Our findings illustrate opinions from managers, doctors and specialist nurses about the role of ANP in municipal healthcare as one way to meeting the increasing healthcare needs of the frail elderly. We categorised their opinions into two main themes: opportunities and challenges. The findings are exemplified with quotations from the participants.
ANP as an opportunity
In this theme, opinions reflecting the role of ANP as an opportunity from four different perspectives are presented which may have a positive impact to meeting the increasing healthcare needs of the frail elderly.
The role of ANP from the perspective to satisfy the frail elderly’s need of healthcare
The participants, especially the nurses, thought the role of ANPs would increase patient safety as the ANP would have the ability to put together several parts of a complex patient picture through their clinical competence, leadership and collaborative practice. The continuity of care was also considered to enhance as the ANP could follow the frail elderly through different types of services and take more responsibility for the patients regarding both nursing and medical care.
It would certainly increase the quality of care for our elderly to have this role. I think it will be safer if we [in the role of an ANP] have a more overall responsibility…and the continuity had become amazingly much better. (Specialist nurse/F).
The nurses stated that an increased patient safety through better continuity would mean a more personalised and person-centred care as the ANP would have in-depth knowledge of the elderly as individuals, not only as patients. The nurses also thought that the ANP would have more time to focus each patients situation as a whole that together with the ANPs advanced skills in knowing, doing and being the quality, safety, continuity and person centredness would improve.
I think that we have more time for the patient. We take time for the patient. We know the patient better, and we know when the patient needs a little extra care, so we take more time for this patient. (Specialist nurse/G).
The role of ANP from the perspective of making healthcare more effective
The participants agreed that access to more healthcare in the frail elderly’s home would be improved with the role of ANP. The nurses believed this would save them time and make their work easier. Instead of spending time finding a doctor to consult, which was described as a tedious process, they stated that it would be easier if an ANP could do the entire assessment, including ordering blood sampling and prescribing medication. They also expressed that the frail elderly would be able to access healthcare more quickly.
It might be a bit quicker for the patient to get help. If there is anything, then you do not need to go through the health center and wait. But then, we [as ANPs] can be faster with the help, I think. (Specialist nurse/G).
The managers considered that ANPs could reduce the doctor’s workload with the frail elderly, so they could spend more time with other patients thus making the healthcare more effective. The doctors agreed that there were tasks that could be done more easily with the help of an ANP, as they often do not assess the patient (in the municipal healthcare) without acting after the nurse’s assessment, often via a telephone consultation.
I think it is about doing things easily. So, if you have conducted an assessment, so why should [the doctors] just click for the prescription? We [the doctors] go anyway on what you [the nurses] tell us. So, this is your [the nurse’s] assessment, right? We [the doctors] don’t go in and assess the patient. It is not better for the doctor to write out the antibiotic, I mean it may just as well have been by the nurses. (Doctor/D).
The role of ANP from the perspective of recruitment difficulties
The participants agreed that the healthcare sector faces difficult recruitment challenges to meet the increasing healthcare needs of the frail elderly. The manager from municipal healthcare said that they had major difficulties in recruiting nurses with the right competencies and in retaining competent nurses. The manager and the nurses thought a key reason was that the nurses do not see any career opportunities in municipal healthcare, and consequently, do not consider this work attractive. However, they believed the role of ANP might be a way to have a clinical career and continue to work in patient care.
When I got familiarized with this [the role of ANP] I realized that it could be an opportunity to make a step in the career, and then many [nurses] might have stayed (Specialist nurse/E).
The managers from primary care have also had difficulties recruiting doctors. Accordingly, they said it was important to be innovative in meeting the increasing healthcare needs of the frail elderly, as the doctors were not able to work effectively with their current resources.
There is such an enormous shortage of doctors, and if we look at our field of General Practitioners, we must do something. I think it is important and am totally convinced that if we are to get anywhere, we must come up with new things … [aim to the role of ANP]. (Manager, primary care/K).
The role of ANP from the perspective of increasing municipal nurses’ skills
Both managers and doctors stressed that some nurses in municipal healthcare do not have enough competence and skills to meet the advanced needs of healthcare for the frail elderly. Today, it is not required that nurses in the municipal healthcare have a postgraduate education specialising in care for elderly and both managers and doctors believe this is reflected in the nurses’ skills. Therefore, the managers believed that a role of ANP also could be used to educate and support other nurses and thereby also increase their competence. The participants highlighted the new healthcare agreement that started 2017  with the meaning of a more advanced medical care will be performed in the patients’ homes instead of in the hospital. All participants agreed that the healthcare of the frail elderly will require high skills among nurses in municipal healthcare and thought the role of ANPs could be valuable to enable this.
A part of the new healthcare agreement is to look at the competencies issues. It is not only about ensuring that we bring in people who have the right skills but also how we use those skills. (Manager, municipal healthcare/J).
ANP as a challenge
In this theme reflected opinions about the role of ANP as a challenge from two different perspectives, which could be seen as barriers to enabling ANPs in municipal healthcare. However, these two perspectives also include aspects that can facilitate the challenges.
The role of ANP from the perspective of closer collaboration between municipal healthcare and primary care
The participants believed it would be a challenge to implement a role of ANP in municipal healthcare because the doctors and the municipal nurses belong to different organisations. The implementation would be easier if municipal healthcare were part of the same organisation as the primary care because the doctors would be more available for support and to hand over assignments and responsibilities to the ANP.
As they have in Sweden today with health centres [i.e. primary care doctors] and the municipal [healthcare] nurses for itself [i.e. separate organisations] if all of our nurses’ assumption from a health centre it had been easier for the doctors to release the responsibility [to an ANP] … but when in two separate organisations, I think it can raise resistance (Manager, municipal healthcare/I).
It is also important for doctors and nurses to work in closer collaboration if the role of ANP become a reality because, according to the participants, an ANP must have a doctor as a supervisor even if they were unsure if they would have enough time to be a supervisor. However, the doctors do not think it is necessary for them to act as a supervisor; instead, they would like to see ANPs as co-workers.
You had hardly needed a supervisor if you felt that you were colleagues… …or partners that could discuss the situation and how to do. (Doctor/A).
The role of ANPs from the perspective of motivating nurses to study and the courage to take on the responsibilities that the role entails
If possible, the nurses thought it would be of interest to them to study as an ANP; however, they also mentioned certain barriers for their motivation. The nurses argued about whether it would be worth it. If it would result in a higher salary, then they thought it would be of interest, otherwise not. The managers expressed that it was the employer’s responsibility to motivate nurses to study as an ANP.
It is important that we, as employers, have a dialogue about levels of compensation. It will be worthwhile, perhaps with paid education, and when that is achieved, there is also money to collect as an incentive. (Manager, municipal healthcare/I).
The managers also emphasised the importance of clarifying what kind of tasks an ANP should have compared with a specialist or a registered nurse. If the nurses knew that they would be given other and more advanced duties after ANP training, that could be a motivator. However, the managers had some doubts about whether the nurses would be interested in training as an ANP even when compensated with a higher salary or greater responsibility. They expressed that a person must have a personal interest and engagement and considered that not many nurses reflect these qualities. The managers and the nurses emphasised that one reason was because of it is a tedious process for experienced nurses with an older education and without a Bachelor’s degree to qualify for studies at the postgraduate level. They thought that the requirements for a Bachelor’s degree could result in a lack of motivation from the nurses to study as an ANP, but nevertheless, they also thought that younger nurses who already have a Bachelor’s degree may be interested in training as an ANP if job openings for ANPs in healthcare became a reality.
Opinions were also stated about whether the nurses would consider taking he responsibility that the role of an ANP entails. The managers believed that the nurses would consider taking it on, but that was a question of education. The managers thought that if the nurses would feel that they have more competence after they have trained to become an ANP, then they would also be confident to work as one. Although the nurses stated that they would consider taking the responsibilities that the ANP role entails, the doctors were not convinced that the nurses would do this. Therefore, the doctors questioned whether this role would be of interest to the nurses if ANP positions became available.
Many [nurses] do not want to take the responsibility that it would mean [the role of ANP] … Some of you [the nurses] had made it brilliant, but many have not. (Doctor/A).