REDUCING BARRIERS TO ACCESSING PRIMARY CARE FOR
INDIVIDUALS WITH SEVERE MENTAL ILLNESS: EXAMINING
CHARACTERISTICS OF CANADIAN NURSE PRACTITIONER PRACTICE

by

Damen DeLeenheer
BScN, University ofNorthem British Columbia, 2004

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF MASTERS OF SCIENCE IN NURSING, NURSE
PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
August, 2012

©Damen DeLeenheer, 2012

UNN£RSITYmN~ERN
BRITISH COLUMBIA
LIBRARY
Prince George, B.C.

11

Abstract
Individuals with severe mental illness experience reduced access to appropriate and
timely primary care. This reduced access has been linked to various barriers and may
negatively affect health outcomes. The purpose of this project is to identify the
characteristics of nurse practitioner (NP) practice that may reduce the most common
barriers to accessing primary care encountered by individuals with severe mental illness.
(SMI). The most common barriers to access can be broadly described by three themes and
include suboptimal therapeutic relationships, complex service delivery, and stigma. A
systematic review of the literature indicated that NPs possess a number of practice
characteristics that help overcome barriers to accessing primary care. These
characteristics can be described as collaborative practice, a holistic approach, and flexible
practice formats. NP practice characteristics have the potential to reduce barriers to care
for individuals with SMI and improve access to primary care.

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Table of Contents

Abstract ............................................................................................................................... ii
Table of Contents .... ... .................... .... .. ........................................ .. .......... .... ... ... .. ..... .. ....... iii
Table ofTables .......... ........... .... ... ........ ........ ..................................... ......... .......... .... .... ...... iv
Dedication ....... ...... .. .................... .. ........ ........ ...... ... .......... .... .......... ..................................... v
Chapter 1: Introduction ....................................................................................................... 1
Methods ........... ........... ... ....... .... ... ...... ...................... ..... ............. .......... ... ......................... 4
Chapter 2: Background and Context .................... .. .................... ... .... ............. .... .. ....... ... ..... 8
Relevant Concepts ......... ............ ... ................ ... ............ .. ............... ............... ...... ...... ... .... . 8
Background and Context ..... .............. ... ............................................... ....... ...... ........ ....... 8
Chapter 3: Findings .... ............... .... ............................ ........................ .... ........ ....... ........ ..... 22
Improving Sub-optimal Therapeutic Relationships ...................................................... 22
Navigating Complex Service Delivery.......................................................................... 26
Reducing Stigma ..... ... ......... ........ ... .... ........... ....... ........ ........ .. ....................................... 32
Limitations and Bias ...................................................................................................... 35
Chapter 4: Discussion ....................................................................................................... 37
Collaborative Practice ............................ .............. ........................... .. .... ........................ 3 7
Holistic Practice ... ............. ............... ...... ....................................................................... 40
Flexible Practice ................... ......... ... .. ... ...... ........... .. .................... .. ........ ......... .. ........ .... 42
Chapter 5: Summary, Conclusions, and Recommendations ............................................. 46
Recommendations ... ........ .. ........................................... ....... ................. .......... ............... 46

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Table of Tables
Table 1: Initial inclusion and exclusion criteria .................................................................. 5
Table 2. First two key word search results .................................................................. ..... 55
Table 3. Second two key word search results .............................................................. ..... 55
Table 4. First three key word search results ..................................................................... 55
Table 5. Second three key word search ............................................................................ 55
Table 6. MeSH term searches ofPubMed ........................................................................ 56

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Dedication

To my family: Quoth the raven, 'Nevermore' (Poe, E. A., 1845).

Chapter 1: Introduction

Individuals with severe mental illness (SMI) experience poorer health outcomes
than the general population. They are also diagnosed with higher rates of chronic illness
such as diabetes, respiratory and cardiac diseases (Parks, Svendsen, Singer, & Foti,
2006). Individuals with SMI also have life expectancies 25 years shorter than the general
population (Bradford et al. , 2008).
The discrepancy in the health status of individuals with SMI compared to the
general population has been linked to barriers to accessing primary care, many of which
have been identified by individuals living with SMI (Bradford et al. , 2008 ; Parks et al.,
2006; Torgerson, Wortsman, & Mcintosh, 2006). Difficulty obtaining transportation to
services, a perceived lack of respect by health care providers (DeCoux, 2005), a
fragmented health care system (Wortans, Happell, & Johnstone, 2006), and stigma (Groh,
2007) are some of the many factors contributing to reduced access to primary care.
Canadian Nurse Practitioners (NPs) are primary care providers who may have a
role to play in reducing the most common barriers to accessing primary care encountered
by individuals with SMI. NPs are "health professionals who have achieved the advanced
nursing practice competencies at the graduate level of nursing education that are required
for registration as a nurse practitioner with College of Registered Nurses of British
Columbia" (College of Registered Nurses of British Columbia, 2010, p. 5). The presence
ofNPs within the Canadian health care system has improved access to primary care and
offers a model of care provision that is potentially well-suited to address the complex
health care needs of individuals with SMI (Choy, Evanson, Martin, & Regehr, 2008)

2

The purpose of this project is to identify the characteristics ofNP practice that
may reduce the most common barriers to accessing primary care encountered by
individuals with SMI. Specifically, this project addresses the question: What are the
characteristics ofNP practice that can reduce barriers to primary care commonly
encountered by adult individuals with SMI?
The question for this project was generated by issues identified in my practice as a
registered nurse (RN) case manager in a community mental health setting. In my role as a
case manager supporting individuals with SMI, I was frequently unable to effectively
connect individuals with SMI to primary care services. Individuals with SMI reported to
me that they felt uncomfortable following up with primary care, and providers would
state that offering services to individuals with SMI was challenging. It was not
uncommon for individuals with SMI to be fired or be declined service by primary care
providers for a variety of reasons. For instance, if a patient with SMI had difficulty
complying with expectations of a primary care practice to provide advanced notice when
they could not attend a booked appointment, the patient would receive a bill and
eventually be released from the practitioner' s care.
I also observed that the organization of primary care was another obstacle to
connecting individuals with SMI to services. When individuals with SMI received
primary care, they often expressed their frustration at having their complex health needs
reduced to a single complaint per visit. Patients reported that when they would attempt to
discuss more than one issue the patient would be reminded of the policy, or have the
second concern dealt with in a superficial manner. Patients also reported that

3

explanations for follow-up procedures, such as medical imaging and laboratory testing
were poor, and that they found the investigative appointments difficult to attend .
Patients in my practice often reported that stigma was a significant barrier to
access to primary care services. Often individuals with SMI would resist attending
primary care appointments for fear of being stigmatized by other patients, providers, and
staff. Patients would tell me they felt uncomfortable being seen with a mental health
worker because they felt they were immediately associated with having a mental illness.
Patients would also express frustration at the rushed approach their primary care provider
would pay to their multiple health concerns. They assumed the provider was not listening
to them because they were "crazy." Collectively, these barriers appeared to reduce access
to primary care for individuals with SMI.
My experience working alongside NPs led me to believe that their practice
characteristics offered a potential solution to the primary care barriers commonly
encountered by individuals with SMI. I observed NPs taking time to consult with a
diverse range of community supports to help patients attend appointments inside and
outside of the primary care setting. I witnessed NPs employing a number of treatment
modalities that reflected a broad range of advanced practice nursing skills and
approaches. I also noticed how NPs were able to adjust their practice to meet the needs of
the individual patients. NPs did not appear to demand that patients conform to practice
rules such as timely attendance and did not bill for missed appointments, thus improving
rapport. I also observed NPs inviting the patient to participate in the design of their own
care, such as asking about medication preferences, the affordability of medications, and
frequency and timing of appointments. It was these characteristics ofNP practice that led

4

me to believe NPs may have an important role to play in reducing primary care barriers
commonly encountered by individuals with SMI.
This project presents findings of an integrative review of current and relevant
literature focused on answering the research question. Critically analyzing the literature is
an opportunity to identify those specific characteristics ofNP practice that are
particularly valuable in reducing barriers and improving access to care. Areas ofNP
practice that may contribute to the presence of barriers may also be identified as part of
this review. This research is an opportunity to compile evidence and make
recommendations to support NP practice to continue to improve access to primary care
for Canadians living with SMI.
In Chapter 2, the background and context for the project are provided, including

definitions of relevant concepts and key terms. The fmdings are presented in Chapter 3,
through a critical examination and synthesis of the literature. In Chapter 4, the discussion
related to the findings is presented that identifies the characteristics and approaches ofNP
practice that may prove effective in reducing barriers to the access of primary care. In the
fmal chapter, recommendations for NP practice are proposed. Strategies that NPs can use
in practice to reduce barriers to primary care encountered by individuals with SMI are
offered as conclusions.

Methods

A thorough review of the literature was completed to search for information
related to barriers encountered by adults with SMI that limit access to primary care, and
NP practice characteristics that reduce those barriers. The academic databases CINAHL,

5

PsyciNFO, and PubMed were selected and searched. These databases cover a broad
spectrum of peer-reviewed literature including journal articles, books, and dissertations
related to the fields of medicine, nursing, allied health, and behavioral sciences. Selected
publications included primary research, literature reviews, and discussion and opinion
articles published within professional journals. Google Scholar was also searched to
supplement the academic databases and locate relevant grey literature. Searches were
conducted between January 2010 and February 2012. Searches were reviewed annually
over this time frame to determine if any new literature had become available.
Table 1: Initial inclusion and exclusion criteria
Inclusion criteria

Exclusion criteria

Published in English

Target population of study limited to
children or elderly

Published between 1999-2012
Addressed at least two of the following:
Nurse practitioners
Primary care

Target population of study of a specific
cultural back ground other than North
American, Australian/New Zealand, or
from the United Kingdom
Published in a language other than English

Mental disorders
Treatment barriers
Health service accessibility
Published in a peer reviewed journal or a
professional/ government website

Inclusion and exclusion criteria were then developed to establish the range of
publications that would be reviewed. It is important to note that publications specifically
examining populations not primarily of a Western European or North American
background were excluded. The rational for this is that the Diagnostic and Statistical

6

Manual of Mental Disorder (American Psychiatric Association, 2000) has been
developed to diagnose mental illness specifically within individuals from Western
cultures and reflects the cultural norms of this population.
Before conducting searches, key words were identified that were related to the
core concepts of the project and generated the largest number of results. The selected key
words included nurse practitioners, mental disorders, primary care, primary health care,
health services accessibility, and treatment barriers. A search for Medical Subject
Headings (MeSH) terms was also conducted looking for terms similar to the key words.
The four identified MeSH terms included nurse practitioners, mental disorders, primary
health care, and health services accessibility. Tables 2 and 3 identify the number of
results for the two key word search combinations. Where search results exceeded 250
articles, additional search terms were utilized to reduce the listing.
Tables 4, 5, and 6 provide the number of three word combination results from key
word and MeSH term searches. Articles were included if key words included any two key
words or MeSH terms and met the remaining criteria. This process resulted in 104
identified publications.
A second review of the selected articles was performed looking for a match of any
three search terms in the key words, title, or abstract. The three search terms were nurse
practitioner, primary care, and health access or barriers. This left 71 publications that
were reviewed in their entirety for relevance to the research project, of which only 24
contained enough relevant information to be included as a finding. One additional
publication was located as part of a review of the references of the selected articles for

7

inclusion. The final number of articles located as part of the review of the literature was
25.

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Chapter 2: Background and Context
This chapter provides the background and context that will assist readers in
understanding this project. This chapter will include relevant concepts, epidemiology,
and pathophysiology of SMI. The barriers to primary care are then organized and
discussed under three broad themes and the chapter concludes with a brief description of
NPs and their role in Canadian health care.
Relevant Concepts
Primary care. Primary care is defined as "continuing, comprehensive, and
preventable health care services that are the first point of health care for a patient in an
ambulatory setting" (Piper, 2008, p. 1265). Primary care is distinguished from primary
health care in that the latter encompasses community factors, which contribute to health
status (World Health Organization, 2001).
Shared medical appointments (SMAs). SMAs involve multiple patients seen at
the same time for routine care (Noffsinger, Sawyer, & Scott, 2003). SMAs were designed
for the primary care setting to improve the efficiency of primary care providers and
therapeutic relationships with patients. In SMAs, a team of providers treat the chronic
health care needs ofup to 16 individuals in a group setting that may last up to 90 minutes.
Background and Context
SMI. SMI is the collective term which encompasses a wide range of diagnoses of
mental disorders. Diagnostic criteria are defined by the Diagnostic and Statistical Manual
ofMental Disorders (4th edition, American Psychiatric Association, 2000). There is no
universally accepted lists of diagnoses that fall under the umbrella term SMI (Gold,
Kilbourne, & Valenstein, 2008). For the purposes of this project, SMI includes psychotic

9

disorders such as schizophrenia, affective disorders such as major depression and bipolar
and generalized anxiety disorders. This group of diagnoses was chosen for this paper as
they represent the most common SMis treated in Canada and reflect the most disabling
and persistent illnesses with a shared pathophysiology (Offord et al. , 1996; Stahl, 2008).
Pathophysiology of SMI. The anatomy and physiology of the neurological
system is complex. The brain is made up of billions of cells called neurons (Stahl, 2008).
A neuron is composed of a cell body, a single branch called an axon, and a multibranched structure called a dendrite. The electrical signal is believed to primarily travel
from the axon to the dendrite. Messages travel along the length of each of these cells in
the form of an electrical impulse. The neurons are not physically connected and the
electrical impulse does not directly travel from one cell the next.
Neurotransmitters are the messenger molecules responsible for the transmission
of signals between neurons. The many different neurotransmitters are grouped into three
categories: amino acids, amines, and acetylcholines. Each neuron primarily releases and
accepts neurotransmitters at either end of the cell in response to the electrical signal and
the neurotransmitters then move back and forth between neurons in the synaptic gap.
Neurotransmitters released by a single neuron are believed to affect numerous nearby
cells, causing the brain to be continually bathed in a complex molecular bath of
messenger molecules (Stahl, 2008).
It is presently understood that, when the composition of the neurotransmitters

released at the synaptic gap is altered for any reason, the interpretation of signals between
neurons is distorted, leading to the symptoms associated with the various diagnoses of
SMI. Potential causes for the onset of SMI include genetic, environmental, and

10

psychosocial factors (Stahl, 2008). Researchers have begun to identify genetic factors
responsible for predisposing individuals to the onset of SMI. Environmental factors such
as stress and trauma are also identified as influencing the onset. Lifestyle choices such as
the use of illicit drugs and alcohol also affect the onset, severity, and outcome of SMI
(Parks et al. , 2006).

Definitions and Demographics of SMI. SMI is an umbrella term that
encompasses a range of diagnoses. One characteristic shared by individuals diagnosed
with SMI is impaired connections to reality and people of importance in their lives (Oud
et al. , 2009). The following is a more detailed description of the SMI diagnoses included
in this project. In 1999-2000, 3. 8% of all hospitalizations in Canada were related to a
SMI (Public Health Agency of Canada, 2012). Deaths from suicide associated with SMI
represent 2% of all deaths in Canada (Burman, McCabe, & Pepper, 2005). Peak annual
prevalence occurs between 15-25 years of age (American Psychiatric Association, 2000).
Schizophrenia is a complex mental illness that affects interpretation of sensory
input, cognitive processing, and emotional responses (American Psychiatric Association,
2000). Symptoms include hallucinations, delusions, thought disorder, reduced emotional
responses, and irritability. Schizophrenia affects men and women equally. Onset is
typically in the teens or young adulthood, but often later in women. The prevalence of
schizophrenia in Canada is approximately 0.3% (Offord et al. , 1996).
Major depressive disorder involves the loss of interest and pleasure in nearly all
activities (American Psychiatric Association, 2000). Symptoms include changes in
weight, sleep, psychomotor agitation, feelings of worthlessness, difficulty concentrating,
and thoughts of death or suicide. Major depression is more common in women than men

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(Patten et al. , 2006). Lifetime prevalence of major depressive disorder (MDD) is 8%
(Public Health Agency of Canada, 2012). The World Health Organization (2001) has
identified major depressive disorder as the fourth highest cause of disability worldwide.
Bipolar disorder is a SMI that involves periods of elevated mood (mania) and
depression (American Psychiatric Association, 2000). Symptoms of mania include
reduced need for sleep, feeling of euphoria, impaired judgment, racing thoughts, rapid
speech, and increased irritability. Periods of mania are mixed with periods of major
depression. Bipolar disorder affects men and women equally, and onset is typically in the
teen years or early adulthood (American Psychiatric Association).
Generalized anxiety disorder is a pattern of frequent or constant worry and fear
related to a variety of situations and events (American Psychiatric Association, 2000).
Symptoms include persistent worry, difficulty concentrating, fatigue, restlessness, and
disrupted sleep patterns. Generalized anxiety disorder affects women more frequently
than men and can appear as early as childhood (American Psychiatric Association). The
12-month prevalence of anxiety disorders are estimated at between 12.2% and 17.2% and
are the most common of all SMis (Burman et al. , 2005).
Economic and health effects of SMI. The economic losses associated with SMI

have an impact on the Canadian economy. The annual cost of treating SMI in Canada has
been calculated at $7.3 billion (Public Health Agency of Canada, 2012). This cost reflects
physician billing, hospitalization, and self-reported economic loss. A 1997-1998 study
concluded annual economic loss associated with SMI was valued at $14.4 billion dollars
(Public Health Agency of Canada, 2012).

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Research has begun to identify that individuals with SMI experience increased
mortality associated with increased morbidity (Vilena & Chelsa, 2006). Individuals with
SMI experience increased rates (versus the general population) of diabetes mellitus
(16.0% vs 4.7%), hypertension (36.2% vs 15.5%), asthma (19.4% vs 7.0%), and chronic
bronchitis (25 .0% vs 4.2%), (Sokal et al. , 2004). These differences contribute to the
reduced life spans of individuals with SMI (Parks et al. , 2006).
Research indicates individuals with SMI experience increased risks to health
associated with lifestyle choices and side effects of treatment. Individuals with SMI are
more at risk for medical illness related to smoking, alcoholism, diet, and a sedentary
lifestyle than the general population (Bartels, 2004). Treatment of SMI, which includes
atypical anti psychotics, is also associated with increased rates of hypertension,
dyslipidemia, and diabetes mellitus (Lawrence & Kisely, 2010).
The discrepancy in the health status of individuals with SMI is thought to be at
least partially explained by inequities in the way health care is accessed by this subpopulation (Druss, 2007). Individuals with SMI are less likely to receive routine medical
screening than is the general population (Druss, Rohrbaugh, Levinson, & Rosenbeck,
2001 ). Individuals with SMI are less likely to receive surgical interventions such as
appendectomies, do not recover as quickly when surgery is performed, and experience
more complications (Lawence & Kisley, 2010). Individuals with SMI experience
inequalities in the access and uptake of medical care compared to the general population
(Mitchell, Malonem, & Doebbeling, 2009).
Access to primary care. Access to primary care is a complex concept in regards
to the provision of health services and can be described as consisting of three sub-

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components; accessibility, availability, and acceptability (Sibley & Glazier, 2009).
Authors such as Sibley and Glazier have developed this way of considering access from
previous conceptualizations and applied them to the current Canadian health care
landscape. Access is a personal issue that reflects the individual's ability to have their
health needs met, and is highly dependent on psychosocial determinants such as
education, financial status, and employment (Torgerson et al., 2006). Access to care is
also an indicator of how well the health care system is performing and is often measured
by the number of appointments made or surgeries conducted. Access to primary care is
also typically described by rates of utilization, and does not commonly reflect who does
not receive care and for what reasons (Sibley & Glazier, 2009).
The goal of improving access to primary care is an important objective for
Canadian health care policy makers In 2004, the Prime Minister and premiers established
the goal that 50% of Canadians would have 24/7 access to a multidisciplinary team of
health care providers by 2011 (First Ministers' Meeting on the Future of Health Care,
2004). Exact figures about the success of reaching this goal is unknown (Standing Senate
Committee on Social Affairs, Science and Technology, 2012), In 2007, Canadians were
reporting the second lowest access to a primary care provider of seven commonwealth
countries-Australia, Canada, Germany, the Netherlands, New Zealand, the United
Kingdom, and the United States. Only 84% of Canadians reported they had regular
access to a primary care provider, compared to 100% of the respondents from the
Netherlands. Only citizens of the United States reported less access to primary care, at
80% (Schoen et al., 2007). To improve access to care and meet designated priorities, the

14

Canadian government began exploring new ways to achieve their goals, one of which
was the wider introduction of nurse practitioners.
Example of barriers in practice. The following is an example from my own
practice as an RN case manager in community mental health that illustrates how a patient
with SMI experiences access to primary care.
A patient with SMI that I provided care for, whom I will call George, experienced
difficulty retaining a regular primary care provider because of the challenges he
experienced in attending appointments. George missed numerous appointments due to
over-sedation related to his medications, and had difficulty obtaining transportation to the
clinic from his rural home. Due to multiple missed appointments George' s primary care
clinic "fired" him and he was no longer able to book appointments with that office. To
receive primary care services George then had to attend a walk-in clinic. George stated he
was uncomfortable explaining the cause of his visit to the walk-in clinic receptionist in
the middle of the waiting room. George was concerned that he might be labeled because
of his diagnosis, and feared being stigmatized by staff and other patients.
Once in the treatment room, a primary care provider who was unfamiliar with his
condition met with George for the first time. George experienced difficulty expressing
the nature and severity of his symptoms within the time allotted for the appointment. As a
result of the communication difficulties and limited time, George' s medications were
refilled, but not readjusted to treat worsening symptoms, and George was referred to
community mental health resources for further assistance. George did not have a
designated community mental health physician at the time and was placed on a waiting
list for these services.

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After his walk-in clinic appointment George arrived at the pharmacy with his
prescription. He was told that he was unable to have the prescriptions refilled because his
provincial special medical coverage for psychiatric medications, Plan G, had expired.
Plan G is a provincial program that pays for psychiatric medication on behalf of
individuals with limited income. The pharmacy was unable to refill the medication
without charging George without current documentation of Plan G coverage. George
could not afford to pay for the medications out of pocket. George was then unable to
schedule another appointment with community mental health staff to have the forms
filled out to reinstate the Plan G coverage until the following week because of staffing
limitations at the community program, and only had enough medication to treat the
symptoms of his SMI for one more day.
In this case George walked to my office in the community mental health building

the following day and I was able to connect him with a mental health physician on an
emergency basis. The physician, who provided only psychiatric care, offered samples of
the required medication that would tide George over until the next week's appointment
with a physician on the community mental health team. Had George been unable to
obtain his medications in time, his mental health could have deteriorated and resulted in
an increase in symptoms and hospitalization related to his schizophrenia.
Barriers to access. In order to understand to concept of access in primary care, it

is important to understand what factors interfere with that access. Another way to look at
this issue is what are the barriers to primary care for patients with SMI? It is important to
note that in this project barriers are self-described reasons for the inability to access care
(Sibley & Glazier, 2009).

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Barriers to primary care have been described as arising from problems with
availability, accessibility, and acceptability (Sibley & Glazier, 2009). Availability is the
lack of services or unacceptable wait times. Accessibility is related to cost and
transportation issues. Finally, acceptability has to do with personal preference based on
the preferences or circumstances of the individual.
The inequities in access to health care are explained in part by barriers to care
experienced by individuals with SMI (Mesidor, Gidugu, Rogers, Kash-MacDonald, &
Boardman, 2011 ). There was no common language in the literature to describe the
barriers to accessing primary care. To help organize this project, the barriers were
organized into three broad themes identified in the initial literature review for this project
and from my own clinical practice. The themes were suboptimal therapeutic
relationships, complex service delivery, and stigma. Each theme captures and distills
similar concepts into a single term that describes the most common barriers. The themes
are both specific to individuals with SMI and similar to the three main barriers to primary
care encountered by all Canadians (Sibley & Glazier, 2009).
Individuals with SMI experience reduced services related to sub-optimal
therapeutic relationships with primary care providers. Sub-optimal therapeutic
relationships arise when the patient and the care provider do not engage with one another
to effect positive change for the patient because of insufficient communication, trust, and
respect (DeCoux, 2005). Individuals commonly report that not therapeutic relationships
with primary care providers are negatively affected when complaints related to the SMI
diagnosis are dismissed as somatic (Davis, 2004). Patients with SMI report receiving
insufficient education related to treatment options and potential side effects which

17

isolates them from treatment planning (Hardy, 2008). Isolation from the decision-making
process results in patients not trusting care providers to consider patient preference and
choice, which leads to a loss of respect (Hardy).
Insufficient appointment times are an important sub-theme of sub-optimal
therapeutic relationships identified by individuals with SMI. Insufficient appointment
times restrict a patient' s ability to express their health care needs in the time available.
This can result in health concerns of individuals with SMI being ignored or overlooked
(Wortans, Happell, & Johnstone, 2006).
In the clinical example provided earlier, sub-optimal therapeutic relationships
developed when the physician was unable to gather enough information to adequately
assess George ' s needs. George's medication was not adjusted as a result, and George
failed to develop trust that his concerns would be validated during the next appointment.
This is an example of how George would experience a reduced access to primary care in
the form of reduced acceptability of services. The insufficient time available in the walkin clinic contributed to restricted access through limited availability.
Patients with SMI also experience reduced access to primary care as a result of
complex service delivery. Complex service delivery is a barrier that exists because of the
organizational, logistical, and bureaucratic challenges of delivering primary care resulting
from a fragmented primary care system (DeCoux, 2005). Complex service delivery
restricts access to care by requiring individuals with SMI to attend multiple primary care
related appointments in different locations. Complex service delivery reduces access to
primary care for individuals with SMI by requiring patients to navigate agency,
professional, and organizational boundaries without adequate support (Glasby & Lester,

18

2004). Individuals with SMI also identify ineffective communication between care
providers as a barrier to accessing services (Boardman, 2006). A lack of effective
communication between primary care providers requires patients to undergo numerous,
redundant assessments that discourages follow-up (DeCoux, 2005).
In the clinical example, George encountered two barriers related to complex
service delivery. George encountered accessibility barriers when he was unable to retain
a regular primary care provider because of his many health and psychosocial factors, and
then was unable to obtain the required medications immediately because Plan G expiry.
George experienced reduced availability when he had to attend a second appointment
with a with a mental health physician to obtain medication samples while his request for
Plan G funding was being processed.
Lastly, stigma reduces access to primary care for individuals with SMI. Stigma
takes two forms that negatively affect access to primary care services. Internalized stigma
is a result of the fears experienced by individuals with SMI of the misunderstanding of
their health care needs by primary care providers, health professionals, and the general
public (Drapalaski, Milford, Goldberg, Brown, & Dixon, 2008). As a result of these
internalized beliefs, individuals with SMI are less likely to seek out primary care
services. Externalized stigma is the discriminatory behavior that patients with SMI
experience as a result of other individuals misunderstanding the nature of mental illness
(Van Den, Tillaart, Kurtz, & Cash, 2009; Wortans et al., 2006). Externalized stigma can
take the form of disrespectful treatment of the individual by staff and other patients, or
access becoming limited by policies that are biased against certain individuals, such as
charging for missed appointments.

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In the clinical example, George experienced two kinds of stigma. George ' s
inability to obtain a regular primary care provider was related to his challenges booking
and attending regular appointments. This is externalized stigma as a result of his SMI.
George could have experienced internalized stigma when he was uncomfortable
providing his reason for the appointment to the receptionist for fear of being labeled by
staff and other patients. Stigma, externalized or internalized, limits access to care by
reducing acceptability of care.
The current model of primary care does not meet the needs of individuals with
SMI. Individuals with SMI have described the ways in which the current model of
delivery fails to recognize their unique health needs and restricts access to services
(DeCoux, 2005). Having identified the most common barriers and the ways in which they
restrict access to primary care, it is possible to search for alternative approaches to
providing primary care to individuals with SMI.
Nurse practitioners. The goal of introducing ofNPs in Canadian health care was
to improve health outcomes and increase access to primary care to families by identifying
and reducing service gaps (British Columbia Ministry of Health, 2006; Canadian Nurse
Practitioner Initiative, 2006). The NP role has been present in North America since the
1960s, and initially described a nurse who worked in an advanced clinical role (Worster,
Sardo, Thrasher, Fernandes, & Chemeris, 2005). There are currently over 3000 NPs in
Canada working in a wide variety of clinical settings that include emergency health care,
psychiatry, internal medicine, surgery, and family practice (Canadian Nurses Association,
2011). NPs employ a holistic and collaborative approach to the provision of preventative
care as well as treatment of chronic and acute illness (Choy et al. , 2008; Keith & Askin,

20
2008). Collaboration in NP practice reflects a core practice competency and reflects both
interpersonal collaboration with patients as well as interprofessional collaboration.
Holistic NP practice refers to the use of a wide range of therapeutic options and treatment
modalities when providing primary care.
NPs in Canada possess a range of clinical skills and educational preparation. The
family NP receives education that emphasizes the provision of care for the family across
the life span (Health Force Ontario, 2006). Prior nursing experience and education affect
how NPs enact their scope of practice while the jurisdiction in which an NP practices
affects the range of skills and treatment options available to them. In British Columbia,
entry level scope of practice includes diagnosing and health care management,
prescribing medications, and consultation and referral to physicians (College of
Registered Nurses of British Columbia, 2010).
While there are no nationally standardized guidelines for NP education and
practice in Canada, all provinces and territories have introduced legislation that formally
defines and describes the NPs (Canadian Nurses Association, 2011). In British Columbia,
for example, the Health Professions Act recognizes the NP role and identifies the College
of Registered Nurses of British Columbia as the regulatory body responsible for
governing NP practice (British Columbia Ministry of Health, 2006). Similar legislation
exists in other provincial and territorial jurisdictions (Worster et al., 2005).
Canadian NPs do not commonly rely on the fee-for-service model of
remuneration employed by other primary care providers including physicians (Donald et
al., 201 0). This characteristic of practice affords NPs a certain degree of flexibility to
extend or modify the structure of appointments to address the health care needs of their

21

patients. Funding models that do not rely on fee-for-service encourages Canadian NPs to
pursue and establish collaborative relationships.

22

Chapter 3: Findings
Review of the relevant literature identified many barriers to primary care
commonly encountered by individuals with SMI. For the purposes of this enquiry, those
barriers have been organized into the three themes previously outlined in the background
section: sub-optimal therapeutic relationships, complex service delivery, and stigma. The
following is a critical review of the literature that describes how NPs improve suboptimal therapeutic relationships, assist individuals with SMI to navigate complex service
delivery, and work to reduce stigma. The concept of access to care will be expanded in
regards to its three components: availability, accessibility, and acceptability (Sibley &
Glazier, 2009).
Improving Sub-optimal Therapeutic Relationships
In several literature reviews, clinical trials, case studies, and articles, NPs were
found to improve therapeutic relationships and access to primary care by adapting
practice style and format to meet the needs of individuals with SMI. NPs used strong
communication skills to support dialogue and share information. These skills assisted
NPs in fostering trusting and respectful practice environments. NPs also integrated
mental and physical health needs as well as psychosocial concerns within the primary
care appointments. Lastly, NPs introduced flexible appointment formats to meet the
unique primary care needs of individuals with SMI.
Several studies demonstrated that NPs reduced sub-optimal therapeutic
relationships experienced by individuals with SMI by improving communication between
themselves and their patients. Hardy (2008) conducted case study that examined models
of care used in treating mental illness. He concluded that a willingness to support the

23

patient in determining what role the NP took in the patient's recovery strengthened
therapeutic relationships. Wortans et al. (2006) conducted a qualitative, exploratory study
examining satisfaction with care provided by NPs to seven individuals with SMI. The
researchers found that the ease with which NPs communicated with their patient' s
strengthened the therapeutic relationship and improved access to care. NPs in these
studies used communication techniques that helped patients feel comfortable sharing
information, promoted the exploration of health concerns, while improving therapeutic
relationships. These techniques included empowering the patient, creating an informal
environment where patients felt comfortable, and using easily understood language to
convey treatment options. These studies represent NPs improving access to primary care
in the form of improving the acceptability of services.
The findings from a case study and a project proposal found that NPs improved
therapeutic relationships between themselves and patients with SMI by developing a
shared vision of treatment. Authors of an American case study which followed an
individual treated simultaneously for Hepatitis C and schizoaffective disorder concluded
that maintaining a flexible and dynamic approach, which recognized the changing health
needs and integrated ongoing patient feedback, improved therapeutic relationships
between the patient and NPs (Gardenier, Neushotz, & O'Connor-Moore, 2007). The NP
earned the trust and respect of the patient by adapting treatment in response to the
complex mental and physical side effects of treatment based on patient feedback. Storfjell
et al. (2008), in a project proposal describing an integrated health clinic in Chicago,
Illinois, concluded that NP-led shared medical appointments improved therapeutic
relationships. Shared medical appointments provided a forum for individuals with a SMI

24

to share the responsibility for health care decisions with NPs and to consider additional
treatment options. The results of these two publications suggest that NPs can reduce
barriers to primary care related to suboptimal therapeutic relationships by collaborating
with patients with SMI. These interventions are also examples of how NPs improved the
acceptability of primary care services to patients with SMI.
NPs were able to improve therapeutic relationships by providing treatment for
mental and physical health needs. Wand and White (2007) employed a qualitative
research approach to assess outcome measures in the treatment of mental health by NPs
in Australia. Two focus groups with a total of 11 participants were interviewed. Wand
and White reported that NPs improved sub-optimal therapeutic relationships by saving
time and reducing delays in treatment through addressing mental and physical health
concerns simultaneously. The authors concluded that NPs improved therapeutic
relationships by empowering patients and fostering resilience. Though the study
examined NPs working in an emergency department setting, the authors contended that
the strengths ofNPs could be transferred to an outpatient, or community setting. This
study demonstrates how NPs were able to improve availability and acceptability
simultaneously.
Three publications exploring strategies to improve primary care access for
individuals with SMI identified a link between integrating psychosocial concerns and
improvements with therapeutic relationships. Groh (2007) concluded from a review of
literature regarding poverty and mental illness amongst women, that NP support for child
welfare and financial issues contributed to improved therapeutic relationships and
attendance to appointments. Bauman (2004) drew similar conclusions from his richly

25

descriptive article examining clinical, conceptual, and operation challenges faced by NPs
when providing care to inner city patients. Bauman reported that, when the NP provided
support for psychosocial issues, the therapeutic relationship between patients and NPs
improved as did access to primary care. Bauman noted that support included recognizing
and integrating social issues as part of treatment planning as well as communicating and
collaborating with various agencies. Bauman's case study clearly emphasized the practice
challenges of supporting individuals with SMI. Johnson (200 1) drew similar conclusions
based on a qualitative study of four focus groups, with a total of 31 participants that
examined primary care needs of women with SMI living in economically disadvantaged
rural areas in the United States. The NPs in Johnson ' s study primarily offered emotional
support for their patients. Unfortunately, Johnson ' s study included NPs and advanced
practice nurses and did not distinguish between the two practice groups when drawing
conclusions, which limits a direct association with NP practice. In each of the three
studies, the efforts ofNPs to recognize holistic health and social concerns improved
therapeutic relationships with their patients and increased acceptability and use of
.
.
pnmary care serv1ces.

Studies that examined NPs ' adaptations of primary care appointments revealed
improved therapeutic relationships when the format of the appointment was adjusted to
meet the unique needs of patients with SMI. In a retrospective, descriptive, correlational
study examining the role of shared medical appointments (SMAs) in the recovery of
patients with SMI, Tierney and Kane (2011) reported that NP-led SMAs improved
therapeutic relationships and provision of primary care for individuals with SMI.
Participants in the study reported that they were very satisfied with the relationship

26
between themselves and the NPs. Participants cited access to the NP for assessment and
treatment within the group as a reason for their satisfaction with NP care. Wortans et al.
(2006) drew similar conclusions from a qualitative, exploratory study of consumer
satisfaction with NPs. This study found that patients with SMI were more likely to attend
appointments with NPs compared to other care providers because NPs were willing to
extend appointments or meet patients in alternative settings such as the patient's home.
Boardman (2006) conducted a quasi-experimental study that sought to assess primary
care access among 76 participants with SMI attending American NP-led clinics.
Boardman found that satisfaction with primary care services was increased when NPs
spent between 45 minutes and an hour with each patient as part of the initial assessment.
Boardman noted that improved satisfaction with NPs in the experimental group was
associated with a 50% increase in attendance to primary care appointments. All three
studies described improved accessibility and acceptability when NPs adapted
appointments to better meet the primary care needs of individuals with SMI.
Not all NPs were able to adapt practice to accommodate the complex primary care
requirements of individuals with SMI. In a study of mental health outcomes in 130
individuals with a major depressive disorder, NPs reported they were unable to provide
the amount of time for appointments that patients requested (Torrisi & McDanel, 2003).
The NPs in the study identified this as a barrier to primary care availability for
individuals with SMI.

Navigating Complex Service Delivery
The findings indicate that NPs reduced complex service delivery barriers
commonly encountered by individuals with SMI. NPs improved the communication and

27

collaboration between patients and other health care professionals, which in tum
improved continuity of care. NPs also offered a wide range of therapeutic options that
reduced the need to interact with multiple care providers. Finally, NPs led collaborative
clinics that supported alternative practice models as a means to streamlining care and
improving access to services.
An American case study examining the role ofNPs in treating and co-managing

psychiatric and medical health issues identified interpersonal collaboration as a means to
reducing complex service delivery barriers (Gardenier et al. , 2007). Gardenier et al.
reported that the NP in the study worked in concert with the patient to advocate for the
coordination of the many appointments required to treat the patient' s complex physical
and mental health needs associated with Hepatitis C. NPs collaborated with the patient to
overcome side effects of hepatitis treatment, such as rashes, made medication
adjustments to treat mood alterations, and provided education for family members to help
them support the patient. As a result of this collaborative relationship, the NPs supported
the patient through his treatment. The authors concluded that it was the intervention of
the NP that maintained the patient's access to care throughout the treatment by ensuring
the acceptability of services.
NPs established effective channels of communication and cooperation with a
range of health care providers to improve access to primary care on behalf individuals
with SMI. Doey, Hines, Myslik, Leavey, and Seabrook (2008) conducted a well-designed
retrospective review of 805 charts from a collaborative clinic in Windsor, Ontario, to
examine patient satisfaction with co-located mental health and primary care services. The
researchers concluded that NPs communicated effectively with allied health care

28
providers and fostered an environment of trust and respect, which helped to improve
continuity of care for individuals with SMI. The quasi-experimental study conducted by
Boardman (2006) and randomized trial by Druss et al. (20 10) also concluded that NPs
effectively coordinated the sharing of client information amongst the members of the
health care team to organize treatment and provision of services. In both studies, patients
receiving care from NPs received increased preventative screening, attended more
referrals, and increased adherence to treatment plans as a result of improved
communication between care providers. Groh (2007), in a case study, examined her role
as a NP in reducing barriers to primary care for women with SMI and concluded that
collaboration was fundamental to reducing complex service delivery barriers that arise
from psychosocial situations. Groh emphasized the need to collaborate with social and
medical services to facilitate access to primary care. Groh concluded that collaboration
between care providers resulted in the increased availability of services, though the
conclusions were based on a single patient and provider.
NPs improved access to primary care by collaborating with psychiatric services to
improve continuity of care on behalf of individuals with SMI. Sabado and Villanueva
(2009) reported in a review of an initiative to integrate primary and mental health care
that offering mental and physical health services in the same location improved
continuity of care and attendance to primary care services by individuals with SMI. The
researchers reported a 12% increase in attendance, which they attributed to the integrated
services. The methodology was not described which reduced the reliability of the
findings. Improving the integration of psychiatric services reflects an increase in the
availability of primary care services.

29
Another way NPs collaborated to improve availability of services was by ensuring
the overall coordination of primary health care. Roberts, Robinson, Stewart, and Wright
(2008) reviewed a NP-led American health center that integrated mental and physical
health care and concluded that NPs reduced access barriers by coordinating psychiatric,
addiction, and infectious disease care. NPs in the study by Roberts et al. relied on strong
working relationships with members of the health care team and administrative support
staff to delegate responsibilities while maintaining a unified treatment plan. A bestpractice case scenario was described in the study by the authors to reinforce the efficacy
of the NP role in arranging care and maintaining the availability of services. The use of
NPs to maintain accessibility was cost effective enough that program coordinators
wanted to integrate more NPs into the program.
Boardman (2006) conducted a quasi-experimental field study of76 participants,
with 39 in the experimental group examining health access for individuals with SMI.
Boardman concluded that patients experienced improved availability of primary care
services such as preventative screens and medical treatments as a result of receiving
primary health care from a NP. These improvements were associated with NPs
coordinating care and sharing the responsibility to arrange and deliver services with case
managers and psychiatrists to improve continuity. The results of Boardman' s study
indicated an increase in attendance at primary care appointments and a decrease in the
use of emergency health services when care was provided by the NP.
Canadian and American NPs were able to reduce complex service delivery
barriers and improve the availability of primary care by offering diverse treatment
options within the primary care setting. A randomized, controlled trial examining barriers

30

and facilitators to health care for individuals with SMI concluded that NPs improved
access to primary care and decreased rates of hospitalization (Mesidor et al., 2011 ). The
authors reported that the provision of rapid access appointments and increased education
regarding a range of topics such as nutrition and lifestyle choices to individuals with SMI
all played important roles in increasing the acceptability of primary care services.
Reynolds, Chesney, and Capobianco (2006) used a bivariate conceptualization that
compared behavioral health risks with physical health risks. Reynolds et al. concluded
that NPs who provided a range of screening, preventative, and educational options as part
of primary care reduced complex service delivery barriers and increased availability of
care. The study methodology was not well described but did demonstrate attendance to
primary care appointments improved as a result ofNPs working to quickly respond to
emerging health care needs, and integrating a range of treatment options, such as wound
and diabetic foot care.
Puskar and Bernardo (2002) also concluded from their literature review that
holistic care, which included increased screening for depression and chronic illness,
would lead to improved health delivery and address the unmet primary care needs of
individuals with SMI. Finally, a publication that reviewed the effects of an integrated
health center reported that the use of primary care and laboratory services for individuals
with SMI increased 62% between the first and second year of the program (Marion et al. ,
2004). The publication did not include clear methodology and referred only to nurses
working at an advanced level with additional education as advanced practice nurse as
opposed to NPs. This weakened the strength of the scholarly findings, but the specific

31

mention of improved access and the similar scope shared by Canadian NPs and the
advanced practice nurses in this publication was enough to warrant inclusion.
Not all studies indicated NPs were successful in reducing complex service
delivery barriers for individuals with SMI when accessing primary care. Burman,
McCabe, and Pepper (2005), in a survey ofNPs asking about their comfort and
competencies in dealing with patients experiencing depression and anxiety, observed that
NPs in Wyoming experienced challenges providing care for individuals with SMI related
to a number of practice issues. NPs reported that they were generally positive about
patient outcomes, and were consistent in medication prescription with national
guidelines, but reported a lack of knowledge regarding pathophysiology and
neurobiology. This conclusion was supported in an assessment of American NPs '
preparedness to treat SMI in the primary care setting (Groh & Hoes, 2003). Burman et al.
(2005) also concluded that the NPs in their study struggled to reduce barriers to care,
such as limited appointment time, competing demands, and systemic health care issues
that interfered with health care delivery.
NPs improved availability of primary care by adapting the organization of
practice delivery to provide increased time to reduce complex service delivery barriers. In
a series of well-designed randomized control trials set within the US Veterans Affairs
(VA) system, NPs reduced the complex service delivery barrier to primary care by
modifying appointment formats to adapt to the specific needs of individuals with SMI.
Druss et al. (200 1) conducted a randomized control trial of 120 participants that
compared the treatment of patients with SMI in an integrated primary care clinic staffed
by NPs and an RN case manager to the standard care in a veteran ' s medical clinic.

32

Patients treated by the NPs reported fewer difficulties with access, continuity, and
coordination of care than the control group. NPs in the experimental group accomplished
these improvements to care by allowing extra time for appointments and flexible
scheduling. The experimental group also supported half the case load of the usual care
group and required additional administrative support to aid in the organization of
services. This study indicated that additional staffing resources that may be required to
improve to the availability and outcomes of care for individuals with SMI.
Sousa and Zunkel (2003) drew similar conclusions in their descriptive survey
investigating ways to optimize mental health care for 151 patients with SMI. NPs
practicing in NP-led clinics extended appointment times to provide additional education
and address multiple health concerns that reduced the need to contact multiple care
providers. Longer appointments were recommended as a means to inform clients how to
use educational tools provided by NPs that could be taken home to work on
independently and reduced the need for one-to-one visits. The discussion and conclusions
were not well described by Sousa and Zunkle, though they briefly discuss the relationship
between lengthened appointments as a means to reduce frequency of visits.
Reducing Stigma

NPs reduced stigma as a barrier to primary care by adopting a variety of
strategies. Normalization of treatment for SMI as part of primary care practice was one
approach. Establishing partnerships with community agencies involved in supporting
individuals with SMI and other health care providers with the goal of providing increased
education also reduced stigma as a barrier to care. Finally, developing alternative models

33

of primary care was another strategy employed by NPs to reduce stigma as a barrier and
to improve access to primary care for individuals with SMI.
Two articles reported that NPs successfully reduced the barrier of stigma by
normalizing the treatment of the disease within the primary care setting. Roberts et al.
(2008) described an integrated mental health practice that was designed to offer treatment
for mental and physical health concerns within an integrated care model. Roberts et al.
observed that initial publicity designed to attract patients to an integrated mental health
clinic actually deterred potential patients from attending because members of the
community living with SMI did not want to be stigmatized as a result of attending the
clinic. Clinic staff overcame reluctance to integrated care by visiting community settings
and carefully placing educational material to provide information about the treatment of
physical and mental health concerns in efforts to normalize the treatment for both. The
authors ' experiences provide good examples for NPs of methods that may help reduce
stigma as a barrier and improve the acceptability of primary care. Torrisi and McDanel
(2003) also reported a reduction of internalized stigma when NPs provided education to
patients regarding the treatment of depression to dispel myths and misconceptions about
the treatment of mental illness as part of primary care. The authors described how the
program used a series of educational pamphlets to provide patients and their family ' s
strategies to help reduce internalized stigma. NPs also participated in a series of speaking
events addressing the general public and health care providers to help reduce externalized
stigma. The authors concluded that these interventions successfully increased the
acceptability of primary care services for patients with SMI.

34

Two publications examining NP-led clinics identified strategies used by NPs to
reduce the stigma of treatment for SMI. In both publications NPs reduced stigma as a
barrier by integrating mental and physical health care within collaborative clinics that
incorporated coordinated and supportive services. Mesidor et al. (20 11) conducted a
qualitative study using ten key informant interviews to determine what effects NPs had
on improving access to health care services. This article addressed barriers to care such as
stigma, service delivery barriers, and sub-optimal therapeutic relationships. The authors
recognized that empowering the patient and fostering a trusting relationship, using
compassion and patience in a setting where patients felt comfortable to share information,
was one method of overcoming internalized stigma. The authors also described
successful interventions implemented by NPs that helped improve therapeutic
relationships such as increasing the availability with walk-in services and increased
frequency of appointments.
Doey et al. (2008) described an Ontario NP-led collaborative clinic that had been
developed to offer co-located mental and physical primary care services in a new and
purpose-built location. One of the benefits of the clinic was the reduction of stigma by
developing a primary care center that facilitated access to resources and programs. The
authors conducted a survey to determine client perception of the services; 51 .6 % of
respondents reported decreased use of emergency health care as a result of accessing the
clinic. This study is valuable in that barriers and NP interventions are described from a
Canadian context, and provides valuable examples of to how NPs can increase access by
improving the availability and acceptability of primary care services.

35
An American publication suggested that NPs use flexible appointment formats as

a means to reduce the stigma of SMI. Storfjell et al. (2008) proposed in an article
describing a new project designed to improve access to NP primary care services for
individuals with SMI, that NP-led shared medical appointments were one way to
accomplish that goal. Patients who accepted the offer of a group appointment found the
longer appointments encouraged casual conversation and sharing of personal coping
strategies not easily provided in traditional one-on-one primary care visits. Adapting
appointments to the meet the needs of a client population is another means by which NPs
reduced stigma and increased availability and acceptability of primary care for
individuals with SMI.
Limitations and Bias
The discussion of the fmdings to this point has not recognized the limitations and
bias of the data, which affect the ability to draw accurate conclusions and replicate
research scenarios. A lack of standardized language across the literature makes it difficult
to determine whether or not a barrier has been reduced (Groh, 2007; Storfjell et al.,
2008). For example, the use and defmition of a term such as patient satisfaction (Doey et
al., 2008) make it difficult to compare the efficacy of interventions meant to improve
therapeutic relationships.
The quality of the research is another limitation of the literature. Small sample
sizes potentially introduce bias and may not be applicable to larger populations as
conclusions are more likely to be affected by the individual characteristics of the
participants. Failure to distinguish between nurses, advanced practice nurses, NPs, and
other primary care providers and their respective roles meant that many studies were

36

excluded because of a lack of clarity in regards to which profession was thought to
contribute to a given outcome. Incomplete descriptions of methodology, such as in the
publication by Sabado and Villanueva (2009), also can decrease the quality of evidence.
A dearth of original research is also a limitation of this project. Reviews of
literature commonly drew upon a small pool of original research, such as the work by
Dross et al. (2001). In this project, the literature reviews cited within the findings have
frequently drawn conclusions based on a limited numbers of original research
publications. These limitations contribute to a lack of a strong evidence base to support
NP practice when attempting to reduce barriers and increase access to primary care for
individuals with SMI.

37

Chapter 4: Discussion
Having completed a review of the findings, it is now possible to identify
characteristics present in NP practice that successfully reduced common barriers and
improved access in regards to the availability, acceptability, and accessibility of primary
care for individuals with SMI. The characteristics may be thematically organized to
include collaborative practice, a holistic approach, and flexible practice formats. NP-led
collaborative clinics and shared medical appointments are then discussed in further detail
as examples of opportunities where NPs may employ all three characteristics of practice
to reduce barriers to primary care.
Collaborative Practice
Collaborative practice describes the characteristic of an NP ' s practice that fosters
partnerships between patients and other health care providers to develop and implement
patient centered primary care. Collaboration represents both interpersonal and
interprofessional relationships. Interpersonal relationships facilitates the development of
trust and respect between the patient and the NP by developing a mutually agreed upon
plan of care and encouraging the individual with SMI to take ownership of their health
outcomes (Wortans et al. , 2006). Interprofessional relationships assist the NP in the
navigating health care services on behalf of the patient by gathering the input of all
members of the health care team and coordinating care based on the capacity of health
systems (Druss et al, 2001). Collaboration also provides new opportunities to offer
primary care in alternative ways that present a range of therapeutic options to individuals
with SMI (Doey et al. , 2008 ; Hardy, 2008).

38

Interpersonal collaboration between NPs and patients with SMI can reduce the
barrier associated with suboptimal therapeutic relationships and improve access to and
acceptability of primary care services. Collaborating with the patient improves
coordination of physical and mental health care and helps formulate a response to address
changing health care needs in an organized and comprehensive manner (Gardenier et al.,
2007). NPs can collaborate to improve therapeutic relationships by moving away from a
prescriptive approach and invites patients with SMI to take ownership and control of their
health care (Storfjell et al., 2008). Developing strategies to overcome psychosocial
obstacles that negatively affect health and access to primary care is another way NPs
collaborate with individuals with SMI to improve therapeutic relationships (Johnson,
2001). Combining the personal experience of the patient with the knowledge and
expertise ofNPs has the potential to successfully reestablish therapeutic relationships that
in the past may have been sub-optimal.
NPs have the potential to reduce service delivery barriers and improve the
availability of primary care by fostering interprofessional collaboration amongst health
care providers. Traditionally, case managers have assumed the role of care coordinators
for individuals with SMI. However, a lack of medical knowledge and an emphasis on
acting as a gatekeeper of services rather than as a provider limits the efficacy of their
interventions in anticipating and navigating barriers to primary care (Collins, Levis
Hewson, Munger, & Wade, 2010). NPs incorporate knowledge from many professional
disciplines, including medicine. NPs bring to their advanced practice knowledge of health
care systems developed as part of their undergraduate nursing experience, and combine
this with graduate level education and advanced nursing knowledge. NPs also foster

39

primary care environments that emphasize collaborative care and integrate a range of
health care professionals (Boardman, 2006). The holistic view and collaborative skills of
NPs can support team decisions and interventions to meet the complex health care need
of individuals with SMI. Whether this is supporting the establishment of new
communication protocols or new models of multidisciplinary care, interprofessional
collaboration by NPs improves the organization and delivery of primary care services to
individuals with SMI (Doey at al., 2008; Druss et al., 2001). NPs demonstrate the
leadership, communication, and organization skills needed to form collaborative,
interprofessional relationships that improve access to primary care for individuals with
SMI.
The research demonstrates that NPs collaborate with other health professionals to
reduce stigma by introducing new venues or formats for primary care delivery. NP-led
collaborative clinics, such as the ones studied by Doey et al. (2008) and Roberts et al.
(2008), illustrate how NPs can assemble the resources to offer comprehensive mental and
physical primary care in venues not stigmatized by an association with SMI. Receiving
educational and emotional support in these centers helps reduce the internalized stigma
that is a barrier to care and improves the acceptability of services. Interprofessional
collaboration with other health providers assists NPs in establishing SMAs that provide
an opportunity for individuals to share coping strategies to help deal with internal and
externalized stigma (Storfjell et al., 2008). The SMA is a valuable tool that assists NPs in
reducing stigma and improving access through improvements in the acceptability of
services for patients requiring care.

40
Holistic Practice

The holistic characteristic ofNP practice recognizes and addresses a broad
spectrum of physical, mental, and psychosocial factors that may improve availability of
primary care for individuals with SMI (Bauman, 2004). Providing more treatment options
within the primary care setting reduces the need to attend multiple appointments with a
range of care providers and may improve accessibility by reducing complex service
delivery barriers. Holistic NP care has the potential to increase acceptability of primary
care by normalizing the treatment of mental and physical health needs that reduces the
stigma of SMI as a barrier to care.
Holistic practice may reduce the barrier of sub-optimal therapeutic relationships
and improve the acceptability of primary care by establishing trust and respect between
individuals with SMI and NPs. This can be accomplished by addressing the emotional
and psychological distress of individuals with SMI (Wand & White, 2007). Recognizing
and treating symptoms of distress beyond physical complaints addresses a gap that has
historically interfered with therapeutic relationships between primary care providers and
individuals with SMI (Wortans et al., 2006). Providing holistic care reduces the need to
introduce multiple care providers that has been traditionally associated with complaints
of what can be characterized assessment fatigue by patients, a situation arising from
multiple assessments (DeCoux, 2005). While not all NPs may initially possess advanced
counseling skills, know ledge of neurobiological processes or practice in a setting that
accommodates regular extended appointments, patients respect and trust the efforts of
NPs to address their physical, mental, and emotional primary care needs (Burman et al.,
2005).

41

Holistic practice offered by NPs can help to reduce the common primary care
barrier of complex service delivery encountered by individuals with SMI. Holistic care
reduces the logistical and financial challenges that result from care delivered in multiple
locations by multiple providers. (Doey et al., 2008; Wortans et al. , 2006). The willingness
to address complex chronic physical health conditions, such as diabetes and heart disease
often experienced by those with SMI, in addition to mental health needs, may also reduce
service gaps and improve access to primary care (Reynolds et al., 2006). Offering
comprehensive assessment, screening, and treatment for physical and mental health can
reduce service gaps and redundancies that can frustrate patients and can lead to
reluctance in seeking primary care (Drapalaski et al. , 2008).
NP holistic practice has the potential to reduce stigma as a barrier to primary care
by normalizing treatment for mental health. Externalized stigma from primary care
providers, administrative staff, and fellow patients may be reduced when individuals
receive care from NPs that adapt their practice to accommodate the communication and
behavioral challenges that may be experienced by individuals with SMI (Mesidor et al.,
2011). When practicing in an environment that anticipates and accommodates the holistic
primary care needs of patients with SMI, NPs can help reduce the fear and anxiety
associated with appointments that can lead to a withdrawal from care. When NPs treat
SMI as part of the continuum of primary care services, the stigma associated with SMI
can be reduced (Hardy, 2008). Placing equal emphasis on the treatment of physical and
mental health concerns can help patients appreciate the chronic nature of SMI and
similarities with other health conditions, such as diabetes or asthma, that are not as

42

stigmatized by the general public (Roberts et a., 2008). These strategies may help
improve the acceptability of primary care services on behalf of individuals with SMI.
It was noted in the literature that not all NPs felt they possessed enough

knowledge, education, or training to practice as holistically as they would have liked
(Burman et al. , 2005). It is understandable that, given the range of clinical experience and
educational preparation each NP brings to practice, not all NPs will initially possess the
practice skills required to address the complex mental and physical health needs of
individuals with SMI. Fortunately, Canadian NPs are required to continue to expand their
practice knowledge as part of continuing education required to maintain registration.
Pursuing education regarding diagnosis and SMI treatment options is one way to meet
practice requirements and to enhance holistic practice as a means of reducing barriers and
improving access to primary care for individuals with SMI.
One other barrier to holistic practice noted in the literature was the legislated
boundaries on the scope of practice experienced by NPs in some jurisdictions (College of
Registered Nurses of British Columbia, 2011). Not all NPs have been able to provide all
of the required care to patients with SMI, as in British Columbia where NPs are unable to
prescribe controlled substances. NPs in this province are required to consult with
additional primary care providers when controlled substances are required, which
restricts the NPs ability to independently meet all of the patient's medication needs.
Flexible Practice

When practicing in settings designed to accommodate patients with SMI, the
flexible characteristics ofNP practice may help establish trust and respect between the
NP and the patient (Boardman, 2006). Flexible practice can also provide time for

43

advocacy and coordination of care while adapting practice to meet the unique primary
care needs of this population. Introducing alternative models of practice, such as NP-led
clinics and shared medical appointments, is another example of how flexible practice
allows NPs to improve access to primary care by reducing stigma as a barrier (Storfjell et
al., 2008).
Flexible practice affords NPs the opportunity to invite individuals with SMI to
join in the development of their own treatment plan and encourages the patients to take
ownership of the health outcomes. Flexible practice allows NPs to take the extra time
required to mutually develop the care plan and consider treatment options based on the
NPs knowledge of health systems (Wortans et al. , 2006). The complexity of providing
primary care to individuals with SMI often requires additional time to consider their
perspective regarding treatment options and psychosocial factors that may affect their
adherence to the treatment plan (Groh, 2007).
Flexible practice allows NPs to adapt the care and treatment provided to meet the
unique needs of individuals with SMI and contributes to improved therapeutic
relationships and acceptability of care. NPs recognize that flexible practice may result in
reduced access for their case load as a whole to accommodate fewer individuals who
would otherwise access no primary care. It may not be necessary to extend every
appointment for every patient with SMI as not all health needs benefit from longer
appointments, but keeping the option open to do so can help improve the acceptability of
primary care. Extending appointments early in the primary care relationship can lead to
greater increased availability of appointments over time as health care issues are resolved
and individuals are empowered (Mesidor et al., 2011). Extending appointments when

44
needed may reverse the loss of respect for primary care providers that has been reported
by patients with SMI (Wortans et al., 2006). A flexible practice affords increased
opportunities to exchange information and the time to develop a plan of care that reflects
the unique needs and wishes of the patient (Storfjell et al., 2008). NPs recognize that,
when they are unable to incorporate flexible practice into primary care, barriers for
individuals with SMI remain (Torrisi & McDanel, 2003). Moving away from inflexible
appointment times and structures removes an important barrier to primary care for
individuals with SMI.
Flexible practice reduces complex service delivery barriers by affording NPs the
opportunity to advocate, plan, and organize the primary care of individuals with SMI.
NPs may adopt the role of coordinator of primary care as needed to improve the
availability and accessibility of care that reduces service delivery barriers (Boardman,
2006; Roberts et al. , 2008). Delegating and assigning tasks to the other members of the
care team, when appropriate, reduces redundancies and may free up NP appointment time
for other patients. Flexible practice also affords NPs the opportunity to implement
alternative models of primary care, such as NP-led collaborative clinics and SMAs to
provide a range of services that improve the availability and accessibility of primary care
to individuals with SMI (Doey et al. , 2008; Druss, 2001).

NP-led collaborative clinics. NP-led collaborative care clinics combine the most
successful characteristics of NP practice that reduce common barriers and increase access
to primary care for patients with SMI (Druss et al. , 2001). Within these clinics, NPs
employ collaborative, holistic, and flexible practice to reduce barriers and increase the
availability of primary care (Doey et al., 2008). In collaborative clinics, NPs can

45

assemble the resources to accommodate the complex physical and mental primary care
needs and provide a one-stop-shop for care (Sabado & Villanueva, 2009). These clinics
may include supporting psychiatrists, occupational therapists, nurses, and dieticians. NPs
foster therapeutic relationships between themselves and patients by offering an informal,
comfortable, and welcoming environment, free from external stigma that improves the
acceptability of care. Practicing in collaborative clinics also supports NPs in adopting
multiple roles, such as provider and coordinator of care, which may not be available in
other primary care settings (Roberts et al. , 2008).
Shared medical appointments. Shared medical appointments (SMAs) provide

another opportunity for NPs to integrate collaborative, holistic and flexible practice
characteristics as a means to reduce the most common barriers and improve access to
primary care for individuals with SMI. SMAs do not require NPs to adopt a leadership
role, but NPs ' communication, leadership, and collaborative skills make them excellent
candidates. Though SMI is not the focus of their article and therefore not included in the
findings, Watts et al. (2009) identified NPs as possessing unique practice characteristics
that make them well suited to lead SMAs. Watts et al. cited the holistic practice ofNPs as
important in providing education and motivation for patients living with chronic illness.
NP-led SMAs potentially reduce complex service delivery barriers to primary care by
providing increased access to treatment and timely support for mental and physical health
issues (Tierney & Kane, 2011). SMAs also increase the acceptability of care by providing
opportunities for patients to share strategies to overcome external and internal stigma
~ with SMI (Storfjell et al. , 2008).

46

Chapter 5: Summary, Conclusions, and Recommendations
The purpose of this project was to identify the characteristics of NPs practice that
may reduce the most common barriers to accessing primary care encountered by
individuals with SMI. The most common barriers associated with reduced access to
primary care identified by individuals with SMI are sub-optimal therapeutic relationships,
complex service delivery, and stigma. The three characteristics ofNPs that were most
effective at reducing these barriers were collaboration, holistic care, and flexible practice.
NPs collaborated with patients and other care providers to coordinate and organize
services that resulted in improved availability and accessibility to primary care. NPs also
practiced a holistic style of primary care that addressed physical, mental, and
psychosocial health needs and provided a range of therapeutic options that improved the
acceptability of services. Finally, NPs implemented flexible practice when required that
allowed for the introduction of alternative appointment formats that recognized the
unique primary care needs of individuals with SMI. These three characteristics ofNP
practice reduced barriers to primary care and improve the availability, accessibility, and
acceptability of primary care to individuals with SMI.

Recommendations
NPs possess a unique combination of knowledge and skills from the domains of
nursing, medicine, and other disciplines that allow them to reduce barriers and improve
access to primary care for individuals with SMI. Knowledge and skills developed as part
of registered nursing practice are enhanced through the education process which is part of
NP preparation. The result is a primary care provider who understands the challenges and
rewards of delivering care to patients with SMI and has the capacity to assess, diagnose,
and prescribe the necessary interventions at the primary care level.

47
Based on the integrative review of the literature completed for this project, the
following seven recommendations for NP practice are offered:
1. Collaborate with patients and other health care providers to integrate personal
preferences when developing plans of care to improve therapeutic
relationships and the acceptability of primary care services.
2. Emphasize a holistic approach in the provision of primary care to individuals
with SMI to improve the accessibility and acceptability of services.
3. Consider incorporating alternative practice models such as SMAs and NP-led
clinics.
4.

Support patients in addressing psychosocial concerns such as financial, legal,
transportation, or cultural needs to improve the accessibility and acceptability
of services.

5. Utilize the requirements for professional development to identify and
undertake training and education regarding the treatment and management of
SMI.
6. NPs that work regularly with patients with SMis should identify research
partners from nursing and other disciplines to advance knowledge regarding
access barriers.
7. Normalize the treatment of SMI a part of primary care practice.

NPs possess the practice characteristics to take a leadership role in reducing
barriers to primary care commonly encountered by individuals with SMI. The uniqueness
of the NP role within the Canadian health care system offers an alternative to existing
primary care systems that sustain barriers to access. Emphasizing the benefits associated

48

with these practice characteristics is an opportunity for NPs to take a leadership role in
improving access to primary care and the health outcomes of individuals with SMI.

49
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Table 2. First two key word search results

Nurse practitioner, mental disorders
Nurse practitioner, primary care
Nurse practitioner, treatment barriers
Mental disorders, primary care
Mental disorders, treatment barriers
Primary care, treatment barriers

206
2397

14

3790

145

189

Table 3. Second two key word search results

Nurse practitioners, mental disorders
Nurse practitioners, primary health care
Nurse practitioners, health services accessibility
Mental disorders, primary health care
Mental disorders, health services accessibility
Health services accessibility, primary health care

206
2721
728
2722
2300

4555

Table 4. First three key word search results

Treatment barriers, nurse practitioners, and mental disorders
Treatment barriers, nurse practitioners, and primary care
Primary care, treatment barriers, and mental disorders
Primary care, nurse practitioners, and mental disorders

4
4
12
53

Table 5. Second three key word search

Primary health care, nurse practitioners, and mental disorders
Primary health care, nurses practitioners, and health service accessibility
Mental disorders, nurse practitioners, and health service accessibility
Mental disorders, health service accessibility, and primary health care

40
195

16
207

56

Table 6. MeSH term searches of PubMed.

Primary health care, nurse practitioners, and mental disorders
Primary health care, nurse practitioner, and health services accessibility
Primary health care, health services accessibility, and mental disorders
Health services accessibility, mental disorders, and nurse practitioners
Health services accessibility, mental disorders, nurse practitioners, and primary
health care

281
201
708
27
12