The aging population, increasing incidence of chronic disease, and healthcare professional shortages urge the redefinition of primary care delivery models.1,2 A great proportion of people lack care, and even people registered with a family doctor experience difficulties in accessing primary care.3 These issues have both global social and economic consequences, including unequal access to care and emergency department overcrowding.4 International studies demonstrate the positive effects on patient-related outcomes, experiences,5,6 and services efficiency6,7 when nurses can exploit their full scope of practice. The optimal contribution of enhanced-role nurses is therefore a promising avenue to develop these new models and to stimulate clinical and organizational innovations.7 Moreover, contextual elements such as the increasing number of innovations including RNs in primary care, or the possibility for nurse practitioners (NPs) to autonomously diagnose and determine medical treatments, placed nurses at the heart of the care trajectory in primary care in Quebec, Canada. However, despite this essential and strategic role, implementation of clinical and organizational nursing innovations has received limited attention, particularly regarding organizational facilitators and barriers.8

To answer a need, expressed by practitioners and decision-makers, and to develop nursing innovations and improve their implementation, a symposium was organized on May 9, 2022, in Montréal (Quebec, Canada). The symposium brought together more than 80 stakeholders (practitioners, decision-makers, and researchers) of Quebec's primary care services, focused on building primary care nursing capacity and to develop nursing innovations in primary care throughout collective learning. The specific objectives of the symposium were to: 1) describe implementation processes, barriers, and facilitators of clinical and organizational nursing innovations in primary care; and 2) identify the strategies for implementing, spreading, and sustaining nursing innovations in primary care.

Methods Participants

Participants included more than 80 key players in the Quebec health and social services sector, such as NPs or RNs working in primary care (referred to as primary care nurses), managers, researchers, decision-makers, and students. Participants were invited based on their roles, responsibilities, and interests toward these types of innovations and to cover the wide spectrum of people involved in these innovations (from the Ministry of Health to the universities). Among those participants, primary care nurses and managers who have implemented nursing innovations were asked to present those innovations.

Appreciative Inquiry

This symposium was built around the appreciative inquiry approach of Cooperrider and Srivastva,9 a socioconstructivist approach that suggests that organizations are created, maintained, and transformed through dialogue. Those innovations are therefore limited by the imagination of individuals and their conventions. This approach was carried out by following the 1st 3 steps of the “4D cycle” (ie, discovery, dream, design, and deliver).

1st Step (Discovery): Description of Innovations. An organizing committee provided together themes and a guide for the description of nursing innovations.10 Presenters had to address the following themes: the genesis of innovation (idea, implementation), its characteristics (financial, structural, organizational) and partners, barriers and facilitators, results, and anticipated evolution.

2nd and 3rd Steps (Dream and Design): Workshops. The 2nd part of the symposium grouped the participants into intersectoral tables (approximately 10 people per table). These steps included 2 distinct workshops. The 1st workshop (Dream) focused on sharing knowledge and experiences about existing nursing innovations, as well as the barriers or facilitating factors for their full deployment. Organizational, financial, human resources, legislative, work environment, clinical and collaborative practices, and training-related (7 dimensions) were addressed. A 2nd workshop (Design) focused on the group perception of the expected benefits regarding the innovation's deployment while considering the current sociopolitical context. The group was driven to elaborate on strategies to implement, enable, and sustain these innovations and the role everyone could play in their implementation.

Data Collection and Analysis. For the 1st step, research assistants recorded and created a transcript of oral presentations. For the 2nd and 3rd steps, research assistants and researchers took notes from each of the cross-sectoral tables, including a transcript of major themes discussed on a flip board. A thematic analysis followed by a content analysis (for the frequency of some themes) from the symposium identified recommendations to be prioritized to support the deployment of nursing innovations.

Results 1st Step: Description of Innovations

Innovations are briefly described in Table 1. The 1st category focused specifically on unmet population needs in the current primary care delivery model. A 2nd category of nursing innovations focused on intrapreneurship models,11 thus innovations implemented within existing primary care structures. The 3rd category of nursing innovations focused on those introducing structural/organizational change.

Table 1 - Description of Innovations Innovation Objectives Structure and/or Nurses' Roles References Population-oriented innovations (focus on unmet population needs in the current primary care delivery model)  SPOT Clinic To provide a systemic assessment of the individual, coordinate care, and play a key role in optimizing interprofessional collaboration A primary care nurse practitioner works part-time and complements the interdisciplinary team while supporting the role of the nurse clinician https://cliniquespot.org/  Book humanitaire To reach people in a situation of homelessness, people with consumption disorders, people limited by administrative barriers (absence of social insurance) or physical barriers (distant hospital centers) and address their needs A mobile clinic, led by a nurse and other services (collective fridge, crisis intervention team, etc) https://lebookhumanitaire.com/  Innovative community nursing intervention with refugees To identify what could improve access to the healthcare system for the territory's clientele and, more specifically, for refugees. The objective was to improve the accessibility and continuity of healthcare and services for the population concerned in an integrated trajectory perspective The care trajectory includes the assessment of the person by the NP who can take charge of the person herself, refer the person to other services or to the NP of the refugee clinic if the person has this status and needs to access health services Maillet L, Champagne G, Déry J, et al. Implementation of an intersectoral outreach and community nursing care intervention with refugees in Quebec: a protocol study. J Adv Nurs 2021;77(11):4586–4597 Intrapreneurship-oriented innovations (innovations implemented within existing primary care structures)  Specialized wound care clinic (in a public primary care setting) To provide the population with access to wound care services and ensure a continuum of wound care services; exposure of trainees, family medicine residents, and nurses to complex wounds; support healthcare professionals through knowledge sharing and support; manage costs related to complex wound care more efficiently An interdisciplinary team, led by a nurse, has been created as well as a partnership with the private sector, notably podiatrists, foot care nurses, and prosthetists N/A  The nursing innovation concerning breastfeeding practice To train nurses in breastfeeding so that they could better equip future mothers. The local clientele is made up in part of mothers of immigrant origin who have little support network Clinic's users are patients who come to the primary care clinic as part of their pregnancy follow-up with a physician who then refers them to the lactation nurse clinician N/A  Case management intervention for people with complex health needs To move toward an individualized approach to service coordination. The current healthcare system operates on a program basis, and clients with complex health needs receive fragmented and unintegrated care that is not adapted to their needs Based on the V1SAGES approach (vulnerability in the 1st line, support for self-management, and case management), this case management intervention places the primary care nurse at the center of the care trajectory https://v1sages.recherche.usherbrooke.ca/ Innovations introducing structural/organizational change in the current primary care delivery models  Clinique Archimède To better respond to the needs of the clientele in the territory of the Lower Town of Quebec, made up of users with increasingly complex and diversified health needs (aging, socioeconomic conditions, difficulty in accessing primary healthcare) The Archimedes model, although implemented in a primary care clinic, is based on the idea of an inverted pyramid in which a diversified interprofessional team gravitates around nurses, who are then at the heart of service delivery https://api.vitam.ulaval.ca/storage/Rapport%20de%20recherche_Archim%C3%A8de.pdf  IPS-Azur clinic project To (1) reduce the number of patients without family doctors, (2) improve access for consultations during unfavorable hours, (3) allow for an increase in the number of referrals from the emergency room, and (4) contribute to the coverage of care and services in long-term care facilities An interdisciplinary clinic, which allows for the full scope of practice of the nursing teams in collaboration with the medical team of the primary care clinic Azur https://cliniqueazur.com/  SABSA solidarity cooperative To offer healthcare and outreach services adapted to a vulnerable clientele The team is composed of 1 full-time and 1 part-time NPs. The rest of the multidisciplinary team is made up of social workers, psychiatrist, administrative staff, and lot of volunteers https://www.sabsa.ca/fr/
2nd Step: Workshops' Results

During a 4D cycle, the approach tends, in lieu of problems, to invite participants to focus on hopes, dreams, and facilitating factors to develop innovations. Researchers grouped the discussion results according to the 7 dimensions introduced in the Methods section.

Organizational Level. An organizational culture that is favorable to the implementation of nursing innovations, with an openness to change, particularly from the medical team and managers, the presence of strong nursing leadership, or role recognition and relevance by managers and other professionals are organizational elements that favor their development. It was also mentioned that the complexity of organizational structures makes it difficult to access resources and mobilize key people for the success of an innovative project. Finally, the lack of flexibility in professional practices and procedures was cited as a limit to reinventing or introducing new ways of organizing primary healthcare.

Human and Material Resources. Allowing nurses to contribute to the development of new projects was a key success factor made possible by the assistance and openness of managers. The presence of innovation leadership, that is, leadership based on discovery, change, and experimentation, and effective interprofessional collaboration were also cited as facilitating innovation. In contrast, the turnover of professional teams, including managers, manpower shortages, and the lack of flexibility of traditional management models, such as Lean management, are all factors that hindered the implementation of innovations. The limited recognition of nurses' expertise, both in terms of clinical and leadership skills, also hinders the implementation of innovative projects that call for their “optimal contribution.”

Work Environment. Accessible data through, for instance, effective electronic medical records are key enablers of innovation as they could capture the impact of real-time change as well as sustain further innovative developments or amendments. Moreover, traditional management styles do not encourage individual or collective innovation. This translates, among other things, into resistance from managers and an increased psychological burden for nursing professionals who feel disengaged and not equipped to develop new innovative practices.

Political Level. Clear support from policy makers, increased partnerships with community partners (policy makers, community organizations), and consistency between orientations were cited as facilitators at the political level. The identification of nursing sensitive follow-up indicators and a better understanding of the specific needs of the population and of the services offered by the territory could act as enablers for the implementation of innovations. Conversely, healthcare lobbying, regarding innovations that could counter certain financial benefits, might make it difficult to generate changes in care settings.

Clinical Level. Ensuring quality professional education in primary (health) care, building clinical and collaborative experiences, and enabling spaces for strong and innovative clinical (nursing) leadership, exemplified by the ability to influence and bring together an interdisciplinary team around a project, facilitate innovation. Conversely, some participants raised the lack of interest on the part of decision-makers and managers in the development of interventions in certain areas of care, for example, in health promotion and prevention. Moreover, personal insecurities or lack of knowledge of some nurses related to their professional scope of practice can hinder the development of nursing innovations.

Financial Level. Political will is an essential component in the value and outcomes from health promotion and disease prevention in primary healthcare. Continuing education should be prioritized, for instance, to further develop collaboration skills in all primary care health professionals. In terms of barriers, the uncertainty of the innovations' funding continuity and the instability of the funding renewal inhibit the full sustainability of nurse-led innovative projects.

Legislative Level. Although progressive and more recent changes in nurses' practice regulations provide more autonomy,12 limitations still remain such as the involvement in the mental health domain of care (ie, primary care nurses cannot diagnose mental health disorders in Quebec).13 Current paradigms of care hinder the relevance and delivery of holistic management of patients' biopsychosocial needs in primary care settings.

Discussion

Overall, based on the 1st 3 steps of the “4D cycle,” this symposium brought on 4 recommendations to support nursing innovations dedicated to improving “patient experiences based on accessibility, quality of care, and value” in primary care.14

The Need to Implement Strategies to Achieve Optimal Scope of Practice for Primary Care Nurses

Most of the innovations described in this symposium were developed to enable nurses to work according to their full scope of practice. Despite bylaws and regulations, studies show an underutilization of the nursing workforce.15,16 This is attributable to multiple factors, including the constant evolution of the nursing scope of practice17 or a variation in its local implementation.18 Indeed, the nursing scope of practice undergoes significant modulation according to local contexts,19 which limits the power of legislation to guarantee the expansion of the practice. It is urgent to have the expertise and leadership of nurses recognized, especially cause it has been shown that nursing leadership has a positive impact on the quality of care and interprofessional collaboration.20 This recognition involves, among other things, reiterating that nurses possess distinct knowledge from other health professionals.21,22 This distinct nursing knowledge translates into a multidimensional professional role that involves, among other things, the provision of direct care, but also the transformation of care and systems through primary care, a role that is very little expressed at present. This requires a strong political and organizational will, to overcome the status quo in primary care as well as possible resistance due to a lack of knowledge of the potential role of nurses. According to a recent study,23 NPs’ added value is context-dependent and is often understood by comparing it with a context prior to implementation or other professional roles, underlining difficulties about the negotiation of professional territories and clinical processes.18

The Importance of Funding and Organizational Models That Support Primary Care Nursing Innovation

Nurses know well the needs of the population and have ideas for services to better meet these needs. However, significant financial and organizational barriers prevent development of those services.23 The recent funding of NP-led clinics in Quebec is a positive step.24 Some studies already demonstrate that patients were, at least, equally satisfied with care provided by an NP compared with physician.25 Nurses can mobilize all healthcare professionals toward interprofessional collaboration to improve the quality of care.26,27 Thus, to ensure more consistent access to and quality of healthcare for the benefit of patients, it seems essential to prioritize holistic care that considers the social determinants of health.28

There are also other innovative organizational models such as the liberated enterprise,29 which support holistic approaches and encourage collaboration and collegiality that help improve the quality of care.30 As an example, the Buurtzoorg model of care,29 implemented in the Netherlands, is a nursing cooperative consisting of a team of nurses who self-manage schedules, partnerships, and services. The nursing approach offered is a community-based and holistic one. Continuity of services is fostered by the nurse creating a network around the patient they are treating.

The Need to Enhance a Collaborative and Democratic Governance Open to Innovation

Results highlighted difficulties for nurses in having their voices heard and described barriers to participating in clinical and organizational decision-making. Previous studies underlined the necessity to rethink the governance of the system and to make room for a more democratic structure, which is essential for (re)thinking, developing, and implementing primary care innovations, including those developed by nurses.7,23 In Quebec, a survey conducted by 8 professional regulatory bodies on the conditions of practice showed that healthcare workers have little decision-making power and that governance does not allow for decision-making or for the full development of the role, autonomy, and professional leadership of nurses.31,32 Collaborative governance is a way to include several actors, both clinicians and users in the organization of care.33,34 This form of governance can better align resources and organizational models with the needs of all stakeholders, including nurses.35 In primary care, organizational structures are predominantly physician-led. Moving decision-making to the point of care and involving nurses are imperative to support the use of their full scope of practice,35,36 an essential component of effective nursing innovations in primary care.

The Opportunity to Create Partnerships With the Research Community and Academic Institutions

Some participants mentioned that they had benefited from a partnership with a research team to build and to assess the impact of their innovation. Support for research is an essential avenue for developing and sustaining innovations.37 This helps develop an evidence-based and evaluative way of thinking to describe the implementation process and to demonstrate the merits of the innovation, the effects, and the expected benefits for its sustainability. To deploy these models, researchers must support clinicians by measuring the contribution of nurses to improving the quality of care using nurse-sensitive measurement indicators.38 It is essential to rethink methods of learning and assessing competencies such as those related to leadership.39 Finally, expanding the range of training and internships for interprofessional collaboration would make it possible to better equip future primary care health professionals for multidisciplinary teamwork, specifically promoting better understanding and acceptance of professional roles.

Conclusion

This symposium on clinical and organizational nursing innovations in primary care was a unique opportunity to bring together key players to discuss the barriers and facilitators to implementing and sustaining nursing innovations. This led to the emergence of 4 recommendations to support the implementation of nursing innovations in primary care. The authors believe it is imperative to operationalize these recommendations, engaging the key players involved and suggesting concrete objectives and actions to be implemented in primary care.

Acknowledgments

The authors thank The Direction de L'enseignement Universitaire et de la Recherche (CISSS de Laval) for their participation in the organization of the symposium; the students who helped organize and facilitate the workshops: Jolianne Bolduc, Hélène Frégeau, Andrée-Ann Rivard, Marie-Josée Emond, Anaëlle Morin, Manon Blécourt, Marion Lazarovici, Émilie Dufour; and the presenters and participants of the symposium.

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