Nurse Practitioners in Community Health Care: A Rapid Scoping Review of Their Role, Tasks, Responsibilities, and Implementation in Northwest Europe

Te objective of this rapid scoping review is to provide an overview of studies from northwest Europe that describe and evaluate community care delivered by a nurse practitioner (NP) in a team of healthcare professionals. In particular, we explore the roles of NPs within community care, the perceived impact at the patient and informal caregivers levels, and infuencing factors (facilitating and impeding). Tis rapid scoping review was performed in accordance with Prisma RR guidelines. Data were collected from online databases between October and December 2020 and an update in March 2023. Medline was used for the search string, and the following databases were searched: Cinahl, Cochrane, Embase, Medline, and Web of Science (WoS). All studies described the roles of NPs, including their tasks and responsibilities in community care. Te main fndings about the roles were that NPs in community care diagnose, treat patients, and support and advise informal caregivers. Tey refer and perform case management for (frail) older people. Tey train DNs and take on project and strategic management roles. Te results showed that the NP meets the increasing and complex care demands in patients’ homes. Te main fndings about the perceived impacts were that patients and informal caregivers were generally satisfed with the deployment of the NP. Healthcare professionals experienced the benefts of NPs working in community care. Some healthcare professionals were sceptical when the role was frst introduced, but attitudes improved after they worked alongside NPs. Other infuencing factors were the competences of the NP, i.e., have a pioneering mentality, a clear vision, and a job profle from community care organisations, and having to collaborate with allied healthcare professionals. However, implementation of the NP in community care is still in its infancy in northwest Europe. Tis review will help policy makers and professionals understand the potential impact of this role and enhance it in the context of community care.


Introduction
Healthcare systems are facing major challenges due to ageing populations and shortages of healthcare professionals.
According to the World Health Organization (WHO), the percentage of people aged 65 and older is expected to increase from 14% in 2010 to 25% in 2050 [1]. Europe's population is ageing rapidly; its median age is already the highest in the world. Te aims for the European region according to the WHO are to achieve universal health coverage while paying attention to age and the specifc needs of older people, to better protect people from health emergencies, and to ensure healthy lives and well-being for all [2]. Te European Commission's policy on active ageing is focused on "helping people stay in charge of their own lives for as long as possible as they age and, where possible, contribute to the economy and society" [3].
Te increase in the number of older people, will lead to an increase in diseases. A steadily rising proportion of people has two or more medical conditions simultaneously, known as multimorbidity [4]. Ageing and multimorbidity contribute to frailty, which creates a higher risk of complications such as falls, disability, hospitalisation, and mortality. Tese developments will require diferent interventions in community care, such as caregiver support and services at home. Assistive technologies, home exercise programs, and better transport and housing policies are also needed [5]. Afordable highquality long-term care services, particularly home-based care and community-based services, are crucial to an ageing population [3]. A growing trend is the hospital@home care [6]. Such services require community care professionals who can meet this increasing demand and deliver complex care.
Academic literature uses diferent terms for community care: nursing in home care, nursing in primary care, district nursing, and community health care. In this article, we will use "community care," which also covers the other terms because the NP delivers care in the people's home, which is part of the primary care and includes district nursing. Community care is defned as the nursing care that people with (complex and multiple) care problems receive at home [7]. It involves any technical, medical, supportive or rehabilitative nursing care, and the provision of assistance with personal care [8].
Most community care is provided by certifed nurse assistants and nurses. However, due to the increasing complexity of care, several countries have added nurse practitioners (NPs) to community care. NPs can provide aspects of primary care, complementing the work of general practitioners (GPs) [9]. NPs have a master degree and are trained to take over medical tasks independently from GPs [10,11]. NPs in community care usually had a few years' experience as district nurses (DNs), before starting the training to become a NP. During their training they develop general medical skills and integrate these skills with complex nursing care. Besides, they were amongst others educated persons to use the best scientifc evidence, deliver personcentered care, provide patient education, work multidisciplinary, and being a leader in innovation and implementation [12]. According to the International Council of Nurses (ICN), NPs can integrate clinical skills associated with nursing and medicine to assess, diagnose, and manage patients in primary healthcare settings and acute care populations, as well as provide ongoing care for populations with chronic illness [13].
In the Netherlands in 2012, the capacities of the NP were codifed by law through the adoption of a government decree. Trough this decree, (registered) NP's are allowed to independently perform medical tasks, such as prescribing medication, giving injection, and catheterization [14]. NPs also play a leading role in professional innovations and health care in general, supported by research and the implementation of research results. Tey contribute to their own professional development and to other professions, and to the quality of care [15] as described in their professional profle [16]. From the patient's perspective, NPs ofer care and cure that further strengthen the continuity and quality of both nursing care and medical treatment. Self-management and quality of life play a pivotal role here [15].
Although the role of the NP is relatively new to the healthcare systems of northwest Europe, it has been common in other parts of the world (e.g., the US and Canada) since the 1960s [17]. Countries like the United Kingdom, Finland, and Australia developed a broad scope for the NP's role [18]: most NPs in there work in a general or psychiatric hospital setting. Only a quarter work in primary health care, with a small proportion in community care [17].
Research focusing on the role of the NP in primary health care has shown that they mainly replace care from GPs. NPs probably provide care that is equal or even better than that provided by GPs and probably achieve equal or better health outcomes for patients [19]. A systematic review by Van Erp et al. [20] found that care from medical specialists is replaced by care from NPs in primary care plus settings, and the NPs perform additional tasks related to nursing care. Tey conclude that the "quality of care within primary care plus delivered by nurse practitioners appears to be guaranteed, at patientlevel and professional-level, with better access to healthcare and fewer referrals to hospital." However, these reviews in primary care and primary care plus settings do not include community care. Te role and impact of NPs in community care are less frequently studied and, to date, no reviews have investigated the care NPs deliver in community care settings.

Research Aim.
Te aim of this rapid scoping review was to provide an overview of studies from northwest Europe that describe and evaluate community care delivered by a NP in a team of healthcare professionals. In particular, we explored the role of NPs in community care, the perceived impact on the patient and informal caregiver, and infuencing factors (facilitating and impeding) for implementation. Tese insights are needed to further develop the NP role in Dutch community health care.

Design.
We conducted a rapid scoping review, a method that Tricco et al. [21] described as "a form of knowledge synthesis in which components of the systematic review process are simplifed or omitted to produce information in a timely manner." PRISMA Rapid Review (PRISMA RR) reporting guidelines were followed [22].

Setting.
Studies form northwest Europe (Sweden, Denmark, Germany, Switzerland, Austria, and the UK) were included, because the healthcare challenges share similar aspects to the Dutch healthcare system. We searched for articles written in English and Dutch.

Setting Research Question.
Te search was limited to care provided by NPs to patients who need home-based care. Tis includes care for patients aged 18 and older who are mentally ill, older people or people with impairment that is provided in the community rather than in hospitals or institutions.

Inclusion/Exclusion
Criteria. Tis rapid scoping review included studies with quantitative, qualitative, proof of action, and mixed-method research designs published from the year 2000 onward. We chose this year because NPs began taking an active role in health care in northwest Europe in the early 2000s. We excluded all texts that were not published in a (scientifc) journal (i.e., book chapters, reports, interviews, and symposium reports) because we were interested in results from peer-reviewed studies. We also excluded studies from the US, Canada, Australia, and other countries outside of northwest Europe. Only studies published in English or Dutch language were included.

Search.
Te literature search for this rapid scoping review was carried out from October 2020 to December 2020 and an update in March 2023. Te search strategy comprised subsequent steps, as proposed in the reporting guidelines from PRISMA RR [22]. First, we used the Medline database to identify relevant keywords for our search string (Appendix 1: Search String Medline). Second, we used those keywords to build an elaborate search string. An information specialist from the HAN University of Applied Sciences and four reviewers (MdL, RW, JV, and AvV) helped to defne terminology by searching for synonyms and broadening defnitions in the search strategy. Te search string was discussed with all the authors of this article. Te search strategy was improved to increase its sensitivity and reduce the risk of missing relevant studies. Finally, the search was performed in Cinahl, Cochrane, Embase, Medline, and Web of Science (WoS).
We also conducted desktop research in grey literature, such as national reports. Other supplemental searching was done in Google Scholar. We checked the reference lists in included articles for snowballing purposes.
2.6. Study Selection. Identifed records were imported into Rayyan QCRI for further investigation and selection. Reviewers (MdL, CH, JV, and RW) supervised by an associate professor (AvV) conducted a pilot exercise in pairs with 70-100 abstracts, and then, each reviewer searched the remaining abstracts. For each abstract, the reviewers assigned one of three choices: include, exclude, or confict. Te abstracts that were labelled as "confict" were discussed by reviewers later using confict resolution principles. Tere were also situations in which some abstracts were initially included by one reviewer but, after discussion and confict resolution, were excluded by all reviewers.

Full-Text Screening and Data Extraction.
We then read the full texts of all "included" articles. Te articles were divided among the four reviewers (and one reviewer read all the articles). Once an article had been read, the reviewer wrote a summary in a standard data extraction format. Tis format was implemented after the reviewers conducted a pilot exercise using a single full-text article.

Synthesis.
Te four reviewers discussed all included articles and synthesised evidence narratively. Te excluded articles were discussed by the four reviewers and excluded based on consensus. Te reviewer (MdL) who read all the full texts formalised the decisions on the standard form.

Results
Te research resulted in 3273 hits ( Figure 1). After duplicates were removed, 1186 hits remained and were screened on title and abstract. Out of these, 69 hits were screened on full-text. After screening and discussion between the researchers, 22 studies remained for full-text reading. Seven articles did not meet the inclusion criteria and were therefore excluded. One more hit was identifed by checking reference lists of relevant studies. One study was included after a search in Google Scholar. In total, 15 articles from 14 studies from databases were included and 2 articles from other sources. Ultimately, 16 studies reported in 17 articles met the inclusion criteria and were included in the rapid scoping review.
Te result section is organized according to the research aim. After the characteristics of the studies, the role of NPs in community care, the perceived impact on the patient and informal caregivers levels, and infuencing factors (facilitating and impeding) are elaborated.

Characteristics of the Included Studies.
All articles were published between 2003 and 2022. Te studies were conducted in the UK (n = 14), Norway (n = 1), and the Netherlands (n = 1). Most applied a qualitative design (n = 13), including semistructured interviews (n = 8). Tere was, one cross-sectional study, one proof of concept, and one study with a mixed design (Table 1: rapid scoping review).

Case
Manager. Ten studies described the role of the NP as a case manager [25,[27][28][29][30][31][32][36][37][38]. When the role of the NP was implemented in the UK in early 2000, the primary goal was to perform case management activities for frail older people with multimorbidity and thus to reduce unplanned hospital admissions and readmissions. Ten studies explored the NPs' focus on promoting self-reliance with the goal of enabling patients to live longer at home and reducing the risk of hospital admission [24-28, 30-32, 36, 37]. Several other elements of the NP's role were described in various studies: they provide holistic care, including psychosocial care [25, 26, 31-33, 35, 36]; they coordinate care for frail older people, encourage patients to be self-reliant, give health advice, and explain medical terminology [25-28, 31-33, 36, 37]; they care for and support informal caregivers [25,32].

Other Roles.
Seven studies described other roles of NPs in community care [25,27,31,33,36,37,39]. Two described a leadership and consulting role in which NPs were involved in project management and strategic development [25,31]. One study also noted that NPs do scientifc research [25]. Two studies described how NPs are involved in activities aimed at increasing their professional skills and knowledge [25,39], and four studies described how NPs were perceived to network and work in partnership with other healthcare and social care professionals [25,33,36,37]. One study explored the role of the NP in multidisciplinary team meetings in which NPs reviewed and shared information with other healthcare professionals [27].   (i) All nurses and NPs said they were satisfed with their role (63%) or highly satisfed (25%) (ii) they obtained enough knowledge (88%) (iii) they were (highly) satisfed with providing heart failure@home care (88%)

Perceived Impact on Patients and Informal Caregivers.
Tirteen qualitative studies explored patient satisfaction with care provided by NPs and concluded it was high [24-33, 36, 37, 40]. Seven studies found that patients experienced better access to healthcare facilities because the NP acts as an "advocate" for them and knows the networks well [25,26,30,32,33,36,37]. Patients also felt that they received more accessible health care (including medical care) because NPs could provide some of the complex medical care on site [24,40]. Five studies found that patients perceived that the NP has more time for patients and is more visible to them, and they felt that NPs see each patient as a whole person [29-31, 36, 37]. Some patients emphasised that they valued the attention from the NP in coordination of care [27,30,32]. Tey even experienced a better quality of life and a better quality of care [24][25][26].
Six studies noted that NPs act as a bridge to other healthcare professionals, which provides a higher quality of care for patients [25,30,32,33,36,37]. Tis improved communication between patients and other healthcare providers [26,32,33]. Some patients also felt that the NP's work improved the connection to their GP [30].
Two studies explored informal caregivers' experiences with NPs [25,32]. Te caregivers emphasised the psychosocial care the NPs provided especially for them, and this was highly valued. Tey felt that they were not alone in caring for someone. One study described how the NP performs health promotion activities and delivers disease education, also to informal caregivers [32].
Despite the positive response from patients and informal caregivers, some patients expected to receive different care than the NPs actually provided. One study found that patients expected the NP to visit them regularly, regardless of need, to monitor their condition [33]. Another study reported that out of ofce hours cover was poor overnight, and patients were encouraged to call for emergency care [31].

Implementation.
Fourteen out of the 16 studies described facilitating and impeding factors associated with implementing the role of NPs in community care.

Facilitating Factors.
NPs working in community care frequently collaborate with other healthcare professionals. Two studies reported that having NPs in this role reduces the workload of GPs [25,28]. One study found that NPs complement the work of other healthcare professionals such as the GP, the DN, and the social worker [28]. In addition, the NP works in a multidisciplinary team coordinating care [28]. NPs also share knowledge with DNs and support them in their work [26,28,39]. GPs fnd it helpful when the NP provides a complete assessment that improves communication between the GP, NP, and DN [39].
Education and training also facilitate the implementation of the NP's role. Some NPs emphasised that knowledge related to prescribing medications and treatments is essential to fulflling their role [34]. Furthermore, their university training in physical assessment skills gives NPs the competence and capability to perform such tasks independently in patients' homes [35].
One study showed that NPs were (highly) satisfed in their role as they provided heart failure@home care [40]; it improved their perspective and job satisfaction. Tey also said that they obtained enough knowledge (88%) to care for heartfailure patients at home.
Other facilitators included expanding NP practice to carry out tasks in addition to case management of patients with long-term conditions. Tis might include taking on a managerial role that involves day-to-day management of staf [36].

Impeding Factors.
Nine studies also found factors that impeded the implementation of the NP role in community care. Four studies found scepticism from GPs and managers due to unfamiliarity with the competences of the NP in community care [26,34,38,39]. In addition, it was perceived that NPs had to gain the GPs' trust [34]. Tree studies by Randall et al. [31,36,37] reported that other healthcare professionals had a limited understanding of the NP's role. Some managers and GPs question whether NPs can really reduce hospital readmissions and reduce GPs' workloads [38].
Another factor that can impede the implementation of the NP role is a lack of vision related to the care and cure delivered by NPs [26,28,31,36,37]. Five studies reported that there was no clear job profle for the NP and thus poor implementation of the role [26,28,36,38,39]. Two studies reported that a confict of role and status can occur between the NP and the DN when the new NP role was created [26,27].
Herklots et al. [34] reported that NPs perceive a need to fnd their own ways of acquiring professional education to keep their pharmacological knowledge up to date. In two studies, NP's reported that they have no easy access to electronic records, which complicates communication with the GP or pharmacist [27,34].
Another study [26] reported that NPs did not earn a salary commiserate to their master-level education.
Gage et al. [29] reported that the monthly costs are higher for patients who live alone and whose care is managed by NPs.

Discussion
Tis rapid scoping review provides insight into the roles NPs take on (including their tasks and responsibilities), the perceived impact for patients and informal caregivers, and the implementation of the NP role in community care in northwest Europe. In total, the review included 16 studies that describe how NPs provide care and cure in the community. NPs in community care take on a wide range of roles: they contribute to medical and complex nursing care at home such as prescribing medication, physical examination, and independently performing diagnostics, and they perform case management for patients with complex long-Health & Social Care in the Community 13 term conditions. Patients and their informal caregivers are generally satisfed with the care and cure provided by NPs. NPs act as a bridge between patients and other healthcare professionals. However, implementation of the NP role in community care is still in an early stage. After some initial scepticism, GPs and other healthcare professionals are coming to see the added value of NPs. Tey can relieve the GP's workload and contribute to educating other healthcare professionals.
Using NPs in community care is a recent development, as indicated by the articles' publication dates . In northwest Europe, the UK has the most experience with using NPs in community care. One study showed the impact of the NP in community care for heartfailure patients in a hospital@home program in the Netherlands [40]. Other European countries are still in the pioneering phase, as shown by the fact that no related studies were found. A Norwegian study also found that the use of NPs in the community is still in its infancy, and NPs are searching for a way to fulfl their role in the community together with GPs and DNs [39]. Although healthcare systems between the UK and the Netherlands difer, it is interesting to learn how the NPs are embedded in the healthcare system in the UK. Tey are autonomous as health care professionals in their role and tasks when they combine their general and specialist expertise. Tey have also a leading role in nurseled clinics.
Increasing complexity of care and demography is creating greater urgency for expertise and highly trained nurses in community care [9]. In the Netherlands, the government strategy is to provide right care at the right place, to transform health care. Te implementation of NPs in community care is seen as an intervention in translating the government vision into practice (Right care Right place/ Juist zorg op de juiste plek, n.d.) [41]. Tus, one might ask why the NP is not yet a common role in community care in northwest Europe. An integrative review by Busca et al. [42] reported barriers to implementing the role of the NP in community care, in thirteen diferent countries from around the globe. Te most frequently reported barriers were related to regulatory aspects of the nursing profession in the contexts of care, cultural, and organisational aspects, training, and transferring specifc skills that had been performed by doctors. Implementation takes time and requires redeployment or role defnition of other professionals already working in community care [42].
Glarcher and Lex [43] found that NPs' skills and job profles depend on the commitment and organisational opportunities of individual healthcare executives. Te evaluation of NPs on health outcomes is based mainly on the individual initiative of these pioneers and is not accessible nationally. Tis may require an efort from the NP to pioneer and position the role.
NPs perform both nursing and medical tasks. Medical tasks include physical examination at home, prescribing medication independently, reviewing, and providing advice on medication management. NPs also treat, diagnose, and refer patients. We found limited information about the degree of responsibility attached to the NP's tasks. It is unclear whether NPs work independently or closely together and under a GP's supervision when providing medical care. An observational study by Michalowsky et al. [44] concluded that an NP in community care can be an adequate substitute for a GP. However, this study was conducted among a specifc target group (i.e., patients with dementia). It is important that the scope of practices is clearly defned for NPs in community care, in coordination with the scope of practice of GPs and DNs. Tis should be done in close collaboration with professional nurse organisations.
Most of the studies we reviewed found that patients and their informal caregivers are very satisfed with the care NPs provide. NPs are easily accessible, patients can be treated at home, and rehospitalisation can be prevented. Tis is in line with fndings from other studies, such as a systematic review conducted by van Erp et al. [20]. Tat review looked at primary care plus and described the role of the NP in it. Primary care plus was developed with the aim of creating substitution and stimulating integrated care by allowing NPs to perform consultations in primary care. Te review showed that the quality of care, at both the patient and professional levels, seems to be guaranteed, and there may be better access to health care and fewer referrals to hospital. Although the type of care given here may difer from that in our study, the setting is the same (i.e., close to patients' homes).
Te systematic review by Donald et al. [45] also noted that NPs prevent rehospitalisation, and they found evidence of reduced rehospitalisation when patients receive care from an NP in the community. Tis was confrmed in a systematic review by Laurant et al. [19] that focused on NPs in GP practices. Patient satisfaction was perceived to be slightly higher in nurse-led primary care. Furthermore, quality of life may be slightly higher for patients who receive NP care than for those who receive usual care.
Most of the included studies found that other healthcare professionals are somewhat sceptical about the role of the NP a priori. Our fndings are in accordance with studies from Ljungbeck and Sjögren Forss [46] and Michalowsky et al. [44]. However, those studies found that the sceptical attitudes from other health professionals change when NPs work with a specifc target group, such as people with dementia or frailty at home. Tis could be explained by the intensity of care and the additional tasks NPs perform in relation to these target groups (e.g., bridging the gap between nursing and medical care or educating nurses who work in the same specialism). Tus, NPs should think about how to remove impediments by working alongside and closely with other professionals, which would allow them to experience the added value of the NP.
Te literature shows that NPs are positioned diferently in primary care, and this has had promising outcomes. Employment settings range from general practice, primary care plus, and outreach in a nursing home to community care organisations [19,20,45]. Our study focused on NPs employed by community care organisations. Te question that emerged is how can the NP be optimally positioned in community care to have maximum impact on patient outcomes?

Strengths and Limitations of the Study.
One strength of our rapid scoping review was the solid methodological approach and the help of an experienced information specialist in conducting the search. Te data analyst helped us compile an extended search string. Another strength of the study was the fact that multiple researchers were involved in selecting articles and extracting data. Te involvement of multiple researchers reduces the risk of selection bias and incomplete data extraction.
Tis study also has some limitations that should be considered when evaluating the fndings. Defning the role and impact of the NP in community care was challenging because NPs who work in community care hold various titles (e.g., advanced nurse, practice nurse, and community matron). During the selection procedure, the review authors critically appraised whether the NP was working in patients' homes. As described in the methods section, the review authors discussed their interpretation of the eligibility criteria for 70−100 records (sorted on best matches) at the start of the selection procedure. After these, they continued screening individually. It is possible that relevant studies were interpreted incorrectly and thus excluded from this rapid scoping review.
Furthermore, we excluded studies that investigated the care provided by NPs employed by general practice. We may have missed some relevant publications because, in some countries, NPs employed by general practices mainly perform home visits and closely collaborate with community care nurses. However, for this review, we were searching for the role of the NP deployed from a community care organisation. Besides, we did not critically appraise the methodology of the included studies. Te research was of an exploratory nature with mostly descriptive studies and was set up as a rapid review. Te quality of the articles is therefore not weighted in the results. It is possible that low-quality studies were included [21].
Finally, we excluded studies carried out in countries outside northwest Europe. By doing so, we omitted studies from countries like the US and Australia where the role of the NP has long existed and where the NP's role in community care has been developed and implemented further.

Recommendations.
Tis study showed that communitybased care provided by NPs in northwest Europe has only been investigated by a few studies to date, mainly in the UK and with restricted methodological quality. Most studies have used a qualitative design and reported selection procedures, population characteristics, and results in insufcient detail. It is recommended that researchers perform an evaluation study of the impact of advanced nursing roles in community care using the framework from Bryant-Lukosius et al. [47]. Tat framework was developed to inform decisions about the efective use of NP roles. Further research should also focus on ethnographic studies to further understand the nurse's adaptability to the various contexts of care, recognizing the patients' role, and the desire to develop multidisciplinary and efective working groups to respond to the health needs of the population in primary care contexts.
Te review by Busca et al. [42] underlines the fact that implementing the NP role seems to be a complex process infuenced by many factors. Tus, there cannot be simple and linear recommendations for developing and implementing the role of the NP. Te role has a direct impact on the work of other healthcare professionals. It is only through a dynamic and context-dependent implementation process that NPs will be able to strengthen the resilience of national healthcare systems around the world. Lessons learned from other countries such as the UK can support other countries with the implementation of the NP role. In the Netherlands, the NP is currently developing for example more integrated care in the community, where the NP can be seen as an autonomous practitioner in integrated care.
Such studies are needed to draw conclusions about the potential role and impact of NPs in community care, so the NP role can be implemented more widely. Implementing the role requires a pioneering mentality from the NP, a clear vision and job profle from community care organisations, and good coordination with other healthcare professionals right from the start.

Conclusion
Although the use of NPs in community care is still in its infancy in northwest Europe, patients and informal caregivers highly value the deployment of the NP. NPs in community care help to meet the increasing and complex care demands in patients' homes. Healthcare professionals such as GPs and DNs also experience the benefts of NPs working in community care. A context-dependent implementation process for the NP role is needed to strengthen community healthcare organisations. Since most of the studies had a descriptive design, fndings should be interpreted with caution. However, this review can help policymakers and healthcare professionals understand and enhance the potential impact of NPs in community care settings.