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BMJ Open. 2019 May 24;9(5):e028169. doi: 10.1136/bmjopen-2018-028169.

Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: a realist evaluation case study.

Author information

Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands.
Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands.
Faculty of Health Sciences, University of Southampton, Southampton, UK.
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands.
Joachim & Anna, Center for Specialized Geriatric Care, Nijmegen, The Netherlands.



This study aimed to gain insight into how substitution of elderly care physicians (ECPs) by nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs) in nursing homes is modelled in different contexts and what model in what context contributes to perceived quality of healthcare. Second, this study aimed to provide insight into elements that contribute to an optimal model of substitution of ECPs by NPs, PAs or RNs.


A multiple-case study was conducted that draws on realist evaluation principles.


Seven nursing homes in the Netherlands PARTICIPANTS: The primary participants were NPs (n=3), PAs (n=2) and RNs (n=2), working in seven different nursing homes and secondary participants were included; ECPs (n=15), medical doctors (MDs) (n=2), managing directors/managers/supervisors (n=11), nursing team members (n=33) and residents/relatives (n=78).


Data collection consisted of: (1) observations of the NP/PA/RN and an ECP/MD, (2) interviews with all participants, (3) questionnaires filled out by the NP/PA/RN, ECPs/MDs and managing directors/managers and (4) collecting internal policy documents.


An optimal model of substitution of ECPs seems to be one in which the professional substitutes for the ECP largely autonomously, well-balanced collaboration occurs between the ECP and the substitute, and quality of healthcare is maintained. This model was seen in two NP cases and one PA case. Elements that enabled NPs and PAs to work according to this optimal model were among others: collaborating with the ECP based on trust; being proactive, decisive and communicative and being empowered by organisational leaders to work as an independent professional.


Collaboration based on trust between the ECP and the NP or PA is a key element of successful substitution of ECPs. NPs, PAs and RNs in nursing homes may all be valuable in their own unique way, matching their profession, education and competences.


nurse practitioner; nursing homes; physician assistant; realist evaluation; skill mix change

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