title: Outcomes associated with nurse practitioners in collaborative practice with general practitioners in rural settings in Canada: a mixed methods study.
abstract: BACKGROUND
  The formalized nurse practitioner (NP) role in British Columbia is relatively new with most roles implemented in primary care. The majority of primary care is delivered by physicians using the fee-for-service model. There is a shortage of general practitioners associated with the difficulties of recruitment and retention, particularly in rural and remote locations. The uptake of the primary care NP role has been slow due to challenges in understanding the extent of its contributions. This study aims to identify the outcomes associated with the NP role in collaborative primary care practice.
  
  
  METHODS
  Three case studies where NPs were embedded into rural fee-for-service practices were undertaken to determine the outcomes at the practitioner, practice, community, and health services levels. Interviews, documents, and before and after data, were analyzed to identify changes in practise, access, and acute care service utilization.
  
  
  RESULTS
  The results showed that NPs affected how care was delivered, particularly through the additional time afforded each patient visit, development of a team approach with interprofessional collaboration, and a change in style of practise from solo to group practise, which resulted in improved physician job satisfaction. Patient access to the practice improved with increased availability of appointments and practice staff experienced improved workplace relationships and satisfaction. At the community level, access to primary care improved for harder-to-serve populations and new linkages developed between the practice and their community. Acute care services experienced a statistically significant decrease in emergency use and admissions to hospital (P = 0.000). The presence of the NP improved their physician colleagues' desire to remain in their current work environment.
  
  
  CONCLUSIONS
  This study identified the diversity of needs that can be addressed by the NP role. Namely, the importance of time to enhance patient care and its associated benefits, especially in the fee-for-service model; the value of the NP's role in the community; the acceptance of the clinical competence of NPs by their physician colleagues; the outcomes generated at the practice level in terms of organizational effectiveness and service provision; and substantiated the impact of the role in improving primary care access and reducing acute care utilization.
authors.forename: Alison
authors.initials: A
authors.lastname: Roots
authors.affiliation: School of Nursing, University of Victoria, HSD A402, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada. marjorie@uvic.ca.
authors.forename: Marjorie
authors.initials: M
authors.lastname: MacDonald
mesh_terms: D001955:British Columbia; D003299:Cooperative Behavior; D003695:Delivery of Health Care / Q000458:organization & administration*; D005069:Evaluation Studies as Topic; D005194:Family Practice / Q000458:organization & administration*; D058005:General Practitioners / Q000458:organization & administration*; D006297:Health Services Accessibility; D006801:Humans; D009722:Nurse Practitioners / Q000458:organization & administration*; D010348:Patient Care Team / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration / Q000706:statistics & numerical data*; D012424:Rural Population