Collaboration between advanced practice nurses and general practitioners in rural France

Abstract

Objective  The objective of this study was to explore the perceptions of general practitioners and advanced practice nurses working in primary healthcare, as well as the barriers and facilitators to effective inter professional collaboration in rural zones.

Methods  Qualitative, descriptive and exploratory study, conducted through semi-directed interviews with 14 advanced practice nurses and general practitioners carried out between January and March 2025 through individual semi-structured interviews held via Zoom. Data analysis was conducted by the researcher using inductive thematic content analysis. The Atlas.ti© software was used for manual coding and analysis support.

Results  The analysis revealed three main themes: a) the importance of access to care in rural areas and the obstacles encountered; b) the conditions for the establishment of advanced practice nurses; and c) the perception of professionals questioned on their interprofessional collaboration.

Conclusion  This study explores the conditions for collaboration between advanced practice nurses and general practitioners in rural areas and highlights the difficulties encountered. It appears to be a promising response to inequalities in access to care.

Keywords:
Advanced practice nursing; General practitioners; Primary health care; Quality improvement; Rural zone

Resumo

Objetivo  O objetivo deste estudo foi explorar as percepções de médicos de clínica geral e enfermeiros de prática avançada que atuam na atenção primária à saúde, bem como as barreiras e facilitadores para uma colaboração interprofissional eficaz em zonas rurais.

Métodos  Estudo qualitativo, descritivo e exploratório, realizado por meio de entrevistas semidirecionadas com 14 enfermeiros de prática avançada e médicos generalistas, realizadas entre janeiro e março de 2025, por meio de entrevistas individuais semiestruturadas realizadas via Zoom. A análise dos dados foi realizada pelo pesquisador, utilizando análise de conteúdo temática indutiva. O software Atlas.ti© foi utilizado para codificação manual e suporte à análise.

Resultados  A análise revelou três temas principais: a) a importância do acesso aos cuidados nas áreas rurais e os obstáculos encontrados; b) as condições para o estabelecimento de enfermeiros de prática avançada; e c) a percepção dos profissionais questionados sobre sua colaboração interprofissional.

Conclusão  Este estudo explora as condições para a colaboração entre enfermeiros de prática avançada e médicos de clínica geral em áreas rurais e destaca as dificuldades encontradas. Parece ser uma resposta promissora às desigualdades no acesso aos cuidados de saúde.

Descritores
Prática avançada de enfermagem; Clínicos gerais; Atencão primária à saúde; Melhoria de qualidade; Zona rural

Resumen

Objetivo  El objetivo de este estudio fue explorar las percepciones de los médicos generales y los profesionales de enfermería de práctica avanzada que trabajan en la atención primaria de salud, así como las barreras y los facilitadores para una colaboración interprofesional eficaz en las zonas rurales.

Métodos  Estudio cualitativo, descriptivo y exploratorio, realizado mediante entrevistas individuales semiestructuradas a 14 profesionales de enfermería de práctica avanzada y médicos generales entre enero y marzo de 2025 realizadas por Zoom. El análisis de los datos fue realizado por el investigador mediante un análisis inductivo del contenido temático. Se utilizó el software Atlas.ti© para la codificación manual y el apoyo al análisis.

Resultados  El análisis reveló tres temas principales: a) la importancia del acceso a la atención de salud en las zonas rurales y los obstáculos encontrados; b) las condiciones para el establecimiento de profesionales de enfermería de práctica avanzada; y c) la percepción de los profesionales encuestados sobre su colaboración interprofesional.

Conclusión  Este estudio explora las condiciones para la colaboración entre profesionales de enfermería de práctica avanzada y médicos generales en zonas rurales y destaca las dificultades encontradas. Parece ser una respuesta prometedora a las desigualdades en el acceso a la atención de salud.

Descriptores
Enfermería de práctica avanzada; Médicos generales; Atención primaria de salud; Mejoramiento de la calidad; Medio rurals

Résumé

Objectif  L’objectif de cette étude était d’explorer les perceptions des médecins généralistes et des infirmiers en praticiens avancés travaillant dans les soins de santé primaires, ainsi que les obstacles et les facilitateurs d’une collaboration interprofessionnelle efficace dans les zones rurales.

Méthodes  Étude qualitative, descriptive et exploratoire, réalisée à l’aide d’entretiens semi-dirigés avec 14 infirmiers en pratique avancée et médecins généralistes, menés entre janvier et mars 2025, au moyen d’entretiens individuels semi-structurés réalisés via Zoom. L’analyse des données a été effectuée par le chercheur, à l’aide d’une analyse de contenu thématique inductive. Le logiciel Atlas.ti© a été utilisé pour le codage manuel et l’aide à l’analyse.

Résultats  L’analyse a révélé trois thèmes principaux : a) l’importance de l’accès aux soins dans les zones rurales et les obstacles rencontrés ; b) les conditions pour l’établissement d’IPA ; et c) la perception des professionnels interrogés sur leur collaboration interprofessionnelle.

Conclusion  Cette étude explore les conditions de la collaboration entre les infirmiers de pratique avancée et les médecins généralistes dans les zones rurales et met en évidence les difficultés rencontrées. Elle semble constituer une réponse prometteuse aux inégalités en matière d’accès aux soins de santé.

Descripteurs:
Pratiques infirmières avancées; Médecins généralistes; Soins de santé primaires; Amélioration de la qualité; Milieu rural

Introduction

The term “diagonale du vide” (diagonal of emptiness) was coined in 1986 to describe an axis stretching across metropolitan France from the southwest to the northeast.(¹) This vast area exhibits an exceptionally low population density, where rural exodus and an aging population have led to socio-economic and political imbalances, threatening the stability of these regions.(²)

The French National Institute of Statistics and Economic Studies (Insee) classifies municipalities into seven categories based on population density and distribution, ranging from major urban centers (levels 1) to extremely sparse rural zones (level 7).(³) According to this classification, over 88% of French municipalities are considered rural (zone 5 to 7), housing approximately 33% of the population—21.9 million people.(⁴)

These rural communities, often socio-economically vulnerable, face significant challenges in healthcare access. The scarcity of medical professionals, lack of infrastructure, and vast geographical distances contribute to the emergence of medical deserts.(⁵)

According to Chambaud, healthcare access relies on three key dimensions: physical accessibility, financial accessibility, and acceptability.(⁶)

Physical accessibility depends largely on the availability of healthcare providers. The 2025 report by the French Council of the Order of Physicians (CFOM) indicates that 67 French departments have seen a decline in active general practitioners (GPs). In the “diagonale du vide,” some areas have lost up to 34% of their GPs over 15 years, with further declines expected due to retirements. Geographic distance remains a major barrier, particularly for accessing specialists.

Financial accessibility refers to individuals’ ability to afford care without economic hardship, encompassing both direct costs (consultation fees) and indirect expenses (transportation, extra billing). Finally, acceptability relates to patients’ willingness to seek care, influenced by socio-cultural factors (beliefs, gender, age) or organizational barriers (e.g., clinic hours incompatible with agricultural work). These obstacles persist even when financial and geographic access are secured.(⁶)

Faced with these persistent inequalities, the French healthcare system has gradually strengthened primary care.(⁷,⁸) The 1990s established GPs as the cornerstone of the system,(⁹) followed by the 2002 Kouchner Law, which reinforced patient rights and interprofessional coordination without fully reforming primary care. In 2009, the “Hôspital, Patient, Santé et Territoire” (HPST) reform promoted the development of multidisciplinary primary care structures to localize care delivery. In 2018, the “Ma Santé 2022” plan further emphasized improving community-based care.(¹⁰) These reforms address critical challenges: reducing hospital overcrowding, supporting an aging population, replenishing the medical workforce, and ensuring quality primary care, particularly in rural areas.

Finally, in 2023, an ambitious action plan was launched to enhance healthcare access in underserved regions. Key measures included: recruiting 10,000 medical assistants to optimize physicians’ time; deploying 100 mobile medical units (médicobus) to provide itinerant care; creating 4,000 new PHC structures. This initiative also relied on expanding the role of Advanced Practice Nurses (APNs).(¹¹)

Advanced practice nursing was first proposed in France in 2003 by the Berland Report(¹²), but was only formalized in 2016 under the Touraine Law, implemented in 2018.(¹³) This innovation responded to growing healthcare shortages in underserved areas, introducing a new actor in the care pathway and necessitating a reconfiguration of professional collaborations, particularly with GPs.

In this context, interprofessional collaboration (IPC) between APNs and GPs emerges as a strategic lever to address rural healthcare challenges. Derived from the Latin “cum laborare” (to work together), IPC—as defined by Canadian theorist Danièle d’Amour—involves relationships and interactions where professionals share knowledge and expertise for patient benefit.(¹⁴)

The 2018 French decree (n°2018-629) defines IPC as cooperation based on effective communication, mutual trust, and recognition of respective competencies, with APNs contributing their expertise within care pathways coordinated by the treating physician. This holistic approach aims to streamline transitions between different levels of care.(¹⁵)

This study focuses on interprofessional collaboration between Advanced Practice Nurses and General Practitioners in rural settings. Although legally established for several years, this collaboration and its impact on primary care quality in rural areas remain understudied. It was therefore essential to understand how these professionals perceive their collaboration, leading to our research question: what are the perceptions of GPs and APNs practicing in rural areas regarding their interprofessional collaboration in primary healthcare?

The objective of the study was to explore the perceptions of General Practitioners and Advanced Practice Nurses working in primary healthcare, as well as the barriers and facilitators to effective interprofessional collaboration in rural zones.

Methods

This qualitative study adopts a descriptive and exploratory approach to conduct an in-depth analysis of healthcare professionals’ perceptions, thereby enriching understanding of the subject.(¹⁶)

The sample consisted of APN-GP dyads working in interprofessional collaboration within the geographical area known as the diagonale du vide. Recruitment of APNs was based on listings from the French Nursing Council, the Ameli.fr website, and the professional social network LinkedIn®.

Inclusion criteria for APNs were: 1) practicing within a multidisciplinary primary care structure; 2) located in areas of the “diagonale du vide” classified as levels 5, 6, or 7 according to Insee’s municipal density grid.

Forty-two APNs meeting these criteria were identified. Non-confirmation of participation served as the sole exclusion criterion.

A purposive maximum variation sampling strategy was employed to select APNs distributed across different regions and departments of the “diagonale du vide.” After initial contact, 14 consented to participate in the study. GPs were recruited using snowball sampling(¹⁶), with the only exclusion criterion being refusal to participate by one member of the dyad.

The final sample comprised seven APN-GP dyads distributed across the six target regions, ensuring geographical diversity. Fourteen interviews were conducted, with 13 retained for analysis. One dyad was excluded due to non-response from the GP, despite the APN having been interviewed. Additionally, two GPs working with the same APN chose to participate. As this configuration did not conflict with inclusion criteria, their interviews were included.

Data collection was conducted by the principal researcher (an APN student) between January and March 2025 through individual semi-structured interviews held via Zoom, according to participant preference. Interviews lasted 7 to 45 minutes (average 27 minutes).

Each interview was fully transcribed and pseudonymized. To maintain fidelity and preserve the spontaneity of responses, transcripts were not returned to participants for validation. Audio recordings were deleted after transcription.

Data analysis was conducted by the researcher using inductive thematic content analysis. The Atlas.ti© software was used for manual coding and analysis support. Transcripts were additionally reviewed by an independent researcher to provide cross-validation and strengthen result validity. Both researchers agreed that thematic saturation had been reached.

The researchers declared no conflicts of interest. Having no prior acquaintance with participants and no personal, professional, or financial ties with them, the researcher ensured neutrality and integrity in the analysis.

This study did not include patient participation and, in accordance with French health research ethical guidelines, did not require approval from an ethics committee. However, a declaration of compliance with reference methodology MR004 was filed with the French Data Protection Authority (CNIL).

Results

Among the thirteen participants, a female majority was observed in both professions: 86% of GPs and 83% of APNs. Age ranged from 30 to 70 years, with a median of 45 years.

Participating GPs reported professional experience ranging from 2 to 45 years (average 19.7). APNs had practiced in advanced roles for 6 months to 5 years, but all came with significant nursing experience (average 21.6 years), demonstrating substantial expertise in both professions. The shorter APN experience reflects the novelty of this role in France.

Thematic analysis of the 13 interviews identified meaningful units grouped into nine sub-themes organized around three main themes that name the subsections of this section.

Health professionals in rural settings: between personal and professional motivations

Most interviews revealed that the decision to practice in a rural area was rooted in personal motivations, such as attachment to rural life, a search for better quality of life, or the desire to be closer to family. In this context, professional choices were often aligned with a broader personal life project.

Some participants reported being from the region and wanting to remain there, while others described returning to rural life after an unsatisfactory urban experience:

“My husband is a farmer, so it was much easier for me.” (M10)

“It was more of a life choice… we were surrounded by concrete; I felt better in the countryside. For family reasons, we needed to be closer to relatives” (I11)

Another key factor was the desire to be useful and meet local health needs. Several participants chose their location specifically to address a shortage in healthcare services:

“One of the doctors was about to retire... I took over their patients.” (M3)

“Given the difficulty accessing care, with almost no doctors left, I thought: an APN really has a role to play here.” (I7)

Motivations were also occasionally linked to professional opportunities, environmental or personal concerns, or the appeal of a more varied practice:

“I like the more versatile aspect... It’s challenging. I like managing trauma, doing sutures, working with firefighters on interventions... I also have ecological concerns.” (M4)

Access to care in rural areas: between medical, geographic, and socio-economic constraints

Interviews revealed that access to healthcare remains a daily challenge in rural areas - for both patients and professionals. One key barrier was the geographical distance from healthcare facilities:

“You have to drive miles to see a doctor, which is kind of expected, given that these are sparsely populated areas spread over large distances.” (M14)

“Patients are forced to go to another town managed by the health center, which is easily 20, 30, 40 minutes away... and it’s an older population” (I5)

This is compounded by a shortage of healthcare professionals, particularly GPs and specialists. Medical desertification was widely reported as a long-standing reality:

“When it comes to primary care doctors, it’s dire.” (I11)

“We have a real issue with medical density—it’s dropping year after year.” (M8)

Logistical issues, such as lack of internet in some areas, further complicate alternatives like telemonitoring.

The limited healthcare offer exists within a vulnerable social context: aging, precarious, and often isolated populations:

“Some people don’t have a car... they’re impoverished and elderly.” (I7)

“They have a relatively low level of health literacy. We face high levels of socioeconomic vulnerability—three-quarters of our patients are precarious.” (M1)

In this context, Healthcare professionals adapt their daily practices to meet local needs:

“I continue home visits for isolated patients.” (I2)

Despite these challenges, some territories benefit from local initiatives that mitigate barriers to care. These include mobile programs offering screening and chronic disease monitoring:

“DIABSAT is a van with a retinal camera for primary health care centers, or DHALIA, for unscheduled care—thanks to a local initiative.” (I11)

“The medical bus goes from place to place but doesn’t replace a doctor.” (M3)

Some participants also mentioned exceptional areas with better access to specialists, but these cases were rare.

Overall, the interviews reflect strong adaptability and commitment in the face of a challenging environment. While participants expressed frustration and exhaustion due to limited resources and excessive workload, they remained committed to care continuity:

“Even if there’s no doctor, we try to ensure patient care.” (I6)

“People keep living here, despite the difficulties.” (M14)

Implementation and interprofessional collaboration

Participants’ perceptions of the early stages of professional collaboration revealed notable differences. Physicians mainly described the circumstances that led to collaboration, while APNs emphasized the difficulties they faced establishing themselves. This gap highlights the complex integration of APNs into primary care.

The main issues were not logistical—financial support for setup was often available—but relational. APNs had to navigate partial acceptance by physicians, lack of understanding of their role, and limitations on their prescribing rights, which hindered their clinical autonomy. This required ongoing organizational adjustments and efforts to carve out a place within the care team.

Misunderstanding of the APN role by other healthcare professionals remained a major obstacle:

“I think resistance from some professionals stems mainly from a lack of understanding.” (I7)

“This profession emerged without much explanation.” (M10)

This confusion also led to mistrust and resistance from patients, particularly during early encounters:

“You’re not allowed to, but what are you allowed to do, then? What am I supposed to tell the patient?” (I7)

“ …at first, some didn’t take it well... there was a lot of resistance.” (M14)

In one isolated case, resistance stemmed from cultural biases linked to the perceived ethnicity of the APN, rather than their skills or role.

Mistrust also extended to some physicians, further hampering collaboration:

“Doctors think APNs will take their jobs, instead of seeing them as complementary.” (I12)

“Doctors weren’t really informed about our profession—they’re hesitant.” (I2)

In some cases, this led to outright refusal to collaborate with APNs:

“...she couldn’t find any physician willing to work with her.” (M10)

“I had a young doctor who was enthusiastic, but his colleague said: ‘There’s no way a nurse touches my prescriptions... there’s no way I’ll work with an APN.’” (I7)

APNs reported taking 6 months to a year to become established—a particularly trying period. In some cases, their activity remained limited after this period, requiring sustained effort to build a patient base.

Despite these barriers, some GPs described successful collaborations with APNs. They viewed the role as a valuable way to improve access to local care and patient-centered management. Some chose to ignore peers’ negative views and form their own opinions:

“But you need pioneers to change mindsets. I’m very satisfied with the APN’s work and our collaboration.” (M8)

“She reached out... I was quite enthusiastic about the idea.” (M14)

From the patients’ perspective, once the role was understood and trust established, acceptance was strong—some even preferred follow-up with the APN:

“Some, once they’ve had a taste of it, can’t do without it—they barely come to see me anymore.” (M14)

APNs emphasized the importance of outreach to local professionals (pharmacists, nurses, physiotherapists, etc.) to present their role and initiate collaboration—an essential step in their integration.

Participants described successful interprofessional collaboration as relying primarily on trust, communication, mutual respect, and recognition of each other’s roles:

“I delegate a lot because I fully trust the APN... she knows her limits... if she’s not around, I don’t work as well.” (M1)

APNs showed a willingness to adapt their organization, adjusting tasks to avoid duplication, preserve professional balance, and foster collaboration for better care pathways.

Beyond these relational barriers, some APNs noted the negative impact of isolated or poorly adapted practices by other APNs, which tarnished the reputation of the role:

“Some... unfortunately gave APNs a bad name—they didn’t want to take on complex patients.” (I11)

Difficulties also arose with other professionals (radiologists, pharmacists) refusing to recognize APN prescriptions, forcing them to seek validation:

“...radiology prescriptions were refused, so I had to go back to the doctor... one or two pharmacies also refused, but after I sent the decree, my renewals were accepted.” (I2)

“...the pharmacy refused to accept the APN’s prescription.” (I11)

Finally, beyond relational issues, regulatory restrictions on prescribing were perceived as major obstacles. The inability to prescribe certain essential acts (e.g., podiatry for diabetics, nursing assessments, transport authorizations) required APNs to regularly consult physicians and disrupted care continuity.

Discussion

This study aimed to explore the perceptions of general practitioners and advanced practice nurses working in rural areas regarding their interprofessional collaboration in primary care. By combining the views of both groups, it highlights the gradual integration of APNs.

Despite the legal recognition of the profession since 2018, APNs still report difficulties in establishing themselves within the primary care landscape. While their role is clearly defined in legal texts, it remains vague in day-to-day practice, leading to mistrust, confusion, and resistance. This lack of awareness—among both doctors and patients—hampers smooth collaboration.(¹⁷) Yet, the APN role is already well integrated in other countries such as the US, Canada, Australia, and China.(¹⁸) In France, their legitimacy is still under construction.

The results show that the choice to practice in rural areas often stems from both personal and professional motivations.(¹⁹) The frequently expressed desire to feel useful highlights a strong social commitment: addressing a need, filling a gap, ensuring a healthcare presence. This stance is often accompanied by a desire for autonomy in work organization, perceived as more attainable in rural settings. Far from being seen solely as a constraint, rurality is experienced here as an opportunity.(²⁰, ²¹)

The analysis confirmed the persistence of structural barriers to healthcare access in rural areas—particularly in the so-called “diagonal of emptiness”—which combines geographic, medical, technological, and socio-economic challenges that are well documented but remain pressing.(²²)The decline in the number of GPs and specialists threatens vulnerable populations and increases pressure on remaining caregivers, who face isolation and growing workloads.(²³, ²⁴)

Mobile health initiatives have been launched to improve access. While they address real territorial inequalities, their deployment is limited by a shortage of professionals to operate them. Other countries have implemented innovative solutions: in Brazil, floating health units deliver care along the Amazon; in the US, over 2,000 mobile clinics serve rural populations with proven results.(²⁵,²⁶) These examples show that context-appropriate access to care is possible.

In this context, the presence of APNs in primary care appears as a promising complementary solution. Some GPs see it as a pragmatic response to physician shortages.

The results show that the barriers and enablers to APN integration are closely tied to those affecting interprofessional collaboration: role awareness, medical acceptance, local care organization, and interpersonal relationships all influence collaboration quality.(²⁷)

When such collaboration does occur, it proves a powerful lever for improving care pathways. Three key elements emerge: role recognition, effective communication, and mutual trust.(²⁰) These factors develop over time rather than spontaneously. This dynamic improves access to care, reduces emergency visits, and boosts caregiver satisfaction.(²⁸)

However, regulatory limitations around prescribing remain a major hurdle. The APNs interviewed described the inconsistency between their clinical responsibilities and their restricted authority. The inability to prescribe certain services (nursing assessments, podiatry, transport forms, etc.) hampers care fluidity and undermines their legitimacy.

Two legislative developments during the study period have strengthened their role: Decree no. 2025-55 of January 20, 2025, grants direct access to APNs, and the Order of April 25, 2025, expands their prescribing rights.(²⁹,³⁰) These are significant steps toward enabling APNs to work more autonomously and complement GPs for improved care quality.

Conclusion

This study explored the dynamics of collaboration between advanced practice nurses and general practitioners in rural areas. In a context of physician shortages and territorial inequalities, it highlighted the potential of such collaboration to improve patient care, strengthen local health service provision, and relieve the burden on GPs. However, this complementarity could only unfold under certain conditions: recognition of competencies, mutual trust, smooth communication, and territorial anchoring. APN integration thus occurred through both practical fieldwork and regulatory evolution. Further research is needed to explore patients’ perspectives and the effects of recent reforms.

Aknowledgments

The research received not external funding. The authors wish to thank our colleagues from the DUSI for their constructive feedback and support.

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  » https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000051533034

• Data availability:
  The authors did not make the data from this article available in repositories prior to submission.

Edited by

• Associate guest editor:
  Marcia Barbieri (https://orcid.org/0000-0002-4662-1983) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Data availability

The authors did not make the data from this article available in repositories prior to submission.

Publication Dates

• Publication in this collection
  23 Jan 2026
• Date of issue
  2025

History

• Received
  25 Mar 2025
• Accepted
  8 Sept 2025