Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: a qualitative study.
BACKGROUND
Due to the increasing demand on primary care, it is not only debated whether there are enough general practitioners (GPs) to comply with these demands but also whether specific tasks can be performed by other care providers. Although changing the workforce skill mix care by employing Physician Assistants (PAs) and Nurse Practitioners (NPs) has proven to be both effective and safe, the implementation of those professionals differs widely between and within countries. To support policy making regarding PAs/NPs in primary care, the aim of this study is to provide insight into factors influencing the decision of GPs and managers to train and employ a PA/NP within their organisation.


METHODS
A qualitative study was conducted in 2014 in which 7 managers of out-of-hours primary care services and 32 GPs who owned a general practice were interviewed. Three main topic areas were covered in the interviews: the decision-making process in the organisation, considerations and arguments to train and employ a PA/NP, and the tasks and responsibilities of a PA/NP.


RESULTS
Employment of PAs/NPs in out-of-hours services was intended to substitute care for minor ailments in order to decrease GPs' caseload or to increase service capacity. Mangers formulated long-term planning and role definitions when changing workforce skill mix. Lastly, out-of-hours services experienced difficulties with creating team support among their members regarding the employment of PAs/NPs. In general practices during office hours, GPs indented both substitution and supplementation for minor ailments and/or target populations through changing the skill mix. Supplementation was aimed at improving quality of care and extending the range of services to patients. The decision-making in general practices was accompanied with little planning and role definition. The willingness to employ PAs/NPs was highly influenced by an employees' motivation to start the master's programme and GPs' prior experience with PAs/NPs. Knowledge about the PA/NP profession and legislations was often lacking.


CONCLUSIONS
Role standardisations, long-term political planning and support from professional associations are needed to support policy makers in implementing skill mix in primary care.
Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands. Mieke.vanderbiezen@radboudumc.nl.
Mieke
http://orcid.org/0000-0001-6682-2558
M
van der Biezen
Foundation for Development of Quality Care in General Practice, Tilburgseweg-West 100, Eindhoven, 5652 NP, The Netherlands.
Emmy
E
Derckx
Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands.|Department of General Practice and Health Services Research, Heidelberg University, INF- Marsilius Arkaden, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany.
Michel
M
Wensing
Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands.|HAN University of Applied Sciences, Faculty of Health and Social Studies, P.O. Box 6960, Nijmegen, 6503 GL, The Netherlands.
Miranda
M
Laurant
D058005:General Practitioners / Q000458:organization & administration*; D006301:Health Services Needs and Demand; D006801:Humans; D009426:Netherlands; D009722:Nurse Practitioners / Q000193:education*; D010823:Physician Assistants / Q000193:education*; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research
General practitioner; Implementation; Nurse practitioner; Physician assistant; Primary care; Skill mix; Substitution; Supplementation