Patient and family views of team functioning in primary healthcare teams with nurse practitioners: a survey of patient-reported experience and outcomes

Abstract

Background: Nurse practitioners (NPs) have been added to primary healthcare teams to improve access to care. Team processes, including communication and decision-making, explicate how patients and families view team functioning. Yet, important gaps exist in our understanding of patient-reported experience and outcomes at the level of the healthcare team. We aimed to examine the influence of individual, team, and organizational characteristics, and role clarity on outcomes of care mediated by team processes in primary healthcare teams that include NPs.

Methods: A cross-sectional survey across six sites representing practices with NPs in Québec, Canada, was conducted between March 2018 and April 2019 as part of a multiple-case study. Patients and families (n = 485; response rate: 53%) completed a validated questionnaire, which included a patient-reported experience measure (PREM) and a patient-reported outcome measure (PROM) of team functioning (Cronbach alpha: 0.771 (PROM) to 0.877 (PREM)). We performed logistic regression and mediation analyses to examine relationships between the individual, team, and organizational characteristics, role clarity, and outcomes of care mediated by team processes.

Results: Patients and families expressed positive perceptions of team functioning (mean 4.97/6 [SD 0.68]) and outcomes of care (5.08/6 [0.74]). Also, high team processes (adjusted odds ratio [AOR] 14.92 [95% CI 8.11 to 27.44]) was a significant predictor of high outcomes of care. Role clarity (indirect effect coefficient ab = 6.48 [95% CI 3.79 to 9.56]), living in an urban area (-1.32 [-2.59 to -0.13]), patient as respondent (-1.43 [-2.80 to -0.14]), and income (1.73 [0.14 to 3.45]) were significant predictors of outcomes of care mediated by team processes.

Conclusions: This study provides key insights on how primary healthcare teams with NPs contribute to team functioning, using a validated instrument consistent with a conceptual framework. Results highlight that high role clarity, living in a non urban area, family as respondent, and adequate income were significant predictors of high outcomes of care mediated by high team processes. Additional research is needed to compare teams with and without NPs in different settings, to further explicate the relationships identified in our study.

Keywords: Mediation; Nurse practitioner; Patient-reported experience measure; Patient-reported outcome measure; Perceptions of team effectiveness; Process; Team functioning.

Fig. 1

Relationships between the independent variables, team processes, and outcomes of care. * Independent variable presenting a statistically significant relationship in at least one of the three models

Fig. 2

Indirect effects of the independent variables on outcomes of care mediated by team processes. * Significant direct effect on outcomes of care (all p < 0.05). † Significant coefficient of indirect effect of role clarity on outcomes of care (ab = 6.48; 95% CI [3.79 to 9.56]; p < 0.001). ‡ Significant coefficient of indirect effect of location on outcomes of care (ab = -1.32; 95% CI [-2.59 to -0.13]; p < 0.05). § Significant coefficient of indirect effect of patient as respondent on outcomes of care (ab = -1.43; 95% CI [-2.80 to -0.14]; p < 0.05). ¶ Significant coefficient of indirect effect of perceived income on outcomes of care (ab = 1.73; 95% CI [0.14 to 3.45]; p < 0.05). AOR = adjusted odds ratio; CI = confidence interval; PREM = patient-reported experience measure; PROM = patient-reported outcome measure