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Practice pathways, education, and regulation influencing nurse practitioners’ decision to provide primary care: a rapid scoping review

BMC Primary Care volume 25, Article number: 182 (2024) Cite this article

Abstract

Background/Objective

Initially established to improve access to healthcare, particularly for primary care, the full potential of the nurse practitioner role is yet to be realised in most countries. Despite this, most countries are working to meet an ageing population’s increasing healthcare needs and reduce healthcare costs and access disparities. Achieving these outcomes requires reform at multiple levels, including nurse practitioner practice pathways, education and regulation, and identifying the barriers and facilitators to optimising their primary care role.

Methods

A rapid scoping review of nurse practitioner practice pathways, education and regulation inclusive of: (1) a systematic search of Medline and CINAHL for peer-reviewed English language articles, including opinion pieces published between January 2015 and February 2022; and (2) a web-based search of nurse practitioner program entry requirements of International Nurse Regulator Collaborative country members with a protected nurse practitioner title and prescribing rights, plus the Netherlands. The individually summarised search data was integrated and synthesised using Popay’s narrative approach.

Results

Emerging evidence from the included nurse practitioner courses (n = 86) and articles (n = 79) suggests nurse practitioners working in primary care provide safe, effective care and improve healthcare efficiencies. However, different regulatory and educational models are required if the primary care nurse practitioner is to meet growing demand.

Conclusions

International variations in entry criteria, curriculum, and regulation shape the global profile of the nurse practitioner primary care workforce and their practice setting. For countries to grow their primary care nurse practitioner workforce to meet unmet needs, different entry requirements, program content and accredited post-registration transitional programs must be urgently considered.

Peer Review reports

Background

Primary care is an essential foundation of effective and responsive healthcare systems as a person’s first point of access to healthcare and the source of referrals to other services [1]. Since the Alma-Ata declared primary care essential to all effective healthcare systems, primary care has been enshrined in numerous global policies [2]. However, effective primary care depends on an interdisciplinary partnership approach that integrates health services to meet people’s health needs. It also addresses the broader determinants of health through multisectoral policy and action and empowers individuals, families and communities to take charge of their health [3, 4].

While global healthcare has rapidly improved over the past three decades [5], and new technologies enable people to maintain their autonomy and function independently for longer in the community, there is a growing need for a well-prepared, diverse, and collaborative primary care workforce [6,7,8]. Global healthcare systems are increasingly required to manage a rapidly ageing population and a growing burden of complex illnesses (e.g., diabetes, chronic kidney disease and cardiovascular disease) [5] in an environment facing substantial health workforce shortages. The need for a skilled workforce to engage in primary and secondary prevention, screening, assessment, triaging and managing activities has never been greater [1, 9]. Without significant health workforce reforms, the ongoing improvement in the health and well-being of those living in high-income countries cannot be guaranteed [5].

With fewer physicians selecting primary care as a career, access to primary care is challenging, leaving many people with unmet healthcare needs. As a result, nurse practitioners (NPs) are increasingly being called upon to strengthen and improve healthcare access and performance, especially for underserved communities and those with complex care needs [1, 10, 11]. Several NP courses have responded to these changing epidemiological needs with the inclusion of specialist content to improve the management of common primary care concerns such as mental health conditions, diabetes mellitus and other common endocrine conditions [12, 13]. However, current regulatory and entry requirements for educational programs in some countries do not facilitate NPs undertaking primary care roles. For example, despite the NP role being explicitly established in Australia to increase primary healthcare access [14], very few of the 2,425 NPs [15] currently practice in primary care [16, 17]. Understanding the educational entry pathways and regulatory requirements and their impact on nurse practitioners’ provision of primary healthcare is critical to addressing this policy mismatch.

As the international healthcare system evolves, and demands increase, it is timely to examine the benefits and limitations of international models of regulation and education on the composition of the NP workforce, and to consider their applicability to shaping the NP workforce of the future.

Aim

To examine the international nurse practitioner practice pathways, education and regulation that prepare nurse practitioners for primary care roles across high-income countries with protected nurse practitioner titles.

Methods

Design

A rapid scoping review including: (1) a web-based review of the international entry requirements of approved NP programs and (2) a review of the peer-reviewed literature. This review sought to determine the international practice pathways, education and regulation that prepare NPs for a primary care role. A rapid review design was adopted to generate an expedient synthesis of multiple sources of evidence, which facilitated streamlining the search strategy, data extraction and bias assessments [18,19,20].

Review 1: Web-based search of the international requirements of NP programs

Inclusion criteria

The International Nurse Regulator Collaborative member countries with a protected ‘nurse practitioner’ title; or other high-income countries with country or jurisdiction-level nursing boards responsible for nurse practitioners’ endorsement, licensure or registration (‘endorsement’); and who require candidates to have completed an accredited Master’s or Doctor of Nursing Practice degree, with mandated supervised clinical placement hours and a dissertation.

Public website pages published in English detailing NP programs from eligible countries with less than 99 NP programs were searched and included. In the United States of America (US), with ≥ 100 NP programs, the 10 top NP programs from the ‘Best Nursing Schools Rankings’ [21] plus the top 20 rankings from central [22] or rural states [23] delivering NP programs were included. This sampling approach captured geographical, socioeconomic and cultural diversity in university rankings and NP program size.

Google searches were conducted between 1st March and April 2022 using i) country name, ii) ‘NP’ or equivalent, and iii) ‘program’, ‘university’, or equivalent local term. If the respective jurisdictional standards for practice were not included on the identified university website, additional country-level Google searches were conducted using “nurs* standards” and the respective country’s name.

Data extraction

Two reviewers (MR & CF) extracted data into a purpose-built proforma that captured: the host organisation, web page and URL, program specialisation, delivery mode (e.g., online or in-person), entry requirements (e.g., clinical hours and clinical specialisation) and supervised clinical hours. The average clinical experience hours required to be eligible to enter a NP course and the average clinical supervision hours for each NP course were calculated for each included country. If clarification or additional information was required, the relevant member country contacts were emailed.

Review 2: Rapid systematic review of NP regulation, education and practice evidence

The rapid systematic review was designed to answer the following search question: What are the practice pathways, education and regulation that prepare NPs for a primary care role?

Inclusion criteria

Eligible publications were (i) peer-reviewed; (ii) published in English between 01/01/2015 and 23/02/2022; (iii) reported empirical quantitative or qualitative data or presented an expert opinion on NP practice pathways, education and regulation; and (iv) undertaken in the included countries as detailed in Part 1 of this review. Publications that (i) did not address the search questions; (ii) focused on outdated NP legislation; (iii) countries other than those identified in Review 1; (iv) reviewed literature published outside of the study time frame; or (v) did not focus on primary care; or (vi) were conference abstracts; or (vii) study protocols, were excluded.

Information sources and search terms

On 23rd February 2022, CINAHL and Medline via EBSCOhost were searched using the pre-defined strings (Refer to Additional File 1). The reference lists of included publications were hand-searched for other relevant studies and grey literature.

Study selection and data collection

After the identified citations were imported into Covidence [24], one reviewer (NE) assessed eligibility before the other reviewers (NE, MH, MR and CF) extracted the (i) author list, (ii) publication year, (iii) country and (iv) key study findings into an electronic proforma.

Risk of bias assessment

While the quality of each study was not assessed, the level of evidence was determined as per the method for grading guideline development recommendations [25].

Synthesis and integration

A narrative synthesis [26] was used to integrate the different data sources to answer the search questions. After the data was extracted it was tabulated, counted and mapped to the key concepts, which helped to highlight the key outcomes and linked the emerging evidence [26]. This process allowed for visual representation of the data, and its alignment to: NP practice pathways, education and regulation. This process was led by one author (NE) before being reviewed by the senior author (JP) before being confirmed by other members of the team [26].

Ethical approval and registration

As this was a review of existing literature and publicly available information, it was exempt from human ethics review.

Findings

Review 1: web-based search of the entry and clinical practice requirements of NP courses internationally

Eighty-six approved NP courses from seven countries, including six of the eight International Nurse Regulator Collaborative member countries: Australia, Canada, Ireland, New Zealand, Singapore, the United States (US), and the Netherlands, were included (Refer Additional File 2). A high-level summary of these NP programs’ entry and program requirements is provided (Refer to Table 1).

International pathways into NP primary care practice

In general, NP courses are available to Registered Nurses with a Bachelor of Nursing, with Ireland, preferring an honours, but this is not compulsory. The exception is Australia, where a postgraduate nursing qualification and approximately 4.22 years of full-time equivalent clinical experience are required for admission to a NP course.

Table 1 Country-level summary of the NP clinical experience and specialisation requirements for program entry and endorsement
Full size table

Review 2: rapid systematic review of NP regulation, education and practice pathways

The original search yielded 7,372 articles (Refer to Fig. 1), with 1,380 irrelevant articles (largely related to nanoparticles or nasal polyps) and 1,787 duplicates removed, leaving 4,205 publications titles and abstracts that were screened by a single reviewer (NE). Of the 470 publications that went for a full-text review, 79 were included in the final review. A brief summary of findings of the included articles can be found in Table 2.

Fig. 1
figure 1

PRISMA flow chart of the rapid systematic review of the literature on NP regulation, education and practice evidence

Full size image
Table 2 Summary table of included articles and relation to review foci
Full size table

Characteristics of the peer-reviewed literature

Three-quarters (73%) of the articles were from the US, where NPs are the largest providers of non-physician primary care but whose scope of practice differs according to state laws [10]. Articles from all of the included countries, except Singapore, were identified and included. Of the 79 included articles, nearly half (47%) related to NP regulation, 42% related to education of NPs and 22% to practice pathways (note that some articles applied to multiple foci) (Refer to Table 2).

The highest level of evidence (Level IV) was generated from 10 secondary analyses of service use and expenditure/billing data studies with a health economic focus [10, 11, 27,28,29,30,31,32,33,34], and one pre-test, post-test study [35].

Impact of primary care nurse practitioners

Internationally, between 2002 and 2015, the growth in the NP workforce was 3–9% greater than the physician workforce [36]. This global growth reflects the increasing demand for NPs, especially in areas of unmet primary care needs [37,38,39,40,41,42]. The existing health economic evidence suggests that primary care NPs increase the communities’ access [43] to high-quality, safe and cost-effective healthcare [10, 11, 27, 44] and their patients have comparable outcomes to physician-led primary care [45, 46]. Despite the potential efficiencies of NP roles, clinical and policy stakeholders suggest that they are still often underutilised in primary care [46,47,48].

Impact of entry pathways and program requirements on the context of NP practice

Several countries provide broad clinical NP study streams, including the US, where NP candidates looking to work in primary care complete their studies in one of the following specialty streams: Family Practice (Generalist in Primary Care); Adult-Gerontology (Primary), Paediatrics (Primary); or Women’s Health [34]. Canadian candidates study one of three streams: paediatric, adult and family streams; and in the Netherlands, candidates focus on physical or mental health.

In the US, defined NP clinical streams determine graduates’ practice context, with rural NPs more likely to have a Family NP certification [49, 50], while urban NPs are more likely to have adult or gerontology certifications [49]. A review of US medical billing and health record data found rural NPs practice more autonomously than their urban counterparts despite no significant differences in the complexity of care [29]. Whilst 70% of all US NPs have a Family Practice certification, less than one-third consider primary care their main focus, with an increasing number of NPs employed in sub-speciality ambulatory practices or inpatient units [51], effectively reducing the availability of NPs to work in primary care.

Removing pre-entry clinical experience requirements in the US has supported a rise in the number of courses accepting candidates directly from undergraduate nursing programs. Some US courses offer direct-entry that allow non-nurses to concurrently obtain their Registered Nurse and NP licensure [52], leading to an increase in the clinical practice hours required by the Doctor of Nursing Practice compared to Master’s candidates from an average of 693 to 981 h (Refer Table 1). This change has raised concerns about Registered Nurses with little or no clinical experience entering an NP course and their ability to gain capabilities to practice safely and effectively, particularly in states with full practice authority [53]. However, a recent qualitative study of primary care NPs found these less experienced NP candidates were equally competent by the end of their NP course as Registered Nurses with more clinical experience prior to entry [52].

In Australia, Ireland and the Netherlands there are few primary care nursing courses [37, 54, 55]. While Irish Universities are willing to expand their offerings in primary care, there is no clear path to actualisation [54]. Most NPs in Australia practice in acute care settings, which has raised concerns in response to increasing societal primary care needs [48, 56]. A modified Delphi study in Australia reported consensus among experienced NPs that primary care should be classified as a ‘meta-speciality’ and be used to guide the development of NP learning and clinical outcomes [39]. Another mixed methods Australian study reported NPs identified the areas of greatest need over the next five years, including aspects of primary care such as chronic disease, generalist and rural/remote care [40]. Only one NP in this study was identified as a primary care practitioner, illustrating the urgent need to prepare more Australian NPs to meet the countries growing primary care workforce demands.

New Zealand has introduced a policy to expand primary care services; however, NPs report numerous practice barriers, including high costs of the NP pathway, reduced funding for primary care nurses and difficulty securing placements, among others [57, 58]. Canadian studies similarly reported that improving access to funding may enhance the integration of NPs into the primary care setting [59]. They identified a lack of defined pathways to primary care roles, particularly in rural locations [60]. Difficulty obtaining placements and irregular clinic funding of primary care NP candidates were similarly flagged as barriers to primary care practice in rural US communities [61].

Education of primary care nurse practitioners

Supervised clinical placement hours

A 2020 global comparative analysis of university programs identified an inverse relationship between the number of clinical hours required for admission and the number of clinical hours embedded in NP programs [62]. The exception is the Netherlands, which has stringent admission criteria and the most clinical placement hours (2000 h) due to government funding of the full-time employment for NP candidates while they study [62]. The web search confirmed this with Canada and the US having lower clinical experience requirements for entry to NP programs, but mandating more clinical placement hours. In contrast, Australia requires an average of 4.22 years of clinical experience to enter the program but mandates fewer placement hours (refer to Table 1).

Primary care skills

Many NPs working in the US and Australian primary care sector perceive their educational program was insufficient in preparing them with the clinical skills required for independent practice [37, 53, 63, 64]. In the US, there is a potential mismatch between the skills taught in the primary care curriculum and those used in NP clinical practice. For example, assessment, diagnostic investigation and interpretation are vital elements of the primary care NP role; [65, 66] however, skills such as mental health assessments [66], ordering diagnostic tests [65, 66], basic primary care procedures [64,65,66], ECG and X-ray interpretation [64, 65, 67], and chronic pain management [66] are inconsistently taught in primary care programs, or missing altogether. As a result, numerous articles focused on the importance of competency-based education in primary care, calling for practice standards and curricula to align with the clinical activities that typify nurse practitioners’ workloads to ensure safe and effective care [65,66,67,68]. There are emerging programs addressing these gaps, such as one reported rural primary care preceptorship for Family Nurse Practitioner students, embedding practical skill workshops into the program and providing clinical placements in rural settings, which led to 56% of participants accepting jobs in rural primary care [69].

The topic of competency-based versus capability-based education is a subject of international discussion. A US study found students spent only 34% of their time on placement with patients or preceptors, arguing that a competency-based demonstration of skills before graduation may be a superior strategy for measuring competency [70]. Australia has a capability-based approach, where the NP’s individual speciality shapes their clinical practice [37, 71, 72]. More recently, it has been suggested that implementing standardised education streams aligned with national health priorities (including primary health) and replacing the significant advanced practice experience hours with competency-based assessments [37]. Another recent Australian study sought industry consensus on key skills and competencies for various NP meta-specialities, including primary care, to help guide local and international NP education [38, 39].

Multidisciplinary and virtual education are changing how education is delivered to nurse practitioner students. Two studies examined the benefits of multidisciplinary education for primary care NPs, finding an improvement in self-efficacy was statistically significant for NPs who completed an interprofessional program with dental students compared with non-participants (p = 0.02) [73]. A 14-week multidisciplinary pharmacy led program improved Family NPs’ recognition and avoidance of medication errors, although overall competency was not statistically improved [35]. Virtual programs for rural primary care NP candidates [74, 75] reported participant satisfaction with virtual education, simulation and evaluation of core clinical skills in primary care, however these two studies reported incomplete methodology. More rigorous research is needed in evaluating education modalities in primary care.

Primary care transitional programs

Qualitative studies suggest focusing on the transition from education to practice is important and is linked to workforce retention [50, 76]. One study of novice NPs in primary care (n = 177) reported mentorship, professional development and role support as facilitators of this transition [50]. Further, positive clinical experience and perceptions of mentorship and preceptors were identified as some of the top predictors of NP students choosing to work in primary care [77]. As a result of growing evidence, the US National Academy of Medicine has recommended establishing accredited and standardised postgraduate training for primary care providers, including NPs [78]. Yet fewer than 10% of US primary care NPs have completed these programs [63, 79] despite participants reporting they were effective in clinical practice preparation. Residencies and fellowships are said to address the transitional challenges many US NPs experience [53, 63, 80,81,82] by improving their confidence [79, 81, 83, 84], clinical competencies [81, 85,86,87], interprofessional collaboration and communication [79, 80, 84, 86], patient outcomes [82, 83] and reducing workforce attrition [78, 79, 82, 83].

The data on these US NP transitional programs are relatively new, and more research is needed to determine the quality and impact of primary care residencies and fellowships [78]. While US primary care residencies are more often accredited than other specialities, there are calls to formally accredit and standardise these programs nationwide [83]. Accreditation assures professional nursing organisations’ involvement in curriculum development and learning outcomes [78]. While this review yielded results of transitional programs only from the US, two articles from Ireland [54] and Australia [81] suggested that primary care residency programs similar to those offered in the US could be beneficial for NP role-preparation.

Regulation of primary care nurse practitioners

Full practice authority in primary care

Much of the literature on regulation is US-centred, with ongoing conversations relating to full practice authority in primary care. In the US, the scope of NPs practice reflects state regulations, which have either full, reduced or restricted practice authority, determining how independently an NP can practice [32]. Much of the literature suggests that full-practice authority is required for primary care NPs if they are to: improve patient access to primary care [28, 30, 33, 46], particularly in low socioeconomic and rural areas [10, 41, 42], reduce hospitalisations [27, 44], and reduce healthcare and training costs [1, 11, 33, 44, 88]. Strong organisational support for independent practice increases NP’s capacity to provide effective primary care, and improves teamwork among NPs and physicians [89,90,91]. States with full authority reported a higher proportion of adults reporting an NP as their main primary care provider [31]. For workforce planning purposes, autonomous practice was associated with a reduction in turnover intention reported by primary care NPs [92]. Only one study reported no association between state regulation and increased use of NPs in primary care [93].

Variations in US state and organisational regulations (e.g., supervision requirements), especially in states with restricted and reduced practice authority, pose significant barriers to entry to primary practice, one study reported NPs were 13% more likely to practice in primary care in states with a full scope of practice [94]. These variations also limit NPs’ capacity to practice to the full extent of their qualifications [47, 95,96,97,98] and across jurisdictions [99]. These restrictions may also increase healthcare costs due to increased service and provider fees [94]. While the number of registered NPs is rising, states with reduced or restricted authority have the largest care gaps in identified primary care shortage areas and rural communities compared with states with full practice authority [32].

The transition from master to doctor of nursing practice programs in the US – implications for primary care

The move to the Doctor of Nursing Practice in the US by 2025 [100] has implications for the primary care workforce. Early evidence suggest that Doctor of Nursing Practice NPs are likely to move directly into leadership, policy or management instead of direct care roles, impacting NP workforce availability and planning [100,101,102,103]. One study identified that only 11% of Doctor of Nursing Practice graduates practice in primary care [101], while another reported that 85% of Doctor of Nursing Practice programs in 2018 were non-clinical, focusing on leadership and administration [103]. These findings have led to concerns within the sector that this change impacts NP roles, and if this trend continues, it may impact the US’s ability to grow its primary care workforce [103].

Non-US perspectives on NP regulation in primary care

While there were few non-US studies, a recurring theme was the ambiguous role of primary care NPs within the health system due to ineffective or insufficient policy and governance [54, 55, 59, 72]. For example in the Netherlands, while the NP hospital role is well established, integrating NPs into primary care is relatively new, with suggestions that a lack of international guidance has prevented standardising the NP role and created role confusion [55].

Similarly in Ireland, the Slάintecare policy was developed to increase NP services in areas of need, including primary care. When the definitions of primary care and the NP role were identified as being unclear, a national project sought international consultation to help define the role, leading to the development of robust regulation and postgraduate continuing education for NPs [54].

In Alberta, Canada, the NP Support Program policy was designed to integrate NPs into the primary care system but is said to have failed due to a lack of clear role delineation within primary care [59]. Stakeholders also reported that this policy had inadvertently limited NPs’ job opportunities, embedded financial disincentives and promoted physician gatekeeping, impeding NPs’ ability to practice independently in Alberta [59].

In Australia, a recent study reported limited advocacy from employers and policy advisors for expanding the NP scope of practice or increasing payment for NP services, suggesting NPs must lobby themselves for regulation changes [72]. Australian and New Zealand primary care NPs face constraints such as restricted items they can claim for government reimbursement through universal healthcare funding, or inability to sign off on vital certifications (e.g. work cover and time off work, death certification), effectively limiting autonomous practice [56, 104]. Despite evidence that NP-led primary care has cost benefits to the health system, reduces hospitalisations and improves early health interventions; policy and legislation in Australia restrict primary care NPs from exercising their full scope of practice [105]. Overall, the international literature and stakeholder feedback calls for better alignment of funding, policy and governance structures to ensure improved integration of NP practice into primary care [54, 55, 58, 59].

Discussion

Despite most of the included articles coming from the US, a country without universal healthcare, several significant findings have emerged from this scoping review that have implications for shaping the global primary care NP workforce. Two distinct NP entry, regulation, and practice pathways have emerged from this scoping review: (1) pre-defined clinical streams versus (2) bespoke clinical expertise.

Globally, there are marked differences in the NP entry requirements, ranging from a postgraduate diploma to new graduates with no clinical experience entering a 3-4-year NP program. In Australia, Ireland, New Zealand, the Netherlands and Singapore, NP candidates must have practised and demonstrated competencies in their chosen sub-speciality, which may include primary care [106]. While countries like the US and Canada have a defined primary care stream, countries such as Australia, New Zealand, Ireland, and the Netherlands lack this definition, with no clearly defined primary care pathways. These countries rely on individual nurses with demonstrated primary care expertise electing to progress into an NP program. While Australia is the only country requiring a postgraduate certificate for NP program admission, Australian and Singaporean NP programs [107,108,109] require substantial full-time equivalent clinical experience in the candidates chosen speciality, which means that candidates tend to enter at an older age, compared to the US.

These differing NP entry pathways reflect each country’s NP workforce profile, including primary care. US and Canadian NPs are younger nurses undertaking more extended clinical supervision in varying practice environments within broad population-based groups in a defined clinical stream, including primary care [62]. Whereas Australian nurses entering an NP program have significant clinical experience in their chosen speciality or sub-speciality, with an individualised scope of practice, undertake fewer supervised clinical placement hours, and, as a result, tend to be older [62]. Few currently have primary healthcare experience because there are fewer primary healthcare nursing programs, and primary healthcare roles are harder to secure, making it difficult for registered nurses to demonstrate their specialist expertise within Australia’s current fee-for-service primary healthcare system [104]. This reality has led to calls for Australia to move from its individualistic specialist entry requirement approach to standardised NP speciality streams aligned with national health priorities, such as primary care [37, 38]. Similar to the focused Canadian specialities, where candidates enter one of three streams: paediatric, adult and family streams, or the Netherlands, where candidates choose to focus on physical or mental health. Considering different entry pathways will be challenging for international health systems, but critical if the NP workforce is to play a more significant role in caring for the growing needs of people living with chronic and other unmet primary healthcare needs.

The findings suggest that building the primary care NP workforce requires targeted whole-of-sector strategies. At a systems level, specialist entry requirements, clinical practice hours and access to reimbursement items or a financial model are critical to supporting NPs to practice in primary care [104]. At the organisational level, the practice environment can serve as a facilitating factor, as evidenced by US rural NPs, who are more likely than their urban counterparts to manage their patient care as primary care providers independently [29, 49, 110]. At a personal level, professional development opportunities, institutional commitment to ongoing education, work-life balance, mentorship, autonomy, ability to use clinical assessment and decision-making skills [57, 77, 90, 98] are additional factors that help attract and keep NPs in primary care practice.

While countries like Australia have adopted a capability framework [111], other countries, including the US, have adopted a competency framework to prepare NPs for practice [112]. There have been suggestions that it might be time to revisit the sector’s need for a suite of generic NP competencies, ensuring that all NPs demonstrate standardised foundational competencies across their speciality [37,38,39,40]. However, the literature suggests the skills necessary for autonomous practice in primary care are not consistently incorporated into NP curriculum, and NP candidates often report feeling inadequately prepared for autonomous practice after registration. Any future competency-based frameworks need to address the skills required in primary care practice.

Despite few being accredited, US transitional primary care residency and fellowship participants report favourable outcomes [83, 103]. Regulation and accreditation of US transitional primary care NP programs would provide a blueprint for other countries to adopt and may help reduce the attrition of NPs from primary care [54, 78, 81, 83].

While it is premature to evaluate the impact of the introduction of the US’s Doctor of Nursing Practice by 2025, on NPs choosing primary care, early data does suggest a larger proportion of Doctor of Nursing Practice graduates take up administrative or leadership positions compared to clinical roles [100, 101, 103]. This is relevant considering US workforce projections indicate an ongoing decline in the primary care NP and physician-to-population ratio [9]. If this trend continues, it may adversely impact the global need for more clinically focused primary care NPs as demand increases.

Numerous barriers exist to practising as a primary care NP. Several US studies identified common barriers to choosing primary care as a speciality, including obtaining clinical placements, a poor understanding of the primary care NP role, and legally mandated NP supervision by physicians [61, 94, 98]. Further, some US states remain constrained by restrictive practices which prevent them from performing to their full scope of practice [1, 9, 41, 42, 47, 94, 95, 97,98,99]. Australia has traditionally had a system of collaborative arrangements in place in primary care practice, where NPs were required to be effectively supervised by a physician, not unlike a similar practice that exists in some US states [97]. This widely criticised practice affects NPs’ ability to practice independently without an arrangement and to claim Medicare rebates and Pharmaceutical Benefits Scheme items [97, 105]. The Australian Government’s recent commitment to remove the mandated requirement for a collaborative arrangement will support Australian primary care NPs to work more autonomously. Independent practice in primary care is an important discussion, as reflected in the Australian NP standards for practice, which specify that NPs can effectively manage care episodes as the primary provider [111]. However, the rise in complex chronic diseases (including heart disease, diabetes, COPD, progressive neurological conditions and increasingly cancer survivorship) [17] means interdisciplinary health teams are necessary to address the complex needs of many primary care patients [113]. Nurse Practitioners are ideally positioned to work as part of these interdisciplinary teams to optimise care for people with chronic and complex conditions [111].

Despite these enormous opportunities, Irish and Australian nurses have limited opportunities within the current educational pathways to build their primary care capabilities [37, 54]. Cultural perceptions of NP-led care as disparate to physician-led care in New Zealand and the Netherlands were identified as barriers, compounded by difficulties completing prescribing practicums, fewer scholarships, personal costs associated with completing a Master’s, and difficulty securing employment as a primary care NP [55, 57]. The policies implemented in Canada and New Zealand with the aim of enhancing the integration of NPs into primary care have inadvertently yielded unfavourable outcomes, such as disparities in funding, policies fostering competition between NPs and Physicians, insufficient opportunities for job creation in primary care and restricted reimbursement items, which, collectively, have impeded the potential growth of NPs in primary care settings [58, 59]. Expanding the workforce in primary care will continue to be a challenge while these barriers exist. Including NP and relevant stakeholder voices in policy consultation is recommended to ensure the goals are operationally viable and beneficial to NPs.

Limitations

There are several limitations and strengths associated with this rapid review. Only including studies published since 2015 may have excluded earlier seminal work. However, the most significant limitation is that most of the included studies generated low-level evidence, making it challenging to draw any definite conclusions, especially as there was no quality appraisal of the evidence as part of the rapid review methodology. Most of the included studies also reported on the US experience, which differs considerably from other countries’ healthcare and regulatory systems. As it was not feasible to review all current US NP program requirements, restricting the appraisal to 30 US NP programs may not accurately reflect the full scope of the available NP programs. This was balanced by including diverse programs from different states. Despite these limitations, this review has considerable strengths. It canvased material from multiple sources, including 86 NP programs, and evidence from the current English peer-reviewed literature to provide a detailed global snapshot of NP regulation, education, and practices and how it enables or restricts the development of the NP primary care role.

Conclusions

Globally, NP roles continue to grow in both numbers and stature. The variations in the entry pathways, accreditation, education, endorsement or licensure, and professional pathways available to NPs across the US, Canada, Australia, New Zealand, Ireland, Singapore and the Netherlands reflect the local needs, changing circumstances and different regulations. Differing entry and practice requirements shape the composition and function of each country’s NP workforce, including age, clinical focus and expertise. These requirements ultimately influence where NPs practice and the populations they serve, including in primary care. It may be timely for countries who wish to grow their primary healthcare workforce to (1) revisit the merits of introducing a non-specialist NP entry pathway that attracts high-quality nurses interested in addressing national health priorities and providing care to underserved communities; (2) consider the limitations of restricted practice and economic implications of removing restrictions and (3) ensuring primary care NP curricula is informed by real-world skills and practice.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

DNP:

Doctor of Nursing Practice

NP:

Nurse Practitioner

US:

United States

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Funding

This research was supported by funds from the Nursing and Midwifery Board of Australia and the Australian Nursing and Midwifery Council to conduct a literature review of the Nursing and Midwifery Board of Australia registration standard endorsement as an NP and the Australian Nursing and Midwifery Council NP accreditation standards. Nursing and Midwifery Board of Australia and Australian Nursing and Midwifery Council representatives were consulted on the scope and methods of the review. All data were collected, and the findings of this review were synthesised independently of the Nursing and Midwifery Board of Australia and Australian Nursing and Midwifery Council.

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Authors and Affiliations

  1. Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia

    Norah Elvidge, Megan Hobbs, Melanie Rolfe & Jane L. Phillips

  2. School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Australia

    Norah Elvidge, Megan Hobbs, Amanda Fox, Jane Currie, Suzanne Williams, Karen Theobald, Melanie Rolfe & Jane L. Phillips

  3. Metro North Health, Redcliffe Hospital, Redcliffe, Australia

    Amanda Fox

  4. Improving Palliative Care Through Clinical Trials (ImPaCCT), Faculty of Health, University of Technology Sydney, Sydney, Australia

    Claire Marshall & Jane L. Phillips

  5. Children’s Health Queensland Hospital and Health Service, Brisbane, Australia

    Suzanne Williams

Authors
  1. Norah Elvidge
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  2. Megan Hobbs
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  3. Amanda Fox
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  4. Jane Currie
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  5. Suzanne Williams
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  6. Karen Theobald
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  7. Melanie Rolfe
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  8. Claire Marshall
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  9. Jane L. Phillips
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Contributions

JLP, AF, JC, SW and KT were responsible for conceptualisation. JLP was responsible for supervision and funding acquisition. NE, MH, MR, CM and JLP were involved in data curation; formal analysis; methodology; writing original draft and writing – review and editing. AF, JC, SW, KT were involved in methodology and writing – review and editing.

Corresponding author

Correspondence to Jane L. Phillips.

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The authors declare no competing interests.

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Elvidge, N., Hobbs, M., Fox, A. et al. Practice pathways, education, and regulation influencing nurse practitioners’ decision to provide primary care: a rapid scoping review. BMC Prim. Care 25, 182 (2024). https://doi.org/10.1186/s12875-024-02350-3

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Keywords

BMC Primary Care

ISSN: 2731-4553

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