Executive Summary

[Table of Contents]

In March, 1999 the federal/provincial/territorial Advisory Committee on Health Human Resources (ACHHR) Working Group on Nursing and Unregulated Workers sponsored a study to describe the nature of the extended/expanded nursing role in Canada. The focus of this project was on the primary care aspect of registered nurses' practice (i.e., assessment, diagnosis, and treatment of episodic, acute and chronic illness, and minor injury). The purpose of the current project was to identify facilitators of and barriers to the effective delivery of primary care services by registered nurses working in extended/expanded roles. A second purpose was to recommend policy options that would facilitate more effective utilization of registered nurses working in these roles.

The extended/expanded role of the registered nurse is most often associated with the north and remote areas where there are limited numbers of health professionals to service the population. However, there are registered nurses practising in the role in other locations and settings. With health care reform, the possibilities offered by greater use of the extended/expanded nursing practice is a matter of interest to all levels of government. This report outlines the research activities undertaken by the project team, key study findings, and policy recommendations that are supported by study findings.

Research Program

The project used a research design which combined data, investigator and methodological triangulation. The phases of the research program included the following sequential activities:

• establishing terms and definitions for the purposes of the project;
• contacting representatives from nursing associations and provincial/territorial ministries of health to develop a profile of policy and legislative/regulatory frameworks governing nursing practice within each jurisdiction, while giving special attention to provisions for the extended/expanded nursing role in primary health care settings;
• conducting an administrative survey of key informants present at sites within each province/territory to construct a profile of the organizational structures present in settings employing nurses to work in the extended/expanded role;
• collecting data at selected sites to gauge physicians' perceptions of the extended/expanded nursing role , as well as the perceptions of registered nurses' working in the role; to describe the experiences of nurses working in the role; and to gauge patient satisfaction with the services delivered by nurses working in the extended/expanded role;
• conducting an integrated analysis of all data sets to identify key facilitators and barriers to the full utilization of the extended/expanded nursing role.

Results & Conclusions

The different phases of the research program provides the framework for highlighting key study findings. The overview of the findings is followed by several important policy implications that emerged during the data analysis phase.

• Developing a Glossary of Terms for the project proved to be problematic due to the absence of common understandings of key terms used in the field.
• The Policy and Legislative Frameworks governing nursing practice in the extended/expanded role were found to be quite variable across provincial/territorial jurisdictions. Overall, the review indicated that the extended/expanded nursing role has evolved without a consistent policy direction and is highly dependent upon the circumstances present in the jurisdiction. While traditionally nurses' authority for performing primary care functions has been derived through delegated medical functions, four jurisdictions have enacted legislation to legitimize the extended/expanded nursing role. The major limitations were noted from a review of provincial/territorial frameworks related to titling, scope of practice and education requirements.

The findings revealed that several titles are currently in use across Canada to designate extended/expanded role nurses, ranging from nurse practitioner to primary care nurse to regional nurse. While the three provinces with legislation in effect have fairly consistent titling within their jurisdictions, the title for the extended/expanded nursing role varies by setting and by employer in all other provinces/territories, with the exception of Saskatchewan.

In jurisdictions with legislation, the scope of practice parameters guiding implementation of the extended/expanded role are very consistent across primary health care settings. This situation was also observed for Saskatchewan which has a province-wide protocol governing extended/expanded nursing practice. Significantly, the scope of practice for the extended/expanded nursing role varies within and across provincial/territorial jurisdictions and are a function of delegated medical authorities.

Provincial/territorial inconsistencies were noted in expectations regarding the educational preparation of registered nurses for the extended/expanded role in primary care. In addition, the nature and duration of education programs preparing registered nurses for the extended/expanded role in primary care varied across and within provincial/territorial jurisdictions (i.e., ranging from 2 to 6 week intensive courses to one-year diploma programs to undergraduate and graduate programs). The most noteworthy variations were in program entry requirements, course and clinical requirements and status upon graduation.

• A Profile of Extended/Expanded Nursing Practice was constructed from the data collected from a survey of administrators working at 44 provincial/territorial sites with different and similar organizational structures. The major content areas emerging from this phase of the analysis related to factors influencing different models of practice, lines of authority and quality of care initiatives and evaluation mechanisms for assessing organizational and client outcomes present in the different jurisdictions. The key factors identified during this phase of the analysis included:
• 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.
• The On-Site Data Collection occurred in urban, rural and remote settings with variant collaborative practice models and levels of autonomous practice. Information was gathered from registered nurses working in extended/expanded roles, physicians working with these nurses, and patients who received care from these nurses. The key themes emerging from the interview data obtained from physicians and nurses' included: practical knowing, collaborative versus independent practice models, role confusion, and barriers to and facilitators of collaborative practice models. A brief summary is presented on each of these themes, as well as patient perceptions of the extended/expanded nursing role and observational sessions conducted with extended/expanded role nurses .

With regard to Practical Knowing, both physicians and nurses voiced concerns about the adequacy of knowledge levels and practical skills of extended/expanded role nurses when first assuming the role. The diversities in knowledge and skills observed by physicians and low feelings of confidence and competence expressed by nurses, as well as the improvements noted after acquiring an experiential base, led both groups to recommend the following: 1) standardize entry requirements into programs preparing nurses for extended/expanded practice, 2) increase the clinical component of these programs, 3) access to continuing education opportunities to promote necessary competencies in expected primary care functions and, 4) establish well-defined and universal standards for extended/expanded nursing practice.

With regard to the Collaborative versus Independent Practice Models theme, both physicians and nurses favoured team work or strong inter-disciplinary collaboration over independent practice for extended/expanded role nurses. Physicians supported autonomous practice so long as nurses working in these roles adhered to scope of practice guidelines and worked under collaborative practice arrangements with physicians. Nurses also felt that collaborative, as opposed to independent, practice arrangements offered the best care to patients, and facilitated full acceptance of extended/expanded nursing practice by physicians and patients.

Role Confusion by patients was a concern of both physicians and nurses. The consensus was that patients experience difficulty differentiating extended/expanded nursing roles from medical roles. Despite this confusion, physicians and nurses believed that patients seemed to be satisfied with the level of care provided by the nurses in the extended/expanded role.

There were commonalities and differences in the identified Barriers to and Facilitators of Collaborative Practice Models identified by nurse and physician participants. Both groups highlighted the benefits for and barriers to quality care delivery, especially from the perspective of comprehensiveness and continuity of services. Physician participants tended to focus more on the potential impact of the extended/expanded role nurses on patient accessibility to health care services, especially medical services. In contrast, nurse participants were more concerned about having the necessary supports in place to ensure full-implementation and acceptance of the extended/expanded role.

The important benefits identified by physicians resulting from having nurses practising in extended/expanded roles included: 1) increased patient accessibility to medical services in rural and remote areas, 2) increased availability of comprehensive health care services, and 3) improved quality of care and increased probability of positive health outcomes. Conversely, physicians identified several important barriers to full-utilization and acceptance of extended/expanded nursing, including: 1) negative impact on the income of fee-for-service physicians; 2) potential for impeding physician recruitment and retention; 3) no mechanism in place for fee-for-service physicians in private practice to hire nurses to work in extended/expanded roles; 4) 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; 5) potential for continuity of care problems when nurses order diagnostic tests independent of physicians; 6) inadequate nurse supervision may result in the provision of poorer quality care to patients; 7) responsibility and liability concerns for attending physicians when nurses see patients independently.

With regards to the benefits from having extended/expanded role nurses, nurses participants identified the following: 1) 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; 2) increased availability of comprehensive health care services (i.e., primary care coupled with prevention and health promotion strategies) to patients; and 3) improved quality and continuity of care and the probability of achieving positive health outcomes. The major barriers to the extended/expanded nursing role identified by nurse participants included: 1) decreased ability to provide comprehensive health care services due to skill/knowledge limitations; 2) 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.); 3) thwarted/delayed acceptance of extended/expanded nursing roles due to inadequate public/professional awareness; 4) 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; 5) increased role strain and delayed confidence-building due to the presence of unsupportive physicians; and 6) resistance from physicians, especially those compensated by fee-for-service, impeded full implementation of the extended/ expanded role.

With regard to Patient Perceptions, the surveys completed by 58 patients at the sites visited confirmed the diversity of the functions performed by extended/expanded role nurses. It was also apparent from the survey data that patients were a very satisfied with the care provided by these nurses.

The final category of data is based on the Observations of Nurses while enacting the extended/expanded role. The 82 nurse-patient observation sessions provided insight into the nature of extended/expanded nursing practice. The observational findings suggested that nurses working in extended/expanded roles in all primary health care settings engage in autonomous practice and perform a broad range of activities when dealing with patients presenting with a variety of acute illness/injury, chronic illness and wellness issues. Overall, nurse participants demonstrated a high degree of confidence and consulted with other health care providers, especially physicians, when patients required care beyond their scope of practice.

• There were several Recommendations derived from the findings generated during the different phases of this research project. The following is a detailed overview of this study's recommendations:

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.

Recommendation 3: It is recommended that core competencies and consistent practice standards for registered nurses in the extended/expanded role be developed and used to facilitate consistency in education programs for beginning competency levels.

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.

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.

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.

• Dissemination Plan

The Centre for Nursing Studies will assume responsibility for dissemination of the research. This report and supporting documents will be available at www.cns.nf.ca.