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1 Coordinator pre-registration Masters of Nursing, Lecturer, Sydney Nursing School, 2 Professor of Nursing, Sydney Nursing
School, 3 Coordinator for Masters of Nursing (Nurse Practitioner), Senior Lecturer, Sydney Nursing School, University of
Sydney, 4 Nurse Practitioner, Campbelltown Hospital, Sydney, NSW, Australia
CURRIE J., CHIARELLA M. & BUCKLEY T. (2013) An investigation of the international literature on
nurse practitioner private practice models. International Nursing Review 60, 435447
Aim: To investigate and synthesize the international literature surrounding nurse practitioner (NP) private
practice models in order to provide an exposition of commonalities and differences.
Background: NP models of service delivery have been established internationally and most are based in the
public healthcare system. In recent years, opportunities for the establishment of NP private practice models
have evolved, facilitated by changes in legislation and driven by identification of potential patient need. To
date, NP private practice models have received less attention in the literature and, to the authors knowledge,
this is the first international investigation of NP private practice models.
Design: Integrative literature review.
Method: A literature search was undertaken in October 2012. Database sources utilized included Medical
Literature Analyses and Retrieval (MEDLINE), the Cumulative Index of Nursing and Allied Health Literature
(CINAHL), ProQuest, Scopus and the Cochrane Database of Systematic Reviews (CDSR). The grey literature
was also searched. The following Medical Subject Headings (MeSH) and search terms used both individually
and in combination included nurse practitioners; private practice; joint practice; collaboration; and insurance,
health and reimbursement. Once literature had been identified, a thematic analysis was undertaken to extract
themes.
Results: Thirty manuscripts and five publications from the grey literature were included in the final review.
Private practice NP roles were identified in five countries, with the majority of the literature emanating from
the USA. The thematic analysis resulted in the identification of five themes: reimbursement, collaborative
arrangements, legislation, models of care and acceptability.
Conclusion: Proportionally, there are very few NPs engaged in private practice internationally. The most
common NP private practice models were community based, with NPs working in clinic settings, either alone
or with other health professionals. Challenges in the context of legislation and financial reimbursement were
identified in each country where private practice is being undertaken.
Keywords: Advanced Practice, International Health, Literature Reviews, NursePhysician, Nurse Practitioner,
Nursing Legislation, Nursing Models, Nursing Regulation, Credentialing, Registration
Correspondence address: Ms Jane Currie, Faculty of Nursing, University of Sydney, 88 Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Tel: +61-416647340; Fax:
+61 2 9036 0000; E-mail: jane.currie@sydney.edu.au.
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Literature Review
436
J. Currie et al.
Introduction
Nurse practitioner (NP) models of service delivery have evolved
internationally, and in some countries, the NP models have
been established in both public and private healthcare systems.
In most countries, NP private practice models are less well
established than public NP practice models and this is further
reflected in the quantity of literature available. These roles are
relatively new to Australia and there is a paucity of literature
identifying their current shape and form. The intent of this
investigation is to explore the international literature relating to
NP private practice models to seek an understanding of how
private practice models have manifested to provide an exposition of commonalities and differences between countries.
Background
NPs are registered nurses who have been trained to perform at
an advanced level of assessment and clinical decision-making.
While the specific definition differs between countries, common
characteristics of the role include the authority to diagnose, prescription of medication, referral for investigations and referral
to other health professionals (International Council of Nursing
Nurse Practitioner/Advanced Practice Nurse Network 2013).
The first country to establish the NP role was the USA, where
the role was implemented in the 1960s to meet the rising
demand for health care in rural and underserved areas (Savrin
2009). Since the introduction in the USA, the role has been
introduced through Europe, Africa, Asia and Australasia, with
NP roles formally recognized in 23 countries by professional
organizations, the government and professional bodies (Pulcini
et al. 2012). The majority of literature on the NP role is published within the Western countries and there is less in the
English-speaking publications from Asian and African countries, although some will be cited in this review (Sheer & Wong
2008). While these roles share the title of NP, there are many differences in the character and implementation of the NP role
internationally. This includes variation in the educational background required, scope of practice, legal authority to prescribe
medications, legislation and even the definition of the NP role
(Pulcini et al. 2012; Sheer & Wong 2008).
Taking the issue of legislation as an example, in the UK, the
NP role is not formally regulated and this is reported to have led
to variation in educational preparation and inconsistency in the
model of care provided by NPs (Griffin & Melby 2006). In contrast, the role of the NP in Australia is regulated, with clear educational pathways to endorsement (Nursing and Midwifery
Board Australia 2011). Australia is similar to the USA, where
educational pathways exist and legislation provides boundaries
and restriction to the NP scope of practice. In the USA, these
boundaries and restrictions may differ from state to state
Aim
The aim of this review is to investigate and synthesize the international literature surrounding the practice model of the NP in
private practice in order to provide an exposition of commonalities and differences.
Methods
For the purpose of this review, the NP private practice model
has been defined as one by which reimbursement for health care
provided by an NP is based on fees for service received from an
individual, health insurance scheme or other third party. Identifying literature that focused specifically upon the NP in private
practice was challenging, given that the funding for healthcare
delivery services differ between countries and applying the definition of private practice required an understanding of each
service. The chosen definition is focused upon the financial
reimbursement aspect of the NP private practice model because
this appeared to be the most fundamental delineating characteristic. This definition does not therefore include the other
Results
Countries from which relevant literature relating to NP private
practice was identified included Australia, South Africa,
437
n=4261
Title and abstract screened and inclusion/exclusion
criteria applied:
Inclusion:
2002Oct 2012
English language
Relevant to private practice NP model
Exclusion:
Non-nurse practitioner roles
Roles not meeting definition of private practice
n= 267
Duplicates removed: n= 45
Final sample
Included n= 30
Fig. 1 PRISMA diagram.
438
J. Currie et al.
Method
Purpose
Key content/findings
Barry (2005)
Discussion paper
Establishing a private
practice
Lindeke et al.
(2005)
USA
Kaplan & Brown
(2004)
Phillips (2005)
Hansen-Turton
et al. (2006)
Clarin (2007)
Phillips (2007)
Discussion paper
Coddington &
Sands (2008)
Literature review
Weiland (2008)
Literature review
Pearson (2009 )
Bauer (2010)
Economic discussion
Brown (2007)
Factors affecting
collaboration between NPs
and physicians
439
Table 1 Continued
Author
Method
Purpose
Key content/findings
Buppert (2010)
Column
Hansen-Turton
et al. (2010)
Discussion paper
Maylone et al.
(2011)
Descriptive study,
convenience sample, n = 99
NPs, completed a
Dempster Practice
Behaviour Scale
Discussion paper
Presley (2010)
Fairman et al.
(2011)
Discussion paper
Lee (2011)
Discussion paper
Restrictions imposed by
collaborative arrangements
Pericak (2011)
Discussion paper
Case study
Economic analysis
commissioned by Office of
the Chief Nursing Officer,
Queensland Health
Discussion paper
Australia
Cashin (2006)
Deloitte (2010)
Harvey (2011)
Legislation as a barrier to
NPs working to full scope
of practice
Acceptability of NP care
Parker et al.
(2012a)
Parker et al.
(2012b)
Acceptability of NP care
Literature review
Report
South Africa
Geyer et al. (2002)
Regensberg (2008)
440
J. Currie et al.
Table 1 Continued
Author
Thailand
Hanucharurnkul
et al. (2002)
Hanucharurnkul
(2007)
UK
Crumbie (2006)
Method
Purpose
Key content/findings
Descriptive report
Case study
NP partnership within GP
surgery
Title
Website
http://www.nurses.org.za
http://www.info.gov.za
http://www.health.wa.gov.au
http://www.aanp.org
http://www.abc.net.au
along with the longevity of the private NP role and the model
for health funding in the USA, which is predominantly privately
funded with subsidized health care available to the uninsured
(USA DoH & Human Services). The other four countries where
NP private practice models were identified have in common
healthcare systems that are based upon universal cover1 with
private health care available to those electing to be insured
(DoHA Australia 2012a; DoH South Africa 2012; Ministry of
Public Health Thailand 2012; DoH UK 2013).
Universal health cover refers to health provision that all people can use
including health promotion, health prevention, curative treatment and
rehabilitative services. These health services are of sufficient quality to be
effective whilst ensuring that the use of them does not expose the user to
financial hardship (WHO 2013).
A thematic analysis of the content of the publications formally included in this review was undertaken. A number of
themes were determined; some showed commonalities and
some showed marked differences between countries. The most
prevalent themes were reimbursement and financial viability
and collaborative arrangements. The themes of models of care,
legislation and acceptability were also identified.
Discussion
There are far fewer NPs working in private practice models per
overall numbers of NPs identified than there are working in
non-private practice models. Even within the USA, where NP
services are more established than in other countries, only 6%
(national total NPs n = 128 000) of NPs function within a
private practice model (American Association of Nurse
Practitioners 2012; Auerbach 2012). This compares with an estimated 10% (national total NPs n = 845) within Australia
(Department of Health Victoria 2013), although the small
overall numbers may inflate the percentage somewhat (Buckley
et al. 2013; Porter 2012). From the literature, it was not possible
to determine the proportions of NPs in private practice in the
other countries.
Legislation
441
Fairman et al. 2011; Weiland 2008). There is evidence that legislation is poorly understood by NPs (Kaplan & Brown 2004)
and, in some circumstances, is difficult to comply with (Geyer
et al. 2002).
As an example of the complexity of the legislation, historically in South Africa, NPs who wanted to practise privately
had the option to establish a group practice within the community and provide primary care services (Geyer et al. 2002).
Regulation 387 of the Nursing Act (1978) (South African
Nursing Council) stipulated that nurses and midwives may
only enter a group practice with a person registered under the
same Act (Geyer et al. 2002). This precluded them working in
collaboration with physicians or allied health professionals,
unless an exemption to this regulation was approved by the
Nursing Council. This legislation has since been amended and
health professionals registered under different Acts may now
be employed by each other (Health Professionals Amendment
Act 29 of 2007 of the Health Professions Act 56 of 1974).
In the USA, the legislation underpinning the practice of NPs
differs between States quite markedly and has implications for
the NPs scope of practice and ability to access reimbursement.
For instance, in Alabama and West Virginia, a prescriptive
agreement between the NP and supervising physician is
required in order for the NP to prescribe, whereas in Washington and Wyoming, this is not required (Pearson 2009). Similarly, in the State of Delaware, physician involvement is
necessary in the diagnosis and treatment of patients under the
care of a NP, whereas this is not required in Montana (Pearson
2009).
It has been argued that the legislation surrounding the NP
role in the USA has imposed constraints that impede the NPs
ability to function to their full scope of practice, in both private
and public roles (Weiland 2008). The process of accessing a
physician for a countersignature or for consultation can be
time-consuming and places restrictions on the NPs ability to
practise (Lee 2011). It has been proposed that revising these
areas of legislation, in particular, would allow NPs far greater
independence in their practice (Pericak 2011) and would
improve their ability to maximize their scope of practice to the
benefit of patients.
Models of care
442
J. Currie et al.
443
NHMCs, who often struggle for reimbursement as a consequence. Despite this, the NHMCs are thriving and have recorded over 2.5 million patient encounters each year with the
capacity to care for even more (Hansen-Turton et al. 2006,
2010). The government has offered financial grants to some
NHMCs to relieve the financial burden (Hansen-Turton et al.
2010).
In circumstances where it is difficult to obtain direct reimbursement, NPs in the USA appear to seek alternative methods
of reimbursement, which includes billing through medical practitioners. While this enables the sustainability of their role, it
can hide the contribution they are making to patient care,
impede their ability to practise truly independently (Weiland
2008) and potentially deter them from establishing independent
private practices. In recent years, NPs in the USA have been
included on some managed care provider panels, which was
perceived as a sign of increasing acceptance (Towers 2005).
However, as previously stated, in certain States, NPs are currently unable to receive 100% reimbursement for the service
they provide and, in order to sustain private practice, NPs must
ensure high volumes of patients (Coddington & Sands 2008;
Presley 2010).
Ensuring high volumes of patients has the potential to
encourage NPs to work more quickly and to perhaps be less
thorough and it may even herald a cultural shift in the way NPs
approach care. Literature from the public sector has reported
that NPs spend longer periods of time consulting with their
patients, which has been linked to patient satisfaction and the
quality of care provided by NPs (Horrocks et al. 2002; Laurant
et al. 2008). Increasing the number of patients treated and
shortening consultation time may impact on the level of patient
satisfaction and the quality of care provided.
In Thailand, patients paid directly for the services the NPs
provided and, in instances where patients could not afford
the costs associated, some clinics allowed payment in vegetables rather than money (Hanucharurnkul et al. 2002). The
remote community clinics are up to 50% lower in cost than
the same services provided by physicians and this has allowed
the clinics to be more accessible for the communities they
served and increased patient satisfaction (Hanucharurnkul
et al. 2002).
Collaborative arrangements
444
J. Currie et al.
Limitations
In presenting the results of this review, identifying literature
pertaining to the role of the private NP was challenging. The
majority of existing literature on the NP role focuses on
elements of the public role, rather than the private, and this
may be a reflection of the infancy of the role and the number
of NPs engaged in private practice. The exclusion and inclusion criteria for the literature search focused upon literature,
which held relevance to the NP private practice role, and
while this is an ambiguous term, it was necessary in order to
identify the full body of literature available. If the exclusion
and inclusion criteria had been more specific, then papers
identifying collaboration and reimbursement issues may not
have been identified.
Despite the breadth of this search, very few international
papers were identified that reported private practice NP models.
When interpreting the results of this review, it is possible that
the body of literature presented here provides a limited perspective of the true state of NP private practice internationally.
However, this review will provide initial insight into a topic area
that is less well explored than its public NP counterpart and
potentially stimulate further exploration of the practice model
of the private practice NP.
Conclusion
This review has provided an investigation and synthesis of the
international literature surrounding NP private practice models
and explored the commonalities and differences therein. There
appear to be very few published accounts of NPs engaged in
private practice. In countries where private practice is established, these practice models are predominantly community
based rather than hospital based and more often located in
underserved areas of the community. It seems worldwide that
Author contributions
JC: study design, data collection, analysis and interpretation of
literature, discussion, writing, manuscript preparation; MC:
interpretation of literature, discussion, writing; TB: interpretation of literature, discussion, writing.
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