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The data analyzed during the current study will be available from the corresponding author on reasonable request.
Before the COVID-19 pandemic, many long-term care (LTC) homes experienced difficulties in providing residents with access to primary care, typically delivered by community-based family physicians or nurse practitioners (NPs). During the pandemic, legislative changes in Ontario, Canada enabled NPs to act in the role of Medical Directors thereby empowering NPs to work to their full scope of practice. Emerging from this new context, it remains unclear how NPs and physicians will best work together as primary care providers. NP/physician collaborative models appear key to achieving optimal resident outcomes. This scoping review aims to map available evidence on existing collaborative models of care between NPs and physicians within LTC homes.
The review will be guided by the research question, “What are the structures, processes and outcomes of collaborative models of care involving NPs and Physicians in LTC homes?” This scoping review will be conducted according to the methods framework for scoping reviews outlined by Arksey and O’Malley and refined by Levac et al., Colquhoun et al., and Daudt et al., as well as the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Statement. Electronic databases (MEDLINE, Embase + Embase Classic, APA PsycInfo, Cochrane Central Register of Controlled Trials, AMED, CINAHL, Ageline, and Scopus), grey literature, and reference lists of included articles will be searched. English language studies that describe NP and physician collaborative models within the LTC setting will be included.
This scoping review will consolidate what is known about existing NP/physician collaborative models of care in LTC homes. Results will be used to inform the development of a collaborative practice framework for long-term care clinical leadership.
The online version contains supplementary material available at 10.1186/s12877-023-03798-1.
Keywords: Nurse practitioner, Physician, Long-term care, Collaboration, Models of care, Knowledge synthesis, Scoping review
As the older adult population grows, worldwide the number of older adults who will require care in long-term care (LTC) homes will also increase. LTC homes provide 24/7 health and personal care support to residents with multiple health and social complexities including neurological, circulation, and musculoskeletal diseases, dementia, acute medical conditions, and stroke [1]. The pandemic impacted the LTC sector significantly, including the disproportionately high rate of COVID-19 deaths amongst LTC residents, the effects of social isolation on residents’ wellbeing, challenges with infection prevention and control practices, and staffing shortages due to limiting staff to single workplaces [2, 3]. This unprecedented situation illuminated long-standing deficiencies in LTC such as timely access to primary care for this complex, mainly older adult population [4]. The current model does not meet the needs of residents experiencing acute and chronic health issues, as limited accessibility to primary care providers is internationally cited as a common challenge [5–8].
There has been a steady increase in the number of NPs employed within the LTC sector over the last 20 years [9]. NPs are advanced practice nurses requiring graduate education for entry; their scope of practice include diagnosis, prescribing medications, and performing medical procedures [10]. Quality of care provided by NPs in LTC homes is comparable to that of physicians and has been shown to improve resident outcomes and reduce hospital transfers [11–13]. Additionally, NPs bring a breadth of advanced nursing skills to resident care, resulting in improved communication with family and care-partners, staff capacity-building, and strong clinical leadership and care coordination [11, 14].
The COVID-19 pandemic made in-person access to physicians increasingly difficult, as some physicians were recommended to adopt a “virtual-first” approach [15]. This experience provided an opportunity to examine the effects of optimizing the NP role and empowered NPs to work to their full scope of practice in a leadership role in LTC homes [16]. Several studies have reported positive outcomes from NP care during the pandemic, including successful COVID-19 recoveries, effective pain and symptom management, and ensuring dignified deaths for residents, demonstrating how NPs can provide urgently needed support to LTC residents [17, 18].
Similar to their physician colleagues, consultation and collaboration with other physicians and specialists is an essential component of the NP provider role; NPs do not function in isolation [3, 19, 20]. The intrinsic collaboration between NP and physician roles has resulted in a higher quality of resident care, decreased hospitalization rates, and the creation of an improved working environment for direct care providers [20]. Studies have investigated the abstract qualities inherent to the collaboration process. For optimal resident care, the NP-physician collaborative relationship requires commitment and time for development, where each care provider is able to employ qualities unique to their role [20]. When the collaborative process remains informal, it can result in an absence of funding to support collaborative practice models, inadequate educational preparation, and a lack of clarity regarding role definitions and the facilitators and barriers in implementing this process. The resources and capacities required to ensure successful collaboration have not yet been clearly elucidated. With some understanding of the underlying principles required for success, several collaborative models for the LTC context have been developed, such as the Evercare model and the Missouri Quality Initiative [21]. However, a comprehensive review and comparison of existing models has not been reported. Further, frameworks evaluating these models to inform best practices do not exist. While it is clear that residents, their care partners, and LTC care providers have benefitted from collaborative practices, a review of the existing models of care involving NP and physician collaboration is required to identify current gaps in the literature. A description of the structures, processes, and outcomes of models of NP-physician collaborative care will inform the development of a collaborative practice framework for LTC clinical leadership.
This scoping review will examine and map evidence for collaborative models of care between NPs and physicians in LTC homes.
This scoping review will be conducted according to the methods framework for scoping reviews outlined by Arksey and O’Malley [22] and refined by Levac et al. [23], Colquhoun et al. [24], and Daudt et al. [25]. This framework is appropriate as the nature of the research question is exploratory, with the intention of mapping key concepts, evidence gaps, and implications. This scoping review will also be conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Statement [26].
What are the structures, processes, and outcomes of collaborative models of care involving NPs and Physicians in LTC homes?