Primary Care Nursing for the Ageing Population

Introduction

In healthcare, the role of the registered nurses has widely evolved within the community, primary and secondary settings. Nurses are regarded as pioneers of advanced and enhanced care within various settings and the NHS currently requires an enhanced skilled workforce in managing the ageing population who express the enhanced need of healthcare. In this context, the framework of Advanced Clinical Practitioner (ACP) (Primary Care Nurses) is to be critically discussed to understand its importance for inclusion into the care. Moreover, the impact of inclusion of the ACP primary care nurses in providing healthcare and perception of the patients in the context are to be critically analysed and explained.

Ageing population and Healthcare demand

In the UK, the population is found to be ageing at a steady rate which is evident as the population of people aged 65 years and over from 2017 are projected to increase by 49% in 2040. Moreover, people of 85 years and over would be the more likely aged care group who would require high need of health care services and it is projected to increased to 2.4 million in 2040 compared to 1.4 million in 2017 (AgeUK, 2019). This indicates that in the next decade the number of older people who require additional health needs would increased exponentially in the UK. The study by Cassell et al. (2018) mentions that the prevalence of long-term and chronic conditions increases with age because of the increased fragility and depleting power of the body to function effectively to support enhanced well-being of individuals.

In the aged population, there is high diversity among them and ageing does not mean people would develop health issues. This is because only 45% of the aged people in the UK are mentioned to be suffering from health issues (commonslibrary.parliament.uk, 2021). However, it is argued that with the increasing aged population, the demand the care among them has increased compared to the other age groups. It is evident as in 2018 the demand for adult care has increased by 1.6% since 2015-16 (AgeUK, 2019). In 2021, the King’s Fund has mentioned they received requests for 120,000 elderly care by the end of 20202 and has been able to provide 14,000 or fewer care services in regard to the response (communitycare.co.uk, 2021). Thus, the growing aged population in the UK indicates demands for care for them would be increasing for which effective number of physicians and healthcare professionals are required to be present.

In the UK, it is found there are not adequate number of physicians or doctors actively present to support the rising demand of care. It is evident as in 2019, it is reported that the number of doctors per capita of the population is one of the lowest identified in Europe. There are only 2.8 doctors per 1000 people in the UK while the average is 3.5 per 1000 people in the OECD countries (Moberly, 2017). This indicates that there is need of more physicians or doctors for healthcare in the UK which is currently not available. In this condition, the NHS promoted the use of Advanced Clinical Practitioner (ACP) (primary nurse clinicians) to support the growing need of care among the elderly population as well as others. This is because the nursing clinicians are seen to have added skill and knowledge of sharing some of the responsibilities from the doctors such as medication administration, diagnosis of health condition, delivery primary care without bothering the physicians and others (Thompson et al., 2019). The action is effective to make the nursing clinicians work along with the doctor to reduce their added work pressure by providing care to the less complex elderly patients and others in the primary care situation to improve their well-being (Thompson et al., 2020).

Role of Advanced Clinical Practitioner (ACP) (primary nurse clinicians)

The Advanced Clinical Practitioner (ACP) (primary nurse clinicians) are master’s level educated individuals who have advanced skills and knowledge to expand their scope of practice to meet the needs of the people for offering them advanced care that are responsibilities of higher health professionals (HEE, 2021). One of the domains in which the ACP (Primary Care Nurses) execute their role is person-centred collaborative working. In this domain, their initial role is to effectively communicate and consult regarding health condition with the patients by using sophisticated media and languages such as skype, telephone, email and others along with executing interaction through traditional methods such as face to face and non-verbal communication with the patients (Williams, 2017). However, it is argued by Vanderhaeghen et al. (2019) that failure to play the role of making efficient communication leads ACP fail to develop the health history of the patients and exactly identify probable causes leading to the current health problem of the patients.

The other role of the ACP (primary care nurse) is to holistically practice personalised care for the patients to promote their health and deliver basic care to patients without need of consultation with physicians (Wilcox et al., 2015). It is in contrast to the role of the nurses where they have the role of implementing care with effective consultation and permission from physicians (Chan et al., 2019). Thus, the role of ACP is more effective than registered nurses as it impacts to improve the health of the patients by delivering person-centred care with personal efficiency which raises their level of satisfaction and acceptance with the care irrespective of involvement of physicians (Wilcox et al., 2015). The role of the ACP is to work collaboratively with multi-disciplinary team as a team leader and perform ethical care practices (HEE, 2021). However, failure to play the role creates disruptive care deliver as different experts from the multidisciplinary team need to deliver care to the patients work in non-cooperative manner creating a chaotic and problematic care scenario where patients needs to wait longer time in receiving appropriate care (Dixon and Knapp, 2018). Thus, ACP’s role impact to create enhanced constructive care delivery to the patient with less waiting time in receiving care. This is because the ACP by leading the multi-disciplinary team creates opportunity for collaborative care to be provided without compulsory need of physicians. It leads the patients to wait less time in accessing care because the presence of lesser number of physicians create increased waiting time for the patients to access care that is resolved with intervention from ACP as they mimic the basic role of the physicians (Ungpakorn et al., 2021).

The role of the ACP includes enhanced gathering of health information and making clinical examination of the patients in a procedural way to interpret the health complications faced by the patients (HEE, 2021). It is argued by Izumi (2017) that nurses compared to ACP is not allowed to make clinical assessment and depend on the interpretation of the patient’s problem on the physicians. Thus, the ACP’s role impacts to lower the care burden on the physicians who have to provide care to patients beyond their normal capacity as well as improve early care delivery to patients with basic health complications. This is because sharing the role of the physicians such as clinical examination and patient’s information gathering assist in sharing of responsibilities by the ACP which creates flexibility at work to provide timely care to the patients (HEE, 2021).

The role of the ACP includes prioritisation of opportunities of the patients for health prevention to lower the problems regarding their health. This leads to support patients to develop better knowledge, skills and confidence in self-managing their condition which impact to facilitates behaviour changes required for enhanced health in everyday life course (HEE, 2021). It is criticised by Eva et al. (2018), failure to support self-management leads patients lack empowerment in taking own care and feel lack of value of being unable to implement their opinion in care. Thus, ACP’s role effects to create greater empowerment of the patients to self-manage their health condition without having to wait for care from others and be burden leading to enhance their well-being (Evans et al., 2021). The ACP have the role to encourage shared decision-making by working with carers and patients for selecting health investigations, nature of treatment and support packages on the basis of clinical evidence and informed preferences of the patient (HEE, 2021). It impacts to create lower error in care and enhanced the quality of support to the patients as well as deliver person-centred care (Harvey and Leary, 2021). The study by Tada et al. (2019) argued that lack of preference for the treatment and support packages for patients makes them lack freedom of care. It makes them feel frustrated as their wishes in care sis not fulfilled. ACP has the role to manage medical and clinical complexity in patients by recognising the inevitable problems to be faced and taking effective actions in limiting the complexity (HEE, 2021). The role creates positive effect on the care delivery to patients as identification of the clinical complexity makes the ACP take active strategies in resolving them, in turn creating smooth care delivery process (Hooks and Walker, 2020). The failure to identify and manage health complexity leads to deteriorating health condition for the patients which is hard to be managed by the physicians at the end (Wingert et al., 2019).

The role of the ACP includes independent prescribing of medication and critically analysing polypharmacy along with evaluating the pharmacological interactions on the physical and mental health of the patients (HEE, 2021). This role affects to create better medication management for the patients as they do not have to wait for the doctors to intervene in prescribing medicine to the patients. As argued by Latif et al. (2020), lack of medication prescription ability in nurses makes them to have limited ability in taking quick intervention for the patients in lack of immediate presence of physicians. However, ACP’s medication management role limits the need for continuous medication review by the doctors and perform investigation of polypharmacy and pharmacological interaction to take active and immediate steps for better medication delivery to the patient (Brown, 2017).

The role of the ACP includes proactively initiating and developing therapeutic relationships with the patients (HEE, 2021). It impacts to create care delivery in considerable and responsible way for the patient as their preferences are known based on which support framework is developed. It is argued by Miciak et al. (2018), failure to maintain therapeutic relationship leads to make the patient’s feel unsafe and their needs remain unaware among the nurses. It leads to deliver dissatisfactory care and makes patients act with non-compliance. The ACP also plays the role of evaluating their own practice as well as others in care (HEE, 2021). This impact to make the ACP determine own positive and negative actions and skills as well as other professionals which intends them to make improvement of their skills to deliver enhanced care (Pearce and Breen, 2018).

The role of ACP is to critically assess the learning needs and negotiate development plan which reflects current condition of professional development. They have the role to facilitate collaboration between team members in assess their care delivery actions along with educate and develop the clinical nurses to address the issues in delivering enhanced care (HEE, 2021). Thus, presence of ACP in primary care environment impact to create education opportunities for them as well as nurses regarding the way to improve current practices that assist in creating best practice in the long-term for the patients.

Comparing ACP and physicians

The ACP (primary nurse clinician) is not considered to be entirely alternative in filling the role of the doctors or physicians. This is because physicians have more in-depth enhanced clinical expertise in understand complex healthcare issues and judge treatment to be provided to such patients in delivering care (Evans et al., 2020). As argued by Harvey and Leary (2021), ACP mainly acts as middle-grade doctor and above the registered nurses. This is because they support enhanced existing and clinical support for improving capacity as well as capability of multi-disciplinary which is above the role of the nurses. Moreover, they act to prescribe medication and offer basic treatment which is partial role of the doctors and above the registered nurses (Harvey and Leary, 2021). The supervision fees for training ACP in the UK is between £2500-3000 per annum (centrallondonhealthcare.co.uk, 2021). In contrast, the fees of training doctors is £220,000 per annum. Moreover, the completion of ACP course required 2 years whereas that of doctors requires 5 years (centrallondonhealthcare.co.uk, 2021; BBC, 2016). This indicates that the cost of ACP is more compared to the doctors in the UK. However, ACP can never entirely replace the doctors because they lack wide number of in-depth understating and evaluation efficiency of complex health issuers that are only able to be determined by the qualified doctors.

Patient perception regarding ACP

The perception of the patients regarding ACP (primary nurse clinicians) are varied as few accept them to provide them care whereas other avoid their need for them to access care. For instance, in the study by Kroon et al. (2021), 1,001 patients are reviewed to determine their perception regarding ACP (primary nurse clinicians) involvement in delivering care. The study mentioned that 87% (majority) of the patients mentioned ACP were as much involved in delivering them care as they wanted to be with them in making decision regarding future care and medical treatment. Nearly 81% of the patients reported their relatives and 75% reported their physicians to have higher familiarity with their future care preference and treatment. A positive co-relation was found between the patient’s perception of ACP involvement in care and their emotional functioning (Kroon et al., 2021). Thus, the study supported that patients have positive perception towards acceptance of care from ACP. However, it is not behalf of the doctors or relatives as they mentioned to have greater understanding of their preferences than ACP. In contrast, the study by Ammi et al. (2017) mentioned that patients still perceive that they are to be cared, monitored and reviewed by the doctors as they still have developed no belief regarding the ACP. The acceptability of care among the patients from ACP is determined to be poor who are not previously cared by the ACP for their health problem. This is because the patients express lack of experience of the capability of the ACP and doubt their actions due to which they avoid accepting care from them and relies on physicians to provide them care (independentnurse.co.uk, 2017).

Impact of ACP in the delivery of healthcare

The presence of ACP (primary nurse clinicians) has an immense positive impact on the delivery of healthcare to the aged population as well as people of other ages under care. One of the initial positive impact is the creation of better and improved patient-journey along with better informed patients experiencing well-focused care (Blomberg et al., 2020). This is because ACP has better knowledge and qualities than the registered nurse in analysis patients’ health and needs. They have efficiency in making primary diagnosis of the health of the patients with minimum need of consultation with the physicians to provide prescribed medication effectively to the patients for basic care required by them. It limits the unnecessary waiting time to avail care among the patients in the primary care leading the individual receive focused care and better management of their health condition at the earliest (England, 2017). As argued by Stewart-Lord et al. (2020), late health diagnosis and care delivery leads to deteriorate the health of the patients and makes them suffer hindered well-being. It makes the patient journey hindered as the timely care as required could not be provided. However, with the primary nurse clinicians (ACP), it is able to provide primary care to the people which reduces their late diagnosis and care for health condition, in turn, leading them to have better health and experience satisfactory patient journey out of timely care delivery (England, 2017).

In the NHS, it is reported that increased pressure is faced on the Accident and Emergency department with need of out-of-hours services as nationally people intended to seek advice regarding care from the most appropriate professionals in the organisation (kingsfund.org.uk, 2015). In this condition, the ACP has been effective in delivering primary care during the out-off-hours in the A&E department to lower work pressure on the existing low number of nurses and physicians (kingsfund.org.uk, 2015). In the UK, the patient population is increasing, and people are identified to be living longer with more individual been suffering long-term condition. In this condition, the shortage of physicians in the country has compounded the primary care delivery as more GPs are trying to take early retirement in overcoming the burden of care (independentnurse.co.uk, 2017). The ACP (nurse clinicians) has impacted to control the compounding of the situation by using their expertise to deliver primary care that includes health diagnosis and medication prescription as well as administration to the patients (Rolfe, 2014). Thus, the introduction of ACP has led to more flexibility in care delivery by lowering unnecessary burden on others.

In the care delivery, the impact of ACP is that it helps to deal with many of the patients who do not require physician appointment. It creates opportunity for the physicians to attend patients with more complicated health issues and provider same-day care to the acute patients requesting for immediate fir their basic health complications (Ware and Mawby, 2015). Thus, the ACP involvement in healthcare resolves the work pressure created on physicians being the sole care providers by sharing burden of care from them which does not or require minimum of their interventions. The ACP impact in the care delivery is that it resolves potential skill gap in care by providing educational assistance to the nurses in delivering enhanced care (Rolfe, 2014). They assist in enhanced continuity of patient care and improve standards of care. This is because the ACP work on the behalf of the physicians for the patients after they have overcome critical health stages where the patient no more requires active support from the physicians but needs regular health check-up to maintain stable health which is performed by the ACP (Rolfe, 2014; independentnurse.co.uk, 2017).

The impact of ACP in the delivery of healthcare is that it enhances communication between the multi-disciplinary team and the patients. This is because the ACP develop effective decision regarding care out of the master level expertise. It helps them determine way different communication modes are to be used for each patient so that they can interact with the specific multi-disciplinary team member who is important to be involved in caring for them (kingsfund.org.uk, 2015). The other positive impact of the ACP in healthcare delivery is that they make enhanced referral of the patients to potential physicians or doctors based on the health condition of the individuals. It reduces delay in reach of specialised care to the patient and ensures their enhanced health management (independentnurse.co.uk, 2017).

Conclusion

The study concludes that ACP (primary nurse clinicians) have effective role in controlling healthcare in the current condition. They have role of making person-centred care and collaborative working, health assessment and diagnosis, condition management and treatment along with leadership, education, and research management. In healthcare delivery the impact of their role is that it helps in reducing gap in care created by shortage of staffs, improve patient communication with multi-disciplinary team, enhance patient journey, increased flexibility at work and others. The perception of ACP regarding patients is mostly positive but few have non-compliance attitude towards them and they are mainly who have never received care from ACP before in the care environment.

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