3.0 Results

[Table of Contents]

3.1 Policy and Legislative Frameworks for Extended/Expanded Nursing Roles

Diverse models have been used across Canada to provide authority to registered nurses performing extended/expanded roles. Diagnostic and treatment functions have been delegated by government to the medical profession through legislation. Registered nurses have been assessing, diagnosing and treating acute, episodic and chronic illness and injury under the authority of delegated medical functions in remote and rural areas of Canada, as well as in a few more populace areas.

The delegation of medical functions is normally through protocol arrangements negotiated between the professional bodies, the employer and sometimes government. Saskatchewan tried to ensure greater consistency across primary health care sites by developing province-wide protocols to facilitate the transfer of medical functions and to clarify the parameters of the extended/expanded nursing role. Although this type of protocol may reduce role uncertainty, the downside is that it does not bring the functions within nursing's scope of practice as defined by the professional legislation. Some nursing associations indicated that the provincial/territorial legislation/regulations governing nursing practice are of sufficient breadth to accommodate extended/expanded nursing roles. In contrast, other associations raised concerns about the inconsistency between the scope of nursing practice outlined in the professional legislation and employer expectations of nurses.

Over the past decade, certain jurisdictions have opted to legitimize the extended/expanded nursing role beyond protocol arrangements by enacting legislation (i.e., Ontario, Newfoundland and Labrador, Alberta and Manitoba). The regimes in Ontario and Newfoundland and Labrador are very similar with both requiring that nurses practice in a collaborative relationship with physicians and receive advanced preparation for the primary care role. Registered nurses regulated within the extended/expanded class have the authority to engage in autonomous decision-making, perform primary care functions in a variety of health care settings (e.g., community health centres, long-term care facilities, nurse-managed clinics, etc.), and access resources within defined limits. When encountering problems beyond their scope of practice, nurses are required to consult with a participating physician.

Manitoba has enacted similar legislation to Ontario and Newfoundland and Labrador which will be proclaimed pending the development of regulations. Alberta's legislation for regulating extended/expanded nursing role also requires registered nurses to receive advanced preparation. The regulations enacted in February of 1999 gave registered nurses the authority to diagnose and treat common disorders of adults and children, and to refer and provide emergency treatment. However, Alberta limited the extended/expanded role to registered nurses employed by a regional health authority or a provincial health board.

The Canadian Nurses Association has formed a committee of provincial and territorial representatives to establish a framework to guide the development and implementation of legislation dealing with nursing roles requiring additional regulation (i.e., primary care functions). This committee is also focussing on identifying the basic standards and competencies required in the role. If these standards/competencies are accepted by all jurisdictions, they would be used to highlight the essential components of education programs preparing registered nurses for primary care roles.

There are key features which must be considered from a global perspective with the extended/expanded nursing role across Canada. Among these are the elements of title, scope of practice and education. As noted previously, there is no consistent policy guiding the advancement of the extended/expanded nursing role across Canada. The repercussions of the absence of such a policy will be highlighted in the discussion that follows.

3.1.1 Title - Policy Framework

The titles used across the country to identify registered nurses practising in extended/expanded roles vary by jurisdiction. Titles are determined by the employer, the Ministry of Health or a combination of stakeholders. The exceptions are those provinces which have enacted legislation. A nurse in an extended/expanded practice role is designated as a RN - Extended Class (RN - EC) in Ontario, and a Nurse Practitioner (NP) in Newfoundland and Labrador. In Alberta, the nurse with the RN - Expanded Practice (RN - EP) designation is usually referred to as a Community Nurse Practitioner.

Table 1 summarizes the various titles in current use across Canada. It is evident from this listing that there is a proliferation of titles for registered nurses who practice in extended/expanded roles. Although there are some similarities in the titling, there is certainly no agreement on the use of the NP term across Canada.

The Canadian Nurses Association has expressed a desire to eliminate the proliferation of nursing titles. In spite of its use in the literature and in some areas of Canada, there is a certain degree of discomfort with the term "nurse practitioner". Despite this reluctance to refer to nurses in extended/expanded roles as NPs, registered nurses licenced in the extended class in Ontario are hired as NPs and have formed an association by the same name. The protection of the NP title under legislation in Newfoundland and Labrador is unique in Canada.

While provincial legislation and protocols may vary, there seems to be recognition by the public that registered nurses in extended/expanded roles undertake some functions that are similar to physicians. Because this is a nursing role not a medical one, practitioners view themselves as working from a nursing perspective. For the purposes of consistency there ought to be some uniformity in the titles used throughout the country to facilitate easy identification of registered nurses with extended/expanded nursing practice roles by the public and other health care providers.

Table 1 - Titles for Registered Nurses in Extended/Expanded Roles by Jurisdiction

Jurisdiction	Title
British Columbia	Registered Nurse (RN). Unofficial use of the title Nurse Practitioner (NP) in Community Health Centers.
Alberta	RN - EP (Expanded Practice) officially, but usually called Community Nurse Practitioners.
Saskatchewan	No fixed titles. Referred to as Primary Care Nurses in protocols.
Manitoba	No title regulated or sanctioned by MARN at this time. Employers may choose to use a specific job description title.
Ontario	RN- EC (Extended Class) and other titles, such as Nurse Practitioner, used by employing organizations.
Quebec	RN (infirmiere/infirmier).
New Brunswick	No separate title; referred to as RN.
Prince Edward Island	Not applicable; no RNs practicing in the extended/expanded role
Nova Scotia	Primary Care Nurse Practitioner.
Newfoundland & Labrador	NP and Regional Nurse.
Yukon	Community Nurse Practitioner.
Northwest Territories & Nunavut	Community Health Nurse but also referred to as Primary Health Care Nurse Practitioner.

Source: Associations of Registered Nurses and Ministries of Health in the respective jurisdictions as of August 2000.

3.1.2 Scope of Practice - Policy Framework

Provincial nursing legislation provides guidance on the functions and activities that constitute the scope of nursing practice. There is no one consistent definition or scope of practice for nursing across Canadian provinces and territories. The title of "registered nurse" may not be defined but is inferred by referencing the definition of the "practice of nursing". The definitions of "registered nurse" or "nursing practice" are used to set parameters around the activities undertaken by members of the profession. Though some statutes are dated, the definitions contained therein are believed to be broad enough to incorporate extended/expanded roles within existing scope of practice guidelines. Table 2 contains a summary of the extended/expanded scopes of practice by jurisdiction across Canada.

The data collected from the various Ministries indicated that there is no agreement on the parameters of the extended/expanded role across and within jurisdictions. This was particularly true for those provincial/territorial jurisdictions which rely on delegation of medical functions as opposed to legislation. Generally, protocol arrangements determine the breadth of delegated medical acts to registered nurses practising in extended/expanded roles. Often accompanying this delegation is the right to access certain health care services (e.g., ordering diagnostic tests, prescribing medications, making referrals to other providers, etc.) which are viewed as essential for nurses to perform the extended/expanded role. One glaring problem identified is the lack of consistency in the protocol arrangements which delegate authorities across and, in some cases, within jurisdictions. The one exception is Saskatchewan where a province-wide protocol is in effect for primary care settings.

During the course of the current study, it became evident that some informants believed that the extension/expansion of nursing's scope of practice can be achieved by "pushing the boundaries". In New Brunswick the legislation governing the nursing profession contains a very broad definition of nursing practice. However, this definition does not seem to be adequate enough to allow for an extension of the nursing role into primary care. More importantly, support for "pushing the boundaries" of nursing's scope of practise to cover primary care functions does not provide registered nurses with the necessary authorities to access services required to execute these functions. In fact, registered nurses who perform primary care functions in New Brunswick do so under the authority of delegated medical acts which are site-specific, for example the MacAdam project and demonstration projects in remote areas.

To gain an appreciation for the mechanisms which facilitate implementation of extended/expanded roles, the legislation governing nursing cannot be read without reference to the Medical Act, the Pharmacy Act and related statutes. The interrelationship among the scopes of practice of physicians, pharmacists and registered nurses is a key consideration. For example, in Nova Scotia the function of diagnosis is clearly within the medical profession's scope of practice. The Medical Act contains legislative authority to delegate functions to nursing which is usually accomplished through protocols negotiated by the relevant regulatory bodies. Thus, the delegated authorities are negotiated by the respective professional licensing bodies.

Amending the legislation relevant to nursing only represents one side of the issue. There must also be amendments to other legislation if nurses are to fully implement the extended/expanded role. In jurisdictions where legislation has been enacted, there are situations were consequential amendments to related statutes have not been pursued as part of the legislative package (e.g., the Hospital Act, Pharmacy Act, Vital Statistics Act, etc.). To illustrate this point nurses working in extended/expanded roles may not have the necessary authority to order certain diagnostic tests (e.g., Newfoundland regulations governing radiology do not grant authority to nurse practitioners for certain x-rays), or are subject to restrictions on their prescriptive authority (e.g., a formulary with an approved list of medications, not able to access narcotics, etc.). However, this raises another issue relating to the potential costs of authorizing another provider to access scare resources.

Table 2 - Summary of Scope of Practice by jurisdiction

Jurisdiction	Scope of Practice
British Columbia	Extended/expanded practice is undertaken by delegated acts which are established by working arrangements according to location, organization and training. RNABC has guidelines for Delegated Medical Functions.
Alberta	The Extended Practice Roster Regulation governs registered nurses in extended/expanded roles. AARN has developed competencies and guidelines to govern nurses providing "extended health services".
Saskatchewan	Scope of practice is defined by the province-wide clinical practice guidelines but subject to site modifications.
Manitoba	Under the new legislation, regulations will be developed for required competencies in extended/expanded nursing practice. MARN has established standards of practice which apply to all practicing registered nurses in the province regardless of their roles or practice settings.
Ontario	Legislated scope of practice is relative to primary care functions only. These controlled acts are to be performed by RNs with an extended class designation.
Quebec	Delegated medical functions are not necessarily supported by protocols. Concerns have been raised by nurses about situations where they could be exposed to liability and have no protection.
New Brunswick	Site specific protocols govern the delegation of function.
Prince Edward Island	Not applicable at present. However, if there were a movement to introduce extended/expanded nursing roles, the nursing association would establish guidelines for core competencies in accordance with CNA guidelines.
Nova Scotia	Scope of practice is defined by delegation of medical functions under guidelines negotiated between the College of Physicians and Surgeons of NS and RNANS.
Newfoundland & Labrador	The ARNNL approves standards of practice and competencies for NP- PHC.
Yukon	Employers have adopted the MSB Scope of Practice Guidelines for Community Health Nurses, Nursing Stations and Health Care Treatment facilities.
Northwest Territories & Nunavut	All extended/expanded practice is under the authority of protocols with the medical profession and employer organizations.

Source: Associations of Registered Nurses and/or the Ministry of Health in the respective jurisdiction August 2000.

3.1.3 Educational Preparation - Policy Framework

Education programs preparing registered nurses for extended/expanded roles have been present in Canada for a period of time. In the early years advanced preparation for the role was primarily delivered through employers, such as the Medical Services Branch. Basically, the educational requirements of nurses working in extended/expanded roles were determined by the particular circumstances of individual settings, as well as the availability of medical personnel on-site.

One significant concern raised in this phase of the research was in relation to the delegation of primary care functions to registered nurses without adequate educational preparation to perform them. Several nursing associations indicated that some of their members were wary about being liable when performing primary care functions that required them to go beyond normally expected competency levels. For example, nurses practising in northern Quebec voiced concerns to the Ordre des infirmières et infirmiers about their responsibility and liability when working under the authority of protocols. In particular, these nurses were concerned about the adequacy of their preparation for performing certain delegated functions in a competent manner.

Today, there are several education programs in place in most Canadian jurisdictions which provide registered nurses with the necessary knowledge and skills to undertake extended/expanded roles. The data collected by jurisdiction are summarized in Table 3. As noted with the title and scope of practice elements of this role, the absence of a consistent policy direction is reflected in the variant education requirements across provincial/territorial jurisdictions. Importantly, some provinces and territories either do not have specific education requirements or rely on employers to determine them.

There are also obvious variations between the different education programs. Noteworthy differences among these programs are the entry requirements and status upon graduation. The education requirements for admission into programs range from diploma to baccalaureate level of preparation. A similar trend is noted in the awarding of a diploma, certificate and/or degree, among others, following program completion. Besides entry requirements and graduation status, the programs also vary in curriculum content, length, and the nature of clinical experiences, especially with regard to the intensity and duration of the clinical practicum. With these program differences, it is questionable as to whether the competencies and skills of the graduates are comparable withoin and across provincial/territorial jurisdictions.

Table 3 - Education Programs for Extended/Expanded Nursing Roles in Primary Health Care Settings by Jurisdiction

Jurisdiction	Education Program
British Columbia	Educational qualifications are set by employing organization.
Alberta	BN or graduate degree required for entry and an Advanced Graduate Diploma in Community Health at Athabasca University.
Saskatchewan	SRNA's criteria for practice in extended/expanded roles is outlined in "The Registered Nurse Scope of Practice: Special Nursing Procedures and Nursing Procedures by Transfer of Medical Functions, 1993". Graduation from a formal course of study is required. The Advanced Clinical Nursing Program at Saskatchewan Institute of Applied Technology is the usual course of instruction.
Manitoba	Standards for registration under the enacted, but not proclaimed, legislation, have not been determined. There is a Masters level program in Advanced Nursing Practice at the University of Manitoba.
Ontario	In 1994, the Council of Ontario University Programs in Nursing approved a program for RN - EC at 10 sites co-ordinated by McMaster University. Program graduation criteria includes: completion of a 24 month course by a diploma graduate to attain a Bachelor of Nursing and NP certificate; or a BN preparation plus completion of a 12 month course to attain a NP certificate.
Quebec	No specific courses identified.
New Brunswick	NANB has published a policy statement supporting education at the Masters level. UNB has introduced a nurse practitioner stream in its Master's program. The nurses practising in the IT/SP projects were given additional educational preparation prior to entering the role.
Prince Edward Island	Not applicable at present.
Nova Scotia	For demonstration projects, a NP certificate will be required from a recognized program, or a licence to practice as a primary care NP.
Newfoundland & Labrador	RN diploma and at least 2 years practice for entry to Nurse Practitioner Program offered by Centre for Nursing Studies. Graduation with NP Diploma. Regional nurses require an RN diploma plus employer in-service education.
Yukon	Employers accept a variety of education options.
Northwest Territories & Nunavut	Preference is for training at Aurora College in the Advanced Nursing Skills Education Program but this is not a fixed requirement.

Sources: Associations of Registered Nurses and/or Ministry of Health in the respective jurisdiction as of August 2000.

3.1.4 Summary

The extension of authority through protocol and legislation is accompanied by rights of access to health care services, for example diagnostic facilities, traditionally limited to physician-use. With most legislation, these rights are extended throughout the jurisdiction to all registered nurses who are licenced to perform the role. Importantly, the right to access resources is not limited to a specific practice setting as is the case with protocols. Furthermore, in jurisdictions with legislation in effect, practitioners with advanced preparation and deemed competent to deliver primary care functions to the public are especially authorized to do so by the regulatory body of nursing.

The common thread permeating this profile of key factors influencing the policy framework is the inconsistencies in the extended/expanded nursing role across Canada. Besides the absence of a common title to describe the role, there are differences in the educational requirements and scope of practice parameters guiding the implementation of a role touted to hold much promise for achieving the objectives of federal and provincial/territorial health care agendas. To complicate matters further, geography and the relative availability of health care providers, particularly physicians, influence the full implementation of the extended/expanded nursing role. While four jurisdictions have enacted legislation to legitimize the position of the extended/expanded nursing role within the health care system, this is not a universally accepted approach. The difficulties encountered by organizations employing registered nurses to work in extended/expanded roles are outlined in the next section on administrators' perspectives on this situation.

From a policy perspective, it is much better to deal with the extended/expanded nursing role through legislative change. This type of approach will ensure that extended/expanded roles are within the purview of nursing practice. Importantly, with the extended/expanded nursing role regulated by the relevant professional body, there would be more stability in the scope of practice guidelines, education requirements, and expected competency levels.

3.2 Organizational Structure: Administrative Personnel Perceptions (see SDI)

The purpose of this phase of the project was to identify and describe the practice models under which registered nurses in extended/expanded roles perform primary care functions. Particular consideration was given to the following: scope of roles and responsibilities, position title, client populations served, most common practice settings, job requirements and expected core competencies, expectations regarding autonomous and collaborative practice, scope of referrals to other providers, and extent of independent access to other available resources. A second purpose was to describe organizational lines of authority for supervising/monitoring registered nurses working in extended/expanded roles. A final purpose was to identify organizational mechanisms for assessing the quality of extended/expanded nursing services and their impact on client outcomes and organizational costs. The findings reported are exploratory in nature, although common links were observed between an organization's mandate and the nature of extended/expanded nursing practice. The findings are presented in four major sections. The first section presents a descriptive profile of different models of practice. The second section describes the lines of authority in different jurisdictions. The third section reviews quality of care initiatives and evaluation mechanism for assessing organizational and client outcomes. The final section presents a summary of the key issues.

3.2.1 Models of Practice

The findings from the forty-four sites surveyed for this study indicated that registered nurses working in extended/expanded roles provide a wide array of services under similar, as well as disparate, collaborative practice arrangements. Despite observed variations, the norm was for nurses and physicians, as well as other health professionals, to engage in an interactive process of joint decision-making and problem-solving based on mutual respect and appreciation for each others knowledge, skills and abilities. This sharing of information and knowledge helped all providers develop better insight into clients' health needs and provide appropriate and efficient primary health care to various population groups.

The findings also indicated that there are significant variations within and between provinces/territories with regard to the enactment of primary care functions by registered nurses. The autonomous nature of extended/expanded nursing practice and collaborative practice relations were the by-product of a peculiar set of separate and interrelated factors: location and setting, client populations, physician and other provider resource adequacy, organizational accountability, educational preparation and experience, access to resources and authorities/protocols. Given the interrelationship among many of these factors, the presentation of findings is organized according to two major themes: 1) location and setting, and 2) job requirements and core competencies.

3.2.1.1 Location and Setting

Organizational structures, employer expectations and job functions changed rapidly for registered nurses performing extended/expanded role functions as one moved from urban to rural to remote areas regardless of whether it was the same or a different provincial jurisdiction. While all nurses working in extended/expanded roles are expected to practice autonomously, variations were noted across practice settings. The key factors influencing the autonomous nature of the role were the supportiveness of the work environment, physician supply, organizational goals and strategies, and the health needs of the local population.

Urban

A total of 14 urban sites participated in the survey. For the most part, registered nurses with extended/expanded practice roles were autonomous members of multi-disciplinary teams and worked with different client groups in a variety of settings (e.g., community health centres, satellite clinics and/or off-site clinics, medical clinics, resource centres, etc.). Without exception, there was a strong emphasis placed on autonomous practice while maintaining collaborative relations with all health care providers, especially physicians for primary care activities. The normal requirement was also for nurses to carry independent caseloads, consult with team members for input into decision-making (i.e., diagnosing health needs and care management), and initiate referrals to other providers when care was deemed to be outside their scope of practice.

In rural areas, registered nurses who performed extended/expanded role functions were expected to work autonomously, as well as collaboratively with physicians and other health care providers in a variety of settings (e.g., community clinics, health care centres, medical clinics, etc.). The norm was for physicians to be present on-site but to have limited involvement with the clinical supervision of nurses. In most instances, rural-based nurses carried independent patient caseloads, consulted with physicians by telephone or in-person for input regarding client care, initiated referrals to other providers and specialists, and accessed available community resources.

The diversity of extended/expanded role functions and required skills observed across rural sites seemed to be contingent upon two main factors: 1) the shifting supply of health care providers, especially physicians, and 2) the willingness of other providers, especially physicians, to engage in collaborative practice arrangements. For example, in rural settings with a sufficient complement of physicians to meet local demands, registered nurses, regardless of their level of preparation for and experiential base in performing primary care functions, exercised a fair degree of autonomy in their role but often shared caseloads with physicians and worked under their direction. In contrast, when there was an insufficient complement of physicians to meet local demands, registered nurses not only practised autonomously but were often expected to provide services that sometimes stretched the boundaries of their defined scope of practice. This situation was more common in settings which operated under delegated functions or protocol agreements.

Remote

Registered nurses constituted the largest group of health care providers working in remote settings (i.e., isolated communities primarily accessible by air). The norm was for the nurse to be the only available health care provider and to assume a very independent role. These nurses worked in a variety of settings (e.g., community health centres, community clinics, nursing stations, etc.) and performed diverse primary care functions (i.e., routine assessment, diagnosis and treatment, as well as dispensing medications, stabilizing and transferring patients to the closest tertiary care centre). Although most of the clinics were nurse-managed, nurses were expected to work in collaboration with other health care providers, especially physicians. With on-site services limited to visits varying from once a week to every 6 to 8 weeks, physician input into clinical decision-making was mainly by telephone consultation and team conferences to review clinical issues.

In general, the extended/expanded nursing role in remote areas was more challenging and diffuse (i.e., involved the delivery and coordination of a broader range and scope of primary care services) than in rural and urban areas. On the negative side, limited diagnostic and treatment modalities were available on-site and collaborative practice arrangements were significantly compromised because supportive interactions with other providers was mostly from a distance. Given the scope of the nursing role and ensuing responsibilities, it was apparent that time and resources, both human and physical, only allowed for the provision of primary care with limited opportunities for health promotion and illness prevention.

3.2.1.2 Job requirements and Core Competencies

One of the most serious and persistent problems confronting health care organizations in rural and remote locations was recruiting and retaining the number and mix of health care providers required to provide the clinical services needed by the local population. A problem of equal significance, especially for remote areas, was the recruitment and retention of registered nurses competent to perform primary care functions and capable of maintaining consistency in delivering high quality care 24-hours a day.

Job Requirements

The job requirements for registered nurses varied considerably across the survey sites and were dependent upon organizational expectations regarding the level of autonomy within the extended/expanded role nursing. Diploma or bachelor of nursing educational background with two to three years of clinical experience in tertiary care or community/rural health care were the minimal requirements. Unfortunately, these requirement were not always met in the more remote areas due to recruitment difficulties. In an effort to circumvent the potential problems posed by limited competency in performing primary care functions, employers developed contingency plans (i.e., intensive skills training with physicians prior to entering the field), especially for those nurses being placed in remote areas. In the territories and some parts of British Columbia and Manitoba, registered nurses are required to complete a program of study offered/sponsored by the Medical Services Branch.

In general, most of the participating organizations in rural and urban settings hired only registered nurses who had completed an approved program. This was particularly true for the community health centres in Ontario which limit extended/expanded practice to nurses who have met the certification requirements for the Registered Nurse - Extended Class (RN - EC) category. A similar situation was noted in Newfoundland where nurse practitioner graduates of a certified nurse practitioner program were employed by several contact sites (i.e., medical clinics affiliated with a cottage hospital, emergency/outpatient department of a rural hospital, health centre, and a Primary Health Care Enhancement Project affiliated with a local hospital).

Saskatchewan has wide-variations in extended/expanded nursing practice across its health districts. However, registered nurses employed by the Beechy Project, as well as a number of other sites which have adopted the primary health care model, are required to have completed the advanced practice program at the Saskatchewan Institute of Applied Technology. Several health authorities in Alberta also only employ those nurses for extended/expanded practice who have completed the certification requirements for the Registered Nurse - Expanded Practice (RN - EP) category.

Core Competencies

All of the survey respondents indicated that registered nurses who were working in extended/expanded roles were required to have well-developed assessment skills and capable of advanced clinical decision-making. Particular importance was placed on not only having the necessary competency to perform functions within one's defined scope of practice but also to recognize situations outside of ones scope and to initiate referrals or consultations with other providers. Without exception then, all respondents placed equal emphasis on the nurse's ability to perform primary care functions autonomously, as well as his/her ability to forge strong collaborative relations with members of other provider groups, especially physicians.

Expected core competencies for registered nurses in extended/expanded roles were either a function of provincial legislation, regulations and/or protocols, scope of practice guidelines developed by nursing associations, colleges of nursing and/or employers, or physician expectations with regard to the performance of each delegated medical function. Further information on specified lines of authorities for ensuring that nurses possessed the required competencies is presented in sections 3.2.2 and 3.2.3.

Most of the sites surveyed also had mechanisms in place to ensure the continued competency of registered nurses working in extended/expanded roles. Without exception, all of the respondents encouraged these nurses to participate in medical and nursing continuing education activities on a regular basis. Some of the sites instituted additional measures to ensure that nurses maintained expected competencies in performing existing, as well as new or revised, primary care functions. Examples of these measures were regular team conferences, in-service activities with visiting physicians/specialists, regular seminars on a variety of topics, internet and teleconferencing access, and support to attend one professional conference annually. In certain provinces, the nursing regulatory bodies required that nurses participate in a minimal number of continuing education activities to meet re-certification guidelines.

3.2.2 Lines of Authority

All of the administrative personnel surveyed referenced organizational efforts to achieve an appropriate balance of co-ordination and integration among the various provider groups, especially registered nurses in extended/expanded roles and physicians. While many organizations had clear guidelines to follow for extended/expanded role functions, others were less fortunate and subject to the constant shifting of role parameters in response to client needs and physician availability. When provincial legislation legitimizing the role was absent, the authority to order diagnostic tests, prescribe medications and perform other primary care functions was addressed through different protocol arrangements. The diversity observed in the lines of authority for extended/expanded role nurses is captured, to a degree, in the three scenarios that follow.

The first scenario relates to registered nurses in extended/expanded roles certified to perform primary care functions (i.e., graduates of an approved program of at least one year in duration) and operated as full autonomous members of multi-disciplinary teams. The constant factor was the lines of authority for supervising and monitoring these nurses: provincial legislation (i.e., Ontario and Newfoundland and Labrador) and/or the scope of practice guidelines developed by the relevant college of nursing or nursing association. There were definite variations, within and between provincial jurisdictions, with regard to the person (s) responsible for overseeing nurses' clinical practice. For both Newfoundland sites, the nurse practitioners reported to a nurse manager. In Ontario, there were four distinct categories of responsible persons. Some sites referenced the self-monitoring clinical team (i.e., nurse practitioners and physicians co-ordinating their efforts as part of a clinical team) and its accountability to the executive director. Other sites reported that nurse practitioners were accountable to the executive director/administrator. Still other sites identified the responsible party as the physician. Finally, several sites emphasized the dual accountability of nurse practitioners to the executive director/administrator and physicians.

A second scenario relates to registered nurses in extended/expanded roles who had variable levels of preparation for performing primary care functions (e.g., masters preparation with NP certification, advanced clinical preparation in a post-RN program, basic diploma preparation with on-site physician direction and guidance in performing specified functions, intensive orientation to promote skill competency and sound clinical judgments prior to entering clinical situations, etc.). Most of these nurses worked in remote areas, as well as urban and rural areas to a lesser degree, and assumed a very autonomous role while engaged in collaborative practice arrangements with other providers (i.e., mostly nurse colleagues and physicians). Respondents reported wide variations in the lines of authority for supervising and monitoring these nurses. The following are examples of such authorities/protocols: 1) delegated medical functions based on protocols negotiated between medical and nursing associations, ministries of health and employers, 2) amended Public Health Act (1995) and accompanying regulations covering extended practice, 3) transfer of functions - umbrella document negotiated between medicine, nursing and pharmacy regulatory bodies, 4) delegated functions under the provincial medical act, and 5) Medical Service Branch Scope of Practice Guidelines. The persons responsible for overseeing the clinical practice of nurses working in extended/expanded roles were also quite variable, including immediate nursing supervisors/nurse managers alone, physicians alone, or nursing supervisors/nurse managers and physicians.

The final scenario relates to registered nurses in extended/expanded roles who were required to meet the minimal requirements for performing primary care functions before actually doing so in clinical situations. Most of the nurses in this category had restricted autonomous functioning in clinical situations (e.g., limited access to diagnostic facilities, no prescriptive authority, restricted referrals, etc) and worked under medical directives or protocol arrangements. In addition, they were mostly accountable to either physicians alone or a combination of immediate nursing supervisors and physicians.

3.2.3 Quality Measures and Evaluation of Outcomes

The performance activity which received the most attention was nurses decision-making and its outcomes. While expertise provides the source and legitimization for the extended/expanded nurses' professional autonomy, organizational outcomes and client outcomes are important indicators of effective clinical decision-making. Organizational outcomes are measured by cost effectiveness and efficient delivery of quality care. Client outcomes are measured by such things as patient satisfaction with care and achieving an optimal level of health. Effective clinical decision-making is measured by the ability to make sound judgments while assessing clients' health problems, arriving at a diagnosis, and choosing the most appropriate plan of action.

Quality Measures

Wide-variations were noted in on-site strategies for monitoring the competency levels of registered nurses working in extended/expanded roles. For the most part, survey respondents reported that evaluation was limited to periodic chart reviews by nursing supervisors and/or physicians. An additional monitoring mechanism instituted at some of the sites was performance appraisals. The more formalized appraisal process involved observing nurses in clinical situations and identifying strengths and areas of weakness on an annual or bi-yearly basis. The informal process primarily consisted of the nursing supervisor and/or physician querying nurses on clinical issues/decisions on an ad hoc basis. Without exception, all of the respondents indicated that this was an area that required further attention. In fact, some sites were in the process of instituting such procedures as peer evaluations and/or self appraisals, as well as developing performance standards. The sites most likely to be actively engaged in formalizing evaluation/monitoring procedures were either preparing for accreditation or were required to do so by the funding or regulatory body.

Organizational/Client Outcomes

The majority of the sites surveyed had not participated in a formal evaluation process either in-house or by external consultants since employing a registered nurse with extended/expanded role capabilities. Only three respondents reported that an independent evaluation had been conducted to evaluate the impact of this type of nursing practice on organizational or client outcomes. In most instances, this was a requirement imposed by the funding body. Respondents from seven other sites reported that an independent evaluation was in-progress or about to commence in the near future. As well, there were a number of other sites that had either completed patient satisfaction surveys or taken steps to do so within the year.

3.2.4 Summary

In summary, registered nurses working in extended/expanded roles are providing a full-range of primary care services in accordance with relevant authorities in the region and/or province. The geography of the region was identified as a key factor influencing not only the availability of provider resources but also the nature of collaborative relations between registered nurses and other providers, the level of preparation for and competency in performing extended/expanded role functions, and on-site evaluation procedures for ensuring quality of care and positive organizational/client outcomes. A few of the key issues affecting effective utilization of registered nurses in extended/expanded roles emerging from the administrative data include:

• Greater restrictions are placed on nurses' autonomous performance of primary care functions when there is a greater concentration of physicians.
• Limited availability of nurses with appropriate extended/expanded role preparation in remote regions of the country necessitated lowering expectations re education standards and experiential base.
• Wide-variations existed in requirements for maintaining competency in extended/expanded role functions.
• Limited support mechanisms in place for extended/expanded role nurses working in remote regions.
• Legislative restrictions (e.g., Hospital and Diagnostic Act, etc.), as well as variations in policies/protocols between sites, sometimes limit or deny registered nurses access to necessary resources.
• Minimal standards and guidelines for accessing the quality of primary care and the impact of services on organizational and client outcomes.

3.3 On-site Data Collection

In the provinces of Saskatchewan, Ontario and Newfoundland and Labrador, face-to-face interviews were conducted with fourteen nurses who were working in extended/expanded roles, as well as eleven participating physicians. The purpose of this phase of the study was to develop a greater understanding of physicians' experiences while working with nurses who performed extended/expanded role in primary health care settings. A second purpose was to document nurses' experiences while performing the extended/expanded role in primary health care settings with similar and different practice models. A third purpose was to identify physicians' and nurses' perceptions of the barriers to and facilitators of full implementation of the extended/expanded nursing role.

The interview data from both groups were subjected to the constant comparison method of analysis to highlight differences and commonalities within and between each provincial jurisdiction. The following sections present a discussion on the dominant categories (i.e., practical knowing, collaborative versus independent practice models, role confusion, and barriers to and facilitators of collaborative practice models) generated from the thematic analysis of study data. Each section also highlights the similarities and differences between physicians and nurses on key issues.

3.3.1 Practical Knowing

A common theme throughout the interview transcripts was participants' perceptions of the knowledge levels and practical skills of registered nurses working in extended/expanded roles. The practical knowing theme reflected improvements in nurses' skills and abilities for performing primary care functions from the early stages of role enactment to the development of an experiential base. All of the participants identified ways to ensure that nurses not only possessed minimal competency levels when assuming extended/expanded roles but also were able to access the necessary resources to help refine/enhance their skills/abilities. Early Stages of Role Enactment

Several physicians indicated that they were dissatisfied with nurses' theoretical and practical knowledge base when they first assumed extended/expanded roles. The wide variations observed in clinical competencies affected the degree of confidence and trust that they had in a nurse's ability to provide and maintain quality health care. Any perceived deficits in knowledge and/or practical skills were attributed to either inadequacies of educational programs preparing nurses for the role and/or their limited experience in performing primary care functions prior to assuming the role.

Many of the nurse participants described the early stages of role enactment as being extremely difficult for a number of reasons. Several participants noted an increased awareness of the gaps between their theoretical and practical knowledge, and overwhelming feelings concerning the diverse skill requirements while dealing with clients. Overall, many of the nurses attributed feelings of low confidence and competence to limitations in the theoretical and clinical components of the educational programs preparing them for the extended/expanded role.

Both physician and nurse participants recommended possible ways to circumvent some of the problems with beginning knowledge levels and practical skills/abilities. Some physicians suggested that curriculum changes were needed in programs preparing nurses for this type of role. Particular emphasis was placed on practical skill enhancement by requiring nurses to spend more time with physicians during clinical rotations. A couple of physicians also commented on the importance of setting minimal competency standards and requiring nurses to participate in continuing medical education.

Several nurse participants commented on the importance of having a standardized entry level for extended/expanded nursing practice. Some participants indicated that they would have felt more comfortable working in the role initially if they had a baccalaureate degree prior to receiving preparation for the extended/expanded role. The general position was that common educational standards are required to ensure greater acceptance and credibility of the role.

Development of an Experiential Base

Most of the physicians attributed the observed improvements in nurses' practical skills and abilities to working more closely with and under their direct supervision, as well as dealing with a variety of clinical problems. As time passed and nurses gained more experience in the role, physicians became more confident with nurses' ability to handle independent caseloads. Overall, physician participants reported having positive experiences while working with nurses in extended/expanded roles.

The nurse participants commented on how their comfort with and confidence in the role increased with the passage of time and exposure to different conditions and clinical situations. Most of them described their movement into primary care as a "learning process". By working collaboratively with physicians in the clinical area and participating in continuing education activities, participants gradually incorporated more primary care functions into their practice, developed greater self-confidence, assumed a more independent role, and consulted with physicians in a more collegial manner.

Summary

Despite the variant experiential base, physicians expressed confidence with the quality of care provided by most nurses after a period of time practising in the extended/expanded role. Significantly, nurse participants emphasized the immeasurable value of experience and the benefits of a strong support system in facilitating their delivery of quality care to clients. The following recommendations about ways to improve nurses' competency for extended/expanded roles were endorsed by many of the nurses and physicians:

• standardize entry level into programs preparing nurses for extended/expanded practice;
• increase the clinical component of programs preparing nurses for extended/expanded roles;
• ongoing continuing education to ensure competency in expected primary care functions;
• well-defined and universal standards on expected competency levels for extended/ expanded nursing practice.

3.3.2 Collaborative versus Independent Practice Models

Participants' descriptions of their experiences with extended/expanded nursing roles portrayed the most conducive and acceptable practice environment as one which favoured team work or strong interdisciplinary collaboration over independent practice. The dominant themes in this category were autonomous practice, balancing collaboration and independent practice, and the rationale for supporting collaborative practice. A brief summary is presented on each of these themes.

Autonomous Practice

Physician participants were supportive of autonomous practice for nurses as long as they operated within their defined scope, consulted with them as required, and did not try to replace them or provide substitute medical care. In fact, most physicians were of the opinion that nurses engaged in independent practice would encounter opposition from their physician colleagues.

All of the nurse participants reported feeling comfortable performing primary care functions autonomously in different settings. The degree of autonomous practice was a function of the scope of practice guidelines and/or protocols governing nursing practice in each jurisdiction. For example, nurses who worked under a transfer of medical functions model, as in Saskatchewan, had a broader scope of practice and thus greater autonomy and responsibility than their counterparts in Newfoundland and Ontario. Regardless of the region or jurisdiction, many of the nurses commented on the challenges of, as well as the personal satisfaction derived from, assessing client health needs, reaching an accurate diagnosis, and facilitating positive health outcomes. As well, most of the participants emphasized the value of using nursing skills and abilities in clinical situations, and the importance of maintaining a nursing focus when performing primary care functions.

Balancing Collaborative and Independent Practice

All of the physician participants believed that a collaborative arrangement was the best practice model for nurses working in extended/expanded roles. However, physicians working in remote and rural areas with limited medical personnel supported greater independence for nurses than their counterparts working in urban areas. Regardless of the location, all of the physicians reported that working in primary health care settings with nurses in extended/expanded roles resulted in strong collaborative relations. More efficient management of physicians time was identified as another important benefit. On the negative side, collaborative practice arrangements with nurses also resulted in a refocusing of physicians' practice on higher acuity and/or more complicated medical cases, leaving less time for a more holistic approach and continuity of care. As well, frequent consultations with nurses disrupted physicians' practice and increased the demands on their time.

All of the nurse participants felt secure working independent of physicians, but emphasized the importance of collaborating, especially on matters outside their scope of practice. In fact, nurses considered the collaborative approach to be more beneficial for everyone (i.e., patients and health care providers). When collaboration worked best, referrals flow both ways between nurses and physicians. Collaboration was not always viewed positively, with some participants noting that the time spent consulting with physicians sometimes resulted in appointment delays for both parties. In addition, participants expressed frustration when the nature of the work environment restricted physician contact to telephone consultations.

Rationale for Supporting Collaborative Practice

Most physician participants were of the opinion that extended/expanded role nurses should work in collaboration with them. This would ensure that patients received optimal care quality. Some physicians were also of the opinion that the nurse's emphasis should be more on wellness than primary care. One special area of concern identified was how well prepared nurses were to deal with patients presenting with high acuity levels, especially when doing on-call coverage without physician back-up.

Nurse participants were of the opinion that a collaborative approach to patient care not only provided all parties with the most benefits but also facilitated greater acceptance of the extended/expanded role by physicians, other health care providers and patients. It was apparent that the ease of access to physicians for consultations provided participants with a sense of security when dealing with problems beyond their normal scope of practice. It was also apparent that working under a collaborative model facilitated positive working relations among the various disciplines, and increased the probability of providing more comprehensive care.

Summary

In summary, physicians supported the autonomous practice of nurses with regard to performing primary care functions with the caveat that it occurs within a defined scope of practice, and necessary consultations are being made with physicians. Physicians, in general, did not support independent practice by extended/expanded role nurses unless there were limited medical resources. Nurse participants also supported autonomous practice, with the understanding that this would occur within the context of collaborative, as opposed to independent, practice arrangements.

3.3.3 Role Confusion: Patient Understanding, Acceptance and Satisfaction

Both physician and nurse participants agreed that patients experienced difficulty differentiating extended/expanded nursing roles from medical roles. Despite these difficulties, most physicians and nurses indicated that patients seemed to be quite satisfied with the level of care provided by extended/expanded role nurses.

Physicians comments differed slightly from the nurses on a couple of issues. Most physicians believed that patient acceptance of nurses was generally positive, especially for health issues related to wellness and minor illnesses. However, some were of the opinion that, for most things, patients would prefer to see the doctor. While a small number of participants felt that limited patient understanding of the role acted as a deterrent to wide-spread acceptance, others indicated that patients' comfort with nurses working in these roles increased over time as they developed more insight into what nurses could and could not do.

Many of the nurse participants believed that patients generally accepted them, were very satisfied with the increased availability of health care services, and experienced a greater sense of stability and continuity of care. Increased acceptance of nurses in these roles was attributed to the quality of the time spent with each person and educating him/her about the role. Importantly, patients seemed to be very supportive of the increased attention given to health promotion and illness prevention by team members. The fact that patients continued to come back to see nurses was viewed as acceptance of and satisfaction with them.

3.3.4 Barriers to and Facilitators of Collaborative Practice Models

Many of the physician participants considered the potential impact of the presence of extended/expanded role nurses in collaborative practice arrangements on patient accessibility to health care services, especially medical services. In contrast, nurse participants tended to focus more on the importance of having supportive structures in place to ensure full-implementation and acceptance of the extended/expanded role. Besides the accessibility factor, nurse and physician participants were especially cognizant of the benefits for and barriers to quality care delivery, especially from the perspective of comprehensiveness and continuity of services. The findings are organized around the three major themes that emerged from the data: 1) accessibility to health care services, 2) supportive structures, and 3) implications for quality.

Accessibility to Health Care: Implications for Medical Services

Due to observed decreases in the number of practising physicians in certain areas, physician participants recognized the need for alternative ways to deliver primary health care services and acknowledged that extended/expanded role nurses could buffer the negative impact of limited medical personnel. Conversely, some participants were of the opinion that these nurses posed significant barriers to physician recruitment and retention. This was especially true for fee-for-service physician colleagues who would perceive extended/expanded role nurses as a threat to their income. One negative consequence of not being able to attract sufficient numbers of medical personnel was the increased workload for physicians already present in the system.

Support Structures

Nurse participants identified the presence of strong working relationships with other health care providers, especially physicians, as an important factor facilitating adjustment to the extended/expanded role. It was also apparent that not all of the nurses received the same level of support from physicians, with participants clearly indicating that fee-for-service physicians were more resistant to their presence than salaried physicians. The combination of physician resistance and the newness of the role impeded the pace at which confidence was developed in implementing the role.

Particular emphasis was placed on the importance of educating the staff on the extended/expanded nursing role to reduce resistance during the early stages of practice. Many nurses indicated that greater awareness about the role through legislation and scope of practice guidelines had a positive impact on health care providers' attitudes toward the extended/expanded role. In addition, some participants believed that role clarification with other health care providers had an indirect effect on increasing public awareness.

Implications for Quality

Several physicians working in under-serviced areas identified an increase in the comprehensiveness of services as an important benefit of having extended/expanded role nurses. Specifically, the quality of patient care was believed to be enhanced because the presence of a collaborative approach meant that more time was available for providing primary care, as well as health promotion and prevention activities, and ensuring greater continuity of care. The downside was that nurses assumed a greater responsibility for providing primary care services while faced with restricted prescriptive authority, the absence of fraternity with speciality physicians, and limited access to resources, especially in remote areas. Furthermore, some physicians believed that without adequate supervision, nurses were operating at increased risk for unexpected problems which could compromise the quality of patient care. As well, continuity of patient care could be jeopardized when nurses referred to specialists without consulting with the primary care physician. Finally, concerns were raised about responsibility and legal issues with regard to who the responsible clinician should be in situations where nurses are seeing patients independently, screening them and deciding on the appropriate treatment plan.

Overall, nurse participants felt that the services being provided by nurses working in extended/expanded roles were having a positive impact on the overall wellness of the community. The success of ongoing public and staff education promoting greater awareness of extended/expanded nursing roles was reflected in increased utilization of nurses in various settings. When collaborative practice models were present onsite, team work was believed to be the key factor responsible for improving the comprehensiveness of health care services available to clients (i.e., health promotion and illness prevention were given as much weight as curative function) and promoting optimal health outcomes.

It was evident that nurse participants' satisfaction with the extended/expanded nursing role was strongly influenced by their ability to provide quality care and improve patient accessibility to different services. Nurse participants' identified several significant barriers to the full utilization of the extended/expanded nursing role within the health care system. One important impediment to the provision of comprehensive care was skills/knowledge limitations and/or scope of practice restrictions, especially with regard to diagnoses, treatment and referral abilities. Additional areas of dissatisfaction included the overall lack of recognition given to the extended/expanded nursing role, consumers' and other health care providers' perceptions of the role, the political climate, professional isolation in remote areas, limited human resources in remote areas restricted participation in continuing education activities, and inadequate financial reimbursement for extended/expanded nursing services. Furthermore, the physician fee-for-service system was identified as a barrier to the full implementation of the extended/expanded role. Participants emphasized the importance of developing an alternate funding mechanism.

Summary

Nurse and physician participants identified the pros and cons of working together under collaborative practice arrangements and being jointly responsible for providing primary care services to the public. The benefits and barriers for both groups of participants are itemized below.

Important benefits identified by physicians:

• increased patient accessibility to medical services, especially in rural and remote areas where there is a shortage of family doctors;
• increased availability of comprehensive health care services (i.e., primary care coupled with prevention and health promotion strategies);
• improved quality of care and increased probability of achieving positive health outcomes;

Important benefits identified by nurses:

• increased access to supportive individuals and collegial relations with other health care providers, especially physicians, facilitates confidence building and adjustment to the extended/expanded role;
• increased availability of comprehensive health care services (i.e., primary care coupled with prevention and health promotion strategies) to patients;
• improved quality and continuity of care and the probability of achieving positive health outcomes.

The barriers to full-utilization and acceptance of extended/expanded nursing roles identified by physicians:

• negative impact on the income of fee-for-service physicians;
• potential for impeding physician recruitment and retention;
• no mechanism in place for fee-for-service physicians in private practice to hire nurses to work in extended/expanded roles;
• decreased effectiveness of extended/expanded nursing roles due to restricted prescriptive authority, absence of fraternity with speciality physicians and limited access to diagnostic services, especially in rural/remote areas;
• potential for continuity of care problems when nurses order diagnostic tests independent of physicians;
• inadequate nurse supervision may result in the provision of poorer quality care to patients;
• responsibility and liability concerns for attending physicians when nurses see patients independently.

The barriers to full-utilization and acceptance of nurses with extended/expanded roles highlighted by nurses were as follows:

• decreased ability to provide comprehensive health care services due to skill/knowledge limitations;
• decreased effectiveness of the extended/expanded nursing roles due to restrictions imposed on scope of practice (e.g., prescriptive authority, ease of access to referrals and diagnostic services, etc.);
• thwarted/delayed acceptance of extended/expanded nursing roles due to inadequate public/professional awareness;
• restricted utilization of extended/expanded role nurses in private physicians practice due to the heavy reliance on a fee-for-service system and the absence of alternative funding mechanisms;
• increased role strain and delayed confidence-building due to the presence of unsupportive physicians;
• resistance from physicians, especially those compensated by fee-for-service, impeded full implementation of the extended/expanded role.

3.4 Patient Perceptions (see SD3)

The surveys completed by 58 patients in the study sites provided information about their experiences and satisfaction levels with registered nurses working in extended/expanded roles. With regard to how patients experienced nurses during clinic visits, special consideration was given to the reason for the current visit, average wait time during clinic appointments, number of appointments over past year, number of times medications were ordered or renewed, and the frequency of referrals to and from nurses. The findings on patient experiences indicated that:

• 83% of visits were for regular checkups and the management of ongoing conditions.
• 62% of patients did not require a new or renewed prescription during any of the visits.
• 79% of patients were not referred to the nurse by another health care provider.
• 52% of patients reported that the nurse did not refer them to other health care providers.
• 69% of nurses usually performed physical exams and 85% provided advice on self-care measures.
• Nurses rarely or never ordered blood tests (60%), x-rays (85%) or prescribed medications (61%).

The second area of investigation focussed on patients level of satisfaction with the care received, information provided on their illness, the amount of time spent waiting to see the nurse, follow-up care, the level of knowledge and abilities that nurses had to treat them, and the time spent by nurses to help them understand illness and treatment requirements. The findings on patient satisfaction were as follows:

• 98% of patients were satisfied with the care received, from nurses, the information provided on their illness (92%), the amount of time spent waiting to see the nurse (84%), and follow-up care (88%).
• 90% of patients were satisfied that nurses had the necessary knowledge and abilities to treat them and spent enough time helping them understand their illness and treatment requirements (96%).

In summary, the findings suggest that most patients responding to this survey had accepted nurses in extended/expanded roles. This conclusion is based on the varied reasons for seeing the nurse, the diverse activities initiated and/or performed by nurses during clinic visits, and the frequency with which patients continued to schedule appointments with nurses. In addition, the high degree of satisfaction with the care provided by nurses working in extended/expanded roles is a further indication that respondents had accepted the extended/expanded role.

3.5 Observation of Nurses Practice (see SD 3)

Findings from 82 nurse - patient observations conducted at the study sites provided insight into the nature of nurses' practice while working in the extended/expanded role. Nurse - patient observation sessions revealed that:

• The majority of patients seen were adult females.
• 84% of patient visits lasted less than 30 minutes.
• 50% of patient visits were for the assessment and management of acute illness or injury, 23% for the management of chronic illness and 27% for well person screening.
• 77% of patients seen were assessed, diagnosed and treated independently by the nurse.
• Nurses, in managing patient care, went beyond the presenting health need and addressed the physical, psychological, emotional and social well being of patients.
• Nurses performed a broad range of preventive, promotive and supportive activities.
• Nurses, when faced with complex medical problems outside their scope of practice, consulted and referred to primary care physicians and/or specialists.

In summary, the observational findings suggest that nurses working in extended/expanded roles in urban, rural, and remote primary health care settings engage in autonomous practice and perform a broad range of activities when seeing patients present with acute illness/injury, chronic illness and wellness issues. Nurses demonstrated a high degree of confidence, sensitivity and definiteness in their interactions with patients. Nurses consulted with other health care providers especially physicians, when it was felt that patients would benefit from being seen by someone else with a different level of expertise.