Nurse practitioners, canaries in the mine of primary care reform

Citation for this paper:

Contandriopoulos, D., Brousselle, A., Breton, M., Sangster-Gormley, E., Kilpatrick,

K., Dubois, C., Brault, I. & Perroux, M. (2016). Nurse practitioners, canaries in the

mine of primary care reform. Health Policy, 120, 682-689.

http://dx.doi.org/10.1016/j.healthpol.2016.03.015

UVicSPACE: Research & Learning Repository

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Nurse practitioners, canaries in the mine of primary care reform

Damien Contandriopoulos, Astrid Brousselle, Mylaine Breton, Esther

Sangster-Gormley, Kelley Kilpatrick, Carl-Ardy Dubois, Isabelle Brault, Mélanie Perroux

2016

© 2016 The Authors. Published by Elsevier Ireland Ltd. This is an open access

article under the CC BY-NC-ND license (

http://creativecommons.org/licenses/by-nc-nd/4.0/

).

This article was originally published at:

ContentslistsavailableatScienceDirect

Health

Policy

jo u r n al h om ep age :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Nurse

practitioners,

canaries

in

the

mine

of

primary

care

reform

Damien

Contandriopoulos

_,

_Astrid

_Brousselle

_,

_Mylaine

_Breton

_,

Esther

Sangster-Gormley

_,

_Kelley

_Kilpatrick

_,

_Carl-Ardy

_Dubois

_,

Isabelle

Brault

_,

_Mélanie

_Perroux

a_{Facultédessciencesinfirmières,UniversitédeMontréal,Canada} b_{Institutderechercheensantépubliquedel’UniversitédeMontréal,Canada}

c_{Départementdessciencesdelasantécommunautaire,UniversitédeSherbrooke,Canada} d_{Centrederecherchedel’hôpitalCharles-LeMoyne,Canada}

e_{SchoolofNursing,UniversityofVictoria,Canada} f_{Maisonneuve-RosemontHospitalResearchCentre,Canada}

a

r

t

i

c

l

e

i

n

f

o

Received7July2015

Receivedinrevisedform14March2016 Accepted29March2016 Keywords: Nursepractitioner Primarycare Quebec Reform

a

b

s

t

r

a

c

t

Astrongandeffectiveprimarycarecapacityhasbeendemonstratedtobe crucialfor

controllingcosts,improvingoutcomes,andultimatelyenhancingtheperformanceand sus-tainabilityofhealthcaresystems.However,currentchallengesaresuchthatthefutureof primarycareisunlikelytobeanextensionofthecurrentdominantmodel.Profound envi-ronmentalchallengesareaccumulatingandarelikelytodrivesignificanttransformation inthefield.Inthisarticlewebuildupontheconceptof“disruptiveinnovations”to ana-lyzedatafromtwoseparateresearchprojectsconductedinQuebec(Canada).Resultsfrom bothprojectssuggestthatintroducingnursepractitionersintoprimarycareteamshasthe potentialtodisruptthestatusquo.Weproposethreescenariosforthefutureofprimary careandfornursepractitioners’potentialcontributiontoreformingprimarycaredelivery models.Inconclusion,wesuggestthat,likethecanaryinthecoalmine,nursepractitioners’ placeinprimarycarewillbeanindicatoroftheextenttowhichhealthcaresystemreforms haveactuallyoccurred.

©2016TheAuthors.PublishedbyElsevierIrelandLtd.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Astrongandeffectiveprimarycarecapacityhasbeen demonstratedtobecrucialforcontrollingcosts,improving

∗ Correspondingauthorat:UniversitédeMontréal,Facultédessciences infirmières,C.P.6128succursaleCentre-ville,Montréal,QuébecH3C3J7, Canada.Tel.:+15143436111x35176.

E-mailaddresses:damien.contandriopoulos@umontreal.ca

(D.Contandriopoulos),Astrid.Brousselle@USherbrooke.ca(A.Brousselle),

Mylaine.Breton@usherbrooke.ca(M.Breton),egorm@uvic.ca

(E.Sangster-Gormley),kelley.kilpatrick@umontreal.ca(K.Kilpatrick),

carl.ardy.dubois@umontreal.ca(C.-A.Dubois),

isabelle.brault@umontreal.ca(I.Brault),

melanie.perroux@umontreal.ca(M.Perroux).

outcomesandultimatelyenhancingtheperformanceand sustainabilityof healthcaresystems[1–4].However,the primarycarecapacitiesofCanada’sprovincialhealthcare systemsaremeagerincomparisontothoseofotherrich countries[5–13].Moreover,theweaknessofprimarycare inCanadaisnotatransientfeature.Despitebeing iden-tifiedasapriorityinallprovincesanddespitesignificant investments,thepromisedresultshavenotmaterialized [5,6].Thissuggeststhatthecausesarestructuralinnature andthatthecurrentsituationislikelyaproductof deeply-rootedsystemiccharacteristics[14,15].

As we argue, current challenges are such that the future ofprimary careis unlikelytobean extensionof today’sdominantmodel.Verysignificantenvironmental

http://dx.doi.org/10.1016/j.healthpol.2016.03.015

0168-8510/©2016TheAuthors.PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons. org/licenses/by-nc-nd/4.0/).

challengesareaccumulatingandlikelytodrivesignificant transformationinthefield.

Inthisarticle,wesummarizeandintegratethefindings fromtwooriginallyunrelatedresearchprojectstoconsider scenariosforthefutureofprimarycaredeliverymodels andthepotentialroleofnursepractitioners(NPs)in pri-marycarereform.WeusethetermNPtodescribenurses withgraduateleveluniversitytrainingandanextended scopeofpractice,includingsomeprescribingrights,which allowsthemtodiagnoseautonomouslyandtreatavariety ofcommonconditions.

Attheconceptuallevel,weuseandextendtheconcept of“disruptiveinnovations”proposedbyChristensenand colleagues[16–18]todiscussempiricaldataderivedfrom two separate but surprisingly complementary research projects.ThefirstwasonprimarycareNPintegrationin Quebec.Thesecondfocusedoncorestakeholders’ percep-tionsofthechallengesfacingQuebec’shealthcaresystem andsolutionstoovercomethem.Theunexpectedlevelof convergenceintheresultsofthoseprojectspromptedusto reflectonNPs’roleandpositioninthecontextofprimary carereform. Inthefirstsection,wepresentand discuss theconceptof“disruptiveinnovations”andits contribu-tiontounderstandingprimarycaresystemreform.Wethen brieflydescribethedataandresultsofbothprojectsand howtheirintersectionsupportsadiscussionofdifferent scenariosforthefutureofprimarycaredelivery.

2. Disruptiveinnovationsandhealthcarereform

Nearlytwodecadesago,Christensen[19]developedthe conceptofdisruptiveinnovationsthathassincebeen fur-therdiscussedand appliedinseveralotherpublications [16–18].Thecoreideaisthatfromtime totime atruly radicalinnovationwillfundamentallyreorganizeafieldby changingtheverynatureofproductsandthewaytheyare embeddedinamarket.Theprocessissomewhatsimilarto theconceptofparadigmchangeintheevolutionofscience [20].Aninterestingfeatureoftheprocessasdescribedin Christensen’sworksisthatdisruptionisusuallybrought aboutbyproductsorservicesthatmaybeviewed,atleast inthebeginning,asnotasgoodasthedominantones.This isbecause,asdominantproductsevolve,theygrowever moresophisticatedandexpensive,untiltheyexceedthe needsofmostconsumers.

Thisideawasspecificallyappliedtothefieldof health-care by Christensen et al. [16], who argued that the autonomousevolutionofthehealthcareservicesmarket ispoorlymatchedtotheevolutionofpatients’needs.The sophistication,specializationandpriceofhealthcare ser-vicesareallsteadilyincreasing,withlittlebenefittomost patients. Careis mainlydeliveredin excessively expen-sivestructures(generalhospitals)byahighlyskilledand evermorespecializedworkforce,butwithoutmuch con-siderationfor serviceconvenienceorfor optimizingthe efficiency of processes. Healthcare is alsoa particularly interestingcontextinwhichtoapplythenotionof disrup-tionbecauseofgrowingevidencethat,inhealthcare,lessis oftenmore[4,21–28].Inotherwords,theclinicalbenefits ofmanyinvasive,intensiveandexpensivetreatmentsand oftechnology-intensivemodelsofcareareoftenmodestat

best.Thisimpliesthatmanypatientswouldbenefitfrom moreprimarycarethanspecializedcare,morehomecare thanhospitalcare,andmorelow-techinterventionsthan heroicmedicine.Likewise,wheneverpossible,substituting familydoctorsforspecialistphysicians,andnurses, phar-macistsandotherprofessionalsforfamilydoctorsallows efficiencyandclinicalgains[29–37].

Regardingtheoptimizationofcaredelivery,itshould benotedthatthedisruptionframeworkisahighly func-tionalistperspectivefocusedonthetechnicalaspectsof care.Suchaperspectivedisregardssocial factorsatplay inthedefinitionof diseases,legitimate health interven-tionsandprofessionalboundaries.Webelieveredefining professionalboundaries(whotreatswhom)willhavean important impact on the definition of illness and care (howtotreatwhat).Perspectivesanchoredin structural-isttraditions[38–41] suggest thatdisrupting thestatus quo involves much more than replacing physicians by nursesforthesametechnicalintervention.Movingtoward interdisciplinaryprimarycareteamshasimplicationsfor professional boundaries, the nature of the professions involved and what is understood by primary care and health.Conceivingofthedisruptionofthecaredelivery statusquoasacomplexsocialphenomenonwillbeuseful inunderstandingthechallengesinvolved.

Withrespecttothenecessaryconditionsforchange,the disruptiveinnovationsconceptualframeworkisanchored in economic theory and underlying rational behavior approaches. It stresses that neither technological inno-vations nor market forces on their own could explain disruptions.Itisthecombinationofaninnovation (tech-nologicalenabler),aviablebusinessmodeltodevelopthis innovation,andamarketforit(valuenetwork)thatwill imbueagiveninnovationwithdisruptivepotential.Thus, disruptivepotentialdoesnotdependsomuchonan inno-vation’sintrinsiccharacteristicsasonitscompatibilitywith thelargercontextandmarket.

InCanada’shealthcaremarket,mostservicesare cov-eredbyprovincial,universalandpublicinsurancesystems funded through generaltaxation (Beveridgean System). Servicesarefreeforpatientsatthepointofcare.In Que-bec,whereourstudieswereconducted,hospitalsandother health institutionsare generally funded though histori-callyset budgets. Non-physicianstaff and professionals arealmostentirelysalariedfromthosebudgets,whereas physiciansaremostly paidthroughfee-for-service(FFS) fromaseparateenvelope.Thereisthusnoemploymenttie betweenhospitalsandphysicianspracticing insidetheir walls,andevenlessdirectcontroloverprimarycare physi-ciansoutsidehospitals.Overthepastdecade,abundleof financialincentiveshasbeenrolledoutforphysiciansto increasepatientrostering andimproveaccessibilityand continuity,butwithlimitedeffect.Giventhenatureofthe healthcareservicesmarketinCanadaandQuebec,three aspectsoftheframeworkaspresentedbyChristensenetal. [16]warrantdiscussion.First,fortheoverwhelming major-ityofcareprovided, patientsincurnoco-paymentsand thusarenotsensitivetothecostofservicesprovided.Yet theoverall costsofhealthcare servicesare borneby all citizensandexertapowerfulpressureonpublicfinances. Moreover,evenifpatientsarenotsensitivetothecostof

services,thelimitedaccessibilityofprimarycareservices translatesintosignificantopportunitycostsforthem,such aslostworktime,andpatientsareverysensitivetothe convenience,orlackofthereof,ofservices.Second,for pri-marycareservicesthereislittleornosurpluscapacity.It isthuslikely thateveryproviderwillobtaina satisfying marketshareregardlessofthequalityorconvenienceof servicesprovided.Third,evenifmostofthemarket-based pressuresareabsent,therearestrongenvironmentalforces pushingforredefinitionofthevaluenetworkofprimary caredelivery,whichweshoulddiscussinsomedetailhere. Theperformanceofprimarycaredeliverystructuresin Quebecisdisappointingintermsofaccessibility,continuity andcomprehensiveness,allofwhichtranslatesintooneof thelowesthealthcaresystemconfidenceratesamongrich countries[5,6,9,10,42].Whetherwarrantedornot,the cur-rentlevelofpatientdissatisfactionandlackofconfidence inthehealthcaresystemisinitselfastrongpoliticalthreat tothestatusquo[14,43].Similarly,thelong-term linear-ityandpaceatwhichhealthexpendituresareoutstripping economic growthis a powerfulincentive toimplement radical change [44]. The status quo is also being chal-lengedfromtheinside,asmanyolderfamilydoctorswho followlargepatientpanelsareretiringorwillberetiring soon;even thoughtheratioofdoctorstoinhabitantsis rising,newlytrainedfamilydoctorsseemtofollowfewer patientsandspendmoretimeinhospitals,makingiteven moreunlikelythataccessibilityproblemsinprimarycare practicewilldissipateontheirown.Recentinvestmentsin physiciancompensationseemtohave,ifanything, exacer-batedtheproblems[45].

3. Datasourcesandmethods

Asstated intheIntroduction,thisarticleis basedon datafromtwounrelatedresearchprojectswhoseresults unexpectedly intersected. The first wasa study on the integrationofNPsintoQuebec’sprimarycareteams.The secondwasastudyofstakeholders’viewsaboutthefuture of Quebec’s healthcare system, its problems, and how toimproveitsperformanceandensureitssustainability. There was some overlap in team composition, as two researcherswereinvolvedinbothprojects(thefirstproject involvedeightmembersandthesecond,six).However,the projectswereconductedindependentlyandno intercon-nectionincontentwasanticipatedbeforehand.Forthesake ofbrevity,thedetailedmethodologyofthesetwoprojects willnotbedescribedhere,butthefollowingparagraphs presentanoverviewofthedatacollected.

3.1. Project1:NPintegrationinQuebec

In2010,Quebec’sgovernmentannounceditwould sup-portNPpracticeandfundtheintegrationof500NPsinto primarycareteamsover thenextdecade[46].Thiswas thestartingpointforaresearchprojectfocusedon sup-portingprimarycareteamsthatintegratedNPstooptimize caredeliverymodels,processesandroles.Project1began withalogicanalysis,inwhichwesystematicallysearched the scientific literature to identify peer-reviewed and greydocuments addressingNP integration and practice

models.Logicanalysis[47]sharesmanysimilaritieswith therealistreviewapproach[48],butisspecificallyfocused on understanding the causal mechanisms between an interventionanditseffects.Ouraimwastounderstandthe factorsandmediating variablesthatinfluencethe effec-tiveness ofNP integrationintoprimary careteams. We selectedanditerativelyanalyzed58documentstobuilda preliminaryconceptualmodel,followingtherealistreview approach[48–51].

Then,weconductedanimplementationanalysisusing acasestudyresearchdesign(n=6)inthreehealthregions ofQuebec.Eachcasewasdefinedasaclinicalteaminto whichoneormoreNPshadbeenintegrated.Thecase stud-iesincluded34 semi-structuredinterviewswithclinical teammembersandotherkeyactors,aswellasanalysis ofavailabledocumentation.

Althoughtheaimoftheprojectwastoprovidepractical advicetoprimarycareteams,italsocontributedtobroader macro-level evidence onthedeterminantsof successful integrationofNPsintoprimarycareteams.

3.2. Project2:stakeholders’viewsonthefutureof Quebec’shealthcaresystem

Project2,stillongoingasthisarticlewasbeing writ-ten,ismoremacroandpolicy-orientedinfocus.Itsstarting pointwasthehypothesisthatthereisgeneralconsensus among healthcaresystemstakeholdersthat changesare neededtoimprovetheperformanceandsustainabilityof Quebec’shealthcare system,but thatthereissignificant divergenceintheirpolicypreferences.Toassessthelevel of consensusontheneedforsignificantreform of Que-bec’shealthcaresystemandtoidentifypolicypreferences, weconductedsemi-structuredinterviewswithcore stake-holdersinthesystem[52,53];inall,31interviewswere conducted, lasting from45minto 2h. Informants were selectedbecausetheyoccupiedor hadoccupiedcentral positionswithinorganizationspotentiallyinfluencingthe evolutionofthehealthsystem(e.g.deansofhealth profes-sionfaculties,presidentsofprofessionalassociations,CEOs oflargeinstitutions).Theinterviewswereloosely struc-turedaroundfourquestions:(1)Whatarethestrengthsof thecurrenthealthcaredeliverysystem?(2)Whatarethe mainchallengesandproblemsfacingthehealthsystem? (3) Whatarethesolutionsneededtotackle those chal-lengesandimprovetheperformanceof thesystem? (4) Whoarethemostpowerfulactorsandinterestgroupsable toshapepolicy-makinginthehealthcaresystem? Sophis-ticatedcodingbasedonsocialnetworkanalysisanddata visualizationtechniqueswereusedtomakesenseofthe data[52,53].

4. Results:twoprojectsthatintersect

Analysis of those two projects’ results showed that many of the best practices and facilitating factors for integratingNPsintoprimarycaredeliverystructures cor-responded to the macro solutions suggested by core stakeholderstoimprovethehealthcaresystem’s perfor-manceandsustainability.Thisstrongintersectionwasthe startingpointforourhypothesisthattheplaceoccupiedby

NPsinprimarycaredeliverysystemsisacrucial determi-nantofthepotentialfordisruptingthecurrentmodel.

A strikingobservationfromtheavailableevidence is that NP integrationisnot a simple and straightforward process. BecauseNPs’scopeof practiceandroles areat theintersectionofmedicineandnursing,theirintegration involveschallengingexistingroledefinitionsofboth reg-isterednursesandphysicians.Thisisnotasinequanon conditionforintegration;manysettingsdidnotredefine rolesandinsteadgaveNPseitheranurse-plusor physician-minusrole.However,failuretoredefineprofessionalroles andworkorganizationwithinteamsjeopardizesthe capac-itytoimplementsignificantprimarycarereform.Inthis regard, NP integration can be seen as a catalyst, as it providesanopportunitytochallengethestatusquoand optimizesubsidiarityinroledefinition.

InQuebec,asinmostCanadianprovinces,the domi-nantmodelofprimarycaredeliveryisstillinfluencedby solomedicalpractice[54].Thatis,eventhoughmost physi-ciansnowpracticeingroupsettings,thedominantmodel intermsofcareprocessesisoneinwhicheachphysician autonomously providescaretohis/her own patients. In suchsettings,nursesoftenhaveanarrowscopeofpractice, and thesharingofresourcesandresponsibilities among clinicians (physicians, nurses,and others) is limited, as isteamaccountabilityforpatientcare.Yetavailable evi-dence[15,54–58] showseffectivenessand efficiencyare improvedbymovingtoatrulyinterprofessionalmodelin whichnurses,NPs,pharmacists,socialworkers, psychol-ogists,andotherhealthprofessionalsallworktothefull extentoftheirscopeofpractice,and inwhich patients, resources and responsibilities are sharedby thewhole teamandprofessionalrolesaredefinedinaccordancewith patients’needs.

Beyondroledefinition,primarycareteamsshouldalso taketheopportunitytorethinktheircaredelivery mod-els. In most clinics the model is supply-driven rather thanneed-based;thatis,servicesoffered,hours, appoint-ment scheduling, etc., are generally defined according tophysicians’preferencesratherthanpatients’needsor preferences.Sincemostfamilydoctorsareself-employed entrepreneurspaidmostlythroughFFS,andsinceprimary caredemandoutstripssupplybyavast margin,there is little incentive tochange. Quebec’sNP integration plan [59–62]involvesdispatchingNPs,whoaresalariedpublic sectoremployees,toworkincollaborationwithphysicians in theirclinics.Theincentives forsalariedNPsand FFS-remunerated physicians are rather different [15,56,63]. DefininghowphysiciansandNPswillsharepatientpanels andwhichpatientsshouldbefollowedbyNPswillhavean impactonphysicians’workloadand,potentially,income. Moregenerally,onceateamstartstoreflectoncare deliv-erymodelappropriateness,effectivenessandefficiency,it alsoopensthedoortoabroaderquestioning.Forexample, isitrealistictoexpectatrulyteam-basedpracticewhen differentremunerationmodelsareappliedtophysicians (FFS)andNPs(salaries)?Whichprofessionalisbestsuited toofferwhatcaretowhichpatient?Isanyonespecifically accountableforaccessibilityofservicesandcontinuityof care?Ifso,isthataccountabilitysharedbytheteam,orisit one-on-onebetweenoneclinicianandonepatient?Iftaken

seriously,thosequestionsarelikelytochallengeexisting professionalrolesandscopesofpracticeandultimatelythe underlyinglogicofprofessionalboundaries[38].

Moregenerally,theavailableevidencereveals consid-erable overlap between the scientific literature on the characteristics of high performance primary care mod-elsandtheliteratureonbestpracticesinNPintegration [1,30,35,52,64–70].Suchanoverlapisalsoobviousinthe resultsfrom theNP integrationproject and those from theprojectonstakeholders’views.Whenthesalienceof thechallengesconfrontingQuebec’shealthcaresystemwas analyzed,fourofthefivemostsalientproblemsand20of the41problemsraisedbyinformantswerefoundtohavea directrelationwithNPintegrationintoprimarycareteams. Similarly,fourofthefivemostsalientsolutionsdiscussed byinformantsand17ofthe46intotalhadtodowithbest practicesorfacilitatorsforNPintegrationandpractice[52]. First, thismeans corestakeholdersshared, toa very large extent, the view that the solutions to the chal-lenges facing the current system are anchored in a stronger and broader primary care capacity. Second, it isnoteworthythat,takentogether,thesolutionspresent a quite coherent model to reform primary care deliv-ery. This reform model calls for significant structural changes,suchasdepartingfromthecurrent mostlyFFS funding mechanism; strengthening providers’ account-ability toward patientsand toward system-wide goals; relyingincreasinglyonnon-physicianprofessionals work-ing within a larger scope of practice; and developing organizationalstructurestosupporttheworkofsuch inter-professionalteams.Third—andthis wasthesurprisefor us—thestructuralchangesneededtoimproveprimarycare and,ultimately,theoverallperformanceandsustainability ofthehealthcaresystemare,toaremarkableextent,the sameasthoseonthelistofbestpracticesandfacilitating factorsforNPintegration.

In our view, this intersection between the two lists—ofsolutions for improvinghealthcare system per-formanceandsustainabilityandofbestpracticesforNP integration—suggestsNPsmaybethe“canaryinthecoal mine”ofthis transformationprocess. Thatis, aprimary caredeliverysystemdisplayingahighratioofNPsinthe workforce,exercisingthefullscopeoftheirpracticeand embeddedintrulyinterprofessionalteams,wouldbethe healthcareequivalentofa last-centurycoalminewitha healthycanary—asignthingsaregoingwell.Conversely, asystemin whichNPsstruggle tofindacoherentplace inprimarycaredeliverystructuresandarepushedtoward nichepracticeorintoworkingaccordingtoa “solo-in-a-group”mode,wouldbeasuresignthatthewholeprimary caremodelisstillveryfarfromimplementingtheneeded transformations.

5. Discussion:threescenariosforthefutureof

primarycare

Inthissection,wepresentthreescenariosforthefuture ofprimarycaredeliverymodelsbasedondevelopingthe ideathatsuccessfulNPintegrationisbothamarkerof pri-marycarereformandapotentialcatalystforreform.

5.1. Scenarioone:perpetuationofthestatusquo

The first scenario consistsessentially of a continua-tion of the existing situation. In this scenario, primary care remains overwhelmingly provided by autonomous physicians working in loosely structured teams. Deliv-ery structures remain mostly under the direct control ofphysicians,whomaintaintheirautonomyindeciding when,whereandhowtheypracticeand whichpatients theytreat.Mostfamilyphysiciansarepartofteam prac-tices, but those structures are little more than a way toshare overhead costs and constraints. Atthe system level,theremightbesomesignificantbutnon-disruptive modifications,suchasagradualincreaseinnon-FFS incen-tives,greaterrelianceoncontract-likeagreementswiththe publicthird-partypayerrelatedtoachievingclinical tar-gets,andothersimilareffortstoexerttop-downcontrol overmedicalpractice.Inthisscenario,mostNPsworkas sub-physiciansubstitutes—theoft-usedterm “physician-extender”isrevealinghere—underthedirectsupervisionof physiciansandwithinphysician-controlledorganizational structures.Moreover,datafromtheUSsuggestthatNPs willnot,inthemselves,driveashiftintheavailabilityor priceofhealthcareservices[66].Asweargueinthenext scenario,todisruptthestatusquo,whatmattersmostis therestructuringofthecaredeliverymodelandnot sim-plythepresenceorabsenceofNPs.Inotherwords,ifNPs areforcedtofindanicheintheexistingecosystem,orvalue network,ofprimarycaredeliveryratherthanbeingableto contributetochangingtheecosystem[16],nodisruption willoccur.

5.2. Scenariotwo:disruptionthroughcompetition

ThesecondscenarioismostlywhatChristensenetal. [16] describe. According to this view, because NPscan respond to a large proportion of primary care needs [36,71–74],especiallyiftheyworkincollaborationwith othernon-physicianprofessionals,theycouldbe instru-mentalindisruptingthedominantmodelofprimarycare delivery.Indeed,NP-intensiveinterdisciplinaryteamshave allthetraitsofadisruptivebusinessmodel:moreefficient, moreconvenientsubstitutesforadominantservicethat isgrowingmoreandmoredisconnectedwithwhatclients needandwant.

Conceivedthisway,thisisascenarioofcompetition,in whichdistinctmodelsofcaredeliveryemergeand com-peteforresourcesandmarketshare.Onemodelislikelyto beamedicalmodelroughlyequivalenttothestatusquo describedabove.Anotherlikelymodelwouldbeanchored innurse-based teamsproviding a non-trivial portionof theoverallsupplyofprimarycare.Nursesinthoseteams wouldincludebothNPsworkingtothefullextentoftheir scopeofpracticeandoutsideofmedicalsupervisionand RNswithadvancedskillsindisease-basedor population-basedprimarycare.SuchNP-basedprimarycarestructures arealreadywell-establishedintheUSandexistinOntario, Canada[71,72,75–77].

Itshould,however,bestressedthatsuchascenarioof competitionmayturnouttobequitefarfromthe micro-economicidealofacompetitivemarket.Thesituationin

theUSsuggestsitmaybemorerealistictoexpectsome formofsegmentationthroughsubmarketsdefinedaround thenatureofcare,specificpopulations,orreimbursement rules [63]. Inthe US,NP-based primary-care deliveryis quiteclearlyskewedtowardruralcommunitiesandpoorer patients[56,65,66].Inthesameway,ongoingpilotprojects inQuebecaretargetedtowardmarginalizedpopulationsor ruralsettingsthatarenotattractivetophysicians.

Webelievetheremightcurrentlybeawindowof oppor-tunityfortheemergenceofavaluenetworksupporting theNP-centeredbusinessmodeldescribedabove.Opening theopportunityforNP-centeredprimarycareteamstoget accesstothesamereimbursementfundsfromwhich med-icalservicesarepaidcouldbethetippingpointwherea competitivescenariobecomespossible[15].

5.3. Scenariothree:disruptionthroughrestructuring Inourview,thecompetitionscenariodescribedabove isneithertheonlynorthemostdesirablewayinwhichNPs canplayaroleindisruptingprimarycaredelivery.Inthe thirdscenario,disruptionisachievedthroughthe restruc-turingofprimarycaredeliverymodels.Thisscenariocould betheculminationofapreviouscompetitiveprocess,in whichadisruptivemodelwouldendupoccupyingmostof themarket.

Here, the emergence of successful nurse-intensive primary care delivery models, combined with mar-ket and political pressures—especially efforts at cost-control—wouldspurtheredefinitionnotonlyofdelivery structures,butalsoofthenatureofprimarycare.

Because of thenatureof theirtraining and scopeof practice, NPswould likely have animportant contribu-tion tomake in redefiningprofessional boundaries and roles.Insuchascenario,caredeliverywouldbeateam, ratherthanindividual,responsibilityandfunding mech-anisms would reflect this fact. Teams would be truly interdisciplinaryandincludeMDs,RNs,NPs,social work-ers,pharmacistsandothers.Morediverseandlargerteams ofless-expensiveprofessionalsremainthemostpromising avenuetoimprovethecurrentsystem’sefficiencyby simul-taneouslyincreasingaccessibilityandcontrollingcosts.In thisscenario,physicianswouldbeaminorityoftheteam’s overallworkforce.

Suchashiftwouldalsohelpredefineprimarycareasa moreinclusiveconceptcombiningpreventive,social, psy-chologicalandoverallwhole-personcare[78],anapproach nurses and NPs have been practicing for many years [79–81].It isunlikely thatthechallenges facing health-caresystemscanbeeffectivelyaddressedbyprovidingever moreintensive,expensiveandspecializedcare.Disrupting theprimarycaredeliverymodelrequiresadeep transfor-mationofthenatureofcareprovided,movingtowardless invasive, less intensivetreatmentoptions,more patient participation,anda“less-is-more”viewofcare appropri-ateness.Assuch,themostdisruptivecharacteristicofthis thirdscenariowouldlieinitspotentialforredefiningthe natureofprimarycare.Astheprofessionalsinvolvedincare deliverychange,sowilltheirunderlyingconceptionsof ill-nessandcare.Thisevolutionrendersthetransitiontoward abroader,moreinclusiveandlessintensivedefinitionor

primarycaremorelikelythanifcaredeliveryremainsa mostlymedicalendeavor.

These three scenarios range fromone inwhich NPs’ potentialcontributionisseverelyunderexploitedtoonein whichtheyareabletocontributetotheoptimalextentof theirrole.Returningtoour“canaryinthecoalmine” anal-ogy,inthestatusquoscenario,theconfinedplacegiven toNPsisaclearsignthat primarycaredeliverymodels have not moved from thepath that ledto the current problems—thebarelybreathingcanarywarnsoftherisk ofabroaderfailureofthehealthcaresystem.Conversely, theplaceandroleofNPsenvisionedinthedisruption sce-narios,andespeciallyintherestructuringone,wouldbe signsofdesirablelarge-scaleandsystemicchanges.

6. Conclusion

A profound reform of primary care delivery struc-turesiscalledforinresponsetochangingenvironmental conditions—technological,fiscal,socialanddemographic. Aswehave,webelieveNPswillplayakeyroleinthereform process.First,asChristensenetal.[16]haveconvincingly argued,NPshaveasignificantdisruptivepotentialas sub-stitutesourcesofprimarycare.Second,astheresultsof studies on NP integration have shown, because of the hybridnatureoftheirclinicalroles,NPs’integrationinto primary careteams alsohasthepotential totriggeran importantredesignofdeliverystructuresandprocesses. Finally, asNP integrationis not a simple plug-and-play innovation,butratheracomplexprocessinvolvinga vari-etyofprofessionalandsocialissues,webelievethat—again like thecanary in the coal mine—the centralityof NPs’ role in future primarycare deliverysystems willsignal theextenttowhichthecurrentdominantmodelhasbeen disruptedandahealthier,moreviableoneestablished.

Thisbringsustothequestionofthedirectionof causal-ity betweenNP integrationand primary care reform. A firstpossibilityisthatoptimalintegrationofNPswilloccur onlyaftersuccessfultransformationoftheexistingprimary careproductionsystemorvaluenetwork.Thesecond, par-allelpossibility,whichinvertsthatcausalrelationship,is thatsuccessfulintegrationofNPswillrequiresignificant changestotheexistingproductionsystem,which,if imple-mented,willleadtodisruptivechangeintheprimarycare deliverystructure.Instrumentally,thissecondpossibility ismuchmoreappealing,asitopensthedoortoNPs’ serv-ingascatalystsforchange.Itshouldalsobestressedthatin practicethosetwocausalrelationscanco-exist: progres-sivegrowthinthecoherentintegrationofNPsinthesystem canspearheadtheemergenceofdisruptivemodelsofcare. GiventhecurrentevolutioninthenumbersofNPsand MDsinNorthAmerica[82,83],thereislittledoubtthat NP-basedprimarycarestructureswillplayaroleinthefuture ofprimarycaredelivery.Therealquestionistounderstand thelevelandnatureofdisruptionthis islikelytobring. Atoneextreme,wecouldimagineanNP-basedequivalent ofthestatusquomedicalmodel.Largeretailstoresinthe USthatofferwalk-inclinicsstaffedbyNPsareanobvious exampleofamarketdisruptionthatfailstoachievereal innovationinthewaycareisdefinedandprovided.Atthe otherextreme,primarycareteamssuchasdescribed in

ourthirdscenariowouldnotonlydisrupttheprimarycare deliverymarket,but wouldalsodisruptsocial identities andthedefinitionofcare.

Inrecentwork,Christensenetal.[17]havesuggested thatdisruptionismuchmorelikelyindomainswhere inno-vationsrelatetowell-defined,straightforwardfunctions.In sectorswherethedisruptionprocesswouldinvolve mod-ifyingdeeply-rootedsocialidentities,theinitialmodelof disruptiveinnovationsneedstoberefined.Thisidea cer-tainlyhasimplicationsforthescenariosoutlinedhere.The positionmedicineoccupiesinoursocietyisveryparticular andanchoredinahistoryofprofessionalstruggleswonby themedicalprofessionovercenturies[38–41].Thechance thatthedefinitionofprimarycarewould,intheshortterm, moveawayfromamedically-centricconceptisverysmall. Aswehavearguedhere,webelievethehybridnatureof NPsandtheirpotentialcontributiontoprimarycare deliv-erycouldbecatalyzingfactorswiththepotentialtotrigger desirable disruptive changes in ourhealthcare systems. Thesecondhypothesisregardingcausalitydirection—that havingmore NPsin a systemcan catalyzea disruption oftheprimary caremodel—has,in ouropinion, enough plausibilitytomeritbeingtriedasadeliberate interven-tion toreform primary care delivery. Recentmultilevel policyrecommendationsforoptimizinginterprofessional workinthehealthsector[15]havehighlightedthe inter-dependence of clinical, organizational and system-level interventionsin achievingchange. The ideasdeveloped herearecomplementarywiththis notionof interdepen-dence. We believe clinical and team-level innovations arisingfrom NP integrationhave the potentialto exert enoughpressureonthesystemtoachievedesirableand much-neededdisruption.

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