1.0 Introduction

[Table of Contents]

1.1 Overview and Purpose

In March, 1999 the federal/provincial/territorial Advisory Committee on Health Human Resources (ACHHR) Working Group on Nursing and Unregulated Workers called for proposals to evaluate nursing practice models in different primary health care settings (i.e., rural, remote and urban) in Canada. The focus of this evaluation was restricted to registered nurses delivering primary care services (i.e., assessment, diagnosis, and treatment of episodic, acute and chronic illness, and minor injury) in variant settings. The purpose of the current project was to identify key aspects of primary health care settings that facilitate or impede the effective delivery of primary care services by registered nurses working in the extended/expanded role. A second purpose was to recommend policy options that would facilitate more effective use of registered nurses working in these roles.

The research process in the current study was guided by the legislative, regulatory, policy, and organizational frameworks of each provincial/territorial jurisdiction. The following document is a synopsis of the research undertaken, major study findings and resulting policy recommendations. Throughout the report, the term extended/expanded nursing role denotes primary care practice by a registered nurse which includes the assessment, diagnosis, and treatment of acute, episodic and chronic illness, and minor injury. The report on the research project will focus on the following key areas:

• commonalities and differences of extended/expanded nursing practice in primary health care settings in Canadian jurisdictions;
• barriers to and facilitators of effective utilization of registered nurses with extended/expanded practice preparation in primary health care settings; and
• future directions for extended/expanded nursing practice in primary health care.

This report is also augmented by the following supporting documents (SD):

• SD1 Profile of Extended/Expanded Nursing Practice in Primary Health Care Settings,
• SD2 Research Protocol for on-site data collection,
• SD3 Results of on-site data collection, and
• SD4 Dissemination plan.

1.2 Rationale

The full implementation of extended/expanded roles by registered nurses remains unrealized despite consistent empirical support for the positive impact on the accessibility, availability and comprehensiveness of health care services, consumer acceptance of and satisfaction with this nursing role, cost containment, and positive health outcomes. Since the early 1990s, the interest of governments and organizations in the extended/expanded nursing role has been inconsistent and reflective of differing agendas. Historically, in remote areas of Canada, registered nurses with advanced preparation have provided a full range of primary health care services, including primary care functions normally limited to general or family physicians. While the delivery of primary care services by nurses in remote regions is acceptable to both the public and physicians, the same can not be said for rural and urban areas where the use of nurses for this purpose has waxed and waned in response to the supply of and the demand for family physicians.

In recent years governments across Canada have become increasingly interested in using registered nurses in an extended/expanding role. This renewed momentum is due to a number of factors, including reduced funding allocations throughout the health care system, restrictions placed on admissions to medical schools, and the looming shortage of nursing and other professional resources. These pressures coupled with the increased demand for primary care services, especially in rural and remote regions, have led provincial/territorial governments to re-evaluate how to best utilize all health care providers within their jurisdictions. One popular response has been to focus on greater use of registered nurses with advanced preparation to provide a broader range of primary care services.

In response to the increased demand for extended/expanded nursing practice, there has been a proliferation of organizational structures, roles, competencies, regulatory regimes, educational programs, and titles. There are a number of problems that accompany this disparate mix. Most important among these are public and professional confusion over what is entailed in an extended/expanded nursing role, and the absence of national standards for core competencies that can be applied equally across all jurisdictions regardless of the setting (i.e., remote, rural or urban).

1.3 Background - Nursing

In Canada, issues concerning the definition, role and functions of registered nurses engaged in extended/expanded practice are being raised at the national, provincial and regional levels. The titles of nurse practitioner, extended class and expanded practice are reflective of common terms used to refer to registered nurses working in primary health care settings and performing primary care functions outside the traditional scope of nursing practice. The nursing profession is struggling to define the boundaries/parameters of its practice while ensuring that its members are providing quality care supported by sound research. An integral component of this process is to develop a national co-ordinated approach to advanced nursing practice that accommodates provincial and territorial variations. There is also a general desire by the nursing profession to ensure that its members receive recognition for and legitimization of the full scope of nursing roles and functions.

Clinical and research data support the positive effects (e.g., increased availability of health services, achievement of health outcomes equal to or superior to physicians, decreased impact on physician workload, increased patient satisfaction, etc.) of extended/expanded nursing practice (Brown & Grimes, 1995; Chambers & West, 1978; Spitzer et al., 1974, Feldman, Ventura & Crosby, 1987; Reveley, 1998). What is less clear is how the environmental context facilitates the utilization of registered nurses in extended/expanded roles. Several studies have investigated the influence of clinical settings on extended/expanded nursing practice and, to a lesser extent, the job expectations and satisfaction of registered nurses. The most consistent barriers to and facilitators of role development and performance identified from the research literature were:

• resistance/acceptance by other health care providers, especially physicians (Crosby, Ventura & Feldman, 1987; Hupcey, 1993; Reveley, 1998),
• efforts expended by the organization/agency to formalize the role (Crosby et al., 1987; Hupcey, 1993; Reveley, 1998), and
• legal/legitimate status of the role (Reveley, 1998; Torn & McNichol, 1998).

The scope of patient care activities, degree of autonomous and independent practice, sense of achievement/accomplishment, and funding models are additional aspects of the practice setting that influence role performance and job satisfaction (Chambers, 1978; Hupcey, 1993; Koelbel, Fuller & Misener, 1991; Manga, 1992; Torn & McNichol, 1998; Tri, 1991).

The current study was undertaken at a time when there is a lack of consensus on what constitutes extended/expanded nursing practice in primary health care settings, as well as provincial/territorial variations in the degree to which these roles are legitimized through legislation. Furthermore, within the Canadian health care system, a number of extended/expanded nursing roles have evolved and are being implemented in different ways and guided by variant regulatory mechanisms. The provision of quality care can be quite a challenge for any health care system, especially one operating under severe cost restraints. Given the current pervasive restructuring and reform initiatives in the health care sector, there is an increased urgency to document key facilitators of and barriers to full implementation of extended/expanded nursing practice in remote, rural and urban settings across Canada. By identifying the most significant barriers and most helpful facilitators, efforts can be undertaken to remove problem areas and build on existing strengths. This approach is needed to ensure maximum utilization of the extended/expanded nursing role in all primary health care settings.

1.4 The Public Policy Context - Policy Objectives and Extended/Expanded Nursing Roles

Public policy refers to decisions or directions undertaken by government to maximize public benefits and protect the public interest. Associated with these decisions is the allocation of resources to support implementation of policy objectives. The division of powers within the Canadian constitution vests legal powers in either the federal or provincial/territorial governments. Jurisdiction over health care and the regulation of professions rest with the provincial/territorial governments. The federal government is involved in health care management through the exercise of the federal spending power as evidenced by the Canada Health Act. Provision of health services through the Medical Service Branch (MSB) of Health Canada emanates from federal jurisdiction over first nation people as determined in the British North America Act.

The authority to establish professional standards and regulate entry to practice is delegated to professional groups through legislation, such as nursing and medical acts. The delegation of legislative authorities is a complex arrangement. While legislation creates rights for a professional group, the powers delegated must be used in accordance with the laws of Canada and the relevant province/territory. As with other self-regulating professions, the role of nursing associations include:

• the establishment and enforcement of standards of practice;
• control of entry into the practice of nursing; and
• a mandate to ensure that nursing practice within the relevant jurisdiction is carried out consistently and safely.

The interface between professional groups and the health care system is multi-faceted. The boundaries of a profession's practice domain is defined within its "scope of practice" guidelines. Of significance to the extended/expanded nursing role are the "scopes of practice" of physicians, registered nurses and pharmacists. The primary care functions included within the extended/expanded nursing role which are of interest in the current study are those functions which have been delegated through legislation to physicians and/or pharmacists. If registered nurses are to perform functions that are within the scope of practice of another profession, authority to do so must be secured from the relevant regulatory body or specific legislation enacted to include them within nursing's scope of practice.

Certain functions may also be shared by nursing with medicine and/or pharmacy. Traditionally shared jurisdictions have been undertaken through protocol arrangements negotiated between the regulatory bodies of nursing, medicine, pharmacy, government, and/or individual employers. Protocol arrangements do not transfer the authority to perform shared functions to all registered nurses but rather restricts these functions to those who have been appropriately trained to undertake them. The important question is what are the most appropriate strategies for providing nurses with the authority and resources to undertake the functions of the extended/expanded role. This is a relevant public policy consideration for all governments, professional associations and the public.

1.5 Health Care Reform and the Extended/Expanded Role of the Registered Nurse

Canada's health care system is being challenged on two fronts: 1) both the underlying fundamental assumptions of our publically funded system and, 2) sustaining the system itself. All levels of government have been promoting a policy direction that recognizes the broadness of the health concept and the need to balance institutional care with illness prevention and early intervention strategies focussed on maintaining wellness. In recent years, the health care agendas of all governments have been focussed on examining ways and means to effectively utilize human resources, especially nursing and physician resources.

There is a growing interest in increasing the use of extended/expanded nursing roles in the future health care system, especially in delivering primary care services. This policy direction is supported by several key initiatives:

• The health care reform initiatives of the federal, provincial, and territorial governments, including demonstration projects funded under the Health Transition Fund with nurses working in extended/expanded practice roles and this study, suggest there is interest in maximizing the utilization of registered nurses in the delivery of primary care services.
• Support for the extended/expanded nursing role exists in the legislation of four Canadian jurisdictions. Although this trend across the country suggests that there is a fair degree of commitment to this role, it could be argued it is taking place without a well-defined national strategy.
• One of the current efforts of the Canadian Nurses Association, through the CNA/Provincial /Territorial Working Group on Scope of Practice, is focussed on generating a framework of common elements to guide the development and implementation of legislation. In addition, considerable emphasis has been placed on developing parameters that address minimal educational standards and core competencies for registered nurses who undertake the extended/expanded role. The work of this Committee is directed toward realizing consistent standards for extended/expanded nursing practice.
• In September 2000, the First Ministers agreed to make primary health care reform a high priority. There was consensus to promote further expansion of the primary health care teams which provide Canadians with the first point of contact with the health care system. Reaffirmation was given by all parties to ensuring that consumers receive the most appropriate care from the most appropriate providers in the most appropriate settings.
• In September 2000, the federal government announced the creation of an $800 million fund ($200 million per year for the next four fiscal years) for Primary Health Care Reform (PHC) to support the agreement reached by the First Ministers to broaden and accelerate PHC initiatives.

It would appear that the policy environment is open to the possibility of formally adopting the extended/expanded practice role for registered nurses. The challenges presented by this possibility will be examined in this paper and options recommended for consideration by policy-makers and decision-makers in Canada.

1.6 Overview

The remainder of the report is divided into three major sections. The first section presents an overview of the methodology guiding data collection. The second section summaries key findings from a review of policy and legislative frameworks, a cross-country survey of organizations employing extended/expanded role nurses, and an in-depth study of select sites in three provinces. The final section highlights key issues emerging from the multiple data bases and recommends possible strategic national/provincial/territorial actions that could result in more effective utilization of registered nurses in extended/expanded roles.