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Abstract

Background:

The role of primary care nurses is expanding significantly due to increasing healthcare demand. This role expansion poses various challenges to the nurses that can impact patient care. Using hypertension care as an example, this study aimed to explore the diverse roles played by primary care nurses and the challenges they faced when performing these roles.

Methods:

An exploratory qualitative study was conducted among nurses in 5 public primary care clinics in Singapore. Purposive sampling was employed to ensure nurses of different cadre and experiences were included. An experienced qualitative researcher conducted the interviews until data saturation was reached. The interviews were audio-recorded, transcribed verbatim, checked and analysed thematically using NVivo (version 14).

Results:

Thirteen nurses of varying age (25-65 years) and experience level (staff nurse to advanced practice nurse) were interviewed. The nurses’ traditional duties in primary care settings included patient triaging, immunisation administration, management of acute and chronic conditions including regular health monitoring, wound care, supporting medication adherence, general lifestyle counselling and mentoring junior nurses. However, they performed expanded clinical roles for hypertension care with additional responsibilities that included counselling on home-BP monitoring and medication titration using motivational interviewing. The key challenges they faced in managing hypertension were: (i) time and manpower constraint, (ii) lack of continuity of care, (iii) lack of clear guidelines, (iv) inefficient workflows, (v) overlapping and competing services, (vi) lack of knowledge and training and (vii) lack of home BP readings from patients.

Conclusion:

This study contributes to the ongoing conversation on the future of nursing, highlighting the importance of balancing professionalism with the increasing demands of healthcare. Our results emphasise the need for strategic planning and role clarification through clear communication of job descriptions, routine reviewing of clinical workflows, targeted training and support for nurses in performing their diverse roles, and fostering regular multidisciplinary meetings to define, communicate and support evolving nursing responsibilities in primary care.

Keywords

workforce challenges hypertension care primary care nurses’ roles

Introduction

The global rise in life expectancy has led to an ageing population and an increased burden of chronic diseases and comorbidities.^1,2 In Singapore, the proportion of residents aged 65 and above is expected to reach 24% by 2030.³ A significant proportion of the Singaporean population (16.3%) is already living with multiple chronic conditions⁴ with hypertension being the most prevalent.⁵ Effective management of these complex needs of the elderly population requires innovative and multidisciplinary healthcare models in primary care.⁶ National initiatives like ‘Healthier SG’⁷ and ‘Age Well SG’⁸ have shifted the healthcare focus towards preventive health in primary care settings with primary care providers, especially nurses playing a pivotal role as both providers and coordinators of care.

With these changes, primary care nurses’ role in hypertension management has evolved significantly, expanding beyond their traditional roles in disease prevention and health promotion to including more complex chronic care management.^9,10 During the 1960s, the nurses focused on providing guidance on blood pressure monitoring and preventive education.¹¹ As hypertension cases grew, their responsibilities expanded to complement physicians’ work and included patient assessment and medication adjustment.¹² Subsequently, the introduction of nurse-run clinics and nurse-led interventions broadened their responsibilities to providing comprehensive and holistic patient care.¹³ Furthermore, nurse practitioners that included advanced practice nurses were empowered to prescribe medications and provide expert care by guiding patients with complex hypertension management regimens.¹⁴ Nurse-led and task-sharing approaches have yielded improved outcomes in chronic disease management, with systematic reviews demonstrating reduced hospitalisations and enhanced quality of life for patients.^15,16 However, most studies have been conducted in Western countries, typically designed for settings where care delivery is not centrally coordinated. There is further emphasis that such models are most effective when roles are clearly delineated and nurses’ responsibilities match their scope of training.¹⁷ Relatively little is known about the challenges that arise in mature, centrally managed systems such as Singapore.

As nurses become increasingly important in improving patient experience and health outcomes, they are entrusted with growing responsibilities.¹⁸ In Singapore, the roles played by the primary care nurses is similar to the roles of Registered Nurses, Family Practice Nurses, General Practice Nurses and Case Managers in developed countries.¹⁰ They are primarily involved in patient triaging, preventive care including screening and immunisation, acute and chronic care management including regular health monitoring, medication and lifestyle counselling, and providing nursing education to junior nurses. With rising healthcare demands and hypertension prevalence, their roles have expanded to include counselling on home-BP monitoring and medication titration using motivational interviewing technique.¹⁹ Similar to global trends,^10,20 this growing scope bereft of additional resources increases the risk of exhaustion and burnout.^21,22

Despite the important role played by primary care nurses in hypertension management, there is limited research exploring their perceptions, experiences and challenges within Singapore’s unique primary care landscape. Using hypertension care, this study explores primary care nurses’ diverse roles and identify the challenges they face while delivering these roles. Understanding these roles and challenges provides systems-level insights to address rising nursing demands in chronic care management, reduce burnout, and improve job satisfaction. This study is part of a larger study to explore the challenges faced by doctors, nurses and pharmacists in managing patients with hypertension in a primary care setting.^23,24

Methods

Study Design

This study utilised an exploratory qualitative methodology involving individual in-depth interviews (IDIs) to understand the nurses’ roles and challenges in managing patients with hypertension.

Study Setting

The study interviews were conducted across 5 public primary care clinics (PC1, PC2, PC3, PC4 and PC5) located in the South-eastern and North-eastern regions of Singapore. The clinics differed in geography, population profiles, manpower, infrastructure and resources. They had a combined daily attendance of 850 patients seeking medical care and about 200 000 hypertension patient-visits in 2022 (based on the institution’s electronic medical record (EMR) system and business database). Two out of the 5 clinics that were newly established had better infrastructure but lower patient load. This difference was critical to capture a wide range of clinical practices.

Study Duration

The interviews were conducted over a period of 6 months between April and September 2022.

Study Participants, Sampling and Recruitment

Nurses, who were 21 years of age and above and had ≥6 months’ clinical experience managing hypertensive patients, were purposively sampled for the interviews based on their seniority and clinical experience to ensure maximal variation. The list of nursing staff was obtained from each clinic and an email invitation with details of the study was sent to the selected nurses by a researcher (CJN). All invited participants agreed to the interviews; they were approached in the clinics by a clinical research coordinator to further explain the study and obtain written informed consent. Face-to-face interviews were scheduled within clinics at convenient timing and the interviews were continued until data saturation was achieved.

Research Team

The research team comprised of 1 clinical research coordinator who explained the study to the participants and took written informed consent; 1 senior male qualitative researcher (CJN) who conducted all the in-depth interviews; 2 researchers (SSK, RFAA) trained in qualitative methodology who analysed the interview data; and a content expert Nurse Manager (LLF) with 17 years of experience in chronic diseases and hypertension care.

Research Instruments

Participants’ demographic details were collected using a semi-structured data collection form that included information about participants’ age, gender, qualification, designation, clinical role and clinical experience. This study was part of a larger study conducted among doctors, nurses and pharmacists to explore the challenges they faced in managing patients with hypertension in a primary care setting. A semi-structured interview guide (attached as Supplementary file) developed through literature review and expert discussion was used to guide the interviews. The interviews captured the nurses’ roles and experiences in hypertension care, and the challenges they faced while performing these roles.

Data Collection

The participants were pre-selected (based on purposive sampling) and invited via emails. Interested participants were approached in-person by the clinical research coordinator and written informed consent was obtained after explaining the study to them. On the interview day, the study was re-explained to the participants; filling up of data collection form and ice-breaking preceded the interviews. All interviews were conducted by a senior male qualitative researcher (CJN) who had a doctoral degree and was a practicing Family Physician in PC1. Hence, the study team avoided selecting any healthcare providers who were close acquaintances or colleagues of CJN. The duration of the interviews ranged from 45 to 60 min, and all interviews were audio-recorded. The recordings were transcribed verbatim by a professional transcriber, checked for accuracy before using them for analysis. Each participant received a USD $15 voucher to compensate for their time. The participants were interviewed until no new findings emerged from the interviews (data saturation). Field notes taken during and after the interviews informed data analysis and helped to determine data saturation.

Data Analysis

The transcripts were analysed thematically by 2 researchers (SSK, RFAA) following the 6-step approach outlined by Braun and Clarke.²⁵ All interview transcripts were first read multiple times by the 2 researchers to ensure data accuracy and familiarisation. The researchers then coded the transcripts individually to generate initial codes inductively, capturing significant features related to nurses’ roles and challenges in hypertension care. Codes with similar content were collated and grouped into preliminary themes (axial coding), which were subsequently reviewed, refined and defined through discussions with a third senior researcher (CJN) to resolve any discrepancies. The 3 researchers (CJN, SSK, RFAA) met regularly to discuss any new codes that emerged during the analysis and removed irrelevant codes. Representative quotations were selected to illustrate each theme. To ensure member checking, findings were checked by a nurse manager (LLF), whose critical feedback informed revisions where necessary. Due to the clinic nurses’ workload constraints and scheduling challenges, returning full transcripts or preliminary results for participant review was not feasible. The data was managed using the NVivo© (Lumivero, LLC) qualitative data management software.

Reflexivity Statement

The interviewer (CJN) is a family physician in PC1 with qualitative research expertise and clinical experience in primary care. This background ensured strong rapport with participants, allowing for rich, clinically oriented narratives. However, the interviewer’s seniority and professional status may have introduced power dynamics or response bias, potentially influencing how participants described their experiences and challenges. To mitigate this, CJN constantly reflected on his role throughout the study. The research team also consciously avoided recruiting nurses who were direct colleagues or close acquaintances of the interviewer. Furthermore, data analysis was conducted by 2 trained qualitative researchers (SSK and RFAA), who had no clinical role or relationship with participants from the polyclinics. Their independent perspective helped minimise bias during the analysis.

Results

A total of 13 nurses whose age ranged from 25 to 65 years were interviewed. The profile of the study participants is shown in Table 1. The key areas explored through the interviews included the nurses’ role in primary care and the challenges they faced in delivering hypertension care. A summary of the key themes and subthemes is given in Table 2.

Table 1.

Demographic Profile of the Participants (N = 13).

Characteristics	n	%
Age (in years)
≤35	4	30.8
36-50	4	30.8
1-65	5	38.4
Gender
Female	13	100.0
Ethnicity
Chinese	9	69.2
Malay	4	30.8
Number of years working in primary care
<10	4	30.8
10-19	6	46.2
≥20	3	23.0
Highest professional qualification
Diploma	2	15.4
Advanced diploma certification^a	4	30.8
Bachelor’s degree	5	38.4
Master’s degree	2	15.4
Current designation^b
Staff nurse (SN)	3	23.1
Senior staff nurse (SSN)	7	53.8
Nurse clinician (NC) ± advanced practice nurse (APN)^c	3	23.1
Number of hypertensive patients seen in a week
Range: 5-90
<15	5	38.4
15-29	4	30.8
≥30	4	30.8

Advanced diploma certification includes Advanced diploma in Community Health, Mental Health; Specialist Diploma in Education, Gerontology.

Job description of (i) Staff nurse – perform physical, nutritional, psychosocial and functional assessments, provide screening procedures, medication administration, and health education; (ii) Senior staff nurse – in addition to staff nurse roles, SSN participate in new clinical initiatives and are involved in development of nurse-led protocols and clinical pathways; (iii) Advanced practice nurse – in addition to SSN roles, APN are involved in conducting advanced health assessments, ordering and prescribing medication; (iv) Nurse Clinician – in addition to the SSN roles, NC lead the nursing services and are involved in developing and leading nurse-led protocols and clinical pathways

A Nurse clinician may sometimes double up as an Advanced practice nurse.

Table 2.

Summary of Key Themes and Subthemes.

Main themes	Subthemes
Nurses’ roles	• General clinical role
	• Specialised hypertension care
Challenges in hypertension care
• Health-system related challenges
	i) Time and manpower constraint
	ii) Lack of continuity of care
	iii) Lack of clear guidelines
	iv) Inefficient workflows
	v) Overlapping or competing hypertension services
• Individual provider-level challenges
	vi) Lack of knowledge, skills and confidence
	vii) Lack of patient-recorded home BP readings

Nurses’ Roles

The general role of the primary care nurses included triaging of patients, delivering immunisations, providing acute care in the emergency rooms, monitoring patients’ chronic conditions and delivering preventive care services. In the polyclinics, there were additional roles assumed by the nurses for managing patients with specific chronic conditions which included counselling on disease-specific healthcare interventions and medication titration using motivational interviewing. Apart from their clinical roles, they were also involved in teaching and mentoring students attached to the clinics.

My role is a staff nurse. Usually, what I do is to triage patients. Usually, in the E (emergency) room we triage patients coming in from home or from our HMS (health monitoring station) where their BP (blood pressure) is high or low. They will always be sent down to us for us to re-check before they (are) sent up to the doctors.

(30-year-old SN, 1 year of experience in primary care)

(Nurses) cover a lot of rooms, like vaccination, we do developmental assessment for children, we give health counselling, treatment for patients. And then today I got a bit of an extra role, I’m taken out for teaching the (nursing) students.

(41-year-old Senior SN, 12 years of primary care experience)

In addition to their general duties, nurses undertook specialised roles in hypertension care, providing counselling on home BP monitoring, diet, lifestyle modifications and medication titration. They were involved in a wide range of hypertension-focused services, including: acute care (managing ‘acute’ problems such as patients with very high BP); Nurse Clinician (NC) Service (co-managing patients with controlled hypertension with doctors); Advanced Practice Nurse (APN) clinic (co-managing patients with uncontrolled hypertension with doctors); Telecare (providing remote care for patients with controlled hypertension via telephone consultation) and Primary Tech-Enhanced Care (PTEC) (managing patients through remote BP monitoring and video consultation).

Basically, I’m a staff nurse. So, we have to counsel patients on chronic conditions and hypertension is one of them. So, if I am based at that service area, and the patient is sent by the doctor, we will need to educate them on blood pressure monitoring. Sometimes, we have to teach them how to use the machine (BP monitoring device), sometimes have to ask patients on compliance of medicine and also, we will counsel them on diet and exercise.

(42-year-old Senior SN, 20 years of primary care experience)

Oh, different types of services (are provided) for hypertension. One of them is the nurse clinician service, the other one is the advanced practice nurse. Then the nurse counselling. Okay, the nurse clinician part is for stable cases. The advanced practice nurse can take on some patients with a little problem, like those old age patients. A lot (of services) for hypertension (laughter).

(65-year-old Chinese NC, 34 years of primary care experience)

Challenges Faced by the Primary Care Nurses in Hypertension Care

The interviews helped to understand the various challenges faced by the nurses when they performed these expanded roles. The key challenges included: (i) time and manpower constraint, (ii) lack of continuity of care, (iii) lack of clear guidelines, (iv) inefficient workflows, (v) overlapping or competing hypertension services, (vi) lack of knowledge, skills and confidence and (vii) lack of patient-recorded home BP readings.

Time and Manpower Constraint

The nurses highlighted doctors’ limited consultation time as a gap that restricted them from exploring patients’ difficulties in hypertension control and medication adherence. This prompted referrals to nurses whose longer consultation time allowed for probing on BP monitoring errors and medication adherence that may have been missed during the doctors’ brief consultations. However, nurses found it difficult to engage in meaningful counselling sessions due to the burden of additional workloads and frequent interruptions that affected their workflow.

They (Doctors) don’t have time. I always tell my patients “Doctors are very busy”. They (Patients) say they know, they understand. But then, there is risk of missing all these things (patients’ monitoring errors) because of the doctors’ busy schedule. So, need to probe the patients to know (such things).

(51-year-old NC/APN, 18 years of clinical experience)

Down here (in the counselling room) we definitely have the luxury of time a little bit. But I guess the nurses’ load is quite high, because not only the nurses do counselling, but we also do referrals. So, the counselling room is not like a closed room or anything, the patients will be able to like “Excuse me, Excuse me”, they will just interrupt. So, it will cut off the momentum, so that is pretty difficult.

(33-year-old SN, 2 years of experience in primary care)

Lack of Continuity of Care

Continuity and good rapport with patients were considered vital for hypertension control, with patients and nurses preferring such a model as patients responded better on continuous follow-ups with the same nurse. However, it was challenging to achieve this due to the current rostering that rotated the nurses through different services.

Actually, it (patient’s attitude towards BP control) depends on our rapport with the patient. If you communicate with them, you listen, they will say “Will I see you next time?” But no – (it’s) according to the roster. Actually if, in future there is a lot of elderly care and there is a follow up with same nurse, it will be better. The condition would be much better. But now it is impossible.

(61-year-old Senior SN, 15 years of experience in primary care)

Language barrier was another important factor for care continuity, with patients preferring follow-up with nurses who shared their native language or dialects. Nurses were concerned about ad-hoc swapping of service stations to match patients’ language needs, and misinterpretation of clinical instructions and medical terminologies during translation into local languages.

But they (patients) definitely have their own preference. Because some nurses are very good with dialects. Then some patients are just hokkien (local dialect) speaking. So, this nurse is like good with hokkien. So, I understand why they prefer this nurse. If there is language barrier then we might call the nurse back.

(39-year-old Chinese Senior SN, 10 years of primary care experience)

Especially now we do get some patients who are from India, they came because their family is here. The local ones, most of them can speak Malay. So, it’s also a challenge to them (patients) if the medical side ask about things which they are not familiar. So, the interpretation (of medical terminologies) may not be so correct.

(65-year-old Chinese NC, 34 years of experience in primary care)

Lack of Clear Guidelines

Although institutional hypertension clinical guideline was available, nurses struggled to apply them based on individual patient profiles and needs. Less experienced nurses were uncertain with readings that fell in the ‘grey areas’ like white coat hypertension, indicating a need for more detailed guidelines.

There is (an institution guideline), but it’s very difficult to really stick to it. Because also depending on how old the patient is, and the history that the patient has, because some of them they have other things, you cannot control it that tight also. So, really have to individualize.

(65-year-old NC, 34 years of experience in primary care)

Because I’m quite new, so every time a patient comes in with high BP, sometimes I feel a bit lost. Like what am I supposed to do. It’s so high, it’s not inside this criteria. Like it’s in between (neither too high, nor too low). So, it’s just that from our side, we don’t know what to do, we cannot do much. I hope maybe, more detailed guidelines will be good.

(30-year-old SN, 1 year of experience in primary care)

Some patients have white coat symptom. So, that’s the part that is quite grey area. Because patient is completely asymptomatic, very comfortable, talk in full sentences, no pain, nothing.

(25-year-old SN, 4 years of primary care experience)

Inefficient Workflows

The nurses articulated that the existing inefficient hypertension care workflows included clinical services, referrals and appointment booking. The issues highlighted the need for clearer role definitions between pharmacists and nurses, empowerment of nurses to facilitate referrals to ancillary services, and providing adequate consultation time for patient care and counselling.

Sometimes when we are overwhelmed and patients just buy a BP [blood pressure] machine, come up and ask you to counsel (on how to use it), it’s a bit difficult. So, I was wondering, how come they buy the machine downstairs, can’t they (pharmacy) just teach? How come have to push up to the nurse to do? Because I think that’s the workflow in the clinic. I find it a bit difficult; I don’t find it logical. Unless you come and tell me “Oh, the patient not just want to check BP [blood pressure], must also get some diet counselling”. But you just tell me to check the machine and how to write, which everybody can teach.

(42-year-old Senior SN, 20 years of primary care experience)

Let’s say I want to refer the patient, I don’t think I can refer to a dietician. So, if we can refer, then I think that will be good. So far, the nurses don’t take on the role to refer. They will just refer to the doctor and let the doctor decide.

(65-year-old NC, 34 years of experience in primary care)

Overlapping and Competing Hypertension Services

The nurses highlighted there were 4 ongoing services that were overlapping and competing for hypertension care (namely Nurse Clinician service, Advanced Practice Nurse service, Telecare, and Primary Tech Enhanced Care [PTEC] for hypertension). This created confusion and ambiguity among the nurses on how to right-site patients to the appropriate service. Additionally, the nurses running these services were pressured to achieve the target number to sustain these services.

I feel that sometimes, because we have quite a number of competing services. A patient can be seen by a doctor, can be seen by the APN [Advance Practice nurse], can be seen by the nurse clinician service, can be on telecare, can be on PTEC [Primary Tech Enhanced Care]. So it is kind of confusing. The doctor doesn’t know, “OK, where should I right site this patient?” Too many programmes, I feel, so they are a bit confused.

(34-year-old Senior SN, 7 years of primary care experience)

For the nurse clinician service, referrals are a measurable KPI [Key Performance Indicator]. If let’s say I have siphoned off those patients that are willing to be on PTEC [Primary Tech Enhanced Care], we will only see them once a year. They are not going to be patients under Nurse Clinician Service (NCS) anymore and it will just be doctor and then PTEC [Primary Tech Enhanced Care] in between. In that case, the NCS referrals would drop. Then we’ll be in the reds.

(34-year-old Senior SN, 7 years of primary care experience)

Lack of Knowledge, Skills and Confidence

The lack of training on hypertension management affected some nurses’ confidence in delivering hypertension care. Although there were regular educational talks and trainings, few focused on hypertension care. As a result, nurses faced difficulty in answering device-specific and evidence-based questions asked by younger patients. Some junior nurses lacked ‘in-depth knowledge’ on pathophysiology and rationale of targets set, indicating a need for a more structured training programme, and regular upskilling to ensure consistent care delivery.

We don’t really have a specific training pertaining to hypertension. There’s a lot of updates on CVD and diabetes, but not so much for hypertension itself.

(59-year-old Senior SN, 21 years of primary care experience)

Sometimes, the patient they will ask you on things a bit complex. They will ask you, “How come I must get the cuff device? Can I get the wristwatch? Would it make a difference?” But it’s not within my knowledge, I’m not sure how accurate it (wrist BP device) is. There must be some differences so I can’t give my comment. So, one of the difficulties I face is this.

(42-year-old Senior SN, 20 years of primary care experience)

More training is needed. I am looking at it from an APN’s [Advanced Practice Nurse] perspective. We understand the doctor’s thinking, we understand why the target is like this. But as for the staff nurses, they don’t have this in-depth knowledge. What they know about hypertension counselling is like low salt, low sodium, BP monitoring and the target. That’s it. Why you do this? Why you start this? Why we target this? I don’t think they know the rationale of it.

(54-year-old APN, 18 years of primary care experience)

I think probably they (nurses) need some updating as well, like what are the guidelines. Because if PTEC [Primary Tech Enhanced Care] is the way moving forward I foresee that more and more people will know about it. So, when the patient comes and tell you, “oh, you know, I’m on this programme”, then you would be like, “but I don’t know what you’re talking about.” Then it doesn’t look good on us that we don’t know what the patient is talking about.

(34-year-old Senior SN, 7 years of primary care experience)

Lack of Patient-Recorded Home BP Readings

The lack of home-recorded BP readings from patients affected the nurses’ clinical decision making. Self-reported readings from patients were prone to errors and caused concerns regarding its accuracy.

(If the patients do not have home BP readings), then it’s a bit of guesswork. If we get a good reading at the health monitoring station, I will just dispense the medicine. But if it’s high, I recheck. Again high, then wait a while, recheck. Still high, then refer back to the doctor. Because if they have a record, that is the best, then it’s consistent.

(65-year-old NC, 34 years of experience in primary care)

Sometimes they (patients) use (the BP monitoring device), they check the readings. Then when you ask them, “where’s your record?”, “Oh, I never write. I just do only. Yeah, I know, first one 120 something, and second one, 100 over.” Sometimes we don’t know whether they are telling me the correct one or not.

(41-year-old Senior SN, 12 years of primary care experience)

From the nurses’ perspective, there were several reasons for the lack of home BP readings; the most common being the high cost of the home BP device. Some other reasons included: patients’ lack of awareness on how to use the home BP device, and the lack of a caregiver to assist with performing and recording the home BP readings, patients’ perception that the doctors did not consider the HBPM readings important, and when the BP readings were within normal range.

We do have patients who are very poor or they have a very bad relationship with their children. So, they don’t have any income. So, you ask them to buy a BP [blood pressure] machine, they will tell you, “It’s not cheap”.

(42-year-old Senior SN, 20 years of primary care experience)

They (elderly patients) say they don’t know how to put the cuff. They don’t know how to press the buttons, how to do the charting. Even though sometimes when you teach them, they kind of like forget. So, it’s more of like nobody to help them, like no caregiver.

(42-year-old Senior SN, 20 years of primary care experience)

Sometimes the patient can tell me “I monitored, but the doctor didn’t even look at it, so I didn’t monitor anymore”. But they (the doctor) documented, so they noted about it, but maybe to the patient it didn’t appear that you were looking at it.

(34-year-old Senior SN, 7 years of primary care experience)

They (patients) don’t see the benefits of self-monitoring when readings are within the normal range. Maybe I think they are also tired of it, after all, every time I monitor, it’s normal.

(65-year-old NC, 34 years of experience in primary care)

Discussion

This study identified the varied and complex roles played by nurses beyond their traditional tasks in the primary care setting. The challenges faced in delivering these roles was influenced by the existing health-system and individual-level factors. Health-system related factors included time and manpower constraint, difficulty in establishing continuity of care, unclear guidelines, inefficient workflows and overlapping or competing hypertension services. The individual-level challenges included lack of knowledge, skills and adequate training and the lack of home BP readings from patients. Expanding nursing roles and the coexistence of parallel services targeting same patient groups, complemented by resource constraints and policy innovations under Healthier SG, represents a novel insight into how system-level fragmentation can emerge even within an integrated national framework.

Traditionally, primary care nurses have been confined to conventional clinical roles such as triaging, administering vaccinations, acute and basic management for acute and chronic diseases.²⁶ With the increasing healthcare demands, their roles have expanded and upscaled through task-sharing, task-shifting or task-supplementation.²⁰ For instance, the introduction of Patient-Centered Medical Home (PCMH) in the United States of America (USA) redefined nurses’ roles to include participating in multidisciplinary team meetings, performing delegated nursing visits and providing telecare services.²⁷ Similarly in the United Kingdom (UK) the role of APN was stepped up to involve them in clinical decision making and independent prescribing to support the additional healthcare demand.²⁸ While nurses’ role expansion improved efficiency of care delivery and patient outcomes, it also raises concerns about increased workload. Consistent to our findings, a study conducted in the USA highlighted the burden the nurses faced in achieving target number of patients within their limited consultation time.²⁹ While task shifting and role expansion to other non-physician healthcare workers can help reduce this burden,³⁰ role ambiguity and inadequate training have caused workplace stress when nurses assumed physician-type duties.^29,31 The findings of our study reinforce established models of task-shifting and role clarity in primary care. The findings underscore that role ambiguity and inefficiency may be due to the concurrent implementation of multiple nurse-led programmes within a single system. Effective task-shifting not only includes role expansion; Clear role definitions and effective healthcare team communication are essential for nurses to perform these expanded roles effectively.³²

A recurring challenge faced by the nurses in this study was the lack of training to support them to perform their roles. Ongoing professional development is essential to equip them with the skills and knowledge required for complex case management, boost their confidence and strengthen professional identity.^33,34 This could include basic details on hypertension including pathophysiology, setting of clinical targets for hypertension control, diet and lifestyle counselling, and information on available hypertension services. The type of training they receive and their career paths will also influence their choice of specialisation.²² While primary care nurses are generalists providing holistic patient care through disease prevention, health promotion and disease management,³⁵ current training often steers them towards specialist expertise like gerontology, palliative care or as care manager for chronic disease management, enabling more targeted, in-depth care for specific patient populations.^36,37

This study also identified overlapping and competing hypertension services as a unique challenge. The growing number of new programmes and services in primary care, most of which are nurse-led, has created a complex healthcare landscape with potential duplication and fragmentation of services. Few global systems exhibit such concurrent implementation of several care models targeting hypertension within 1 primary care infrastructure, providing a rare opportunity to evaluate the impact of programmatic overlap on workforce efficiency. A systematic review assessing different nurse-led interventions in primary care highlighted the lack of adequate buy-in from healthcare providers and community as a key barrier to its implementation.³⁸ Most nurse-led services were introduced independently and without coordination, resulting in programmes with similar goals targeting same patient groups and unclear roles for healthcare providers. This confuses providers about service expertise and referral pathways, impeding optimal patient care. Streamlined clinical protocols, coordinated implementation and regular evaluations are needed to prevent duplication and ensure new services enhance, rather than complicate patient care.

The findings reinforce existing task-shifting and role-clarity frameworks by demonstrating that expanding nurses’ responsibilities for chronic disease management, without clear alignment at the system level, may introduce inefficiencies and increase uncertainty in care delivery.^32,39 Additionally, the importance of nurses’ ability to navigate cultural and language barriers provides novel insight into how cultural diversity shapes care continuity in primary care. For healthcare systems moving towards integrated or digital chronic care management, Singapore’s experience highlights that introducing multiple parallel nurse-led programmes without unified coordination can potentially increase system complexity and implementation challenges.

Limitations

The study has several limitations. Firstly, the interviews were conducted in 5 public primary care clinics, which may limit the transferability of the results to other healthcare settings, such as private clinics or hospitals, where the dynamics and challenges may differ. Additionally, the study only captured the perspectives of the primary care nurses regarding patient care and did not include the patients’ perspectives which may be different. The research team is currently conducting a study to explore challenges faced by hypertensive patients in primary care. Furthermore, social desirability bias and sampling bias may have been introduced due to the interviewer being a practicing clinician in one of the clinics, and the participants being purposively selected for the interviews. These were mitigated by the study team making conscious efforts to avoid recruiting nurses with close professional relationship to the interviewer and the interviewer constantly reflecting on his role throughout the study. During data analysis, 2 independent researchers reviewed the transcripts and had regular discussions to ensure balanced interpretation of the findings.

Conclusion

This study uncovered a pressing issue within the nursing profession when managing patients with chronic diseases such as hypertension, where the increasing demand for healthcare services has led to an expansion of nurses’ roles but, often, with resource constraints and inadequate training. Beyond documenting practical challenges, this study contributes novel insights on how the dynamics of overlapping nurse-led clinical services, coupled with a lack of clarifications regarding the nurses’ role in these services, has resulted in role ambiguity among the nurses. These results provide globally relevant lessons for health systems pursuing integrated nurse-led chronic care models, especially under policy reforms similar to ‘Healthier SG’. To address these systemic gaps, there is a need to map and streamline existing services, implement disease-specific care guidelines and provide targeted training to the nurses. Future research should focus on evaluating the integration of nurse-led services within health systems, optimal models for workforce planning, and suitable healthcare training interventions to support task-shifting and role expansion of allied health professionals. Future nurse-led or nurse-involved chronic care programmes should integrate these measures from the outset to ensure effective, coordinated and sustainable primary care delivery.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251400853 – Supplemental material for Nurses’ Challenges When Managing Patients with Hypertension in Primary Care: A Qualitative Study

Supplemental material, sj-docx-1-jpc-10.1177_21501319251400853 for Nurses’ Challenges When Managing Patients with Hypertension in Primary Care: A Qualitative Study by Swetha S Kumar, Raashidha Farveen binte Akbar Ali, Ling Ling Foo and Chirk Jenn Ng in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

The authors would like to thank the nurses who participated in this study.

List of abbreviations

IDI: In-depth interview

PC: Primary care clinic

EMR: Electronic medical record

HMS: Health monitoring station

BP: Blood pressure

HBPM: Home blood pressure monito

NC: Nurse clinician

APN: Advanced Practice Nurse

PTEC: Primary tech-enhanced care

ECG: Electrocardiogram

CVD: Cardiovascular disease

PCMH: Patient-Centered Medical Home

ORCID iD

Swetha S Kumar

Ethical Considerations

The study was approved by the SingHealth Centralised Institutional Review Board (CIRB reference no. 2022/2168). All research activities were carried out in accordance with relevant guidelines and regulations as set forth by the SingHealth Centralised Institutional Review Board. The objectives and the study processes were clearly explained to the participants and a participant information sheet with relevant study details were provided to them prior to their participation.

Consent to Participate

The participation was purely voluntary and written informed consent was obtained from each participant in alignment with the Declaration of Helsinki.

Consent for Publication

Not applicable.

Author Contributions

CJN conceived and developed the study protocol, conducted the interviews and supervised the study. SSK and RFAA checked the transcripts and analysed the data; CJN and LLF provided valuable inputs and helped in resolving discrepancies. SSK drafted the manuscript and revised it based on other authors’ feedback. CJN, LLF and RFAA critically reviewed the manuscript. All authors read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by the EmPaTHy Programme funds (14/FY2021/G2/01-A167) supported by the SingHealth AM General Fund, SingHealth Polyclinics, and Duke-NUS Medical School. The funds were utilised to support all research activities; however, the funding bodies had no influence on the design of the study, data collection, analysis or interpretation of the data or on writing the manuscript. This research is also supported by the National Medical Research Council (NMRC) through the SingHealth PULSES II Centre Grant (CG21APR1013).

Declaration of Conflicting Interests

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

Data Availability Statement

All data generated or analysed during this study are not publicly available due to participant confidentiality.

Clinical Trial Registration

Not applicable.

Supplemental Material

Supplemental material for this article is available online.

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