Research : Reports

4.0 Conclusions and Recommendations [Table of Contents]

4.1 Policy and Legislative Frameworks

The extension/expansion of the nursing role through legislation has not been universally accepted across Canada. While some provinces/territories have legitimized, or are contemplating legitimizing, primary care functions through legislative intervention, other jurisdictions prefer to rely on protocol arrangements. Delegated medical functions have traditionally been the means by which nurses have been able to legally undertake the curative functions of primary health care. Unfortunately, there is no consistency in protocol arrangements across jurisdictions as the authorities are reflective of the unique circumstances of the practice setting.

The findings from the administrative survey and on-site data collection indicated that the full utilization of nursing competencies in the extended/expanded role is dependent upon the location (i.e., remote, rural and urban) and relative supply of other health care providers. The more remote the location and the lower the concentration of physicians, the greater the reliance on the nurse for providing a broad range of primary care services. In contrast, when there are greater concentrations of physicians and other providers in rural and urban areas, there is more competition for access to scarce resources and less evidence of delegation of medical authorities even though extended/expanded role nurses have the required competency to perform primary care functions.

The one great advantage of delegated medical functions is their flexibility which allows for more situational-specific responses. Although Saskatchewan implemented a province-wide protocol agreement as part of its primary health care initiative, both the primary care nurses and physicians interviewed noted that delegated medical functions vary by site and depend on physician preference. The administrative survey results also indicated that extended/expanded role nurses in other provinces/territories perform primary care functions under the authority of site-specific protocols. The disadvantage of relying upon delegated functions is that the parameters of the extended/expanded nursing role are subject to influence from the medical and/or pharmacy professions, and employers. One important question that surfaces from all of this is whether or not registered nurses who are operating under protocols are performing medical or nursing acts. Stated somewhat differently, if the authority to perform primary care functions is by protocol arrangements through the authority of medicine as opposed to nursing legislation, is this really extended/expanded nursing practice? Advocates within the nursing profession who endorse a legislative approach argue that deriving authority under delegated medical functions does little to establish the extended/expanded role nurse as a legitimate provider in the health care system.

Another area of concern emanating from delegated medical functions relates to responsibility and liability issues. This seems to be true regardless of provinces'/territories' educational requirements for the extended/expanded nursing role. The reality of this situation is supported by the issues confronting the nursing association in Quebec (i.e., adequacy of existing legislation and/or protocol agreements to authorize nurses' to perform certain primary care functions). Furthermore, several of the physicians who participated in the on-site data collection phase in different jurisdictions expressed concern about the level of autonomous practice that nurses were expected to assume in certain situations (e.g., on-call coverage, remote clinics, etc.). In fact, some of them questioned whether the nurse or physician would be held accountable in the event of problems. The general feeling was that there should be a better match between what employers expect of extended/expanded role nurses in the practice setting versus what they are prepared to do in their education programs.

A final area of concern that surfaced during the course of this study related to legislative barriers that prevented full enactment of the extended/expanded role, even in areas where the role was protected by nursing legislation and regulation. As reported by participating individuals in both the administrative surveys and study sites, registered nurses working in extended/expanded roles may have restrictions imposed on diagnostic, prescriptive and referral authorities, as well as hospital admitting privileges. The relevant legislation which covers these matters also require amendment to accommodate extended/expanded role nurses.

In conclusion, a more coordinated approach is required in extending authorities to registered nurses responsible for delivering primary care services. As long as the extended/expanded role is a delegated medical function, it is difficult for the nursing profession to regulate extended/expanded nursing practice and/or ensure that registered nurses are appropriately educated for and competent to perform primary care functions. A legislative approach will ensure that the nursing profession has more control over the scope of practice for registered nurses working in extended/expanded roles. The most conducive approach then is to amend nursing legislation, develop additional regulations for the extended/expanded nursing role, and amend other relevant legislation to facilitate full enactment of the role.

Recommendation 1

It is recommended that legislation be introduced in all remaining jurisdictions to legitimize the extended/expanded role of the registered nurse and to facilitate access to necessary resources within the health care system. This approach will ensure that extended/expanded roles for registered nurses are included within the scope of practice of the nursing profession.

Recommendation 2

It is recommended that all relevant legislation be amended to facilitate consistent access to necessary resources within the health care system and the full implementation of the extended/expanded nursing role as mandated in each jurisdiction.

4.2 Regulatory Framework

There are educational programs in most Canadian jurisdictions that provide nurses with the required knowledge and skills to perform primary care functions. In the provinces which participated in the on-site data collection component of this project (i.e., Ontario, Newfoundland and Labrador, and Saskatchewan), many of the registered nurses practising in the extended/expanded role had successfully completed an advanced program of study. However, inconsistencies were observed in the level of nursing education requirements for entry into these programs. It was also noted in the cross-country survey of administrative personnel in organizations employing nurses to work in extended/expanded roles that mechanisms for ensuring beginning and continued competency in performing primary care functions were quite variable regardless of whether the responsible authority was legislation or delegated medical functions.

One significant concern raised throughout the different phases of this research project was the delegation of medical functions to registered nurses without adequate educational preparation and/or the required clinical expertise to perform them. Several nursing associations indicated that some of their members were wary about being liable when performing primary care functions which required them to go beyond their defined scope of practice and/or normally expected competency levels. Physicians interviewed during the on-site data collection phase expressed similar concerns about the uncertainty surrounding the scope of extended/expanded nursing practice and the required competencies of registered nurses performing primary care functions. While physicians indicated that nurses were valued members of the collaborative team, one significant barrier to wide-spread acceptance was the inadequacies observed in nurses' educational preparation, especially with regard to practical knowledge and abilities. Without exception, every physician stressed the importance of ensuring that nurses receive adequate practical experience before assuming extended/expanded roles. In addition, some physicians raised concerns about the absence of minimum standards for entry into the extended/expanded role and stressed the need for more extensive clinical experiences with physicians during education programs.

The nurses interviewed were concerned about the absence of standards of practice for extended/expanded nursing roles and inconsistent entry requirements into education programs which impeded their mobility within and across Canadian jurisdictions. In essence, the findings from different sources highlighted the need for more clearly defined scope of practice parameters for the extended/expanded nursing role, as well as the development of consistent standards for entry into this type of nursing practice. If such measures were instituted, registered nurses who practice in extended/expanded nursing roles would have the required core competencies to perform all functions expected of them.

Some of the nurses who participated in the interviews on-site suggested that the program preparing them for the extended/expanded role could have been longer in duration, especially with regard to the clinical component. This factor, along with having a degree, was seen as having a significant influence on personal feelings of competency, as well as credibility in the eyes of other health care providers. Many participants also felt strongly about the importance of public education and standardizing qualifications for extended/expanded practice. These activities were considered essential to ensure full understanding of nurses' scope of practice as well as maximum utilization of nursing services.

Another area of concern was the variant practice requirements for registered nurses working in extended/expanded roles in remote versus rural versus urban settings. From a practice perspective, remote settings may present particular challenges. The obligation is on the employer to ensure that nurses practising in the extended/expanded role have access to the resources needed to deliver services to the public that are safe and of acceptable quality. From a public policy perspective, the location of a nurse in an extended/expanded role should not be an issue. It is the responsibility of the licensing body to ensure that all registered nurses working in this role are licenced to meet expected core competencies. With the license to practice in extended/expanded roles, nurses must satisfy minimal education requirements and be deemed competent to perform required primary care functions.

Every physician stressed the importance of ensuring that nurses receive adequate practical experience before assuming extended/expanded roles. In addition, some physicians raised concerns about the absence of minimum standards for entry into the extended/expanded role and stressed the need for more extensive clinical experiences with physicians during education programs.

The nurses interviewed were concerned about the absence of standards of practice for extended/expanded nursing roles and inconsistent entry requirements into education programs which impeded their mobility within and across Canadian jurisdictions. In essence, the findings from different sources highlighted the need for more clearly defined scope of practice parameters for the extended/expanded nursing role, as well as the development of consistent standards for entry into this type of nursing practice. As well, many of the nurses indicated that they were restricted to continuing medical education offerings. While it is positive that such continuing education opportunities are accessible to nurses, they also need access to programming that is based on the philosophy, values and knowledge of the nursing profession. This is an issue that must assume high priority in the immediate future.

Recommendation 3

It is recommended that core competencies and standards of practice for registered nurses in the extended/expanded role be developed and used to facilitate consistency in education programs for beginning competency levels. Importantly, education programs must ensure that the clinical component is of sufficient breadth, length and intensity to facilitate registered nurses' entry into primary care practice.

Recommendation 4

It is also recommended that nurses working in extended/expanded roles be supported with continuing nursing education activities relevant for the primary care aspect of primary health care. This type of supportive structure is needed to ensure that registered nurses keep abreast of latest developments and maintain required competency levels.

4.3 Terminology and Definition Problems

Early in the research process, the project team searched for an appropriate and acceptable glossary of terms to use in this study. This proved to be quite challenging due to the inconsistences noted across Canada. In particular, there was no common understanding of the terms and definitions used to describe those aspects of the extended/expanded nursing role which relate to the performance of primary care functions in primary health care settings. This state of affairs was evident in the data collected from the organized nursing community, other professional groups, Ministries of Health and members of the public. A few of the problem areas are outlined below:

The confusion over terminology and definitions does little to facilitate full implementation of the extended/expanded nursing role in all jurisdictions. There is an obvious need for greater consistency in term usage, as well as greater clarification of the parameters of extended/expanded nursing role which relate to primary care functions. When professionals outside nursing and decision-makers are asked to support greater use of extended/expanded role nurses in providing primary care services, there must be a clear understanding of what they are being asked to endorse. Goals are not easily attained when there is an absence of common understandings.

Recommendation 5

National, provincial and territorial nursing associations and stakeholder groups facilitate consistent language and definitions relative to the extended/expanded nursing role in primary health care. This approach will heighten awareness of the role and facilitate greater acceptance of registered nurses' delivering primary care to diverse populations in all Canadian jurisdictions.

4.4 Availability of Quality Services to the Public

Overall, key informants who participated in all phases of this project indicated that the most conducive situation for ensuring that quality primary health care was available to the public was for all health care providers to work collaboratively within close proximity to each other. The administrative survey participants felt that provider collaboration and team work enhanced the coordination and continuity of care provided by their organizations. The physicians and nurses who participated in the on-site study component viewed the presence of nurses with extended/expanded roles in primary health care settings as having a positive impact on the quality of health care services available to patients (i.e., improved accessibility to primary care services and health promotion and illness prevention activities).

While physicians participating in this study believed that the multi-disciplinary team approach espoused by community health centres is a "good way of providing care", they also had serious reservations about the benefits for medicine. Physician resistance to the extended/expanded nursing role was identified as one barrier to its full implementation. The heavy workload for all providers in under-serviced areas was also identified as a major barrier to delivering primary health care. Additional physician concerns related to the negative repercussions of having nurses assume too much autonomy or independent function (i.e., greater potential for compromising continuity of care; decreased ability to recruit and retain physicians, especially fee-for-service physicians; and increased responsibility and legality issues).

Nurse participants in the on-site data collection phase also identified some of the negatives of working in extended/expanded roles in primary health care settings. One recurring theme was the importance of the presence of a supportive working environment to help facilitate the introduction and acceptance of nurses. A second theme was that physician resistance was the most significant barrier that these nurses had to confront and overcome since assuming their positions. It was apparent that physician cooperation or resistance was a key factor influencing satisfaction with the role, confidence building, and the ability to implement the role as defined by scope of practice guidelines. A third theme related to the significant changes experienced in their practice with the changing supply of local physicians. In areas with physician shortages, nurses were responsible for co-ordinating activities in busy clinics and assuming most of the responsibility for patient follow-up. In areas with a greater concentration of physicians, especially those working under fee-for-service mechanisms, participants had restrictions imposed on their scope of practice and access to diagnostic services and other community resources.

Both the nurse and physician participants mentioned the negative impact of current physician compensation schemes on effective integration and coordination of primary health care services. Resistance from fee-for-service physicians and specialists was highlighted by both nurses and physicians as a significant barrier to full-implementation of the extended/expanded nursing role in certain jurisdictions. Participants identified a number of reasons for this resistance: 1) fee-for-service physicians working in private practice cannot charge for consultation with a nurse in an extended/expanded role; 2) fee-for-service physicians can not hire extended/expanded role nurses because they are prevented from billing the compensation scheme for the services rendered to patients by this provider; and, 3) specialist physicians can not be compensated at specialty rates for services rendered when referrals are initiated by a nurse practising in the extended/expanded role. Without an adequate compensation package for physicians, successful integration of the extended/expanded nursing role is being severely compromised.

Recommendation 6

It is recommended that collaborative practice arrangements between physicians and extended/expanded role nurses, along with other providers, be the norm for all practice settings. This type of approach will facilitate the effective use of all health care providers and ensure that the most comprehensive and integrated primary health care services of the highest quality are available to diverse population groups.

Recommendation 7

It is also recommended that the necessary mechanisms be instituted in all provincial/territorial jurisdictions to ensure ongoing monitoring of the quality and comprehensiveness of primary health care services available to the public.

Recommendation 8

It is recommended that alternative funding mechanisms for physicians be established. This will ensure that physicians are fairly compensated for collaborating with extended/expanded role nurses.