Nurse practitioners and pharmacist prescribers in primary health care: A realist evaluation of the New Zealand experience
Internationally, health workforce redesign provides a means to cope with an increasing demand for health services. The development of advanced practitioner professions provides a major change in health service delivery that challenges traditional practice boundaries. Yet, we know very little about how to introduce such roles into existing health systems successfully. This research investigates how nurse practitioner and pharmacist prescriber roles are developing in New Zealand primary health care, and what is needed to better support the future development of these roles. A realist methodology guided this research. The study used a qualitative research design involving semi-structured interviews of (1) policy, training, and advocacy stakeholders; (2) primary health care nurse practitioners, pharmacist prescribers, and general practitioners; and (3) patients of advanced practitioners and carers of patients using such services. Documents provided by interviewees relating to practice-specific roles supplemented these interviews. Data analysis facilitated the generation, testing, and refinement of theories on nurse practitioner and pharmacist prescriber role development. This research provided an account of the complexities of developing new health professional roles in an already established health system. Theories formed in this research considered advanced practitioner role creation, realisation, and subsequent delivery of health services. Mechanisms for their development included: (1) engagement in planning and integrating roles; (2) establishing opportunities as part of a well-defined career pathway; and (3) championing role uptake and work to full scopes of practice. Various health system and workplace contexts, practitioner goals, and patient needs influenced the ability for these mechanisms to trigger and thus have an effect on role development. Theories arising from this research emphasise the complexity inherent in the development of advanced practitioner roles. In addition, the findings demonstrate that a structured and informed health workforce redesign could improve use of roles, such as those of the nurse practitioner and pharmacist prescriber. In light of these results, this study recommends, implementing a national strategy that aligns policy and practice decisions if we are to succeed in making better use of such practitioner skills and expertise.