The World Health Organization (WHO) declared 2020 to be the ‘International Year of the Nurse and Midwife’, in part, to mark the 200th birth anniversary of Florence Nightingale, the 19th century founder of modern nursing (WHO, 2020) who said ‘money would be better spent in maintaining health in communities rather than building hospitals to cure’ (Monteiro, 1985: 185). Since nursing's beginning, investing in community health and primary care have been identified as a means of improving health outcomes and reducing costs of the healthcare system as a whole. Despite this, two centuries later, the Lancet identified the need for ‘more evidence on the roles of nurses in primary care’ (The Lancet, 2020: 1879). To better understand why progress in this knowledge area has been slow, we discuss challenges to advancing the evidence on the roles and contributions of family practice nurses (known as general practice nurses in the UK) (The Queen's Nursing Institute, 2015). We also provide recommendations to facilitate the advancement of nursing research that addresses the provision of primary care. Over the past decade, Canada has made notable investments in primary healthcare research and policy development. Therefore, the landscape of family practice nursing within the Canadian context will be described and referred to throughout this article.
Family practice nursing in Canada
Canada is a federal system wherein ten provinces and three territories have the responsibility to administer and deliver healthcare, including the licensing of health professionals (Deber, 2018). In most provinces/territories, newly educated Registered Nurses (RNs) are required to complete a university baccalaureate degree and pass a national certification examination in order to be licenced in their respective jurisdiction (Lukewich et al, 2018a; National Council of State Boards of Nursing [NCSBN], 2020; Canadian Nurses Association [CNA], 2020b). Certifications in specialty areas of nursing are offered through the Canadian Nurses Association (a national body that represents and promotes the role of nurses within all regulatory designations), but are not mandatory for licensure or employment (CNA, 2020a). Similarly, nursing associations that represent specialty areas of nursing, such as the Canadian Family Practice Nurses Association (CFPNA), may have standards of practice and/or competencies that define the unique contributions of that nursing speciality (CFPNA, 2019; CNA, 2020a; Lukewich et al, 2020). Like the UK, there are no formal or specialized training requirements to work as a family practice nurse. Rather, family practice nurses often seek out their own professional development to adapt and broaden their scope of practice, enhancing their ability to support the healthcare needs of patients and medical governance in their practice.
As in the UK, primary care in Canada is considered the entry-point into the healthcare system, and focuses on delivery of health promotion, disease prevention and management of episodic and chronic conditions across the life span. Primary care is typically carried out in clinic/office settings in the community (CNA, 2005). Before the 2000s, primary care was often equated with family medicine, with family physicians viewed as the central healthcare provider. Primary care reforms in the early 2000s introduced funding models that would allow fee-for-service physicians to build interdisciplinary teams, specifically by either supplementing fee-for-service funding with additional funding or moving physicians to a capitation payment (per capita funding based on number of patients on practice roster or panel) (Hutchinson and Glazier, 2013). While multiple funding models were introduced across Canada, these reforms resulted in an increase in the number of nurses working in primary care practices. Similar reforms promoting interdisciplinary primary care teams have been introduced in other countries, such as Australia and New Zealand (Karnon et al, 2013). As a result of these reforms in Canada, one of the most notable changes is the transition of family practice nursing from an assistant role completing basic, administrative-type tasks under the supervision of a physician (eg answering phones, taking patients to rooms) to a collaborative role delivering a broad range of health services – much like general practice nursing in the UK. Today, family practice nurses are a key member of healthcare teams working alongside physicians, nurse practitioners, social workers, pharmacists, family members and other members of the healthcare team (Lukewich et al, 2018b). However, there remains a lack of clarity about the roles of family practice nurses and the contributions of their care to outcomes, as well as the absence of thoughtful leadership and coordinated efforts to advance the evidence on this fundamental workforce in primary care.
Challenges to advancing evidence on family practice nursing
One of the prevailing challenges associated with advancing evidence is that there is no professional or standardized title to refer to RNs who work in primary care in Canada. The terms ‘family practice nurses’ and ‘primary care nurses’ are often used interchangeably. Moreover, there are three regulated nursing designations who work in primary care, namely nurse practitioners, RNs and licensed practical nurses, each with unique scopes of practice and formalized education/training standards. Nurse practitioners are masters-prepared providers who can autonomously diagnose, prescribe medications and perform a wide range of clinical tasks (Lukewich et al, 2018b). RNs are baccalaureate-prepared, care for patients with complex health needs in unpredictable situations and have a scope of practice that is wider than that of licensed practical nurses, but more limited than that of nurse practitioners. Licensed practical nurses (or registered practical nurses in the province of Ontario) are diploma-prepared providers who care for stable patients in predictable environments and have the most narrow scope of practice of nursing professionals (Lukewich et al, 2018a). Documents in policy, education and practice and research evidence is often limited by a lack of distinction between these three nursing designations and the frequent application of the general term ‘nurse’.
Moreover, in Canada, primary care nursing is encompassed in community health nursing, an umbrella-term that describes community-based nursing that supports the health and well-being of individuals, families, groups, communities, populations and systems. Community health nursing includes community health nurses who work in rural and remote health stations, public health nurses, home health nurses, in addition to family practice nurses, nurse practitioners and licensed practical nurses who work in primary care (Lukewich et al, 2018b; Community Health Nurses of Canada [CHNC], 2019). Similar to this lack of visibility among nursing designations in primary care, workforce documents, such as the Canadian Institutes of Health Information annual workforce reports and provincial/territorial nurse regulator statistics, rarely distinguish family practice nurses from the other types of nurses in community health nursing (ie RN and nurse practitioner data are not separated) (Canadian Institute for Health Information, 2017).
Recommendations to facilitate family practice nursing research
In order to advance the role of family practice nurses in primary care, deliberate actions are needed to generate evidence on their roles and impact and incorporate this evidence into policy and health administration decisions. There are several challenges associated with research on family practice nursing. First, family practice nurses are not prioritised in primary care research. Well-established and influential physician organizations have a strong record of leading primary care research and reforms. While the College of Family Physicians of Canada (CFPC) has taken the lead on developing the new Patient Medical Home concept to guide collaborative primary healthcare in Canada (CFPC, 2019), the integration of nurses and other health professionals has been given less attention. Similarly, the Canadian Institutes of Health Research (CIHR), a national health research funding agency, recently concluded a large-scale funding program, the Community-Based Primary Health Care Innovation teams, to research primary care reforms in Canada (CIHR, 2018). Although a number of these teams examined interdisciplinary care, to our knowledge, none have focused specifically on family practice nurses. Moreover, dedicated funding to support research and research capacity in nursing, such as the Nursing Research Fund, is no longer available in Canada (Canadian Health Services Research Foundation [CHSRF], 2008). This is in contrast to the National Institute of Health (the USA equivalent to the Canadian Institutes of Health Research), which has a subdivision called the National Institute of Nursing Research that provides dedicated grant funding for nursing research (NINR, n.d.).
Second, data supports and research methods that delineate the contribution of family practice nurses need to be developed. Many existing primary care studies rely on administrative data, such as physician fee-for-service billings, and do not capture family practice nurses' unique role contributions to patient care. Other commonly used sources of data in primary care research, such as population-based surveys (eg Canadian Community Health Survey, international Commonwealth Fund Surveys) (The Commonwealth Fund, 2019; Statistics Canada, 2020), seldom include items specifically related to family practice nurses or services attributed solely to them. These surveys also rarely distinguish between the different nursing designations providing care. Moreover, there is an absence of RN-focused studies; most studies conducted in primary care with nurses include nurse practitioners and RNs in the same group. As a result, research focused on family practice nursing relies on high-cost methods, such as chart abstraction, has primarily been exploratory and descriptive in nature and has been conducted in non-randomly selected practices, limiting the generalizability of study findings.
Box 1.Further reading and useful resources
- Canadian Family Practice Nurses Association https://www.cfpna.ca/
- National Competencies for Registered Nurses in Primary Care: A Delphi Study. 2020; 42(12): 1078–1087. https://doi.org/10.1177/0193945920935590
Recent advancements in family practice nursing research
Despite these challenges, there have been a number of steps taken to advance research on family practice nursing in Canada. In 2006, the CFPNA was established as a national association to represent family practice nurses. CFPNA promotes family practice nursing as a distinct specialty within community health nursing and the broader nursing discipline, advocates for role integration and advancement, provides networking opportunities, offers a biennial conference and other professional development opportunities, and serves as a contact liaison with other professional associations both within and outside of nursing (CFPNA, 2020). Working with an expert team of researchers, in December 2019, the CFPNA launched a set of national competencies for family practice nurses (CFPNA, 2019; Lukewich et al, 2020). These competencies outline the specific knowledge, skills and expertise expected of family practice nurses and will be used in the update of the Canadian Nurses Association's Community Health Nursing Certification Examination to integrate this specialty area of nursing.
Researchers in Canada who have expertise and experience in this field have also been steadily working to generate evidence on the roles, activities and outcomes related to family practice nursing. For example, they have described the supports needed to promote effective interdisciplinary work in primary care teams (DiCenso et al, 2010; Al Sayah et al, 2014; Oelke, 2014). Researchers have also identified the unique role of family practice nurses across a variety of primary care settings (Todd et al, 2007; Akeroyd et al, 2009; Martin-Misener et al, 2010; Oandasan et al, 2010; Lukewich et al, 2014; Lukewich et al, 2016; Norful et al, 2017; Poitras et al, 2018a; Poitras et al, 2018b) and developed conceptual frameworks that serve as a foundation for delineating nurse outcomes (Martin-Misener et al, 2014; Lukewich et al, 2019). There is also on-going research to identify outcomes and methodological approaches to report on the effectiveness of family practice nurses (Lukewich et al, 2018c). Similarly, research is emerging to develop and adapt existing instruments to capture family practice nursing within the broader context of primary care teams (Braithwaite, 2016; Norful et al, 2018).
Conclusions
In order to further the integration of family practice nurses in primary care in Canada, funding agencies and governments need to invest in and prioritise family practice nursing research. Nursing leaders can advocate for the renewal of dedicated funding sources for nurse-led research, promote the establishment of nursing focused research priorities, such as family practice nursing within larger funding programs focused on primary healthcare, and advocate for gender equality in research funding.
Additionally, nursing and primary care researchers must continue to adopt innovative tools and analytic designs to demonstrate the contribution of family practice nurses to patient outcomes and system efficiencies. Collective leadership between decision-makers, nursing leaders and nursing researchers to adopt nursing focused questions within existing primary care-based surveys, incorporate common templates within electronic medical records that capture the provision of nurse-led care and create a mechanism for the identification of nursing in administrative data sources, are only a few strategies to overcome some of the methodological challenges associated with advancing family practice nursing research. More broadly, building research capacity is fundamental to advancing the evidence on family practice nursing. A recent article published by a research team at Queen's University (Tranmer et al, 2020: 9) stated, ‘research-based graduate programs (ie MSc and PhD) are the platforms for advancing nursing knowledge.’ Despite the increasing number of nursing doctoral programs in Canada, there remains a considerably small number of nursing scientists to obtain funding and lead research. Academic units should support research and scholarship growth and consider harnessing common means used by other departments to support the success of promising researchers, such as teaching release time (Tranmer et al, 2020).
Finally, family practice nurses themselves need to become stronger advocates for their unique contributions to a more effective primary care system. Ultimately, high-quality research will continue to strengthen the evidentiary base from which to educate physicians and other healthcare providers, inform health administrators and policy makers and improve the health and well-being of patients and caregivers.
KEY POINTS:
- Family practice nurses in Canada work alongside physicians, nurse practitioners, and other healthcare providers, and are key members of primary care teams
- Since nursing's beginning, community and primary care have been identified as means of improving health outcomes and reducing costs. Despite this, two centuries later, The Lancet identified the need for ‘more evidence on the roles of nurses in primary care’
- Many challenges exist to advancing evidence in this area, including the absence of standardized terms for this role, a lack of distinction surrounding different regulated nursing designations in primary care, and the need for greater visibility
- Research on family practice nursing needs to be prioritised by different stakeholder groups, such as funding agencies, nursing leaders, nursing researchers, and academic units. A high-quality evidence base will inform policy-makers and providers, as well as improve primary care outcomes
CPD reflective practice:
- What other challenges, not identified in this article, might hinder the advancement of family practice nursing research?
- How might the recent development of national competencies for registered nurses in primary care lend to advancing evidence/research in this area?
- What types of methodological approaches might be the most effective in measuring family practice nursing? Are there any pre-existing frameworks or approaches that could be adapted?
- What additional role can nurse leaders play in promoting and advocating for nurse-led research focused specifically on family practice nursing?
- In what ways can nurses themselves take initiative and advocate for greater visibility regarding their unique contribution to primary care?