A framework of the institutional policies and practice environments of nurse practitioner primary care models: A cross-case analysis.

Abstract

The purpose of this article was to compare the implementation of distinct models of nurse practitioner (NP) integration into primary care offices. A multiple case study design of three NP primary care practice models allowed for in-depth exploration of the management processes supporting the utilization of NPs. At each site, semistructured qualitative interviews, document review, and site tours/observations were conducted and subject to cross-case analysis guided by the NP Primary Care Organizational Framework (NP-PCOF)-developed for this study based on existing theory. Our case study sites represent three distinct NP primary care models. In the restricted practice model, NPs care for same-day/walk-in acute patients. NPs in the independent practice model have an independent panel of patients and interact collegially as independent coworkers. NPs in the comanagement model function on a team (a physician and two NPs), have a team office space, collectively care for a shared panel of patients, and can earn financial bonuses contingent upon meeting team quality metrics. Our cross-case analysis confirmed differences in physical space design, the relational structure of a workplace, and the capacity for innovation via NP compensation and performance metrics across different NP primary care models. Our findings suggest that NP primary care models are supported by complex management systems and the NP-PCOF is a tool to help understand this complexity. The NP-PCOF is a framework to understand the management systems that facilitate the utilization of NPs within primary care organizations.