Contandriopoulos et al.

BMC Health Services Research (2015) 15:78

DOI 10.1186/s12913-015-0731-5

RESEARCH ARTICLE Open Access

A process-based framework to guide nurse

practitioners integration into primary healthcare
teams: results from a logic analysis
Damien Contandriopoulos1, Astrid Brousselle2, Carl-Ardy Dubois1, Mélanie Perroux1*, Marie-Dominique Beaulieu3,
Isabelle Brault1, Kelley Kilpatrick1, Danielle D’Amour1 and Esther Sansgter-Gormley4

Abstract
Background: Integrating Nurse Practitioners into primary care teams is a process that involves significant
challenges. To be successful, nurse practitioner integration into primary care teams requires, among other things, a
redefinition of professional boundaries, in particular those of medicine and nursing, a coherent model of inter- and
intra- professional collaboration, and team-based work processes that make the best use of the subsidiarity principle.
There have been numerous studies on nurse practitioner integration, and the literature provides a comprehensive list
of barriers to, and facilitators of, integration. However, this literature is much less prolific in discussing the operational
level implications of those barriers and facilitators and in offering practical recommendations.
Methods: In the context of a large-scale research project on the introduction of nurse practitioners in Quebec (Canada)
we relied on a logic-analysis approach based, on the one hand on a realist review of the literature and, on the other
hand, on qualitative case-studies in 6 primary healthcare teams in rural and urban area of Quebec.
Results: Five core themes that need to be taken into account when integrating nurse practitioners into primary care
teams were identified. Those themes are: planning, role definition, practice model, collaboration, and team support.
The present paper has two objectives: to present the methods used to develop the themes, and to discuss an
integrative model of nurse practitioner integration support centered around these themes.
Conclusion: It concludes with a discussion of how this framework contributes to existing knowledge and some ideas
for future avenues of study.
Keywords: Collaboration, Delivery of health care, Integrating process, Logic evaluation, Nurse practitioners, Practice
model, Primary health care, Role definition, Team support

Background primary care over specialized hospital-based care and a

Major challenges for developed countries’ health systems greater role for nurses and other non-physician profes-
in the next decades include pervasive health inequalities; sionals in primary care teams are of particular importance
limitations in health services accessibility, care compre- to simultaneously improve efficiency and accessibility
hensiveness, and continuity, especially in primary care; [8-12]. In this general context, the current article is fo-
demographic shifts; technological developments; and fis- cused on one specific objective, which is to provide
cal constraints [1-7]. The pressing nature of these chal- evidence-based, practical advice to support the effective
lenges should not, however, obscure the fact that, at the integration of primary care nurse practitioners (NP) into
programmatic level, there is strong evidence on effective care delivery systems. We have pursued this objective
intervention paths. Among those, increased reliance on using an original research strategy combining results from
logic and implementation analyses [13].
* Correspondence: melanie.perroux@umontreal.ca
There is a large body of evidence suggesting that in-
1
Faculty of Nursing, University of Montreal, C.P. 6128 succ. Centre-Ville, Montréal, creased reliance on NPs has the potential to improve
Québec H3C 3J7, Canada accessibility of primary care services while controlling
Full list of author information is available at the end of the article

© 2015 Contandriopoulos et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Contandriopoulos et al. BMC Health Services Research (2015) 15:78 Page 2 of 11

expenditures [8,14-20]. However, integrating NPs into which train medical residents in family medicine; and
primary care teams has proven challenging in practice family medicine groups (GMFs). GMFs are private med-
[8,19,21,22]. There is abundant literature analyzing the ical clinics where public hospitals cover the salary and
underlying causes of those challenges, but operational benefits of nursing staff (both RNs and NPs) in exchange
literature on the solutions to overcome them is consider- for clinics providing extended opening hours and in-
ably more limited. creased care continuity.

Context Methods
In 2010, Quebec’s government announced it would sup- In this paper we report on finding obtained from an ori-
port NP practice and fund the integration of 500 pri- ginal research strategy combining results from logic and
mary care NPs over the next decade. The main objective implementation analyses [13]. The logic data were de-
put forward was to improve accessibility [23]. This decision rived from published literature and implementation data
was the starting point for a large-scale research project fo- were derived from case studies conducted by the re-
cused on supporting primary care teams that integrated search team in Quebec (Canada). The recommendations
NPs as they went through the process of rethinking care presented here are based on a combined logic and im-
delivery models, processes, and roles. plementation analysis. Both evaluation approaches aim
The majority of healthcare services in Quebec are to assess the potential value of a given intervention, but
funded through a Beveridgean public insurance system. each has a different focus. On one hand, “Logic analysis
Essential Care, whether offered in publicly owned insti- is an evaluation that allows us to test the plausibility of
tutions or in private medical clinics, is usually free at a program’s theory using available scientific knowledge—
the point of service. The Ministry of Health and Social either scientific evidence or expert knowledge” [25]. Im-
Services (MSSS) funds services through public taxation plementation analysis, on the other hand, relies mostly
and has a direct responsibility in the overall governance on empirical observations to identify factors that actually
of the healthcare delivery system. When the government enhance or impede the implementation of the interven-
decided to add 500 NPs to the healthcare system, the tion or the production of its effects [26]. Combining
MSSS had a central role in drafting, implementing, and these two evaluation approaches allowed us to build a
supervising a “deployment plan” that would reach the comprehensive understanding of factors and contextual
broader policy objective of improving accessibility to pri- characteristics potentially influencing NP implementa-
mary care services. For example, students in NP master’s tion, which in turn made it possible to provide evidence-
programs are offered a generous bursary package by the based advice to optimize implementation and maximize
MSSS to support their studies and professional travel ex- NPs’ effectiveness. Furthermore, implementation analysis
penses in exchange for a commitment to work at least was helpful in identifying which determinants of imple-
three years in a location approved by the Ministry. mentation effectiveness were more important than others
In Quebec, primary care NPs are registered nurses who as deployment of NPs was being planned and phased-in.
have successfully completed a master’s-level, university- At the operational level, the research team first conducted
based, NP program. Upon employment they are required a logic analysis of Quebec’s NP deployment plan and of
to work in collaboration with at least one physician, with NP practice patterns, mostly based on a realist review of
whom they sign a “partnership agreement”. NPs have the the literature and on expert advice. We then conducted an
legal and regulatory authority, in collaboration with a implementation analysis using a case study research de-
physician, to assess, diagnose and treat patients for acute sign (n = 6 cases) in three health regions of Quebec. The
common illnesses and injuries, manage chronic diseases, evidence derived from both the logic and implementation
provide pregnancy care up to 32 weeks of gestation, and analyses was then combined into practical advice pertain-
engage in health and wellness promotion. They order and ing to five core themes that structure the NP integration
interpret diagnostic tests, prescribe drugs (based on a for- process. Figure 1 below represents phases of the research
mulary) and perform specific procedures within their leg- process schematically.
islated scope of practice [24]. Upon completion of their
educational programs, and prior to registration, NP gradu- Logic analysis
ates are accorded the right to practice under medical First we began with a logic analysis which is a three-step ap-
supervision as “candidates” and have two years to pass the proach [25,27] consisting of building a logic model, devel-
certification exam jointly drafted by the nursing and med- oping the conceptual framework, and evaluating program
ical professional boards. theory. To build the logic model, we consulted available
NPs are expected to provide primary care in public or- documents produced by the Ministry, regional boards, pro-
ganizations providing primary care and social services fessional organizations and experts from the MSSS who
(CLSCs); hospital-based family medicine units (UMFs), were directly involved in the NP implementation plan in
Contandriopoulos et al. BMC Health Services Research (2015) 15:78 Page 3 of 11

Figure 1 Research process.

Quebec. We then reviewed the available published evi- editorial type material with no discernable evidence base,
dence through a method inspired by the realist review ap- reviewers also had the option of removing the article
proach [28-31]. Using the logic model of the MSSS’ NP from the database (score of 0). Only documents with a
implementation plan we established as a starting point, we combined score (relevance and validity) of 4 or higher,
iteratively built, from the literature, a conceptual model of 43 articles were retained as primary sources for analysis.
the best practices and supporting conditions for NP inte- At the time of conducting the review, the APN Litera-
gration into primary care teams. ture Database was limited to literature published between
Given the complexity of NP implementation, purely 2000 and 2009. To include publications after 2009, we
keyword-based search syntaxes were unlikely to provide reproduced the search syntax used to compile the APN
satisfactory results [28,31-34]. As a starting point, we chose Literature Database to identify articles published between
instead to conduct a manual search in the Advanced- 2010 and 2012. We applied the same sorting methods to
Practice Nursing (APN) Literature Database [35], in which this second corpus of articles and retained 53 articles for
all the scientific literature published on advanced practice full textual analysis. Of these, 15 were added to the 43
nursing between 2000 and 2009 had been systematically documents selected in the first phase. Altogether 58 docu-
compiled. We extracted the 3,674 references identified as ments were selected for in-depth analysis.
relevant to advanced-practice nursing in the APN database The documents, both peer-reviewed articles and research
and manually assessed their relevance for the purpose of reports, were then iteratively read, often several times, and
our study based on titles and abstracts. A total of 159 arti- analyzed to build a preliminary conceptual model according
cles were retained for further review. To be retained, docu- to the realist review approach [28,31,34,36]. The model
ments had to address NP implementation in primary was focused on structuring available evidence to support
healthcare teams, practice models, or integration processes. NP integration. From the literature, five major themes
Two members of the research team independently assessed were inductively identified as the conceptual model’s core
the retained articles for relevance. elements: 1) planning the integration, 2) role definition, 3)
Next documents were summarized using an abstrac- patient management, 4) collaboration, and 5) support to
tion tool and given a relevance score and a scientific val- the team. For each theme, we produced a first summary
idity score, both ranging from 1 to 3. The relevance of the information collected in the literature review. At
score ranged from 1 for documents offering a minor or this point, the interdisciplinary expertise of the research
marginal contribution to the understanding of the phe- team (which included registered nurses, NPs, physi-
nomena studied to 3 for documents providing detailed cians, and experts in organizational theory and health
insights directly focused on those phenomena. The val- administration) was applied to identify new documents
idity score ranged from 1 for an editorial opinion or sig- on an ad hoc basis. The draft summary for each theme
nificantly flawed research to 3 for an article presenting was then used as the analytical framework for the im-
results from a robust and well-conducted method. For plementation analysis.
Contandriopoulos et al. BMC Health Services Research (2015) 15:78 Page 4 of 11

Implementation analysis to incorporate empirical knowledge derived from the case

The second data source, upon which the advice provided studies. Ultimately, the evidence from the logic analysis
here is based, comes from an implementation analysis and the implementation analysis was integrated into one
using six qualitative case studies. Each case was defined single theme-based narrative, and the specific expertise of
as a clinical team into which one or more NPs had been each team member was mobilized in that process. The ob-
integrated in Quebec. We identified potential cases in jectives of using two different approaches to analysis were:
collaboration with MSSS and with the Regional Health 1) to be able to cross-validate and compare the evidence
and Social Services Agencies (ASSS) involved. Cases were derived from the literature to practices identified in our
selected based on two criteria. First, cases had to involve case studies and; 2) to assess the applicability and use-
teams whose NP integration was seen as successful by fulness of the literature-based advice in real-world con-
the MSSS or the ASSS, in order to identify and analyze texts and determine which of the factors identified in
successful integration models. Second, to improve the the literature were most important in supporting the imple-
external validity of the findings [37-39] we deliberately mentation of primary care NPs; and 3) to better appraise
sought maximum variation in terms of environment implementation dynamics and understand how factors are
(rural, suburban, urban), organizational setting (privately intertwined during the implementation process.
owned clinics, community-based publicly owned clinics, Three important points should be made regarding the
and hospital-based primary care teams), and stage of NP final integration of the material. First, our focus was
integration. Table 1 below provides additional information to offer practical advice. Much of the literature is struc-
on the characteristics of each case study site. tured around identifying barriers and facilitators [8,40-44]
Findings from the case studies are based on 34 semi- but offers little to support teams’ improvement. It might
structured interviews conducted with members of the also be worth stressing here that integration is a process,
clinical teams and other key actors as well as on analysis and thus a dynamic phenomenon, whereas a list of bar-
of available documentation. In each setting, researchers riers and facilitators is a very static analytical frame-
skilled in interviewing conducted interviews with the work. Second, we aimed for a single set of theme-based
main stakeholders involved in the NP integration into recommendations for all team members, whether NPs,
the primary care team, such as the NP, the physician RNs, MDs, administrators, or support staff. What is
partner, and the Chief Nursing Officer of the local hos- your third point?
pital, and most of the nurses and the administrative staff
of each of the primary care teams. All informants gave Results
informed consent, and best practices for the ethical As described in the Methodology section above, unless
conduct of research were followed. The project was ap- otherwise specified, the findings provided here come
proved and supervised by the research ethics committees from the integration of evidence from the logic analysis
of all institutions involved. Each of the six cases was and implementation analysis components of the study
under the responsibility of one team member, who pro- and are structured around the five themes identified.
duced a narrative case summary per case, structured
around the five themes identified in the literature review. Planning to integrate an NP: an opportunity for clinical
Those summaries were discussed in research team meet- teams
ings, and cross-case insights were identified. In a second The first element in successfully integrating an NP into
step, we produced five narrative theme-based cross- a primary care team is advance planning. Although this
analyses of the cases to synthesize the contribution of may seem obvious, our data suggest inadequate planning
empirical case-study evidence according to each of the is all too common [21,22,45]. The first step in the plan-
five previously identified themes. ning process is to reflect on the intended practice model
in discussions among all the different actors involved
Combined analysis (physicians, nurses, managers, and other members of
After completing the implementation analysis, we revised the team). A comprehensive plan developed collectively
the summaries constructed during the logic analysis phase by all team members is a key factor in implementing

Table 1 Location and team composition for each case study site
Case 1 Case 2 Case 3 Case 4 Case 5 Case 6
Location Urban Rural Rural Rural Urban Urban
Type and 2 NPs, 67 MDs, RNs, 1 NP, 15 MDs, 2 2 NPs, 2 MDs, 4 RNs, 2 NPs, 2 MDs, 1 NP, MDs and 1 NP, 3 MDs, RNs, social
number of nursing assistant, social RNs, 1 nursing 2 nursing assistants, 1 RN, 1 nursing residents, RN, worker, occupational
professionals worker, psychologist, assistant, 1 3 social workers, 1 assistant nursing assistant, therapist, physiotherapy
within the team nutritionist, kinesiologist nutritionist occupational therapist pharmacist technicians, pharmacists
Contandriopoulos et al. BMC Health Services Research (2015) 15:78 Page 5 of 11

an effective and satisfactory practice model. In practical team members share the desire to develop a collaborative
terms, it is thus important to take into account the time practice, misunderstandings and conflicts around roles
and energy this process will require from the clinical are frequent and significant barriers to NP integration
team and the consequent timeline [46]. and practice. When the NP’s role set is well-defined,
Our analysis suggests there are often preconceived no- there is consensus about how patient management re-
tions about the nature of NPs’ training and practice [47]. sponsibilities are distributed, each team member’s skills,
It is also important not to underestimate the distance and scope of practice, as well as differences and similar-
between making administrative and regulatory informa- ities of roles [63].
tion about NPs’ role and scope of practice available and Overall, there is solid evidence to support the need
ensuring that all team members are aware of this infor- for team consensus on role definition. However, evi-
mation. Preparation is a matter not only of making in- dence to support more instrumental recommendations
formation available but also of transforming available on how to create such a consensus inside interdisciplin-
information into practical knowledge [48-50]. ary care teams is much weaker. The optimal level of
More broadly, the arrival of an NP should be seen as role formalization, in particular, is open to debate. The
an opportunity to reflect on the current practice model’s level of formalization describes the extent to which
strengths and weaknesses and to establish a shared vi- each person’s role is defined, in more or less detail, in
sion of the desired future practice model. This reflection written documents. Some [51,56] suggest that the role
should cover certain fundamental considerations, such definition process should result in each person’s role
as fit between patients’ needs and appropriate response, being formalized in writing. However, we have found
solutions to improve the practice model and role of each no strong empirical evidence to support the conclusion
professional in the team [21,51-55]. that role formalization is the sole or best way to support
Once the practice model is defined, the broad dimen- consensus around role definitions. One hypothesis derived
sions of the NP’s role and expected contribution should from our study is that the optimal level of formalization is
be discussed. The NP’s actual role needs to be discussed a function of team size and that larger teams may require
during the hiring process and determined in collabor- greater formalization. In any case, role formalization
ation with the NP hired; however, by defining broad should be sufficiently flexible and malleable to allow
dimensions beforehand, the team will be able to assess team members’ practices to evolve [64,65]. Excessive
whether their expectations are realistic and consistent role formalization that attempts to set down in writing
with the regulatory and administrative framework govern- every possible situation and all interventions is probably
ing NP practice. A team-generated definition also provides counterproductive to collaboration [65,66].
a useful tool for candidate interviews. It will also be im- Notwithstanding the level of formalization, a central
portant to take into account the level of experience of the element in the process of defining the NP’s role is, in
NP hired and the potential evolution of that person’s prac- fact, the recognition that the process cannot be limited
tice with growing experience and abilities. All available to the NP’s role. Coherently defining the NP’s role and
evidence suggests the first year of practice after graduation practical scope of practice involves rethinking everyone’s
is one of transition [42,45,46,56,57]. role z [53,67,68]). Failure to do so is likely to produce
Our data suggest that a key operational factor is to for- role overlaps, redundancies, and frustrations. Sibbald,
mally designate a person to be in charge of the practical Laurant and Scott [69] proposed a useful typology for
steps of the integration process, including setting up defining primary care roles using four logics:
communication strategies to ensure effective informa-
tion transmission within and outside the team [45,58].  enhancement, which involves widening the field of
Finally, throughout the process, it is important to both practice or the competencies of a professional
conceive of and present the arrival of an NP as an op- group;
portunity for the whole team to improve by reflecting on  substitution, which involves replacing one type of
how things are currently done, identifying areas for prac- professional by another in the provision of certain
tice improvement, and creating a vision for the entire services;
team’s future practice.  delegation, which involves allowing a subordinate
professional to provide extended services, but under
Role definition and consensus building the supervision of another type of professional;
The importance of appropriately and coherently defining  innovation, which involves establishing new types of
the NP’s role and scope of practice is, by far, the point services or creating new professional roles.
most often made in the literature on obstacles to collabor-
ation or to NP integration [40,59-62]. The results from These logics are not mutually exclusive but can serve as
our combined analysis show that, even when all clinical guideposts for thinking about the process of redefining
Contandriopoulos et al. BMC Health Services Research (2015) 15:78 Page 6 of 11

roles in a team. As a general rule, role definition should Second, our data show that, in practice, the models
enable all team members to: implemented were generally hybrids of the two types
presented here. Several regulatory factors, such as proce-
 practice to the full scope of their capacities;. dures for enrolling patients with physicians or clinics,
 contribute efficiently and effectively to patient had a determining influence on the patient care models
management according to each professional’s created. Lastly, in the cases analyzed, consultative man-
expertise. agement figured much more frequently than joint man-
 develop their own expertise and capacities and agement. This could be the result of a better fit between
facilitate this development process. the consultative management model and structural char-
acteristics of Quebec’s healthcare system. It might also
At the practical level, an essential factor in the role def- have to do with many primary care physicians’ limited
inition process is the identification of one or more project experience of working collaboratively or from how phy-
champions in the organization, such as chief nursing offi- sicians expect to practice with other physicians.
cers or nurse consultants, who will help ensure the full Overall our results do not allow us to suggest that one
scope of the NP’s practice is respected. It is also helpful to patient care model is inherently better than the others. It
repeat periodically the interactive process of discussing is likely that a model that works well in one setting may
team members’ roles, as those evolve over time. be inappropriate in another. On the other hand, there is
convergent evidence to support the notion that it is the
Several patient care models but no simple recipe overall coherence of the model that matters [55]. If the pa-
The practice model for NPs in Quebec, as described in of- tient management model is incompatible with the types of
ficial documents and regulations [70-77], is one in which clientele followed, with the team’s composition and collab-
NPs and their physician partners look after patients’ needs oration process, or with the NP’s level of experience, its
collectively. In practice this general principle can take two operation will be both dysfunctional and frustrating [9,84].
different forms: the “joint model” and the “consultative Examples of dysfunctions observed included difficulties in
model” [21,51]. A model is considered joint when the NP assembling a sufficient patient panel for the NPs, or a
and the physician partner follow the same panel of pa- non-functioning consultative model due to overly strin-
tients. In such a model, both professionals may see the gent interpretation of procedures for the NPs’ practice;
same patients at different points in their treatment. Con- such dysfunctions were symptoms that the models needed
versely, a model is considered consultative when the NP to be reviewed and adapted [47].
and the physician partner each follow a different panel of There appear to be three determining factors to con-
patients and the physician is consulted as needed. In that sider in choosing a patient management model: clientele
model, most patients followed by the NP never see the characteristics, physicians’ and NPs’ experience and prefer-
physician except for the occasional specific need. Follow- ences, and number of physician partners. The nature and
ing the evidence derived from the literature, we used three complexity of the clientele followed must be consistent
dimensions to assess the suitability of patient care models: with legislative and regulatory frameworks for NPs’ scope
group practice, interdisciplinary practice, and collaborative of practice, including the range of diagnostic tests and
practice [67,78-82]. Group practice is characterized by team drugs they can prescribe, and procedures for referring to
members’ sharing of resources and responsibilities. In inter- specialists [85,86]. Teams that opt for a consultative pa-
disciplinary practice, the patient management model is tient management model need to establish parameters re-
based on pooling the complementary expertise of the vari- garding the characteristics of patients followed by the NP
ous professionals. Lastly, we describe as collaborative the so that the NP is able to meet most of those patients’
communication and task-sharing processes that optimize health needs [9]. It is also important to understand that
efficiency and quality of care. A coherent definition of the this implies a potential increase in the average complexity
practice model is a crucial determinant of the quality of in- of the patients followed by the physicians in the team. The
terprofessional collaboration and of the capacity to establish data from our case studies suggest that physicians caring
operational definitions of each team member’s role. There for more complex patients could impact the amount of
is also credible evidence to suggest the coherent definition time required for the patient visit and, in a fee-for-service
of a patient care model is an important determinant of job scheme, physicians’ revenues.
satisfaction in primary care interdisciplinary teams [83]. As far as NP’s experience and preferences are con-
Three general observations emerged from our imple- cerned, there is convincing evidence that their first year
mentation analysis regarding the patient care models im- of practice is one of transitioning toward fully occupying
plemented. First, the models implemented by the teams their scope of practice and developing autonomy. It is
were generally not the result of an explicit choice. They thus important that the patient management model be
seemed rather to have emerged through trial and error. allowed to evolve over time as the NP gains experience
Contandriopoulos et al. BMC Health Services Research (2015) 15:78 Page 7 of 11

and confidence. As well, somewhat akin to the great members opportunities to talk about values and their vi-
variability seen in general physicians’ practice profiles, sion of the role and how it can contribute to service
the preferences and skills of both the NP and the phys- provision [21,46,63,67]. Space is also a strategic element in
ician partner should play a role in developing patient collaboration. Professionals need space in which to be able
care models. Here again, it appears important to keep to meet and talk together both formally and informally.
these parameters open and to be ready to redefine them Finally, collaborative practice does not always emerge
over time. spontaneously [21,88,91]. The literature on training for
The third element to consider is the number of differ- physician–NP collaboration identified in our review recom-
ent physician partners with whom the NP will need to mends a variety of learning strategies, such as case discus-
collaborate [55]. While the literature is not specific on sions, scenario building, and discussions around clinical
the optimal number of physician partners per NP, the and organizational issues [8,55,56,67,88-90,92,93]. Our
difficulties encountered in our cases suggest that the op- implementation analysis data suggest that NPs greatly
timal number of physician partners is probably between appreciated activities involving joint training or clinical
two and four. Having only one physician partner results case discussions and considered them to be team-building
in logistical challenges when that physician is absent. activities to construct a joint practice. Focusing discus-
Conversely, the more physician partners there are, the sions on quality of care and emphasizing a patient-
more adaptation is required from the NP, as bonds of centered approach are also good ways to foster productive
trust are built up slowly and differently from one person team discussions.
to another.
Supporting teams integrating an NP
Collaboration: a tool for optimal patient care Professionals’ capacity to develop effective and satisfactory
The fourth theme that needs to be taken into account by clinical practices depends primarily on the energy, open-
interprofessional primary care teams, whether they include ness, and mutual trust of the clinicians themselves. Yet it
NPs or not, is that of collaboration processes. This is the is important not to underestimate the key roles of man-
focus of a huge body of literature, which we will not try to agers, nursing and medical directors, and administrative
summarize here. However, it is worth remembering that assistants in supporting practice and its development
good collaborative relationships among professionals fos- [58,64,94]. Our study identified three complementary
ter a positive work climate and help to optimize quality of spheres of activity needed to adequately support primary
care and patient management [87-89]. care teams integrating NPs: clinical-level support, team-
The extensive literature on collaboration suggests deter- level support, and leadership and systemic support.
minants can be organized into three levels: interpersonal,
which includes elements such as confidence, attitudes, Clinical-level support
and communication skills; organizational, which encom- The data from our implementation analysis coincide with
passes leadership, egalitarian relationships, communica- findings from experiences in other provinces and countries
tion, coordination, and role clarification; and systemic, showing that some NPs are not able to fully exploit their
which refers to regulatory environments, funding, and re- roles due to issues related to drug prescribing, diagnostic
muneration, as well as educational frameworks [89,90]. testing, and receiving consultation reports from specialist
At the practical level, three elements seem to stand out physicians [8,21,51,86,95,96]. These problems are some-
as particularly important. First, it is important to identify times caused by administrative failures and sometimes by
leaders, both managers and clinicians, to whom team the opposition of certain professionals. Support provided to
members can turn for support to settle differences, resolve NPs at both the clinical and systemic levels is essential to
problems, or provide help in situations where communica- smooth out these difficulties [89,91,97].
tion is problematic [46]. Second, developing collaboration NPs also need to be able to develop their clinical judg-
among clinicians, whether inter- or intraprofessional, re- ment and decisional autonomy and apply these in prac-
quires time, in particular for mutual trust to develop. For tice. These are competencies that develop over time and
this trust to be built, new NPs need to demonstrate their depend on the quality of interprofessional collaboration
competence in managing patients. Although much of the and the comprehensiveness of the patient care model
literature focuses on relations between physicians and [21,88,91,98,99]. Likewise, access to continuing educa-
NPs, collaboration between NPs and nurse clinicians is tion is an important factor in developing good clinical
also a key issue. Our empirical data show a period of ad- practice, not only for NPs, but also for physicians and
justment is required during which nurses can get to know other professionals [63]. The lack of availability of spe-
each other and talk about their visions and respective re- cific training, difficulties in being liberated from work,
sponsibilities, building up their collaborative relationship and distance to training locations were identified as sig-
over time. Time also needs to be allocated to give team nificant obstacles in this regard.
Contandriopoulos et al. BMC Health Services Research (2015) 15:78 Page 8 of 11

In those settings where the NPs’ scope of practice was important. This person who has the legitimacy, capacity,
most extensive and where their role definition was evolving and motivation to take on this role will be responsible for
positively, several determining factors were observed: joint preserving an overall vision of all the work processes [58].
meetings among managers, nursing or medical directors,
and partner physicians; a shared vision of the NP’s role; Systemic support
mobilization of the care team members’ complementary ex- Beyond their internal functioning, primary care teams
pertise; and collaborative work with nurse clinicians. The are also part of larger healthcare systems. As such,
NPs’ prescribing authority and decisional autonomy were the operations of primary care teams are also structured
also discussed and clarified by the whole team, including by the environments in which they practice, with regard
the medical team. to such things as billing policies, enrolment of new pa-
tients, or referrals for tests or specialized services. As
Support for the team with any other practice change, introducing an NP
There is solid evidence that strong leadership and consist- entails adjustments and communications between the
ent support to primary care teams foster the emergence of primary care team and its external environment [85].
an effective patient management model [21,40,64]. Our However, the NP role is still evolving, and part of that
cases showed great variability in the administrative struc- role is played out at the interface between medicine and
tures in place and in the persons mobilized (e.g. clinic nursing. To fulfill their responsibilities, NPs must be
managers; head nurse; licensed practical nurses; physician able to rely on collaboration from other actors in the
clinic manager; manager, etc.). Only rarely were there clear external environment (specialist physicians, diagnostic
lines of authority delineating the responsibilities of services, pharmacists). It is therefore important that
managers at different hierarchical levels. Organizational clinical teams be given the systemic support needed to
theory suggests that the characteristics of primary care identify appropriate solutions and to ensure problems
teams (small professional groups, very autonomous partic- are resolved [14,88,91]. Fulfilling this mandate takes
ipants, decentralized power in terms of operations) favor time and a good knowledge of the local environment.
informal functioning and structures that are not very hier- This is why, in practice, the functions of direct supervi-
archical [66,100]. This type of structure produces good sion and systemic support may need to be shared
results when there is a consensual vision of the organiza- among the local leaders [58].
tion’s goals and values but carries the inherent risk that Finally, while it is useful to divide the discussion on
no one would feel accountable for resolving problems. support for practice into three spheres here, it is also im-
There thus needs to be positive leadership from one or portant to remember they are interdependent and, in
more key persons who have strong legitimacy and a clear practice, necessarily integrated.
sense of purpose.
Effective communication mechanisms are a key factor Discussion and conclusion
in encouraging the emergence and maintenance of a The results of our logic and implementation analyses
shared vision of the team’s objectives and values [45,58]. suggest the existing literature on NP integration could
Communication must be balanced between formal and be improved in two ways. First, taken as a whole it is too
informal opportunities for exchange. Similarly, a balance often intradisciplinary, offering analysis and advice that
is required—depending on the persons, subject, and is too targeted to one professional group. Yet, by defin-
context involved—between direct communications (such ition, integrating NPs into primary care teams is an in-
as discussions between two professionals to improve a terprofessional endeavor. Second, while the literature
suboptimal work practice) and indirect communications offers much converging descriptive evidence regarding
(such as transmitting suggestions for improvement to the barriers to and facilitators of NP integration [8], it is
person in charge of a specific aspect) [56,58,90]. In any much less helpful in terms of practically oriented advice.
change process, it is normal that tensions and differences When practical advice is found, it is often structured as
in preferences would arise between team members. In a step-based linear model. However, in our view such
some cases, tensions are best resolved by face-to-face linear models are vulnerable to the broader weaknesses
discussion. Resolving disagreements directly within the of linear planning strategies [101,102].
team is part of the process of creating team dynamics. Integrating NPs into primary care teams is likely to be
Even so, it is essential to be able to consult a neutral third a dynamic, complex, and messy process. In real life,
party when necessary, someone prepared to take on a many elements often need to be tackled simultaneously;
boundary-spanning role between the medical and nursing it might make sense to backtrack to find and fix some-
disciplines. Here again, there is no solid evidence for thing that was not done right in the first place, and it is
any specific operationalization, but several credible data impossible to draw a line between what constitutes inte-
sources in the literature suggest the principle itself is gration and what are normal activities. This is not to say
Contandriopoulos et al. BMC Health Services Research (2015) 15:78 Page 9 of 11

that NP integration ought to be conceived as a some- Received: 2 July 2014 Accepted: 6 February 2015
thing to be improvised, but rather that it is a process for
which the best advice may not be step-based, as is
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