A successful model of nurse-practitioner (NP) and physician comanagement in primary care includes effective communication, mutual respect and trust, and clinical alignment, also known as a shared philosophy of care, according to a study published in the Annals of Family Medicine.

Allison A. Norful, RN, PhD, ANP-BC, from the Columbia University School of Nursing in New York City, and colleagues conducted a literature search to propose a model of nurse practitioner–physician comanagement, as NPs are increasingly managing patient care as independent clinicians. A total of 156 studies were reviewed, and information was extracted about NP–physician comanagement antecedents, relationships, defining attributes, and consequences. The researchers conducted 26 in-person qualitative interviews with NPs and physicians to obtain their perspectives on NP–physician comanagement, including the willingness of primary care professionals to comanage care, descriptions of the dimensions of comanagement, and how NP–physician comanagement affects patient care.

In evaluating the quality of comanagement, the researchers obtained information about comanagement structure, which involves the organizational and clinician resources or policies that needed to be in place for NPs and physicians to comanage the same primary care patient. Next, they evaluated process, or how comanagement was being practiced, what interactions were necessary, and the interprofessional relationships between NPs and physicians. Furthermore, they evaluated outcomes, which included the results of their systematic review and the reported perspectives of the primary care professionals in the qualitative study.

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The researchers found that the 3 vital attributes of NP–physician comanagement are effective communication, mutual respect and trust, and clinical alignment.

Comanagement communication is essential for developing the patient care plan, managing a change in patient health status, individualizing patient goals, and delegating each primary care clinician’s role in the care plan as part of coordinating patient care, according to the authors. Comanagement communication must be performed in a timely manner that is dependent on the patient needs, such as a change in patient acuity level. Communication needs to be reciprocal with equal sharing of ideas, new patient information, and feedback necessary to improve quality of care.

Respect and trust will increase over time as physicians and NPs work together longer, as the development of reciprocal trust and respect of each other’s role in care delivery can take up to 6 months. By gaining trust, physicians are less likely to feel that they need to supervise or “double-check” the work of the NP, thereby reducing redundancy of documentation and diagnostic testing. The physician must have an understanding of the education, training, and scope of practice for NPs to build trust during allocation of tasks and responsibilities, the authors noted. The optimal combination of NPs’ and physicians’ knowledge, culture, and disciplines has the potential to positively contribute to the quality of patient care.

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Physicians and NPs who were interviewed agreed that each primary care professional must have complementary practice styles that are congruent to mutual goals for patient care, such as a shared philosophy or having a clinical alignment in their patient care plan. This shared philosophy includes approaches to care management. Variability of approaches may challenge nurse practitioner–physician comanagement.

“The 3 vital attributes from our nurse practitioner–physician comanagement model—effective communication, mutual respect and trust, and a shared philosophy of care—cannot exist without the presence of legal and organizational policies that recognize nurse practitioners as autonomous primary care clinicians,” the authors concluded. “Further, effective nurse practitioner–physician comanagement requires adequate organizational resources and the willingness of nurse practitioners and physicians to comanage.”


Norful AA, de Jacq K, Carlino R, Poghosyan L. Nurse practitioner–physician comanagement: A theoretical model to alleviate primary care strain. Ann Fam Med. 2018;16:250-256. doi: 10.1370/afm.2230