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| 2.0 Methodology | [Table of Contents] |
2.1 MethodThe current study used a research design which combined data, investigator and methodological triangulation. By using a flexible, methodological approach, the rich data that emerged helped the research team develop meaningful insights into the extended/expanded role of registered nurses working in primary health care settings. The Project Logic Model was the framework used to identify relevant sources for data collection. Figure 1 outlines the key components of the model, activities initiated with target groups, and the projected short and long term outcomes of this project.
2.2 Determination of Terms and Definitions
Given the wide differences in terminology across Canada in health care generally and the profession of nursing specifically, it was considered essential that the terms and definitions of the study be agreed upon as early as possible. The team used the working definitions provided in the Call for Proposals document as a starting point and began to construct a more comprehensive listing upon notification of project start-up. Finalizing this list proved to be extremely problematic because of the lack of agreement on the terms used to describe the extended/expanded role within the nursing profession. Despite the difficulties in identifying consistent terminology and/or definitions, the team selected the most commonly used ones for the purpose of this project. The finalized list is presented in the Glossary of Terms section placed at the beginning of this document.
During the initial stages of the current project, all relevant provincial/territorial legislation and regulations were reviewed and a cross-country survey of key informants undertaken to document existing information on nursing practice models. Data were gathered from consultants employed by the nursing associations concerning the regulation of, as well as the policy and standards for, extended/expanded nursing practice in their respective jurisdictions. Representatives of provincial/territorial ministries of health were also contacted to augment and/or clarify information received from the nursing associations. Summaries of the information compiled for each jurisdiction were subsequently forwarded to the relevant ministries of health and provincial/territorial nursing associations for review and confirmation. All summaries were confirmed and/or updated in July and August 2000. The final component of this phase of data collection involved a survey of administrative personnel in different provincial agencies/organizations that employ registered nurses to work in extended/expanded practice roles. During the second phase of data collection, an in-depth study was conducted at select sites in primary health care settings in the provinces of Newfoundland, Ontario and Saskatchewan. The population of interest consisted of physicians working in primary care settings, and registered nurses working in extended/expanded roles with physicians in these settings. A third target population was patients/clients receiving care from registered nurses performing these roles at the study sites.
The consulting team collected background information to describe the context for extended/expanded nursing practice. The first step in this process involved a review of relevant legislation across Canada, and initiating contact with Legislative Counsel offices or solicitors on staff with ministries of health. Nursing regulatory bodies within each jurisdiction were also contacted to obtain information on the interpretation and application of provisions relevant for extended/expanded nursing practice in primary care settings. The information on policy directions and planning for extended/expanded nursing practice collected from nursing associations and ministries of health was subjected to an in-depth analysis to identify commonalities and differences.
The persons contacted at the provincial/territorial ministries of health and nursing associations were also asked to identify primary health care settings where registered nurses perform primary care functions, work under similar and different practice models, and have variant education preparation requirements. Interviews were subsequently completed with representatives from 44 provincial/ territorial sites. The findings suggested that there were significant differences among the approaches used to deliver extended/expanded nursing services. Although there were a number of possible explanations for these disparate conditions, one significant factor influencing the enactment of nursing roles in each jurisdiction was the environmental context (i.e., legislative, regulatory, employing organization, nurse/physician relationships, etc.). Thus, the decision was made to select sites from two provinces with legislation and regulations, and one with medical directives and/or protocol agreements in place. The final selection of sites was made following consultation with representatives on the Advisory Committee on Health Human Resources Working Group on Nursing and Unregulated Workers.
Data collection at the sites selected for participation in this study was initiated following approval of the Research Protocol by relevant site personnel (see SD2). Data collection consisted of interviews with registered nurses working in extended/expanded roles and physicians working with these nurses, surveys of patients/clients accessing the resources at the centre/clinic, and participant observation sessions with the registered nurses during patient/client appointments. The nurses and physicians were identified through consultation with management personnel at each site. The contact person(s) approached nurses and physicians to briefly explain the study and provide them with a summary sheet of the project (see SD2, Appendix A), and ascertain their willingness to be contacted by a member of the research team. Those who indicated an initial willingness to participate were subsequently contacted, the study explained more fully and any questions/concerns addressed at this time.
Data collection at the sites occurred over a four-week period. In Ontario and Saskatchewan, the data were collected by two Masters prepared faculty teaching in the Primary Health Care Nurse Practitioner Program at the Centre for Nursing Studies, the Health Care Corporation of St. John's. In Newfoundland, data collection was completed by a registered nurse with extensive intensive care experience in a major tertiary care centre and enrolled in the Masters of Nursing Program at Memorial University.
Informed, written consent was obtained prior to the beginning of interviews with nurses and physicians (see SD2, Appendix B). Most participants agreed to be audiotaped. All participants were asked to provide information on select demographic variables prior to the interview. The interviews were conducted using a semi-structured interview schedule (see SD2, Appendix C), and lasted approximately 30 to 60 minutes.
Patients were approached by the interviewer or site receptionist during a regularly scheduled centre/clinic visit. The rationale for the study was explained to them and any questions/concerns addressed. If they agreed to participate, the survey instrument was given to them to complete at this time (see SD2, Appendix D). The survey questionnaires were designed so that the patients were able to fill out the questionnaires anonymously while waiting to see the nurse. Thus, informed, written consent was not required for this group of participants. Depending on patient preferences, some of the surveys were administered by an interviewer.
One to two participant observation sessions were conducted with registered nurses in their clinical practices at the study sites. The observation sessions were conducted on the same day of the interview and/or the following day depending on the nurse's centre/clinic responsibilities. Observational checklists were used to collect data on each nurse-patient/client encounter (see SD2, Appendix E).
The instruments used during data collection included surveys of Legal Role and Regulation of Nursing in Primary Health Care Settings (see SD1, Appendix A), Association Views: Nursing Practice in Extended/Expanded Roles and Regulation of Nursing in Extended/Expanded Roles (see SD1, Appendix C), and an Administration Survey Instrument (see SD1, Appendix E). Instruments were also developed for data collection at the selected sites, including the Interview Schedule: Nurses and an Interview Schedule: Physicians (see SD2, Appendix C), an Observation Checklist (see SD2, Appendix E), and a Patient/Client Survey (see SD2, Appendix D). Training sessions were conducted with interviewers/observers prior to data collection by the principal investigator for this phase of the project who has an extensive theoretical and experiential basis in qualitative and quantitative research methodologies.
The data collected from the provincial/territorial statutes, regulatory bodies, ministries of health, nursing associations, and administrative personnel at various sites were summarized and described according to key variables. Further in-depth analysis of these data bases provided the Project Team with the necessary information to select appropriate sites for data collection in three provinces.
The taped interviews were transcribed verbatim and checked for accuracy. Interpretive summaries were compiled for each transcribed data set. The interpretive summaries were forwarded to each participant for review and confirmation. A modified version of the constant comparative method of analysis as defined by Glaser and Strauss (1967) was applied to each data set by a minimum of two raters/coders (the principle investigator and research assistants) working independently. Debriefing sessions were held regularly to discuss major themes and to identify the conceptual categories and properties being generated by the initial joint coding and analysis.
The categories in the participant observation checklists were developed based on commonalties found in a review of provincial regulations and nursing associations/colleges standards of practice and competencies for nurse practitioners. Data sets were reviewed to locate incidents of relevant content for each category. Counts of the number of times key components were identified in the data were tabulated.
The data from the patient/client surveys were analyzed using descriptive and parametric statistical analysis. Descriptive statistics included appropriate summary measures and frequency distributions. A series of one-way analysis of variances were conducted to determine if there were variations across sites. An alpha value of 0.91 for the current study suggested that the satisfaction scale had strong internal consistency.
2.7 Overview of Restrictions and Limitations
2.7.1 RestrictionsIt was decided at the outset of the project that the primary focus would be on the extended/expanded nursing role in areas where physicians have traditionally been responsible for the delivery of primary care services. The MSB of Health Canada has played a significant role in supporting the educational preparation of registered nurses for assuming extended/expanded nursing roles. Nurses sponsored by the MSB have provided primary care services to residents of northern Canada and rural/remote areas that have been under serviced by physicians. The contribution of the MSB is acknowledged by the research team. Within the parameters defining the current project, the settings utilizing MSB guidelines were not the primary focus of research activities.
Limited attention was also given to primary care delivery by nurses working in extended/expanded roles in First Nations and Inuit settings. Due to the cross-cultural diversities and complexity of issues present in aboriginal settings, the project team, following consultation with the Advisory Committee, decided to restrict data collection in these settings.
The research team did not address the cost effectiveness of the extended/expanded nursing role. Besides the time and cost constraints on the project, recognition was given to the inherent difficulties in trying to access data under the control of Ministries of Health and/or employing organizations. In addition to access problems, it was acknowledged that there are different tracking mechanisms in place to account for expenses associated with human resource utilization. The level of meaningful comparisons required within and across jurisdictions was well beyond the expertise of the research team and, in fact, the scope of this project. Evaluation of the cost effectiveness of extended/expanded nursing roles could certainly be the focus of a separate study.
