Characteristic of the included studies
We screened 18257 records and considered 283 full texts for inclusion in this integrative review. Fifty-six papers met the inclusion criteria (20,21,30–39,22,40–49,23,50–59,24,60–69,25,70–75,26–29), and six papers (30,45,47,49,59,61) coming from three unique studies (Figure 1).
Studies were conducted across thirteen countries: nine studies in Oceania (26,32,35,44,60,66,68–70), one in Asia (36), twenty-one in Europe (20,21,51–54,57,58,62,65,67,73,22,74,29,33,34,41–43,46), twenty-four in North America (23,24,40,45,47–50,55,56,59,61,25,64,71,72,75,27,28,30,31,37–39) and one in Latin America and the Caribbean (63) (Figure 2). Thirty-six studies employed a qualitative design (20,22,38–42,44,46,48,51,52,24,53–59,61,62,64,25,69–71,73,74,26,29,31,32,35,36), fourteen a quantitative design (21,27,60,63,72,75,28,30,34,37,43,45,47,49) and six used a mixed method (23,33,50,65,66,68). Participants included registered nurses, nurse practitioners, general practitioners, health leaders (chairpersons of health boards), managers, nursing leaders, key informants (University employees, Ministry of Health employees, policy makers), health and social care professionals, administrators and patients (Additional file 2).
Nurse’s role and Task
Studies included nurse’s role referred to nurse practitioner working in advanced role (21,23,37–42,44–47,24,48–56,59,26,61–64,66–69,72,74,27,75,28–31,35) and registered nurse working in advanced practice level or with specialist designation (20,22,60,65,70,71,73,25,32,33,36,42,43,57,58). The registered nurse in many studies takes on different titles: "community nurse", "family health nurse", "public health nurse", "mental health nurse", "community matron", "mental health nurse of community "and'' district nurse ". Many studies have described the qualification of the nurse, from the bachelor's degree to the post-graduate qualification (master's degree, doctorate in nursing) (24,25,38–42,44,48,49,51,52,26,53,56,63,64,66–69,72,74,27,75,28–31,35,36). The main tasks carried out by nurse practitioners and registered nurses are illustrated in figure 3. All nurses worked in primary care settings, including general practice, health care centre and rural and remote areas.
Legend: NP-nurse practitioner, RN-registered nurse
FACTORS INFLUENCING IMPLEMENTATION
Concerning this domain of CFIR framework, four main factors emerge from the studies analysis: scope of practice, nursing workload, nursing education, and funding.
Restrictions of nurse scope of practice and autonomy was the most frequently reported barrier to the nurse’s role implementation (21,23,53,55,56,24,28,31,35,44,45,47,48). Arbitrary laws (31), state restriction, hospital regulations (28), and health care professionals’ expectations (35,55) contributed to restricted nurses' independence and the full potential of the role. For instance, regulations require that nurses be supervised by physicians when exercising their prescriptive authority (38–40). Also, physicians advocated the use of a protocol (21) or their supervision (45) using a collaborative practice agreement (23,31).
Studies described excessive caseload numbers and complex cases as a barrier (25,30,32,57,58) inhibiting care provision (33,71). Furthermore, patient care complexity combined with other non-clinical (administrative-bureaucratic) functions further increased the nursing workload (57).
Education was identified as a barrier to role development in thirteen studies. Nurses expressed their concern about educational programs: the adequacy of training (41,56,63) and nurses' ability to meet the competencies required (25,45,62,65,70). Several studies described concerns about training opportunities and ongoing education (50), such as lack of information regarding course availability (26), difficulty taking time off work (26,54), geographical barriers and the need to travel (32), and lack of funding (26,51).
Funding to sustain the nurse position was described across eleven studies (21,23,66,36,39,42–44,50,52,54).
Facilitators described during implementation were adaptability of the nurse’s role to the existing context (53) and trialability (46). Education and training were also reported as contributing factors facilitating nurse’s role implementation. Educational resources (e.g., master’s degree program) have been put in place to improve clinical skills and further retraining options, especially in the setting of primary care (26,29,36,46). Moreover, additional experiences such as residency or fellowship programs after graduation supported role transition in primary care (30). One study reported that motivating nurses to study was also an important factor in achieving an advanced practice level (62). Another facilitator was nurses satisfied with their full scope of practice (24–29). Working in autonomy was described by nurses, also related to their work settings (27,30–33).
Studies have referred to the value of performing tasks and procedures previously assigned to physicians (29,35,36) and the nurses' role as links between the patient and other healthcare professionals (29,34).
Patients factors were reported as a key barrier across studies. From a patient perspective, one of the main factors that negatively impacted the acceptance of the nurse’s role was the lack of knowledge and understanding of the role (42,48,56,68,69,72). Other factors were negative patients’ prior experience (68), patients' preference, and medical condition (68,69).
Five studies considered the external policies. Studies highlighted prescribing restriction (38–40) and remuneration policies (46,48).
Facilitators identified were related to the patient's factors. Patients perceive care delivered by nurses as satisfactory (21,41,50,65,67) and having a number of advantages. Patients referred to nurses' adapted solution and proposal to meet their needs in their environment (25,35,36,57), listened more carefully to them and had time to their concerns (46,50,62,68,69). They also described how access to care was quicker and easier (34,50). Several studies emphasized the acceptance of the nurse’s role from patients (23,36,48,63,66,68) due to knowledge and role recognition (59,61) and nurse-community connection (50).
Barriers identified across studies were linked to organizational factors.
Recruitment and retention of nurses were described as a barrier across studies. Studies described difficulty in recruiting qualified nurses (29,62,65) and retaining them (20). Organizational factors such as lack of long-term human resource planning (52), uncertainty employment (20,26,29,55) and lack of career opportunities (62) contribute negatively to role implementation. Consequently, some studies reported nurses' high staff turnover (20) and intention to leave among newly hired nurses (20,72).
Some studies referred to the organization's culture, hierarchical structure (29,36,48), and difficulties in adopting a flexible approach to service delivery (73) as the main barrier to nurse’s role implementation. The nursing practice was overshadowed by the more dominant medical model (51,58,61,63), giving priority to medical solutions to health problems rather than patient wellness-centred care (35,43).
The nature and quality of communications. The environmental factors as a barrier to access of information and support in a rural area, such as isolation (32,33), poor internet connection, and lack of electricity to run equipment (64), are described. Also, the lack of sharing information between staff administrators and health professionals had negative consequences (38,64,72). Some studies reported that a lack of shared understanding of patients’ needs to be impacted by the team's ability to provide care (57,70,71).
Unfavourable implementation climate was the most frequently reported barrier to the implementation of the nurse’s role. The professional relationship between health workers (22,41,42,56) and other inter-professional workers (42,56) associated with the lack of regulation of the role of the nurse (22,41,42) hinders the implementation of the nursing role (42). In this regard, in fact, the lack of professional collaboration is described as a further obstacle (24,29,39,41,42,48,67,74). Nurses stressed that counsellors and secondary care providers either did not accept their referrals (24,39,41,42,48,67,74) or refuse share information (41). Furthermore, the lack of support from doctors, managers, and administrative staff have been reported as a professional collaboration problem (26,30,33,43,44,64,72). From the nurses' point of view, they did not receive the same level of support as doctors (38,40) or the same respect as their peers (30,72). Consequently, nurses have raised the invisibility of their role in the community (22,38,72). Professional isolation was reported as an additional barrier in seven studies (24,30,32,33,50,51,64). Isolation has been described as the lack of nurses' integration into existing (51) or other health professionals in the same workplace(32). The studies also show the non-sharing of objectives between the organization and the nurses, which are not communicated clearly (30,32). Furthermore, the contractual context influenced the climate. Studies have reported the lack of a reward system (20,30) and the effects of a lack of a reward and incentive system on nurse morale (30,55).
The lack of resources has been reported as a barrier to implementing the role of the nurse in the studies (20,29,34,36,38,39,56,57,70).
Facilitators mainly referred to challenges for workforce development, nature, and quality of communication and implementation climate.
Several studies faced workforce challenges providing opportunities to nurse’s role development in primary care, including changing patient case-mix (20,42) and shortage of primary care providers (26,50).
Nurses reported that communication strategies and technology helped them to establish a relationship between primary and secondary care. On-call systems to connect health care professionals, telemedicine equipment, and team sharing of patient information, including case-reviews, were crucial to the continuity of care (59,64). Moreover, studies highlighted that regular communication, preferably using the same electronic patient records, was deemed important in the collaboration and coordination between health care professionals (34,42,50,56).
Professional trust, mutual respect and a close doctor-nurse relationship were seen as an enabler of role implementation and collaborative work by nurses (31,32,42,46,50,51,56,61). In addition, inter-professional relationship and team working played a key part in facilitating development of the nurse’s role (25,27,35,39,41,43,48,58). Several studies reported that nurse’s role implementation was positively influenced by support from physicians, pharmacists, managers and colleagues (23,24,26,29,31,38,48,64,71). Also mentoring, mainly from doctors and colleagues, was central to providing support during transition into the role (26,30,39,41,44,64).
Characteristics of individuals
Barriers identified across studies were linked to team acceptance and nurse belief in their own capabilities.
Studies described physician’s resistance (23,42,56) related to lack of role clarity and concern about nurses practice (24,25,47–51,66,72,26,30,36,38,43–46). There was consensus among nurses, administrative staff and team members that professionals were not aware of the scope of nurse practice (21,28–30,39,45,52,53,66). In addition, physicians expressed lack of trust in nurses’ skills and knowledge (29,36,45,47,51,54,66,72). From a physician perspective there were concerns about doctor’s workload, nurse-doctor competition, fragmentation and duplication of services (51,52,66),
particularly when roles were perceived to overlap.
The last barrier was nurse self-doubt (44,47). In one study, nurses reported that they felt uncertain when colleagues did not utilize them as a resource (61).
The nurse’s role clarity and understanding were identified as important in gaining doctor acceptance (61). The nurse’s role was understood more easily once professionals had previous nurse-doctor collaboration experiences (23,26,41,52). From a physician's perspective, there were some motivations to employ nurses in primary care, including complementary relationships (52,74) and enhance quality and delivery of healthcare (28,42,66,67). Many physicians were satisfied with nurse collaboration (31,34,45,50). Studies reported that a nurse's role in primary settings reduce doctors’ workload (21,42,46,62) and allow them to focus on other tasks (e.g., coordinating complex cases (42,45)). From nurses perspective, they believed to improve quality of care and increase patient safety (31,33,35,46,48,52,59,62). This was linked to consider their work “valued” “worthy”. Nurses cited their satisfaction in providing more than patient care compared to other health professionals (25,41). Moreover, studies identified that nurses were confident with their skills and knowledge (49) and aware of their own limits (31,46).
Barriers were related to the lack of planning to employ nurse’s roles, including how new services were adapted to meet changing needs (33,73), absence of clear leadership (71), top-down approach (56), and evaluation. Several studies described difficulties in identifying outcomes to measure and tools to track nurse’s contributions (25,59).
Few studies highlighted the importance of developing an implementation plan with a focus on workforce integration. Review of the existing nursing service, definition of roles and functions, and team involvement were useful considerations that guided planning (43,56,65). Factors associated with better role development and integration were nurses’ involvement in developing their role (e.g., drafting job description) (24,60), support from management and strategic alliance with health authorities (24,59,61). Universities were identified as external agents to the organization who formally influenced role development (63). The last facilitator was linked to the evaluation process. Nurses cited the need to evaluate their effectiveness (25) and identified research and audit mechanisms as resources to subject their practice to scrutiny (41).