title: Experiences of nurse practitioners and medical practitioners working in collaborative practice models in primary healthcare in Australia - a multiple case study using mixed methods.
abstract: In 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models.
  
  
  
  A multiple case study of five primary healthcare sites was undertaken, applying mixed methods research. Six nurse practitioners, 13 medical practitioners and three practice managers participated in the study. Data were collected through direct observations, documents and semi-structured interviews as well as questionnaires including validated scales to measure the level of collaboration, satisfaction with collaboration and beliefs in the benefits of collaboration. Thematic analysis was undertaken for qualitative data from interviews, observations and documents, followed by deductive analysis whereby thematic categories were compared to two theoretical models of collaboration. Questionnaire responses were summarised using descriptive statistics.
  
  
  
  Using the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners' and medical practitioners' adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals.
  
  
  
  Findings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions. However, strategic support from healthcare reform decision-makers is needed to strengthen nurse practitioner positions and ensure the sustainability of collaborative practice models in primary healthcare.
authors.affiliation: Faculty of Health Sciences, School of Nursing Midwifery and Paramedicine, Australian Catholic University, Melbourne, Australia. verena.schadewaldt@myacu.edu.au.
authors.forename: Verena
authors.identifier: 0000-0003-3256-6458
authors.initials: V
authors.lastname: Schadewaldt
authors.affiliation: Nursing Research Institute, St Vincent's Health Australia/Australian Catholic University, Sydney, Australia.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: McInnes
authors.affiliation: School of Health Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia.|School of Public Health, University of Adelaide, Adelaide, Australia.
authors.forename: Janet E
authors.initials: JE
authors.lastname: Hiller
authors.affiliation: Faculty of Health Sciences, School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Canberra, Australia.|James Cook University, Townsville, Australia.
authors.forename: Anne
authors.initials: A
authors.lastname: Gardner
mesh_terms: D001315:Australia; D003299:Cooperative Behavior; D005260:Female; D006291:Health Policy; D006801:Humans; D007349:Insurance, Health, Reimbursement; D007400:Interprofessional Relations; D016365:Liability, Legal; D008297:Male; D017146:Models, Organizational; D009722:Nurse Practitioners / Q000191:economics / Q000458:organization & administration*; D019982:Organizational Case Studies; D010819:Physician's Role; D010820:Physicians / Q000458:organization & administration*; D020399:Practice Management; D011320:Primary Health Care / Q000458:organization & administration*
keywords: Collaboration; Health policy; Nurse practitioners; Physician-nurse-relation; Primary health care