Perceived Barriers to Primary Care for Nurse Practitioners

Background and Significance of the Problem 

Nursing Practitioners (NPs) provide care and health promotion to patients in the primary and acute care setting aware of the challenges in their work environment. Due to the range of care requirements that the nurses provide including diagnosis, care for patients with chronic illness, patient education and health promotion (Dellava, 2017), the barriers to primary care affect a wide range of these requirements. Issues relating to the poor quality of care and work-related stress emerge from the challenges faced by NPs in the primary care setting. Full utilization of the skills and abilities of NPs is deterred by the barriers to primary care. Certainly, these barriers are prevalent in health care although measures to overcome them have not been fully successful. As these challenges persist even in the presence of the evidence-based nursing practice, they hinder service delivery by NPs. Therefore, an adequate measure in overcoming these barriers in the primary care setting is to understand NPs perception of the obstacle they face. Perception, in this case, refers to their understanding of the challenges posed by their work environment and the extent to which these challenges affects the care that they provide to patients. Thousands of patients die in hospitals worldwide due to incongruence between the care that NPs provide and the actual needs of the patients (Dellava, 2017). Furthermore, patients are unable to receive the best quality care due to the barriers in the primary care setting. 

Problem Statement and Purpose for Study 

NPs make up about 20% of the primary care workforce, with their roles and numbers increasing today, they form a vital part of health providers (Poghosyan, et al., 2013). Although NPs offer various benefits to the primary care setting, various barriers pose a problem to the optimal utilization of their presence and role in the same environment. A whole range of factors such as organizational and management issues, policies, nature of the work environment and cultural issues prevent NPs from offering excellent care to patients. These factors sometimes work independently to the disadvantage of the nurses and the patients or tangle to make the work environment undesirable for proper service delivery. The result of these challenges is the low patient outcomes, reduced trusts for the healthcare system and high medical costs. Hence, the need for corrective measures to improve service delivery to patients and improve the work environment for NPs. 

Surprisingly, few studies have explored the perceived barriers towards primary care by NPs. Most studies focus on barriers to primary care in healthcare from a general perspective while at the same time offering solutions to these problems (Dellava, 2017; Poghosyan, et al., 2013). These studies, though crucial, place assumption on how NPs perceive these barriers and how they affect them. Therefore, this study intends to bridge this study gap by offering insights into these perceived barriers. Awareness of these obstacles offers a new dimension to finding methods of overcoming them. Since NPs are directly affected by challenges in their work environment, they can best provide solutions depending on their experience providing care for patients. 

Literature Review 

NPs work closely with physicians in primary care settings. Regulations stipulate that the NPs are supervised while providing care to patients. However, most NPs who have taken part in studies view supervision as unnecessary in such settings and adds little value to care offered to patients (Poghosyan, et al., 2013). As a result, they feel pressure and the supervision is likely to affect their performance. Such policies or laws eventually hinder the optimal utilization of the skills and potential of NPs. Provision of a positive work environment is necessary for NP practice. Therefore, allowing NPs to practice without unnecessary constraints in crucial in the provision of excellent healthcare. 

The importance of a positive work environment is highlighted through its contribution to recruitment and retention of healthcare professionals (Lambrou, Merkouris, Middleton, & Papastavrou, 2014). Similarly, NPs perceive their work environment as a determining factor in the quality of services that they offer. Again, the relationship between NPs perception of their work environment affects patient outcomes. A positive work environment boosts morale and contributes towards job satisfaction (Lambrou, Merkouris, Middleton, & Papastavrou, 2014). The professional practice environment can determine the NPs ability to reach the goals of the organization. Some healthcare facilities build their reputation on the ability to create an environment facilitates positive performance. The fact that NPs prefer such organizations provides evidence that undesirable work environment is viewed as an obstacle to NP practice. 

Furthermore, the role of rewards in NP practice is vital. Reward opportunities available determine the job satisfaction levels and abilities of the NPs to offer their best services (Ryan & Ebbert, 2013). Although reward opportunities may sometimes be tied to the salaries offered to NPs, this study effectively highlights the autonomy of these opportunities in NP practice. Treating reward opportunities as part of the general remuneration factor ignores the role that these opportunities play in determining the quality of services that NPs offer. Lack of these opportunities is therefore a barrier to primary care by NPs. These opportunities are not limited to monetary rewards but extend to career development, management recognition and awards together with promotions. Rewards like promotions lead to job satisfaction. Just like a positive work environment serves influences job satisfaction, reward opportunities create the zeal and motivation for NPs to work harder. Therefore, provision of more opportunities in crucial in overcoming the barriers to NP practice in primary care. 

Importantly, NPs have a considerable role to play in nursing research to advance the way they handle patients and deal with challenges in their work environment. NPs have distinct knowledge and skills according to their education level, hence can lead or engage research to meet specific needs in their work environment (Lambert & Housden, 2017). They should also set the standards for evidence-based practice by applying research findings in their practice. However, failure of NPs to fully participate in research or incorporate research findings in clinical practice is a hindrance to the attainment of high standards of practice in primary care settings. NPs are also better placed to identify problems or weaknesses in clinical practice and come up with appropriate research questions or new ways of looking at the issue (Lambert & Housden, 2017). It is also a requirement that NPs become cognizant of sthe need to collaborate with other health practitioners in research. A multidisciplinary approach to study can aid in developing new and better techniques in primary care. Although most NPs understand either partially or fully their role in research involvement, most do not play an active role in carrying out the actual research. Undeniably, research involvement improves primary care. Therefore, failure to participate in research limits NPs to already existing techniques with little improvement and consequently hinders the provision of quality care. 

Research Question 

Based on the purpose of this study to identify the barrier to primary care for nursing practitioners in the modern context, the leading research question for this study is: 

Which are the perceived hindrances to excellent primary care for patients by NPs and how do the impediments negatively affect the type of care offered by NPs? 

Hypothesis 

The hypothesis statement for this study is: 

NPs perceive hindrances to excellent health care as adversely impacting on primary care. 

Variables 

The independent variable for this study is the quality primary care provided by the NPs. 

The dependent variable is the ability of the NPs to provide quality care to patients which are determined by the level of job satisfaction, reward opportunities and the environment in which the NPs operate. 

Operationalizing the variables will be achieved through the data gathered from the articles selected for this study. 

Theoretical Framework 

Leininger’s Culture Care Theory or Transcultural Nursing Theory focuses on improving the type of care offered to patients by determining their healthcare needs through their culture (Wayne, 2014). The application of Leininger’s theory into NP practice enables the improvement of care provided by NPs through the three concepts of ethnonursing, environmental nursing, and professional nursing. Furthermore, this theory explains the need for care providers to become cognizant of the needs of their patients and develop techniques that overcome barriers to quality care. 

Ethnonursing involves nursing practice where the NP first determines that beliefs and culture of the patient before engaging fully in caring for the patient. Ethnonursing seeks to develop patient-specific methods in primary care to reduce costs and enhancing patient outcomes. This practice overcomes the barriers to quality care by focusing on individual needs as opposed to generalizing patient conditions. Nursing in the environmental context, on the other hand, determines the physical contact of the NP and the patient. The NP then assess the environment to determine its suitability for the provision of the best care for the patient. The best primary care environment offers excellent working conditions for NPs while at the same time providing confidence to patients. Ideally, such a situation must contain all the knowledge and support that the NP wants. However, such conditions are im[possible to achieve hence NPs are always working to improve their environment. The management also has a crucial role in providing the best possible environment for NPs to work. 

Finally, culture care theory highlights the importance of professional in NP practice. Professionalism involves the application of learned and cognitive skills in supporting, enabling and supporting activities within the primary care environment (Wayne, 2014). NPs are skilled professionals with the ability to deal with various challenges within their work environment. However, failure to provide the highest level of healthcare in primary care settings is partly due to weaknesses in their professional practice. For instance, applying research findings into practice is a critical requirement in overcoming the barriers to primary care for NPs. Again, failure to get involved in nursing research is another sign of weakness in professional practice. NPs must, therefore, applying their professional skills and knowledge to improve the quality of care offered to in primary care settings. 

Culture care theory has its applications in this study through the interrelationship between Leininger’s ideas of providing the best care for patients and the perceived barriers to primary care for NPs in the modern context. This study aims to identify the barriers to primary care for NPs and determine how the barriers negatively affect the quality of services offered by NPs in primary care settings. Since culture care theory focuses on improvement of the level of care provided, these barriers ultimately cause deviation from the concepts of the theory. This deviation becomes evident in practice through patient outcomes and job satisfaction levels. Because the practice environment, rewards and opportunities and research involvement all determine the success of NPs in the primary care setting, Leininger's theory offers a more in-depth explanation of these factors contribute towards service delivery. 

Methodology 

Sample 

This qualitative study will utilize a data suitability approach to select a sample for the research. This approach is based on the selection of sample data from a large pool of previous studies. Adequacy of research chosen to analyze in the will rely on rational decision making with the understanding that too little data will compromise the depth and meaningfulness of the study while study while too much data will introduce complexities that will make thorough analysis impossible (JAN, 2014). Therefore, selection of articles for this study will depend on the convenience of the data and its suitability for the study. In light of that, the criteria for inclusion is research conducted in the last five years relating to barriers to primary care for NPs. The data will be obtained from peer-reviewed articles which offer the most reliable data and findings from the research conducted. 

Sampling Strategy 

An accurate representation of the perception of RNs towards barriers to primary care is necessary to ascertain the authenticity of the study. Although the selection of data from peer-reviewed journal guarantees reliability, an accurate representation of these perceptions must be determined. Consequently, articles selected must have a representative sample size chosen from various facilities in the US. The sample must also be distributed geographically to avoid bias due to use of samples from a small geographical location. The convenience of the previous research is also a consideration. Although previous research may focus on the barriers to primary care, the design of the study may be inappropriate for this quantitative study. Therefore, such an article is unsuitable for this study. Convenience, in this case, refers to the ability of the material to provide relevant data for analysis in this study. 

Research Design 

A systematic review of current data on barriers to primary care for RNs is appropriate for this study. Based on the research question which aims to determine the hindrances to the provision of quality care for RNs, a systematic review of previous research is appropriate. The review will answer the research question and also guide the research to achieve the intended purpose of the study. The review will also offer exhaustive evidence on the topic while also maintaining the study on track to determine how the barriers negatively affect the quality of the services provided by RNs. 

Furthermore, systematic reviews are well-suited for studies in healthcare (Gray, Plath, & Webb, 2013). Such studies combine the findings of several new studies to come up with comprehensive conclusions by merging the ideas and findings of previous researchers. The review minimizes bias by using different further studies, hence maintaining the authenticity and reliability of the study. Therefore, a systematic review of the data from the five articles is appropriate. 

Extraneous Variables 

The extraneous variables for this study will involve differences in perceptions of samples used by the researchers in the five different studies. For instance, the researchers in a single study may have used PNs who work in poor conditions; thus their perceptions of barriers to primary care may vary from those working in right circumstances. The other extraneous variables may include the influence of the researchers in the responses such that their question may offer a clue as to their perception of barriers to primary care. This study will control against these variations through the application of decision processes that use the most reliable responses or those that are more consistent with the other articles. 

Instruments 

For this qualitative research, the primary instrument for the study is the technical competence to review different studies on the topic and select the most suitable. Knowledge and experience from previous studies will facilitate selection of the most appropriate articles for the study. The validity of this instrument relies on the ability of the researcher to adequately judge the most appropriate information for this study (Research Rundowns, n.d). Given my previous experience in carrying out qualitative studies, as well as my technical competence, this methods offers the highest degree of validity. Indeed, the reliability of the instrument is not in doubt. The ability to analyze data from the peer-reviewed articles is a significant strength is attaining valid results for the study. Furthermore, the data provided if reliable thus will contribute to the reliability of the method applied. 

Intervention 

The intervention in this study is to improve the quality of care that NPs offer to patients by identifying the perceived barriers to primary care. NPs understanding of these barriers enables them to instigate measures to overcome them adequately. Furthermore, understanding how the restrictions affect the quality of services that NPs offer will aid in the development of means to overcome the barriers. Through research, the extent of these barriers and their effects on primary care becomes apparent. Therefore, this study is crucial in improving service delivery by NPs. 

Data Collection 

Data collection for this study will follow a structured approach where peer-reviewed articles from the previous research will provide the data for this study. However, the existence of numerous articles from online sources and in libraries implies that a procedural approach to the issue is necessary. Therefore, articles on new research on the barriers and challenges to primary care by NPs will provide the data. Then the reliability of the content in the article is determined from the same size used by the researchers, the geographical location of the participants and the analysis of the data. Since both statistical data and tests are necessary for this study, the five articles selected will contain all the essential data. 

Data Analysis Plans 

Data analysis for this study will follow a comparative approach where data from each of the five researchers conducted will be compared and as a single unit as opposed to individual analysis. Joint analysis of the data will provide an in-depth valuation of the barriers to primary care while at the same time enabling conclusive results as opposed to individual analysis where it is possible for different conclusions to be drawn. After the data is analyzed, it will then be described according to the results of the analysis (Thorne, 2018). 

Data Analysis for Demographic Variables 

Since the study will cover data from previous research, including statistical and descriptive data, demographic variables will require analysis based on the data available. For instance, based on age the study will determine how the barriers affect care provided by NPs at different ages. Similarly, the staffing in the facility will be studied on how it affects the barriers to primary care for NPs. Here, statistics such as mean, mode and median will be calculated. Again, measures of spread will also apply. 

Data Analysis for Study Variables 

Dependent variables such as culture, reward, and levels of job satisfaction will also be analyzed. For instance, levels of job satisfaction in the studies conducted will determine how these satisfaction levels influence primary care. A reliable scale for measuring the standards will be used to analyze the two variables. Again the effect of reward and culture on quality of care demands comparison on a different level to come up with purposeful results. For the inferential data, the data in the studies will be compared wholesomely to conclude it. 

Ethical Issues 

This study intends to abide by all ethical requirements of qualitative research. Since the study will be applying secondary data were collected and analyzed by previous researchers, acknowledgment of the sources of this data will follow due procedure including permissions to use the data in this study. Furthermore, clarification of the role of the study will be necessary to avoid a clash between this study and others conducted previously (Sanjari, Bahramnezhad, Fomani, Shoghi, & Cheraghi, 2014). Data gathering will then follow the correct procedures for ensuring all the data remains unaltered to protect the authenticity of the study. Analysis and interpretation will follow clear guidelines on theory and procedural review. 

Limitations 

Although this study intends to determine the perceived barriers to primary care for PNs, the utilization of previous research may fail to provide all the obstacles or challenges that PNs face in different environments. Hence, the findings will be limited to the areas that the initial researchers explored. Again, PNs may fail to identify some of the barriers thus causing this study to lack crucial information in sections of this topic. 

Implications for Practice 

Evidence-based practice and improvement of primary care are vital for achieving a positive patient outcome. Thus, this study purposes identify barriers to primary care for NPs to develop techniques for overcoming these barriers and improve healthcare. NPs who are cognizant of the factors that hinder excellence in the provision of primary care can effectively develop techniques to overcome these obstacles. Therefore, this study ultimately improves practice by providing awareness for NPs on the barriers to primary care and the way these barriers affect the quality of care that the NPs provide. 

References 

Dellava, C. (2017). Nurse Practitioner Perspectives on the Barriers and Facilitators of Advance Care Planning. Retrieved June 4, 2018 from, 

https://digitalcommons.ric.edu/cgi/viewcontent.cgi?article=1187&context=etd 

Gray, M. J., Plath, D., & Webb, S. A. (2013). Implementing evidence-based practice: A review of the empirical research literature. Research on Social Work Practice, 23(2) , 157-166. 

JAN. (2014). Data collection and sampling in qualitative. John Wiley and Sons Ltd. Retrieved from, https://onlinelibrary.wiley.com/doi/pdf/10.1111/jan.12163 

Lambert, L. K., & Housden, L. M. (2017). Research Reflection: Nurse practitioner engagement in research. Canadian Oncology Nursing Journal, 27(1) , 1-7-110. 

Lambrou, P., Merkouris, A., Middleton, N., & Papastavrou, E. (2014). Nurses’ perceptions of their professional practice environment in relation to job satisfaction: a review of quantitative studies. Health Science Journal 8(3) , 298-317. 

Poghosyan, L., Nannini, A., Smaldone, A., Clarke, S., O’Rourke, N. C., Rosato, B. G., & Berkowitz, B. (2013). Revisiting scope of practice facilitators and barriers for primary care nurse practitioners: a qualitative investigation. Policy, Politics, & Nursing Practice, 14(1) , 6-15. 

Research Rundowns. (n.d). Instrument, Validity, Reliability . Research Rundowns. Retrieved June 5, 2018 from, 

https://researchrundowns.com/quantitative-methods/instrument-validity-reliability/ 

Ryan, M. E., & Ebbert, D. W. (2013). Nurse practitioner satisfaction: Identifying perceived beliefs and barriers. The Journal for Nurse Practitioners, 9(7) , 428-434. 

Sanjari, M., Bahramnezhad, F., Fomani, F., Shoghi, M., & Cheraghi, M. A. (2014). Ethical challenges of researchers in qualitative studies: the necessity to develop a specific guideline. Journal of medical ethics and history of medicine, 7 , 14-22. 

Thorne, S. (2018). Data analysis in qualitative research. Evidence-based Nursing, 3(3) . 

Wayne, G. (2014). Madeleine Leininger’s Transcultural Nursing Theory . Nurselabs. Retrieved June 5, 2018 from, 

https://nurseslabs.com/madeleine-leininger-transcultural-nursing-theory/