Patients' perceptions toward the role and acceptance of advance practice nurses in integrated care models: A qualitative study

Introduction: The increasing prevalence of multi-morbidities among people living with cardiovascular disease (CVD) has increased the complexity of their clinical care. Implementing the role of advanced practice nurses (APNs) in integrated models of care has been shown to improve outcomes in the CVD population. However, cardiac patients’ perceptions and acceptance of the role of APNs have not been examined in Singapore. Methods: An exploratory descriptive qualitative design using semi-structured face-to-face individual interviews was undertaken with cardiac outpatients (November 2017 – March 2018). Outpatients with CVD were purposively sampled from a national cardiac centre in Singapore. Data were analysed using thematic analysis. COREQ guidelines were adhered to. Results: The sample was multi-ethnic (43% Indians; 36% Chinese; 14% Malays; 7% Eurasians), ages ranged from 41 to 80 years. Two main themes were identified: (1) APNs play a complementary role to doctors and (2) the acceptance of the APN role takes time. Each theme was supported by three subthemes to further elucidate the role and acceptance of APNs. Discussions: From cardiac patients’ perspectives, APNs play a complementary role to doctors and add value to patient care. Despite appreciating the value APNs bring to healthcare, cardiac patients’ acceptance for APNs is not yet optimal due to the lack of understanding of what APNs do. Therefore, there is a need for APNs themselves and for healthcare services to put in more efforts to inform the public of this new model of care. Conclusions: Limited research has elucidated patients’ perspectives towards the role of APNs in Asia, in comparison to mature contexts like the UK, the USA, Canada and Australia. This study illustrates how despite experiencing the value APNs bring to care, cardiac patients preferred seeking outpatient consultations with doctors as these were what they were accustomed to. A lack of understanding of the role of APNs is present, thereby causing less than optimal patient acceptance of APNs. As cardiac patients gain greater exposure to APN-led services, they may increase in appreciation for and be convinced of APNs’ competence in managing their chronic conditions. Lessons learned: Patients need to be convinced that APNs are qualified healthcare professionals. The utilisation of APNs in integrated models of care may accentuate the APN role. Greater efforts are needed to publicise the APN role through strong medical and nursing voices. Limitations: The strength of adopting a qualitative methodology, i.e. the purposiveness of the study participants, was a limitation. The study participants were cardiac patients who were recruited from one national heart centre, thereby limiting generalisability. Nonetheless, the intention of this study was not to generalise but to allow for the transferability of knowledge from one context to another. The study findings can possibly be transferred to similar contexts where cardiac patients require long-term outpatient services. Suggestions for future research: Strategies to increase patients’ awareness and acceptance of expanded nursing roles in integrated care models that moves away from conventional physician-centre care can be explored.