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Abstract

Background:

Virtual care is increasingly used to improve access to primary care. However, the roles of primary care nurses (ie, nurse practitioners [NPs], registered nurses [RNs], licensed practical nurses [LPNs]) in virtual care delivery are not clearly defined. A better understanding of these roles can improve their integration and optimization in virtual primary care delivery and the availability and quality of virtual primary care.

Objectives:

The purpose of this scoping review was to identify and map the international literature on nurses’ roles in virtual care delivery in primary care.

Methods:

Following the Joanna Briggs Institute methodology, we searched academic databases for published literature and webpages for gray literature sources. We included studies that described the roles of nurses (NPs, RNs, LPNs) in providing virtual primary care. We excluded studies that focused on nurses’ use of digital technologies without nurse-patient interaction.

Results:

After screening potential sources, we included 34 sources from countries such as the United Kingdom, Canada, the United States, Australia, and Sweden. Most were specific to RNs (n = 12) or did not specify a regulatory designation (n = 12). Primary care nurse roles in virtual care were mostly related to care coordination, chronic disease management, and triage and assessment using various modalities (eg, telephone and video). Many factors influenced nurses’ roles in virtual care, such as patient/nurse experiences, training/support, access to resources/equipment, and ethical/privacy concerns.

Conclusions:

Nurses are well-positioned to provide virtual care based on their diverse roles across primary care settings; however, their roles could be better optimized to improve primary care access and quality.

Keywords

nurses primary care nursing telenursing nurse’s role scope of practice scoping review

Introduction

Virtual care involves the use of information communication technologies (such as telephone or video) in interactions between patients and/or providers that do not occur in the same physical space. The COVID-19 pandemic catalyzed the use of this care delivery approach to improve access to primary care, particularly for patients who live in rural or remote geographies, have economic challenges, or experience competing priorities at home/work.^1,2 Primary care is the first point of contact individuals have with the healthcare system³ (differing from primary healthcare as an approach to care that involves primary care delivery, policy action, and empowerment^4,5); this makes virtual care particularly relevant to explore in primary care. Family physicians and nurse practitioners (NPs) have professional autonomy to use their judgment to interchange in-person and virtual delivery.^6,7 Unfortunately, the process taken by other nurses in primary care to shift their roles between in-person and virtual care is poorly understood. Although there is evidence that nurses improve patient, provider, and system outcomes (eg, weight loss, blood pressure, glycemic control, smoking cessation, physician workload, and adverse events),^8-11 their integration and optimization in primary care has progressed at different speeds internationally.^12,13 Nurses’ contributions to virtual care requires further research as countries increase nurses’ involvement in primary care environments.

Role Clarity in Virtual Nursing Practice in Primary Care

NPs (advanced practice nurses who diagnose and treat as primary practitioners) and registered nurses (RNs; nurses who provide care and support in varying capacities) are commonly identified in the literature as key providers in primary care delivery, though titles used to identify nurses in primary care differ internationally.¹⁴ Licensed practical nurses (LPNs; nurses with a reduced scope of practice compared to NPs and RNs) have also been identified globally as potential contributors to primary care delivery,¹⁵ however, there is less published literature about this designation within the primary care context. Nurses’ scopes of practice across designations are informed by legislation and professional regulation and standards (ie, referred to as legislated scope of practice), and this applies to both in-person and virtual care.^16,17 Nurses’ scopes of practice are further informed by factors such as the organization where they are providing care (eg, funding model, availability of infrastructure); nurse training/education (ie, individual competencies¹⁸); the needs of the patient/population receiving care (informed by the complexity, predictability, and risk associated with patient disease/condition)¹⁶; and geography (nurses in rural and remote settings often practice more autonomously with expanded scopes of practice than nurses who work in urban settings).^19,20 This is often referred to as the nurses’ professional scope of practice.

Nursing roles refer to the responsibilities, activities, and tasks carried out through interventions, programs, and/or initiatives in practice.^21,22 Improving the understanding of nurses’ roles across regulatory designations, primary care practice settings, and virtual care modalities is integral to optimize team-based primary care.^22,23 Role clarity also promotes appropriate task-shifting (ie, reasonable redistribution of tasks from a more highly qualified professional to another²⁴), which has the potential to improve clinical (eg, prevent and manage cardiovascular disease, diabetes, and mental health concerns) and system (eg, cost) outcomes in primary care.²⁵ Clarifying the roles of nurses in providing virtual care in primary care will inform the adoption of virtual care delivery by nurses and has the potential to improve the reach of service delivery and increase panel size within primary care settings.²⁶

Guiding Framework

We used the Nursing Care Organization Framework²⁷ (NCOF; Figure 1) to define key concepts, collect and analyze data, and map study results. The NCOF²⁷ outlines dimensions in the organization of healthcare services that can influence the delivery of patient care by nurses (ie, scope of practice, staffing, work environment). Notably, “scope of practice” is the language used in the NCOF, though it is referring to the scope of services delivered by nurses and not the scope of practice as it is commonly defined in the literature (ie, the roles, functions, and activities carried out by nurses based on their professional legislation, education, and competence¹⁶).

Figure 1.

Nursing Care Organization Framework.

Purpose and Objectives

The purpose of this scoping review is to identify and map the international literature surrounding nurses’ (ie, NP, RN, LPN) roles in virtual care delivery across primary care practice settings, including differences across urban and rural geographies. The research objectives of this review are to:

Outline the roles that NPs, RNs, and LPNs perform to contribute to virtual care delivery in primary care practice settings;

Describe the key characteristics of primary care practice settings that involve virtual care delivery by NPs, RNs, and LPNs; and

Identify barriers and facilitators to role enactment for NPs, RNs, and LPNs in virtual care delivery in primary care practice settings.

For the purpose of this review, “role enactment” will refer specifically to the application of behavior and knowledge (ie, carrying out activities/tasks) that align with professional expectations.²⁸

Methods

Design

We conducted this review based on the Joanna Briggs Institute (JBI) scoping review methodology²⁹ and a protocol published a priori.³⁰ We report results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.³¹ Prior to beginning the review, we conducted a search of CINAHL, JBI Evidence Synthesis, Cochrane Database of Systematic Reviews, Google Scholar, and Embase to determine if any systematic or scoping reviews had already been published or were in development on this topic, and we found no published reviews.

Search Strategy

In consultation with a health sciences librarian (M.S.), we developed a search strategy aimed at locating both published and unpublished sources. We conducted preliminary searches in CINAHL and MEDLINE databases to identify text words in titles and abstracts, and index terms of relevant articles. We used these words to develop a full search strategy adapted for each included database (ie, CINAHL, MEDLINE, Embase, and PsycINFO) using unique keywords and index terms (Supplemental File). In addition to the database searches, we screened relevant systematic reviews, reference lists of included sources, and used the descendancy approach³² to identify primary studies that were not present in our original searches. To locate gray literature, we searched ProQuest Dissertations and Theses Global, Google Scholar, and webpages of national nursing organizations (eg, Canadian Nurses Association, Australian Primary Health Care Nurses Association), digital health-focused organizations (eg, Digital Health Canada), and primary care networks/centers, among others. Database searches were conducted on June 21, 2022 and updated on May 28, 2024.

Eligibility Criteria

We included English and French published sources that used any qualitative, quantitative, or mixed-method design and various types of gray literature (eg, dissertations/theses, organizational/government reports, and nursing-specific policies), and did not place any location or publication date restrictions on search criteria. We excluded commentaries and conference abstracts.

We used the Participants, Concept, Context framework³³ to outline the content eligibility criteria for this review. The “Participants” and “Concept” components align with the scope of practice (nurse roles) dimension of the NCOF, and the “Context” component aligns with the overall organizational context where the NCOF is situated for this review.

Participants

We included sources that involved nurses from any regulatory designation (ie, NP, RN, LPN) practicing in primary care, as well as sources that did not specify nurse designation (eg, referred to generally as “nurses” in primary care). This included nurses across community types (ie, urban, rural, and remote); primary care was viewed broadly for nurses in rural areas who often practice within a community health scope (ie, public health, primary care, and home care).³⁴ Search strategies included generic and primary care-specific nurse titles used across countries (eg, general practice nurse and family practice nurse).¹⁴ We excluded sources that focused on student nurses and nurses who were not licensed to practice. We also excluded nurses who require additional training (beyond entry-to-practice) for their roles, such as registered psychiatric nurses, specialized nurses (eg, foot care nurse and diabetes nurse specialist), and clinical nurse specialists (ie, advanced practice nurses who engage in roles beyond clinical practice, including leadership, research, and education, to address complex healthcare concerns in a specialized area³⁵).

Concept

We only included sources that focused on the roles of nurses in the delivery of virtual care within primary care. With respect to nurse roles, a nurse action component was required within nurse-patient interaction(s); these interactions could have involved patient presence (eg, delivering care remotely via telephone) or not (eg, consulting another provider remotely regarding patient assessment/concerns). Nurse roles must have been initiated in primary care settings. We excluded sources that involved nurses using technology for administrative purposes (eg, sending digital reminders to patients) as there was no care delivery component. We required that nurse roles were explicitly stated or able to be interpreted clearly based on the description of virtual care being delivered (ie, not grouped alongside other providers).

Context

The context for this review included both primary care and virtual care. Other terms used to refer to primary care (eg, general practice and family practice) and virtual care (eg, telehealth, digital healthcare) internationally were included in our search strategy. Sources involving virtual care delivery using any modality (eg, telephone, video, text message, and e-mail) were included. Studies that were situated in community health without a primary care focus (eg, specialty clinics, call centers, and prisons) were excluded. We also excluded studies that referred to the use of digital healthcare but did not involve nurse action that directly impacted patients’ plan of care (eg, using electronic medical records, using simulation for clinical-based training/education, research study recruitment, and disease reporting).

Selection of Information Sources

Search results were entered into Covidence for screening and review. We used the eligibility criteria to develop a tool for title/abstract and full-text screening. To pilot the screening process, 2 researchers (C.V., D.R.) independently screened 5% of the total results (random sample of various designs, n = 86 studies) and achieved 85% agreement.^29,30 Discrepancies were discussed with the supervising researcher (J.L.), and the tool was refined to improve clarity. We then used the updated tool to screen titles/abstracts of remaining articles and to complete full-text screening of sources for eligibility.

Data Charting

Following the selection of eligible full-text sources, we completed a pilot test of the extraction procedure using a pre-determined data extraction tool informed by the NCOF and developed by the research team. Data situated within the scope of practice dimension (in the NCOF) included demographic details (eg, level of education/specialty training), professional designation, and role(s) performed. Further, we described primary care practice characteristics (eg, geographic location and team composition); the nature of virtual care delivery, including type of virtual intervention (eg, consultation, prescription renewal); patient population receiving care (eg, demographics and current illness/disease), delivery source (eg, telephone and video); and any barriers or facilitators that contributed to virtual care delivery. We developed a legend to ensure each component was clear for all researchers involved in the extraction. The pilot test for the extraction included 2 researchers (C.V., D.R.) who independently extracted 5 randomly selected sources across different study designs. We resolved discrepancies through discussions with the supervising researcher (J.L.) and amended the extraction tool to improve clarity. Following the pilot test, we extracted data from all full-text articles that met our inclusion criteria.

Synthesis of Results

We inductively analyzed data and the NCOF was used to map review findings deductively using 4 separate tables that correspond to the study objectives. The reciprocal relationships that exist between scope of practice (nurse roles), staffing, and work environment concepts of the NCOF were considered in the analysis of findings. Nurse roles were deductively categorized using the Registered Nurse Virtual Primary Care Practice Guide developed by the Innovation Support Unit within the Department of Family Medicine at the University of British Columbia.³⁶ This guide includes 6 role categories (ie, care coordination, chronic disease management, triage and assessment, health education, COVID-specific care, health promotion and disease prevention). These role categories were further analyzed and defined by describing specific nurse roles. When we described barriers and facilitators to nurse role enactment, we separated these factors by patient characteristics, work environment, and scope of practice and staffing (as per the NCOF).

Results

The PRISMA diagram (Figure 2) outlines the process for identifying and screening published and gray literature sources for inclusion following our most recent search (May 2024). In total, 34 sources were included in this review (Table 1).

Figure 2.

PRISMA diagram outlining the search results.

Table 1.

Source Details and Characteristics of Included Sources (n = 34).

Author, year, country	Purpose	Design/source type	Setting, community type^a	Nurse and patient characteristics^b	Intervention, delivery modality	Key message(s)^c
Anderson et al, 2024, United Kingdom	To explore how nurses working in general practice experienced remote and technology-mediated work during the COVID-19 pandemic	Qualitative (exploratory, social constructionist approach)	Various general practices Not specified	RN General patient populations (nonspecific)	Teleconsultations Telephone, video	• Increased workload; reduced comprehensiveness and safety of care; improved staffing availability • Preferred a “blended” approach to care (ie, face-to-face and virtual)
Ashley et al, 2023, Australia	To investigate the perceptions of GPs, RNs, NPs, and allied health clinicians with sustaining telehealth in primary healthcare post-pandemic	Qualitative descriptive (part of mixed-methods study)	Various general practices Not specified	NP, RN General patient populations (nonspecific)	No intervention Telephone, video, online messaging, e-mail	• Recognized the necessity of virtual care during the pandemic • Believed virtual care will be sustained after the pandemic, likely using a hybrid model (ie, face-to-face and virtual visits)
Bangs et al, 2002, United Kingdom	To evaluate a new telemedicine approach to vascular care for patients managed in primary care	Qualitative (narrative)	Single health center Urban	Not specified Diabetes or peripheral ulcer disease, mostly elderly	Teleconsultations Video	• Teleconsultations allowed for interprofessional collaboration to facilitate remote assessment and coordination of care • Approach was well received by patients
Barker, 2015, United States	To assess the efficacy of a telemonitoring intervention on glycemic control for adults with type 2 diabetes receiving care at a rural primary care clinic	Experimental, pre- and post-test intervention (part of mixed-methods study) Dissertation	Single NP-led primary care clinic (with urgent care) Rural	NP Diabetes	Virtual education/teaching Telephone	• No statistically significant reductions in weight or blood glucose (small sample size); there is potential for clinical importance • Statistically significant improvements in active days, activity importance, and medication compliance after intervention
Canadian Family Practice Nurses Association, n.d., Canada	To describe the potential roles for primary care nurses and guide nurses’ transition into primary care practice	Role description of RNs in primary care Practice guide	General primary care settings (nonspecific) Not specified	RN General patient populations (nonspecific)	No intervention Telephone	• Primary care nurses can carry out a variety of roles centered around assessment, management, education, and health promotion and prevention
Canadian Institute for Health Information, 2022, Canada	To describe the current landscape of virtual care data and information in Canada	National report	Community health centers Rural	Not specified Chronic disease (nonspecific)	Teleconsultations Video	• Virtual appointments with NP(s) increased patients’ confidence in chronic disease self-management
Charles-Jones et al, 2003, United Kingdom	To explore the perceptions of general practice providers about the purpose and impact telephone triage nurses have on their clinical roles and identities	Qualitative (part of larger ethnographic study)	9 General collaborative practices Urban and rural	RN General patient populations (nonspecific)	Triage Telephone	• Nurse triage allows patients to be allocated to the most appropriate clinician based on their biomedical diagnoses • Managerial influences were at the forefront, aiming for efficient and cost-effective care
de Moraes et al, 2022, Brazil	To investigate the feasibility and preliminary results of a telehealth system tool used for optimizing care delivery in a new primary care-based health system	Observational, prospective cross-sectional	Remote setting (using online platform) Not specified	Not specified General patient populations (nonspecific), mostly healthy individuals, 68.1% female, median age 28	Case management (electronic portal system) Telephone, video, online messaging	• Nurse management of patient care through electronic system resulted in reduced readmissions to the emergency room • Patients were highly satisfied and confident with nurse care received through electronic system
Giesen et al, 2007, Netherlands	To explore the association between negative patient evaluations of nurse telephone consultations and characteristics of patients and general practice cooperatives	Observational, cross-sectional	28 General practice cooperatives (with out-of-hours service) Urban and rural	Not specified General patient populations (nonspecific)	Triage Telephone	• Patients were more receptive to nurse telephone triage if they were older; and less receptive if they lived a far distance away or were expecting an in-person visit • Nurse telephone consultations with a supervising physician present were preferred
Government of Canada, 2022, Canada	To describe Nunavut’s Virtual Care Action Plan	Program description Webpage	Community health centers Rural	LPN Chronic disease (nonspecific)	Teleconsultations Video	• The clinician virtual care service will be utilized to reduce travel for Nunavut residents and improve chronic disease management
Haith-Cooper et al, 2015, United Kingdom	To describe the characteristics of pregnancy-related telephone consultations to out-of-hours service and the differences in management of calls between NPs and GPs	Observational, retrospective analysis	General practice cooperative (with out-of-hours service) Not specified	NP Pregnant women, mostly age 20-34 (75%) and in first or second trimester (79%)	Teleconsultations Telephone	• Provided services primarily to patients in early pregnancy or late pregnancy if complications presented • NPs more likely to offer follow-up visits to callers and had longer call times (than GPs)
Hakimjavadi et al, 2022, Canada	To explore how NPs’ use of an eConsult service may improve access to specialist care for older adults	Multiple case study, retrospective analysis	Variety of settings (eg, NP-led clinic, community health center) Urban and rural	NP Older adults, acute and chronic disease (eg, spinal injury, diabetes, chronic epilepsy)	Teleconsultations Online messaging	• eConsults can be used to improve timely access to specialist care for older adults • eConsults may empower NPs to promote patient-centered care for older adults
Halcomb et al, 2016, Australia	To explore the perceptions of community dwelling older people with chronic and complex conditions toward a nurse-led telemonitoring intervention	Experimental, pre- and post-test intervention	Single large general practice Urban	RN Chronic disease (ie, cardiac, respiratory)	Telemonitoring Remote patient monitoring, telephone	• Experience and exposure to telemonitoring technology increased patient’s acceptance of technology and improved self-care and self-management behaviors
Hands et al, 2006, United Kingdom	To investigate an e-health approach to managing patients presenting with vascular-type symptoms	Observational, prospective cohort	Community health center Rural	RN Patients with vascular ulcers	Teleconsultations Video	• Teleconsultations could be used for initial assessment with the help of a nurse on-site to coordinate care and facilitate the visit
Hanley et al, 2015, United Kingdom	To explore the experiences of patients and professionals taking part in a RCT of BP/blood glucose and weight telemonitoring in patients with type 2 diabetes	Qualitative, interpretive description (follow-up of an RCT, Wild et al⁵³)	12 GP-led primary care practices Urban, socially diverse populations	RN Diabetes (type 2)	Telemonitoring Remote patient monitoring, telephone, text messaging, e-mail	• Telemonitoring and the involvement of nurses in reviewing findings is an appropriate approach to improve diabetes management in primary care
Hanley et al, 2013, United Kingdom	To explore the experiences of patients and professionals taking part in an RCT of remote BP telemonitoring	Qualitative descriptive (follow-up of an RCT, McKinstry et al54)	6 GP-led primary care practices Urban, socially diverse populations	RN Hypertension	Telemonitoring Remote patient monitoring, telephone	• Telemonitoring is a trustworthy approach for BP monitoring at-home and a motivator for self-care among patients • Achieving BP control using telemonitoring increased provider workload
Holmström et al, 2016, Sweden	To explore older persons’ experiences of telephone advice nursing	Qualitative descriptive	Primary healthcare centers Urban and rural	Not specified Older adults (age range 68-95 years)	Support/advice Telephone	• Communication is central to telephone advice nursing to build relationships and mutual understanding of the older persons’ health problems
James et al, 2021, Australia	To explore the experiences of primary healthcare nurses in the use of telehealth during the COVID-19 pandemic	Qualitative descriptive (part of mixed-methods study)	Private general practices (both private and public funding for nursing) Urban and rural	RN^d General patient populations (nonspecific)	No intervention Telephone, video	• Two key areas should be considered when nurses deliver care via telehealth: nurse preparedness and the availability of appropriate resources for nurses/patients
Kwak et al, 2021, Korea	To explore the effects of a chronic disease management program utilizing the P-NTM on medication adherence and quality of life	Experimental, pre- and post-test intervention	11 Primary healthcare centers Rural/remote areas, medically underserved populations	Not specified Chronic disease(s) (mostly hypertension, 66.4%), average age 69.74 years, age range 47-86 years	Teleconsultations Video	• The P-NTM model is an effective approach for managing chronic diseases, including improved medication adherence and health-related quality of life • Effectiveness of the intervention was influenced by patient age and sex
Little et al, 2016, United Kingdom	To estimate the effectiveness of an internet-based behavioral intervention combined with brief remote nurse support	RCT	56 Primary care practices Urban	RN Overweight (with or without chronic disease)	Support Telephone, e-mail	• Clinically important weight loss increased with intervention and remote nurse follow-up • Written material and brief nurse follow-up could be used to maintain weight loss
Mammen et al, 2022, United States	To evaluate efficacy, feasibility, and acceptability of a smartphone telemedicine program to deliver asthma care remotely, support provider adherence to asthma management guidelines, and improve patient outcomes	Mixed methods (explanatory sequential – longitudinal intervention study, qualitative interviews)	Hospital-based clinic, “safety-net practice” Urban	Not specified Asthma (“persistent”), predominantly minors, lower socioeconomic status	Telemonitoring Video	• Smartphone telemedicine could extend healthcare reach for young asthmatic patients and improve outcomes with minimal cost and workflow disruption; and high patient and provider satisfaction
McCallum-Crawford, 2022, United States	To improve patients’ self-management of prediabetes and type 2 diabetes through nutrition and show how nutrition counseling can improve HbA1c values	Experimental, pre- and post-test intervention Dissertation	2 Private primary care clinics Not specified	NP Diabetes, prediabetes (average age 51.6 years, age range 31-67 years)	Teleconsultations Video	• Nutritional counseling via telehealth by an NP improved patients’ HbA1c but did not cause any significant changes in weight after 3 months
McKinstry et al, 2013, United Kingdom	To determine if an intervention consisting of telemonitoring, supervision of home self-measured BP and optional patient decision support leads to clinically important reductions in daytime systolic and diastolic BP	RCT	20 General practices Urban, socio-economically diverse populations	RN Hypertension (average age ~60 years in both intervention and control group)	Telemonitoring Remote patient monitoring, telephone	• The telemonitoring intervention was effective at reducing systolic BP and was supported as an effective self-monitoring method for achieving clinically important reductions in BP in patients with uncontrolled hypertension
McNally, 2020, United States	To evaluate the impact of a prediabetes education and text message reminder program on knowledge and management of prediabetes after 12 weeks	Experimental, pre- and post-test intervention Dissertation	Single primary care office Urban	NP Prediabetes (age range 37-77 years)	Virtual education reminders Text messaging	• The NP-led education intervention was clinically important in improving patient knowledge score and perceived health management
Nurses Association of New Brunswick, 2018, Canada	To describe NPs’ scope of practice and identify expectations for NP practice in New Brunswick	Standards of practice Practice guide	General primary care settings (nonspecific) Urban and rural	NP General patient populations (nonspecific)	No intervention Telephone	• These standards outline the minimum professional practice performance, ie, expected by the public when receiving primary care from NPs in New Brunswick, Canada
Registered Nurses’ Association of Ontario, 2012, Canada	To explore the role of RNs, LPNs/RPNs in primary care, and to make recommendations that optimize nurse roles to strengthen patient and system outcomes	Role description and nurse advocacy Provincial report	General primary care settings (nonspecific) Urban and rural	RN, LPN/RPN General patient populations (nonspecific)	No intervention Telephone	• The scope of practice of nurses in primary care in Ontario should be maximized and when necessary, expanded to improve primary care delivery and widespread system benefits
Regragui et al, 2023, Canada	To explore the use and implementation of teleconsultations by primary care nurses in the context of the COVID-19 pandemic	Mixed methods (explanatory sequential – electronic survey, qualitative interviews)	48 University-affiliated family medicine groups Urban and rural	NP, RN General patient populations (specifically includes elderly, vulnerable, chronically ill)	Teleconsultations Telephone, video, text messaging	• Teleconsultations were viewed positively by nurses as they perceivably improved care continuity and access to care • Teleconsultations allowed nurses to have better work-life balance
Richards et al, 2005, United Kingdom	To elicit current use of, and attitude toward eHealth of professionals in primary care in remote areas of Scotland	Observational, cross-sectional (postal questionnaire)	193 General practices Rural and remote	Not specified General patient populations (nonspecific)	Teleconsultations Telephone, video	• Access to/use of eHealth was low among nurses • Professional isolation was mitigated using eHealth with GP when nurse was located in rural area
Saigí-Rubió et al, 2021, Spain	To analyze the determinants of HCPs’ intention to use a new digital clinical consultation tool in the post-COVID-19 context	Mixed methods (exploratory sequential – literature review, interviews, questionnaire)	285 Primary care teams Urban	Not specified General patient populations (nonspecific)	Teleconsultations Online messaging	• Nurses are involved in the use of digital consultations to improve patient care • Nurses’ use of the tool was influenced by familiarity with the tool and work location/environment
Stoddart et al, 2013, United Kingdom	To compare the costs and cost-effectiveness of managing patients with uncontrolled BP using telemonitoring vs usual care	Secondary analysis of data from RCT (McKinstry et al54)	20 General practices Urban, socio-economically diverse populations	RN Hypertension (average age ~60 years in both intervention and control group)	Telemonitoring Remote patient monitoring, telephone	• With the telemonitoring intervention in place, nurse telephone consultations were in higher demand to meet patient needs; this had minimal effects on overall costs
Tort-Nasarre et al, 2023, Spain	To understand the perspectives of COVID-19 patients on home isolation who received telenursing during the initial phase of the pandemic	Qualitative descriptive	Various primary care centers (within 1 health system) Not specified	Not specified COVID-19 infection (mild to moderate symptoms)	Follow-up care Telephone	• Virtual care by nurses improved self-care and reduced psychological distress for patients navigating their COVID-19 infection at home
Wardig et al, 2022, Sweden	To explore nurses’ experiences of suicide risk assessment in telephone counseling	Qualitative descriptive	9 Primary care health centers Not specified	Not specified^e Mental health illness (specifically experiencing suicide risk)	Telecounseling Telephone	• Nurses’ competence with providing telephone counseling increased with experience and they were guided by their intuition (without adequate practice support)
Waterworth et al, 2018, New Zealand	To determine which aspects of nurse-patient telephone communication are viewed positively or negatively to meet older persons’ needs	Qualitative, grounded theory (constructivist approach)	6 Private fee-for-service general practices Urban and rural	Not specified Older adults, chronic disease (multimorbidity)	Teleconsultations Telephone	• Telephone nursing was an effective form of care delivery, though the effectiveness depended on patient need (ie, advice, treatment) • Patients remained skeptical over nurses’ ability to deliver primary care services and/or virtual care
Wild et al, 2016, United Kingdom	To investigate whether HCPs’ review of telemetrically transmitted self-monitored glucose results improved glycemic control	RCT	42 Family practices Urban, socially diverse populations	RN Diabetes (type 2)	Telemonitoring Remote patient monitoring, telephone, text messaging, e-mail	• The involvement of nurses in telemonitoring interventions for poor glycemic control is effective in improving self-management of diabetes and has positive impacts on BP management

Abbreviations: BP, blood pressure; GP, general practitioner; HCP, healthcare provider; LPN, licensed practical nurse; NP, nurse practitioner; NS, not specified; P-NTM, physician-primary-healthcare nurse telemedicine model; RCT, randomized controlled trial; RN, registered nurse; RPN, registered practical nurse.

Community type describes whether the primary care setting(s) in each source was located in an urban, rural, and/or remote area. There is no universal definition that can be applied across sources.⁷¹ Therefore, rurality was defined by each individual source, or the Statistics Canada definition was applied to sources that described their setting but did not explicitly identify it as rural or not: “rural” settings refer to towns or municipalities with a population <10 000 people⁷² and “remote” is an expansion of rural and defines communities that have no residents who commute to an urban location for work.^72,73

Nurse designation may not have been explicitly stated in each study, however, if primary care-specific titles were used that are equivalent to RNs as per Barrett et al¹⁴ (eg, practice nurse in the United Kingdom), RN was the nurse designation identified.

Outcomes reported are related to the virtual nursing practice component of the study; all patient outcomes and other key findings that do not relate specifically to the nursing role have not been reported here.

This study included other designations (ie, NP, LPN, or enrolled nurse in Australia), but only 2 quotes from the qualitative output were specific to these designations, whereby role description could not be extracted; therefore, findings/role descriptions discussed here are specific to RNs.

This study included RNs and district nurses. It is unclear what designation district nurses are equivalent to in Sweden (ie, NP, RN, or LPN), so we have grouped them all under “not specified.”

Characteristics of Included Sources

Sources were published between 2002 and 2024 and were conducted in the United Kingdom (n = 12), Canada (n = 7), the United States (n = 4), Australia (n = 3), Spain (n = 2), Sweden (n = 2), as well as Brazil, Korea, The Netherlands, and New Zealand (all n = 1). Sources comprised 29 published research studies and 5 studies retrieved from the gray literature. The published studies used qualitative (n = 13; qualitative descriptive, interpretive description, grounded theory, case study); experimental (n = 8; pretest-posttest, randomized controlled trial); observational (n = 5; cross-sectional, cohort); or mixed-methods (n = 3) designs. The 5 unpublished sources identified from the gray literature included national or provincial reports (n = 2), practice guides (n = 2), and 1 program description webpage. Many sources were specific to RNs (n = 12), fewer sources focused on NPs (n = 6), and LPNs (n = 1); however, several did not specify nurse regulatory designation (n = 12) or were relevant across multiple designations (n = 3). The virtual care modality also varied but was identified across sources. Most frequently, nurses were using the telephone to deliver virtual care (n = 23); other modalities included video calls and messaging/e-mail (using online platforms and mobile devices/smartphones). Many sources involved nurses using multiple different modalities for care delivery (n = 13).

Categorization of Primary Care Nurse Roles in Virtual Care

Nurses carried out a variety of roles in their delivery of virtual care. Table 2 maps nurse roles to regulatory designations according to the 6 role categories outlined in the Registered Nurse Virtual Primary Care Practice Guide.³⁶ Table 3 presents role categories in primary care further defined by specific nurse roles, patient characteristics, and nurse characteristics. Most often, nurses were involved in roles related to care coordination (n = 25), such as referring and/or arranging follow-up visits (eg, electronic consults) with the appropriate level of care based on assessments^37-43; and engaging in virtual consultations alongside patients and their primary provider(s) (ie, physicians, NPs) and/or specialist(s) to codevelop care plans and arrange follow-up care.^44-49 Nurses were also involved in chronic disease management (n = 13), including reviewing telemonitoring readings/other at-home assessment findings transmitted through online platforms^50-55; providing patient support via telephone after reviewing these findings^50-58; and delivering lifestyle/nutrition counseling to promote self-management of chronic disease.^59,60 Nurses’ roles also included triaging and assessing patients to identify their health needs and the priority of their concerns (n = 11)^{37,39,40,43,61}; health education (n = 7; eg, self-care advice/support^{38,39,41,56,62-64}); COVID-specific care (n = 4; eg, education related to COVID-19 questions/concerns^44,56,61,63); and health promotion and disease prevention care (n = 1; eg, reinforcing patient engagement in health education⁶⁵). Notably, roles categorized under chronic disease management may have also involved an element of health education, and promotion and disease prevention related to the patients’ chronic disease, accounting for compounded roles in this category (ie, more than 1 role within each role category outlined in the Registered Nurse Virtual Primary Care Practice Guide³⁶).

Table 2.

Breakdown of Nurse Role Categories in Virtual Care^a by Nurse Designations.

Abbreviations: LPN, licensed practical nurse; NP, nurse practitioner; NS, not specified; RN, registered nurse.

These role categories are from the Registered Nurse Virtual Primary Care Practice Guide developed by the Innovation Support Unit within the Department of Family Medicine at the University of British Columbia.³⁶

Table 3.

Role Categories in Primary Care^a Further Defined by Specific Nurse Roles, Patient Characteristics, and Nurse Characteristics.

Role category^a	Nurse role	Patient characteristics	Nurse characteristics
Care coordination	Refer and/or arrange follow-up visit with appropriate level of care based on patient assessment (eg, electronic consultation to physician, social work)	• Mental health with suicide risk⁴³ • Older adults^38,70 • Older adults, chronic disease (nonspecific)^39,58 • Pregnant women⁶² • Vulnerable populations⁵⁸ • General patient populations (nonspecific)^{37,40-42,44,56,64,66,67}	• NP^58,62,66,70 • RN^{44,56,58,64,67} • LPN⁶⁴ • Not specified^37-43
	Engage in virtual consultations with primary provider (ie, physician, NP) and/or specialists to codevelop care plan and subsequently coordinate the follow-up care required	• Diabetes and peripheral ulcer disease⁴⁸ • Vascular-type symptoms⁴⁹ • Chronic disease (nonspecific)^45-47 • General patient populations (nonspecific)⁴⁴	• RN^44,49 • LPN⁴⁵ • Not specified^46-48
	Arrange follow-up care for medication changes based on telemonitoring data	• Diabetes^51,53 • Hypertension^50,52,54	• RN^50-54
	Coordinate medication changes by communicating new prescription to pharmacy via telephone	• General patient populations (nonspecific)⁶⁶	• NP⁶⁶
Chronic disease management	Review patient telemonitoring readings (or other at-home assessment findings) transmitted through online platform	• Diabetes^51,53 • Hypertension^50,52,54 • Asthma⁶⁹ • Older adults, chronic disease (nonspecific)⁵⁵	• RN^50-55 • Not specified⁶⁹
	Follow-up calls to provide support to patients based on telemonitoring readings/other clinic or at-home assessment findings	• Diabetes^51,53 • Hypertension^50,52,54 • Asthma^56,69 • Older adults, chronic disease (nonspecific)^55,58 • Overweight, chronic disease (nonspecific)⁵⁷ • Vulnerable populations⁵⁸	• NP⁵⁸ • RN^50-58 • Not specified⁶⁹
	Lifestyle and nutrition counseling via telephone and/or video for self-management of chronic diseases	• Diabetes^59,60 • Prediabetes⁶⁰	• NP^59,60
Triage and assessment	Triage patients via telephone to identify their health needs and the priority of their concerns	• COVID-19 infection on home isolation⁶¹ • Mental health with suicide risk⁴³ • Older adults, chronic disease (nonspecific)^39,58 • Pregnant women⁶² • Vulnerable populations⁵⁸ • General patient populations (nonspecific)^{37,40,44,64,67,68}	• NP⁶² • RN^58,64,67,68 • Not specified^{37,39,40,43,61}
Health education	Self-care advice/support based on patients’ reported needs using telephone- and video-based platforms	• Older adults³⁸ • Older adults, chronic disease (nonspecific)³⁹ • Pregnant women⁶² • General patient populations (nonspecific)^41,56,63,64	• NP^62,63 • RN^56,63,64 • LPN⁶⁴ • Not specified^38,39,41
COVID-specific care	Provide education surrounding COVID-19 questions and concerns	• COVID-19 infection on home isolation⁶¹ • General patient populations (nonspecific)^44,56,63	• NP⁶³ • RN^44,56,63 • Not specified⁶¹
Health promotion and disease prevention	Reinforce patient engagement in health education through text message reminders	• Prediabetes⁶⁵	• NP⁶⁵

Abbreviations: NP, nurse practitioner; RN, registered nurse; LPN, licensed practical nurse.

These role categories came from the Registered Nurse Virtual Primary Care Practice Guide developed by the Innovation Support Unit within the Department of Family Medicine at the University of British Columbia.³⁶

Patient Characteristics and Specific Primary Care Nurse Roles

Overall, and not unexpectedly, the services nurses delivered virtually varied across patient populations (Table 3). Many studies included general patient populations (unspecified diseases/conditions; n = 10), which exemplified the broad range of patient populations who can receive nursing care via virtual delivery. Patients with different chronic diseases were represented across sources, including diabetes or prediabetes (n = 6), hypertension (n = 3), and asthma (n = 1); 5 studies referred generally to populations with chronic diseases. Other studies described the roles of nurses in virtual care delivery with older adult populations (n = 4), pregnant women,⁶² vascular surgery patients,⁴⁹ COVID-19 patients,⁶¹ and mental health patients with a risk of suicide.⁴³

When a source focused on general patient populations in primary care, nurses were most often arranging or referring patients to other providers for follow-up with the appropriate level of care (care coordination)^{37,40-42,44,56,64,66,67}; or triaging patients via telephone to identify the priority of their concerns (triage and assessment).^{37,40,44,64,67,68} Patient populations with different chronic diseases relied mostly on nurse contributions in coordinating follow-up care related to their chronic disease (care coordination)^45-48,50-54; and/or reviewing assessment findings that were collected remotely from patients at home (chronic disease management).^50-55,69 Patients with COVID-19 diagnoses relied on nurses delivering COVID-specific care virtually, such as triaging and providing education/guidance surrounding COVID-19.⁶¹

Characteristics of Primary Care Practice Settings

Setting, Funding Model, Team

Nurses delivered virtual care in different primary care settings, such as NP-led clinics^59,70 and hospital-based primary care clinics,⁶⁹ though most settings were described using basic terms (eg, primary care practice, general practice, community health center, primary healthcare center) and lacked detail regarding the specific practice model. Many studies involved team-based or collaborative environments (n = 11; eg, general collaborative practices, general practice cooperatives, family medicine groups, primary care teams),^{37,42,44,48,50,52,54,55,58,62,67} though the specific team composition (ie, other members of the team) was often not clearly stated but involved at least nurses and physicians. No notable differences were found in nurse roles within these team-based environments.

Funding models were only explicitly discussed by 2 sources; 1 source referred to their setting as private fee-for-service practices,³⁹ while the source had a fee-for-service element in their private practices (ie, funded by service delivery component) but also received national government funding⁴⁴ (interpreted as a blended capitation model).

Geographic Location

Sources were specific to urban areas (n = 11), rural areas (n = 6), urban and rural areas (n = 9), and 8 studies did not specify the geography of their study location. As there was no universal definition for “rural” that could be applied across sources,⁷¹ we allowed individual sources to define rurality, or used the Statistics Canada definition when sources described their setting but did not explicitly identify it as rural or not: rural settings refer to towns or municipalities with a population <10 000 people⁷² and remote is an expansion of rural and defines communities that have no residents who commute to an urban location for work.^72,73 Some geographical areas were described in detail, providing information about the community/population served (eg, socially diverse populations,^50,51,53 medically underserved populations⁴⁶). Sources that clearly presented rural-specific findings^{38,41,44-47,49,59,70} came from Canada (n = 3) and the United Kingdom (n = 2); and Australia, Korea, Sweden, and the United States (all n = 1). Rural settings included NP-led clinics, community health centers, and general practices/clinics. Rural-specific sources included nurses across designations: NP (n = 2), RN (n = 2), LPN (n = 2), and not specified (n = 3).

Within rural settings, nurses were mainly involved in care coordination (n = 8), health education (n = 2), chronic disease management (n = 1), and COVID-specific care (n = 1); this is consistent with findings across urban areas and settings in general whereby care coordination was the most common role category for nurses in virtual care. Nurses referred to other providers and/or arranged follow-up care^37,43,46,49; or engaged in virtual consultations with primary providers and/or specialists to codevelop patient care plans.^49,50,55-57 Nurse roles across the other categories were centered around self-care advice/support,^37,43 lifestyle and nutrition counseling,⁴⁷ and education related to COVID-19.⁴⁹

Barriers and Facilitators

Table 4 presents barriers and facilitators that influenced nurses’ role enactment, organized by the NCOF. Overall, patient perceptions and experiences with virtual care, either positive or negative, were the most influential on nurse roles.^{37,39,40,46-48,50,51,55,56,61,63,65,67,69} When nurse roles were perceived to have an impact on quality of patient care (eg, improving self-care),^{48,50,51,56,61,70} patient advocacy,^48,49,70 and continuity of care,^39,47,49 nurses were more likely to deliver virtual care. Barriers included concerns with patient privacy (eg, safeguarding issues) and ethical care delivery (eg, during remote care delivery from home)^41,56,58; equitable care delivery (eg, hearing and visual impairments)^38,58; and accessibility of resources (eg, devices with necessary online platforms, high-speed broadband internet connection).^56,58

Table 4.

Barriers and Facilitators to Nurse Role Enactment in Virtual Care Organized by Dimensions Within the NCOF.

NCOF dimensions	Barriers	Facilitators
Patient characteristics	• Negative perceptions and experiences^38-40,50,63 • Privacy and ethical issues^41,56,58 • Inequities for vulnerable groups^38,58 • Limited access to resources (eg, devices, online platforms, high-speed Internet connection)^56,58	• Positive patient perceptions and experiences^{37,39,40,46-48,50,51,55,56,61,63,65,67,69} • Perceived quality of care^{48,50,51,56,61,70} • Perceived access to healthcare^{39,40,44,48,56,70} • Advocacy from nurses during appointments^48,49,70 • Perceived continuity of care^39,47,49 • Existing/prior nurse-patient relationship/rapport⁵⁶
Work environment	• Costs for infrastructure^41,49; service delivery^52,53; or provider training^39,52 • Practice guidelines/support^{37,43,44,56,63} • Availability of equipment^44,58,63 • Service utilization^38,39,53,69 • Information technology connectivity issues^38,46,51,56 • Integration of digital health platforms^50,51 • Funding models^44,63 • Involvement in virtual care decision-making⁵⁶	• Costs for virtual appointments by nurses vs physicians^39,49,58,65 • Necessary infrastructure available^{44,52,56,58,63} • Organizational functioning^49,60,63,67 • Leadership and teamwork/communication^43,58,59 • Ability to independently manage patients using virtual care⁶²
Scope of practice and staffing	• Specialized training^{37,41,43,49,56,60,63} • Workload to manage virtual care programs^{41,50,56,59,60} • Expectations when working from home⁵⁶ • Teamwork/interprofessional collaboration⁵⁸ • Time constraints for virtual assessments⁴³	• Intersectoral and/or interprofessional collaboration^41,48,56,70 • Positive perceptions and experiences^41,42,58 • Virtual care knowledge/expertise⁵⁶

Abbreviation: NCOF, Nursing Care Organization Framework.

Lack of nurse training and practice guidelines/support in virtual care were major barriers to nurse role enactment.^{37,41,43,49,56,60,63} Increased workload (eg, more time required to set up virtual appointments)^{41,50,56,59,60} and service utilization (ie, longer visits, increased follow-up visits)^38,39,53,69 were also commonly reported barriers. Other barriers, reported less frequently, to nurse role enactment in virtual care included reduced teamwork and collaboration (eg, during decision-making processes where physicians had the strongest voice)^41,56,58; poor integration between digital health platforms, requiring multiple programs to be functioning simultaneously to deliver and manage care virtually^50,51; primary care funding models (eg, fee-for-service) not favoring nurse involvement in virtual care delivery^44,63; limited time designated to virtual appointments, restricting nurses from completing comprehensive assessments⁴³; and nurse expectations when working remotely from home (eg, work with children present, work even when ill).⁵⁶ Another factor – mode of delivery (eg, text message preferred over telephone interactions) – impacted patients’/providers’ experience with virtual care delivery depending on the context of the visit.⁵⁹

Some rural studies discussed factors that influenced nurse involvement in virtual care delivery specific to rural contexts. For example, the availability of suitable equipment and resources (eg, high-speed internet, computers) contributed to nurses’ successful involvement in virtual care delivery.^38,41,44,46 Across many rural studies, training and practice guidance were noted as a barrier to role enactment,^41,44,49 though this was more commonly noted in sources that were situated in urban areas or did not specify their geographical context.

Discussion

In this scoping review, we mapped the international literature that described nurses’ contributions to virtual care delivery across primary care practice settings and aimed to outline nurse roles, practice setting characteristics, and barriers and facilitators to role enactment. Our findings demonstrated that nurses’ roles in virtual care delivery are heavily focused on the areas of care coordination, chronic disease management, and triage/assessment. Nurse roles are contributing to key elements of patient care, including consulting other providers, arranging follow-up care/testing, monitoring remote collection of patient data, and assessing/prioritizing patient concerns. Further, nurses’ role enactment is influenced by a variety of factors specific to patient characteristics (eg, patient perceptions, privacy/ethical concerns), work environment (eg, costs, practice guidance/support), and/or scope of practice and staffing (eg, virtual care practice training).

Primary care nurses’ roles in coordinating patient care using virtual modalities underscore their pivotal role in transforming care delivery, which aligns with growing evidence that physicians are increasingly acknowledging the critical function of information communication technologies in effective care coordination.⁷⁴ It has also been found that when physicians collaborate with other providers, such as nurses, care coordination can be improved.⁷⁵ Therefore, nurses using virtual modalities can have a compounding improvement on coordination of care in primary care (ie, care coordination improved through the use of virtual modalities and collaboration). Beyond care coordination and other roles reported in this review, other virtual care roles such as mental health/behavioral management⁷⁶ and rehabilitation⁷⁷ were not identified, though there is potential for primary care nurse roles to extend to these patient populations. Also, no trends were noted in nurse roles across designations in this study, which might differ from what is actualized in practice; deliberate exploration of virtual nursing practice across individual designations (eg, NPs, RNs, and LPNs) could provide more concrete insight on how practice in this area varies based on nurse education/training.

Despite the global shift toward team-based models of care in primary care settings,⁴ only a limited number of studies in this review investigated nurses’ roles within a team-based context. When teams were identified, they were not well described and lacked depth, which influenced our ability to understand the team impact on nurse roles. Studies have shown the interdependent nature of scopes of practice for nurses, physicians, and other providers in primary care, as the roles of one provider influence those of another^15,78 contributing to nurses’ professional scope of practice. By generating evidence within team-based environments in primary care, we can better understand how nurses complement their colleagues in delivering comprehensive care (eg, how roles shift, narrow, or expand) and facilitating the optimization of each provider’s scope of practice.

A recent report by Canada Health Infoway⁷⁹ aimed at assessing the use of digital technology in nursing practice outlined nurses’ thoughts about technology in practice. The report noted barriers that prevented nurses from maximizing the value of digital technology in practice; many of these aligned with the barriers to role enactment in our study, including time constraints, equipment/technology constraints, and education and training. These barriers are also consistent across virtual care literature focused on other healthcare professionals, including family physicians during the COVID-19 pandemic^80,81 and generally in primary care.⁸² A report from the International Council of Nurses⁸³ has highlighted the need to address these barriers, among others (eg, integrated care delivery to coordinate both virtual and in-person services), at a global level to enhance nurses’ contributions to digital health initiatives in primary care. Other barriers were more contextual and not consistently reported; for example, when nurses had atypical work arrangements (ie, worked from home) during the pandemic, they were, at times, asked to work even when feeling unwell.⁵⁶ This would not be applicable in more typical work arrangements (eg, working in clinic). Understanding barriers and facilitators to role enactment in virtual nursing practice in primary care is needed to focus future research and policy efforts.

Resources developed to guide virtual nursing practice in primary care are largely focused on physician practice or healthcare professionals generally. These practice guides, standards of practice, and other resources^6,84,85 are beneficial due to the unique considerations that are required in virtual care delivery; however, nursing is a distinct healthcare profession that requires nursing-specific knowledge to inform role enactment, limiting the value of these resources in nursing practice. Virtual care has been found to promote shorter visits,⁸⁶ which contradicts a barrier noted in this review, whereby virtual visits by nurses were found to be longer³⁸ or require more frequent follow-ups^39,53,69 than in-person care. By understanding nurses’ roles in virtual care delivery across primary care settings, we can develop resources that are targeted at nursing practice (eg, standards of practice in virtual care, communication approaches in virtual interactions) to optimize their roles and improve the efficiency of virtual nursing practice.

Limitations

Studies included in this review did not consistently report on practice characteristics (eg, practice settings, geography). Although we made efforts to compare across practice characteristics where these were reported, the majority of our findings focused on virtual care delivery across primary care settings more generally. Select studies did not provide enough detail on nurse roles; therefore, role categories could be deduced, but specific exemplars of nurse roles could not be further defined, limiting the depth of our understanding of specific nurse roles. Roles could also have been skewed if nurses were specialty trained, but this information was not reported in the manuscript. Similarly, not all sources explicitly discussed barriers and facilitators, nor could this type of data be interpreted.^{45,54,57,64,66,68} Lastly, there were many studies that did not meet our language eligibility criteria (ie, English or French sources) and were excluded from our review. This may limit the generalizability of our findings to non-English or French-speaking jurisdictions/countries.

Conclusion

In conclusion, nurses make important contributions to virtual care across primary care settings. They are well-positioned to improve the availability of and access to primary care through their integration in digital health initiatives. They continue to face challenges with role enactment when delivering virtual care, which should be considered in future research and policy efforts to improve nurses’ competence in, and patients’ experiences with, virtual care delivery. All providers, including nurses, should also mindfully consider the challenges that infiltrate virtual care as they transition toward optimizing their virtual care roles across primary care settings.

Supplemental Material

sj-pdf-1-wjn-10.1177_01939459251397729 – Supplemental material for Nurses’ Contributions to Virtual Care Delivery in Primary Care: A Scoping Review

Supplemental material, sj-pdf-1-wjn-10.1177_01939459251397729 for Nurses’ Contributions to Virtual Care Delivery in Primary Care: A Scoping Review by Crystal Vaughan, Julia Lukewich, Maria Mathews, Lindsay Hedden, Marie-Eve Poitras, Shabnam Asghari, Michelle Swab, Dana Ryan and Ruth Martin-Misener in Western Journal of Nursing Research

Footnotes

Acknowledgements

We would like to acknowledge Katie Kehoe, Library Assistant at the Health Sciences Library at Memorial University of Newfoundland for her support with document delivery of included sources.

ORCID iDs

Crystal Vaughan

Dana Ryan

Ethical Considerations

This review involved the secondary analysis of published and/or publicly available sources; therefore, ethical approval was not required.

Consent to Participate

This study involved the collection of sources/literature and did not involve study participants. Informed consent was not applicable to this study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Rural360 (with funds provided by the International Grenfell Association); Mitacs; Newfoundland & Labrador Support for People and Patient-Orientated Research and Trials (SUPPORT) Unit (Graduate Student Funding Competition; award/grant: N/A); the Canadian Nurses Foundation (award/grant: N/A); and the Seed, Bridge, and Multidisciplinary Fund (grant #20230220) at Memorial University of Newfoundland.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

References

Jamieson

Wallace

Armstrong

, et al Virtual Care: A Framework for a Patient-Centric System. Women’s College Hospital Institute for Health Systems Solutions and Virtual Care; 2015.

Hensel

Lemoine

Bolton

, et al When “virtual” works and when it doesn’t: a survey of physician and patient experiences with virtual care during the COVID-19 pandemic. Digit Health. 2024;10:20552076241258390. doi:10.1177/20552076241258390

Starfield

Shi

Macinko

Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457. doi:10.1111/J.1468-0009.2005.00409.X

World Health Organization. Operational Framework for Primary Health Care Transforming Vision into Action. World Health Organization and United Nations Children’s Fund; 2020. Accessed April 14, 2025. https://www.who.int/publications/i/item/9789240017832

Muldoon

Hogg

Levitt

Primary care (PC) and primary health care (PHC) what is the difference?

Can J Public Health. 2006;97(5):409-411. doi:10.1007/BF03405354

Segal

Davis

Dukhanin

Working framework for appropriate use of virtual care in primary care. J Am Board Fam Med. 2022;35(3):629-633. doi:10.3122/JABFM.2022.03.210469

Charalambous

Hollingdrake

Currie

Nurse practitioner led telehealth services: a scoping review. J Clin Nurs. 2024;33(3):839-858. doi:10.1111/JOCN.16898

Lukewich

Martin-Misener

Norful

, et al Effectiveness of registered nurses on patient outcomes in primary care: a systematic review. BMC Health Serv Res. 2022;22(1):740. doi:10.1186/s12913-022-07866-x

Lukewich

Asghari

Marshall

, et al Effectiveness of registered nurses on system outcomes in primary care: a systematic review. BMC Health Serv Res. 2022;22(1):440. doi:10.1186/s12913-022-07662-7

10.

Barnett

Balkissoon

Sandhu

The level of quality care nurse practitioners provide compared with their physician colleagues in the primary care setting: a systematic review. J Am Assoc Nurse Pract. 2022;34(3):457-464. doi:10.1097/JXX.0000000000000660

11.

Paier-Abuzahra

Posch

Jeitler

, et al Effects of task-shifting from primary care physicians to nurses: an overview of systematic reviews. Hum Resour Health. 2024;22(1):74. doi:10.1186/s12960-024-00956-3

12.

Norful

Martsolf

De Jacq

Poghosyan

Utilization of registered nurses in primary care teams: a systematic review. Int J Nurs Stud. 2017;74:15-23. doi:10.1016/j.ijnurstu.2017.05.013

13.

Brownwood

Lafortune

Advanced Practice Nursing in Primary Care in OECD Countries: Recent Developments and Persisting Implementation Challenges. OECD Health Working Papers, No 165. OECD; 2024. Accessed April 14, 2025. doi:10.1787/8e10af16-en

14.

Barrett

Mathews

Poitras

, et al Job titles and education requirements of registered nurses in primary care: an international document analysis. Int J Nurs Stud Adv. 2021;3:100044. doi:10.1016/J.IJNSA.2021.100044

15.

Freund

Everett

Griffiths

Hudon

Naccarella

Laurant

Skill mix, roles and remuneration in the primary care workforce: who are the healthcare professionals in the primary care teams across the world?

Int J Nurs Stud. 2015;52(3):727-743. doi:10.1016/J.IJNURSTU.2014.11.014

16.

Almost

Regulated Nursing in Canada: The Landscape in 2021. Canadian Nurses Association; 2021. Accessed April 14, 2025. www.cna-aiic.ca

17.

College of Nurses of Ontario. Providing Virtual Care. College of Nurses of Ontario; c2025. Accessed April 14, 2025. https://cno.org/standards-learning/ask-practice/providing-virtual-care

18.

Mrayyan

Abunab

Abu Khait

, et al Competency in nursing practice: a concept analysis. BMJ Open. 2023;13(6):e067352. doi:10.1136/BMJOPEN-2022-067352

19.

MacLeod

MLP

Martin Misener

Banks

“I’m a different kind of nurse”: advice from nurses in rural and remote Canada. Nurs Leadersh. 2008;21(3):40-53. doi:10.12927/CJNL.2008.20060

20.

Martin Misener

MacLeod

MLP

Banks

, et al. “There’s rural, and then there’s rural”: advice from nurses providing primary healthcare in northern remote communities. Nurs Leadersh. 2008;21(3):54-63. doi:10.12927/CJNL.2008.20062

21.

Mathews

Spencer

Hedden

, et al Development of a primary care pandemic plan informed by in-depth policy analysis and interviews with family physicians across Canada during COVID-19: a qualitative case study protocol. BMJ Open. 2021;11(7):e048209. doi:10.1136/bmjopen-2020-048209

22.

Brault

Kilpatrick

D’Amour

, et al Role clarification processes for better integration of nurse practitioners into primary healthcare teams: a multiple-case study. Nurs Res Pract. 2014;2014:1-9. doi:10.1155/2014/170514

23.

Busca

Savatteri

Lorenza Calafato

, et al. Barriers and facilitators to the implementation of nurse’s role in primary care settings: an integrative review. BMC Nurs. 2021;20(1):171. doi:10.1186/s12912-021-00696-y

24.

World Health Organization. Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guidelines. World Health Organization; 2008. Accessed February 26, 2025. https://iris.who.int/handle/10665/43821

25.

Leong

Teoh

Fun

Lee

SWH

. Task shifting in primary care to tackle healthcare worker shortages: an umbrella review. Eur J Gen Pract. 2021;27(1):198-210. doi:10.1080/13814788.2021.1954616

26.

Rouleau

Parry

Providing compassionate care in a virtual context: qualitative exploration of Canadian primary care nurses’ experiences. Digit Health. 2024;10:20552076231224072. doi:10.1177/20552076231224072

27.

Dubois

Damour

Tchouaket

, et al. A taxonomy of nursing care organization models in hospitals. BMC Health Serv Res. 2012;12(1):286. doi:10.1186/1472-6963-12-286

28.

Besner

Doran

McGillis Hall

, et al A systematic approach to maximizing nursing scopes of practice. Alta RN. 2005;16(1):14-15.

29.

Peters

Godfrey

McInerney

, et al. Scoping reviews. (2020). In: Aromataris E, Lockwood C, Porritt K, et al. (eds) JBI Manual for Evidence Synthesis. JBI; 2024. doi:10.46658/JBIMES-20-12

30.

Vaughan

Lukewich

Mathews

, et al Nursing contributions to virtual models of care in primary care: a scoping review protocol. BMJ Open. 2022;12(9):e065779. doi:10.1136/bmjopen-2022-065779

31.

Tricco

Lillie

Zarin

, et al PRISMA extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-473. doi:10.7326/M18-0850

32.

Van Den Akker

Peters

GJY

Bakker

, et al Increasing the transparency of systematic reviews: presenting a generalized registration form. Syst Rev. 2023;12:170. doi:10.1186/s13643-023-02281-7

33.

Peters

MDJ

Marnie

Tricco

, et al Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. 2020;18(10):2119-2126. doi:10.11124/JBIES-20-00167

34.

Community Health Nurses of Canada. Canadian Community Health Nursing Professional Practice Model & Standards of Practice. Community Health Nurses of Canada; 2019. Accessed April 14, 2025. https://www.chnc.ca/en/standards-of-practice

35.

Canadian Nurses Association. Position Statement: Clinical Nurse Specialist. Canadian Nurses Association; 2009. Accessed April 4, 2025. https://www.cna-aiic.ca/en/nursing/advanced-nursing-practice/clinical-nurse-specialists

36.

University of British Columbia. Registered nurse virtual primary care practice guide. Accessed April 15, 2025. https://isu.familymed.ubc.ca/registered-nurse-virtual-primary-care-practice-areas/

37.

de Moraes

Ferreira

Kawagoe

, et al. An integrative telehealth platform managed by nurses. BMC Res Notes. 2022;15(1):301. doi:10.1186/s13104-022-06197-8

38.

Holmström

Nokkoudenmäki

Zukancic

Sundler

AJ.

It is important that they care – older persons’ experiences of telephone advice nursing. J Clin Nurs. 2016;25(11-12):1644-1653. doi:10.1111/jocn.13173

39.

Waterworth

Raphael

Parsons

, et al. Older people’s experiences of nurse-patient telephone communication in the primary healthcare setting. J Adv Nurs. 2018;74(2):373-382. doi:10.1111/jan.13449

40.

Giesen

van Charante

Mokkink

, et al. Patients evaluate accessibility and nurse telephone consultations in out-of-hours GP care: determinants of a negative evaluation. Patient Educ Couns. 2007;65(1):131-136. doi:10.1016/j.pec.2006.06.021

41.

Richards

King

Reid

, et al Remote working: survey of attitudes to eHealth of doctors and nurses in rural general practices in the United Kingdom. Fam Pract. 2005;22(1):2-7. doi:10.1093/fampra/cmh716

42.

Saigí-Rubió

Vidal-Alaball

Torrent-Sellens

, et al Determinants of Catalan public primary care professionals’ intention to use digital clinical consultations (eConsulta) in the post-COVID-19 context: mixed methods study. J Med Internet Res. 2021;23(6):e28944. doi:10.2196/28944

43.

Wärdig

Engström

Carlsson

et al.

Saving lives by asking questions: nurses’ experiences of suicide risk assessment in telephone counselling in primary health care. Prim Health Care Res Dev. 2022;23(10):e65. doi:10.1017/S146342362200055X

44.

James

Ashley

Williams

, et al Experiences of Australian primary healthcare nurses in using telehealth during COVID-19: a qualitative study. BMJ Open. 2021;11(8):e049095. doi:10.1136/bmjopen-2021-049095

45.

Government of Canada. Nunavut’s Virtual Care Action Plan. 2022. Accessed April 4, 2025. https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/bilateral-agreement-pan-canadian-virtual-care-priorities-covid-19/nunavut-action-plan.html

46.

Kwak

Hwang

Lee

TH.

Effects of the physician-primary-healthcare nurse telemedicine model (P-NTM) on medication adherence and health-related quality of life (HRQoL) of patients with chronic disease at remote rural areas. Int J Environ Res Public Health. 2021;18(5):1-12. doi:10.3390/ijerph18052502

47.

Canadian Institute for Health Information. Virtual care in Canada: strengthening data and information. 2022. Accessed April 15, 2025. https://www.cihi.ca/sites/default/files/document/virtual-care-in-canada-strengthening-data-information-report-en.pdf

48.

Bangs

Clarke

Hands

, et al. An integrated nursing and telemedicine in vascular care. J Telemed Telecare. 2002;8(suppl 2):110-112. doi:10.1177/1357633X020080S250

49.

Hands

Clarke

Mahaffey

An e-Health approach to managing vascular surgical patients. Telemed J E Health. 2006;12(6):672-680. doi:10.1089/tmj.2006.12.672.

50.

Hanley

Ure

Pagliari

et al.

Experiences of patients and professionals participating in the HITS home blood pressure telemonitoring trial: a qualitative study. BMJ Open. 2013;3(3):2671. doi:10.1136/bmjopen-2013-002671

51.

Hanley

Fairbrother

Mccloughan

, et al Qualitative study of telemonitoring of blood glucose and blood pressure in type 2 diabetes. BMJ Open. 2015;5(12):e008896. doi:10.1136/bmjopen-2015-008896

52.

Stoddart

Hanley

Wild

, et al Telemonitoring-based service redesign for the management of uncontrolled hypertension (HITS): cost and cost-effectiveness analysis of a randomised controlled trial. BMJ Open. 2013;3(3):e002681. doi:10.1136/bmjopen-2013-002681

53.

Wild

Hanley

Lewis

, et al Supported telemonitoring and glycemic control in people with type 2 diabetes: the Telescot diabetes pragmatic multicenter randomized controlled trial. PLoS Med. 2016;13(7):e1002098. doi:10.1371/journal.pmed.1002098

54.

McKinstry

Watson

Pinnock

, et al. Telephone consulting in primary care: a triangulated qualitative study of patients and providers. Br J Gen Pract. 2009;59(563):e209-e218. doi:10.3399/bjgp09X420941

55.

Halcomb

Purcell

Hickman

Smyth

Telemonitoring is acceptable amongst community dwelling older Australians with chronic conditions. Collegian. 2016;23(4):383-390. doi:10.1016/j.colegn.2015.09.007

56.

Anderson

Scantlebury

Galdas

Adamson

Remote and technology-mediated working during the COVID-19 pandemic: a qualitative exploration of the experiences of nurses working in general practice (the GenCo Study). J Adv Nurs. 2024;80(4):1592-1606. doi:10.1111/jan.15921

57.

Little

Stuart

Hobbs

, et al An Internet-based intervention with brief nurse support to manage obesity in primary care (POWeR+): a pragmatic, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2016;4(10):821-828. doi:10.1016/S2213-8587(16)30099-7

58.

Regragui

Abou Malham

Gaboury

, et al Nursing practice and teleconsultations in a pandemic context: a mixed-methods study. J Clin Nurs. 2023;32(17-18):6339-6353. doi:10.1111/jocn.16756

59.

Barker

KL.

Telemonitoring to change standard diabetes education and management in a rural healthcare practice. 2015. Accessed January 12, 2025 https://researchrepository.wvu.edu/etd

60.

McCallum-Crawford

Is Dietary Teaching via Telehealth Effective in Lowering HbA1c in Adult Patients With Prediabetes or Type 2 Diabetes? [UNLV theses, dissertations, professional papers, and capstones]. UNLV; 2022:4436. doi:10.34917/31813325

61.

Tort-Nasarre

Espart

Galbany-Estragués

Álvarez

Subias-Miquel

Romeu-Labayen

Experiences of telenursing in overcoming challenges and applaying strategies by COVID-19 patients in home isolation: qualitative study in primary care. Healthcare. 2023;11(14):2093. doi:10.3390/healthcare11142093

62.

Haith-Cooper

Stacey

Edwards

, et al. Pregnancy-related telephone consultations to an out-of-hours provider: a retrospective study. Prim Health Care. 2015;25(2):24-29. doi:10.7748/phc.25.2.24.e936

63.

Ashley

Williams

Dennis

, et al Telehealth’s future in Australian primary health care: a qualitative study exploring lessons learnt from the COVID-19 pandemic. BJGP Open. 2023;7(2):BJGPO.2022.0117. doi:10.3399/BJGPO.2022.0117

64.

Registered Nurses’ Association of Ontario. Primary solutions for primary care: maximizing and expanding the role of the primary care nurse in Ontario. 2012. Accessed April 4, 2025. https://rnao.ca/sites/rnao-ca/files/Primary__Care_Report_2012.pdf

65.

McNally

RT.

Improving Pre-Diabetes Knowledge and Management Among Adults in Primary Care Using Text Messaging [doctoral dissertations]. Salve Regina University; 2020:53. https://digitalcommons.salve.edu/doctoral_dissertations/53

66.

Nurses Association of New Brunswick. Practice guideline: telenursing practice. 2021. Accessed May 25, 2022. http://www.nanb.nb.ca/media/resource/NANB-PracticeGuideline-Telenursing-July20-E.pdf

67.

Charles-Jones

May

Latimer

Roland

Telephone triage by nurses in primary care: what is it for and what are the consequences likely to be?

J Health Serv Res Policy. 2003;8(3):154-159. doi:10.1258/135581903322029502

68.

Canadian Family Practice Nurses Association. Sample role description for registered nurse in family practice for adaptation to your primary care practice. Accessed April 4, 2025. http://www.cna-aiic.ca/CNA/practice/scope/default_e.aspx

69.

Mammen

Schoonmaker

Java

, et al Going mobile with primary care: smartphone-telemedicine for asthma management in young urban adults (TEAMS). J Asthma. 2022;59(1):132-144. doi:10.1080/02770903.2020.1830413

70.

Hakimjavadi

Levi

LeBlanc

, et al Electronic consultation by advanced practice nurses to improve access to specialist care for older adults. J Gerontol Nurs. 2022;48(4):33-40. doi:10.3928/00989134-20220307-02

71.

United Nations Statistics Division. Population density and urbanization. 2017. Accessed March 31, 2025. https://unstats.un.org/unsd/Demographic/sconcerns/densurb/default.htm

72.

du Plessis

Beshiri

Bollman

Clemenson

Definitions of rural.

Rural and Small Town Canada Analysis Bulletin (Catalogue no. 21-006-XIE). Statistics Canada. 2001;3(3). Accessed April 14, 2025. https://www150.statcan.gc.ca/n1/pub/21-006-x/21-006-x2001003-eng.pdf

73.

Vodden

Cunsolo

Canada in a changing climate: national issues report – rural and remote communities. 2021. Accessed April 15, 2025. https://changingclimate.ca/national-issues/

74.

Chan

Hussain

Francis

The Commonwealth Fund Survey of primary care physicians reveals challenges experienced by family doctors and emphasizes the need for interoperability of health information technologies. Healthc Q. 2023;26(3):9-11. doi:10.1503/cmaj.71818

75.

Canadian Institute for Health Information. Survey results reveal the challenges experienced by family doctors. 2023. Accessed December 21, 2024. https://www.cihi.ca/en/survey-results-reveal-the-challenges-experienced-by-family-doctors

76.

Ward

Vagholkar

Sakur

et al.

Visit types in primary care with telehealth use during the COVID-19 pandemic: systematic review. JMIR Med Inform. 2022;10(11):e40469. doi:10.2196/40469

77.

Agarwal

Fletcher

Ramamoorthi

Uses of virtual care in primary care: scoping review. J Med Internet Res. 2025;27:e55007. doi:10.2196/55007

78.

Contandriopoulos

Perroux

Cockenpot

, et al. Analytical typology of multiprofessional primary care models. BMC Fam Pract. 2018;19(1):44. doi:10.1186/S12875-018-0731-8

79.

Canada Health Infoway. 2023 Canadian survey of nurses: use of digital health technology in practice. 2024. Accessed June 16, 2024. https://insights.infoway-inforoute.ca/nursing-practice-in-digital-environments/

80.

Hedden

Spencer

Mathews

, et al “There’s nothing like a good crisis for innovation”: a qualitative study of family physicians’ experiences with virtual care during the COVID-19 pandemic. BMC Health Serv Res. 2023;23(1):338. doi:10.1186/s12913-023-09256-3

81.

Hedden

Spencer

Mathews

, et al “Technology has allowed us to do a lot more but it’s not necessarily the panacea for everybody”: family physician perspectives on virtual care during the COVID-19 pandemic and beyond. PLoS One. 2024;19(2):e0296768. doi:10.1371/journal.pone.0296768

82.

Teng

Russo

Kanuch

Caron

Virtual care adoption – challenges and opportunities from the lens of academic primary care practitioners. J Public Health Manag Pract. 2022;28(6):599. doi:10.1097/PHH.0000000000001548

83.

Stewart

Schober

Catton

. Nursing and primary health care: towards the realization of universal health coverage. 2024. Accessed April 15, 2025. https://www.icn.ch/resources/publications-and-reports/nursing-and-primary-health-care-towards-realization-universal

84.

Ontario Health. Clinically appropriate use of virtual care in primary care – guidance reference document. 2022. Accessed April 15, 2025. https://www.ontariohealth.ca/providing-health-care/clinical-standards-guidelines/clinically-appropriate-virtual-care-guidance/primary-care

85.

Healthcare Excellence Canada, Canada Health Infoway. Providing safe and high-quality virtual care: a guide for new and experienced users. 2022. Accessed April 14, 2025. https://www.infoway-inforoute.ca

86.

Campbell

Greenfield

, et al The impact of virtual consultations on the quality of primary care: systematic review. J Med Internet Res. 2023;25:e48920. doi:10.2196/48920

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