNs is a possible solution to the high workload and shortage of physicians in healthcare for older people and it provides opportunities for physicians to fulfill a more coordinating role. They can also fulfill a role as clinical expert for older people with more complex needs. However, a limited focus on substitution does no justice to person centered care and does not contribute to the right care in the right place by the right person. A vision on how to organize person centered healthcare for older people should be the starting point of care and this vision should be translated into the most optimal skill mix. Changes in skill mix by introducing NPs, PAs or RNs can only be successful if stakeholders are familiar with these functions and legislation, and if functions are embedded in the new model of care including funding.