
	Research : Reports

3.0 Profile of Extended/Expanded Nursing Practice [Table of Contents]

During the initial stage of developing profiles of registered nursing practice models in Canada relating to primary care in primary health care settings, it became evident that there are significant differences among the provinces and territories with respect to approaches to the delivery of nursing services. Although there are a number of possible explanations for these disparate conditions, one key influencing factor is the environment in which the profession is operating under in each jurisdiction.
In order to develop a profile of registered nursing primary care practices in primary health care settings, it is necessary to state the assumption underlying the profile, and to identify the factors used in the development of the profile. Upon completion of the profile, this information was used to assist with the selection of sites deemed most appropriate for in-depth research to contribute to an assessment of nursing practice models in primary health care settings.
Several key factors were identified across jurisdictions which provide an overview of the legislation, policy and standards guiding the various nursing practice models operant in Canada today.
These factors are:

Policy Framework

Legal Authority

Title

Scope of Practice

Education Programs

Organizational Structure

There is an inconsistency in the approaches taken across the provinces and territories with regard to the types of extended/expanded practice models in operation. This is not surprising as each jurisdiction is responsible for the regulation of nursing within its boundaries and each province or territory must respond to differing needs and circumstances. The factors forming the profile help to highlight the broad parameters of the practice models.
3.1 Policy Framework
Public policy refers to decisions or directions undertaken by government that are intended to benefit or protect the public interest. Associated with these decisions are allocations of resources to support the implementation of the underlying policy objective. To consider various nursing models, and more particularly the functions under consideration in this research, they must be considered in the context of public policy and how the goals of public policy relate to the extension/expansion of nursing roles.
When a public policy issue arises, there are many options that can be considered. Government may decide to do nothing if intervention is not seen as appropriate or required to protect the public interest. On the other hand, government may decide to intervene, for example, by the introduction of legislation. It depends on the nature of the issue and the circumstances that determine the action by government.
The functions under consideration of this study, namely assessment, diagnosis and treatment of acute, episodic chronic illness or injury, have traditionally been delegated by government exclusively to the medical profession. For the purposes of this paper, these functions are described as functions of primary care. In certain circumstances, these been delegated to nurses to respond to the need for primary care services particularly where there is an inadequate supply of physicians to provide these services. In this case, the nurse must undertake special preparation before performing these functions. Nurses in these roles have extended or expanded their practice into the these areas of medical practice.
Some Canadian jurisdictions prefer to rely on the delegation of medical functions through protocol arrangements between licensing bodies, employers and sometimes government to provide authorities for nurses to perform primary care. The protocol arrangements do not transfer the authority to all nurses to engage in the activity, only those who are subject to the arrangement. Nurses have to be educated to undertake the functions transferred. In order to perform the role there is a requirement to access resources of the health care system such as ordering diagnostic tests, prescribing medications and/or referring to other heath care providers. Some protocols permit the nurse to access resources that are not otherwise available to them, e.g., authority to order tests at the employing hospital.
In recent years these have been delegated to nurses in some through specific legislation. This intervention essentially expands the scope of practice of nursing, but only for those who qualify to practise in extended/expanded role.
Thus the policy context of this study is the policy direction of the provincial and territorial governments have authorized nurses to primary care services. Either it has been delegated to the medical profession which in turn has delegated certain functions to nurses within limits. Alternately, if has been through the enactment of specific legislation extending authority, within defined limits, to nurses to undertake these functions.
In under serviced areas, like the north, physician shortages mean greater reliance on nurses for primary care delivery. The Medical Services Branch (MSB)of Health Canada guidelines deal, in part, with functions undertaken which lie outside the traditional scope of registered nursing practice. Although this is a situation of long standing, present day concerns about jurisdictional autonomy, legality, responsibility and accountability are being expressed more frequently by various nurses’ associations.
There are provinces/territories contemplating legislative intervention; others have no plans to do so. There are implications for either decision for the nursing profession. There is evidence of a movement toward uniformity and consistency in the policy positions related to extended/expanded practice which is driven in part by national agreements and also by the efforts of the Canadian Nurses Association. While the broader implications for the nursing profession are beyond the scope of this research, the issues must be highlighted from a public policy perspective.
3.2 Legislative Framework
Under the Canadian constitution, the regulation of occupations such as medicine and nursing is the responsibility of each province and territory. Through the passage of legislation, professions have been extended authorities of self-regulation. All jurisdictions with Canada have delegated authorities of self-regulation to the nursing profession.
There are three provinces that have recognized, through legislation, the extended functions of registered nurses - Ontario, Alberta and Newfoundland. In these jurisdictions, there is a specific class or certification process undertaken that gives registered nurses the privilege to practise in the extended/expanded roles. Manitoba has enacted legislation but it is not yet proclaimed. In these jurisdictions, practitioners who are prepared through additional education and those who are deemed competent to deliver these services to the public are authorized by the regulatory body to do so. Yukon has legislation sufficiently encompassing to accommodate a broad scope of practice when combined with the adoption of the Medical Services Guidelines.
The circumstances of each jurisdiction will be considered from the policy and legislative frameworks currently in place.
The legislative frameworks can be classified as broadly falling into one of several regimes:

Specific reference of extended/expanded scope of practice under nursing legislation;

Regulation of nursing practice, including nursing practice in extended/expanded roles, under delegated authority of a Medical Act; or

Nursing practice within the scope of nursing practice in nursing legislation that does not contemplate extended/expanded roles;

Jurisdictions in which the situation is not so well defined or clear. These range from:

a jurisdiction being required to revise the legislative framework to accommodate modern views of nursing practice;

a jurisdiction being positioned to avail of extended practice when conditions indicate that it is acceptable to proceed;

a jurisdiction which has enacted legislation which has yet to be proclaimed;

a jurisdiction which has sufficiently encompassing legislative provisions to accommodate growth in the areas of extended/expanded practice.

These regimes will be addressed in turn.
Specific Authorities for Extended/Expanded Nursing Practice in Legislation by Jurisdiction
Three jurisdictions that specifically accommodate extended/expanded nursing practice through legislation, namely Alberta, Ontario and Newfoundland. This regulation is related to nursing practice in primary care settings and namely for the purposes of this study the functions of assessment, diagnosis and treatment of episodic, acute and chronic illness or injury. Each province has addressed the situation slightly differently in response to the sensitivities in its respective jurisdiction.
Alberta
The provision of extended health services is provided for through an amendment to the Public Health Act (1996) and accompanying regulations. A companion regulation under the Nursing Profession Act is titled: “Nursing Profession Extended Practice Roster Regulation”. This regulation was enacted in February1999 to set out a specialty roster for those registered nurses who require additional regulatory authority enabling them to diagnose and treat common disorders of adults and children, and to refer and provide emergency treatment as is appropriate. Specific requirements must be met in terms of education and experience to be eligible for the roster.
The regulations are intended to provide the basis for the continuing development of extended practice initiatives in the province. In the regulations, “extended practice” is defined as “the practice of a registered nurse that is authorized under an enactment and has been recommended by the Registration Committee as extended practice and approved by the Council”. In 1998, a regulation was made under the Pharmaceutical Profession Act to enable registered nurses to prescribe drugs if they are permitted to do so under the Public Health Act regulations.
Currently, Alberta is making use of extended practice nurses in some community health centres where their practice is the complete responsibility of the governing body of the centre. They can only be employed by the Department of Health, a regional health authority or a regional health board.
Ontario
Under the Regulated Health Professions Act, Ontario has relatively well-defined scopes of practice for each profession because the functions of practice or “controlled acts ” for each profession are defined. This method of operation does not prevent the possibility of overlap between professions. “Authorized acts” as identified in the Nursing Act, can only be performed when permitted by regulation or when ordered by a physician, midwife, dentist, chiropodist or RN (EC).
Ontario has created an extended class certificate of registration by way of an amending statute under the Nursing Act for those who practice in primary care as a “Nurse Practitioner”. This statute, known as Expanded Nursing Services for Patients Act, was enacted in 1997. It defines the scope of the role of the nurse practising in the extended class.
Generally speaking, the registered nurses in the extended class RN (EC) have additional authorities including:

communicating a diagnosis of a disease or disorder;

ordering the application of a form of energy as prescribed in the regulations under the Act,

prescribing and administration of medications within a Schedule of medications; and

administering, by injection or inhalation, a drug that may be prescribed under the Schedule of medications.

These authorities are subject to terms and conditions identified in regulation. The Standards of Practice for RN (EC)s clearly identify expectations for consultation with members of other professions. Related professional statues were amended to accommodate the extension of the authorities to nurses practising in the extended class.
Newfoundland and Labrador
The Newfoundland Nurse Practitioner - Primary Health Care Regulations are prescribed under the Registered Nurses Act. The regulations have created a regime extending similar authorities as the Ontario regime, that is, the ability to assess, diagnose and treat emergent, urgent and non-urgent illnesses and injuries as per the approved schedules. This includes the ordering of diagnostic tests and prescribing of drugs as per approved schedules. The statute also specifically protects the title "nurse practitioner" or "NP". This is the only jurisdiction in the country which does so.
As with any new regime or program, there are issues identified through experience that require attention. For example, there is a requirement to consult with a physician in circumstances defined in the regulations, such as when chronic illness or injury destabilizes. There have been concerns raised by the Newfoundland Medical Association respecting the potential liability of physicians arising from the overall responsibility of physicians. This seems to have been settled for the moment.
Complicating the issue of liability are the policies governing physician compensation in the Province. The policies allow payment for fee-for-service for "consultation" defined as physician consulting with a physician, not a nurse practitioner. Thus there are circumstances where a physician may not be paid for services rendered. This situation is recognized by the Department of Health and Community Services and proposals to alter the compensation scheme are under consideration.
There are other issues which are under review that may require amendment to existing statutes and/or additional access to health care resources by Nurse Practitioners.
Manitoba - enacted by not yet proclaimed
Manitoba has nurses practising in extended/expanded roles under the authority of delegated medical function. The province has taken the step to prepare and pass new legislation (The Registered Nurses Act, SM 1999, Chapter36). This Act, once proclaimed, will specifically permit nurses who have fulfilled regulatory requirements to perform "included practices". The included practices cover ordering and receiving reports of screening and diagnostic tests designated in the regulations, prescribing drugs designated in the regulations and, performing minor surgical and invasive procedures designated in the regulations (sect. 2(2)). No specific title relative to extended/expanded nursing role practice is protected in the new legislation.
Other Frameworks
Yukon
The statutory framework of the Yukon , while not specifically referencing extended/expanded practice, was crafted to permit a wide scope of practice for registered nurses which may include extended/expanded practices for which nurses have satisfied required competencies. The Registered Nurses Profession Act was enacted in 1992. The completion of the transfer of all health services and administration formerly provided by the Medical Services Branch (MSB) of Health Canada to the Government of Yukon was accomplished in 1997. Yukon adopted the MSB scope of practice guidelines to guide nursing practice in community health facilities. The legislative framework for nursing in Yukon is sufficiently open to accommodate the growth of extended/expanded nursing practice within the existing provisions. Some extended/expanded functions may require additional regulatory provisions.
Nova Scotia
The definition of " nursing " in the Registered Nurses Act does not include medical diagnosis within the scope of nursing practice. Physicians have the sole authority to diagnose under the Medical Act. In the Medical Act there is authority to create regulations enabling the delegation of functions. Delegation of the function of diagnosis to nurses is as determined by regulations issued under the authority of the Medical Act.
Through guidelines negotiated between the Nova Scotia College of Physicians and the Nova Scotia Association of Registered Nurses, an expanded/extended role/nurse practitioner position was introduced for tertiary care settings. The guidelines provide for certain authorities to be delegated from physicians to facilitate the expansion of the nursing functions for registered nurses with additional educational preparation at the graduate level. These delegated functions are to be exercised within defined parameters, e.g. a prescription can be written by an expanded role nurse/acute care nurse practitioner but a physician must co-sign the prescription within 12 hours.
Similar guidelines have been negotiated for use in a demonstration project funded by the Health Transition Fund where there will be four (4) sites with nurses practising in extended/expanded roles primary care roles. Recent amendments to the Pharmacy Act will facilitate nurse practitioners to prescribe medication from a list to be designated by regulation.
New Brunswick
New Brunswick has no specific provision for extended practice in its Nurses Act 1984. However, the definition of nursing is broad enough to include diagnosis and treatment. There is a delegation process whereby medical functions can be delegated to nurses. Protocols are used to accomplish this delegation.
There has been relative success in expanding the nurses' role given the limitations of pilot projects and the lack of legitimization of the role through legislative means. A model based on the delegation of medical functions used initially in a pilot project at Mc Adam will be replicated in 8 other health centres in Region 3 under the jurisdiction of the Board concerned. An effort by the Department of Health and Wellness to introduce a similar model in three other rural health settings has met with limited success to date. Explanations of the extent of progress vary by site.
These projects are concerned with those functions of assessment, diagnosis and treatment of common, minor, acute illness or injury and ongoing management of uncomplicated chronic illness. These functions traditionally lie in the scope of medical practice. From the perspective of the nursing association in New Brunswick, these functions can be accommodated under the Nurses Act. They are exercised by nurses, through delegation by way of protocol. Plans for the introduction of expanded nursing functions have been suspended subsequent to a change in government.
Saskatchewan
Saskatchewan's operative statute, The Registered Nurses Act, 1988, does not refer to 'advanced or extended' practice or to 'nurse practitioners' though the statute is structured in such as way that it is viewed as broad enough to provide authority for nurses to undertake extended/expanded roles. Under the legislation there is provision for "special categories " none of which have been used by the Association. The extended/expanded role is carried out under the authority of delegation of medical functions embodied in a province-wide protocol. Site specific protocols may be enacted to recognize the particular needs of a health care setting. Currently there are discussions ongoing between the Ministry and the Association to ensure nurses are adequately protected from the perspective of legal liability.
Saskatchewan is undertaking a primary health care reform initiative that favours a collaborative model of service delivery. There are several pilot projects operating in the Province that are using integrated teams. To date there has been good response from the public to the demonstration projects.
The SRNA is monitoring initiatives throughout the country.These developments may affect Saskatchewan's future direction with respect to the enhancement of extended/expanded practice. There is no intention to introduce legislation at this point in time.
Northwest Territories
NWT does not provide for extended or advanced practice in its statute or regulations. Nursing services provided by Health Canada were transferred to the authority of Northwest Territories Government in April, 1988. The nurses previously employed by Health Canada are now employees of the territorial government. The Northwest Territories Registered Nurses Association (NWTRNA) has regulatory authority over nursing in the territory.
The NWTRNA has been lobbying for legislative changes and is actively involved in establishing competencies for primary health care nurse practitioners in the jurisdiction.
Nunavut
As Nunavut is so recently formed, the Northwest Territories Registered Nurses Association (NWTRNA) has been given the legislative authority for the registration, licensure and discipline of nurses in the new territory until a Nunavut association is fully formed and operational. Officials with NWTRNA said that nurses in Nunavut continue to provide expanded services throughout the new territory in the same way as when they were still a part of NWT, that is, by delegation of medical functions. As the governing body for two territories, the NWTRNA does not feel it necessary to separate issues relating to nursing according to the specific territory as the issues are similar in both territories.
British Columbia
British Columbia does not have any specific regulation or statutory reference to 'extended practice' for nurses. There are several projects and services that have been identified as providing extended/expanded functions. The nurses derive authority under either delegated medical functions or, if the setting is under federal jurisdiction, the Medical Services Branch guidelines.
British Columbia is in a state of transition with respect to all health professions as, under the Health Professions Act, the Health Professions Council is charged with the responsibility to review all health professions and provide a statutory scope of practice which includes 'reserved acts'. This approach is much like that which has been implemented in Ontario. The Health Professions Council (HPC) held public hearings on June12 and 13, 2000 to accept submissions based upon its recommendations concerning the practice of nursing and the RNABC's response to the HPC initial recommendations.
Quebec
The nursing profession in Quebec is governed by the Nurses Act which does not recognize extended/ expanded practice. As in Nova Scotia, the Medical Act outlines the acts which may be performed by medical doctors and there is regulatory power to delegate medical functions. The function of diagnosis is reserved exclusively for physicians. There has been little development to enable nurses to share this or other functions. The Order of Nurses is working toward proposing legislative amendments to update the scope of practice of nursing.
The Association is developing a position paper on advanced nursing practice (not the subject of this research) which is due for public release for purposes of consultation. As well, a Commission of Inquiry on health services and social services has commenced work in the Province. The goal of the commission is to present recommendations for revision to the health care system. There have been three consultation documents released for public discussion:

The Health of Quebecers: a few indicators;

Funding: current situation and outlook;

Organization of services: current situation and outlook.

The Association will be providing its view to the Commission
Prince Edward Island
Prince Edward Island. has no provision for extended/expanded practice in its legislation governing nurses. There are no nurses currently involved in extended practice hence there has been no regulation of such a class. The original Nurses Act (1974) regime was revised in 1988 but remains dated in its provisions. The PEI Nurses Association has indicated that the statute may be considered for revision in the near future.
Summary
The policy framework for practice of the extended/expanded nursing role is inconsistent across Canada. While it is understandable that variances will be present to reflect the unique circumstances in a jurisdiction this does raise issues for consideration. Governments and nursing associations are aware of

the need to ensure the public is protected through appropriate regulation; and

the need to legitimize extended/expanded nursing practice and that practitioners are able to practice an within authorized scope of practice.

Governments are being challenged by the pressures in the environment to maximize human health resources. Allocation of resources to facilitate the execution of the extended/ expanded nursing practice role may require amendments to legislative provisions of related statutes. The legitimization of this role through legislation presents an opportunity to achieve this goal.
3.3 Key Elements of Extended/Expanded Nursing Practice
This section of the report will address the general legal authority extended to nursing generally. The key issues of title, scope of practice and educational programs will be addressed by jurisdiction whether under the authority of delegation of medical functions or specific legislation.
Title
The nurses performing the functions under consideration in this study do not have a consistent title across all jurisdictions. At the present time in Canada, the title "nurse practitioner" is protected legislatively in only one jurisdiction, namely that of Newfoundland and Labrador. In both Alberta and Ontario, nurses performing the functions of assessment, diagnosis and treatment of episodic, acute and chronic illness and injury, are registered in a class specifically requiring additional regulation. These nurses are thereby entitled to use the designation, RN - EC in Ontario to indicate licensing in the Extended Class, or RN - EP in Alberta as nurses licenced in the expanded practice category.
The following is a summary of the titles in use by jurisdiction across Canada. This not an all inclusive list as there are nurses practising in roles with job titles that vary by employer.
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.
There is reference to nurse practitioner in the literature, however, there is considerable debate as to whether titles such as nurse practitioner should be used at all. It is apparent both from the literature and the interviews conducted for this study that without unanimity of acceptance of such titles, their use could do more to divide rather than unite the profession. It is argued by some that new descriptions are redundant as all nurses are practitioners of nursing. Thus the title is susceptible to constant interpretation which may reduce its usefulness as a formalized term. Notwithstanding the objections, other sources that favour the title view the term 'nurse practitioner' as imparting a general understanding of a professional who is a registered nurse but performs certain functions that are comparable to those of physicians. This also begs the question if the functions performed by these nurses are similar by jurisdiction and whether the skills are comparable across the country.
Although the title of nurse practitioner is not usually protected, it appears to be in common usage. In Ontario, the nurses registered in the extended class are called nurse practitioners and have a similarly named division of the nursing association representing their interests. The research team has been advised that the term nurse practitioner, although not recognized in legislation, is often used to refer to nurses employed in roles in rural and remote areas, and more recently in specialty areas such as acute and long-term care. Thus it is not necessarily the legislated titles that will assist in identifying primary care functions. Employers may label nurses who perform these functions in any number of ways such as community nurse practitioner, regional nurse, or outpost nurse. There is a question as to the similarity of functions performed by these nurses and whether there is one title that is sufficient in describing all the aspects of the role.
The Canadian Nursing Association's view is that the crucial concern must be the characteristics of the practice role and the competencies required to undertake the role. The title and credentials are not the material issue; rather, it is the characteristics of the role a registered nurse undertakes, whether within the existing scope of nursing practice or if delegated thus specifically regulated, that determine if one is practising in a nursing role in need for additional regulation. The competencies required to undertake such roles are currently under consideration by the Canadian Nurses Association. Indications are that the provincial nursing associations are supportive of this approach.
There is a dichotomy regarding the title used to describe nurses in extended/expanded practice roles. On one hand, reportedly there is public recognition of the fact that there is a difference between a registered nurse and a nurse who practices in an extended/expanded role. On the other hand, there is an effort by the Canadian Nurses Association to eliminate or lessen the proliferation of titles which is seen as divisive among nurses. Preference appears to be for the use of the common designate "registered nurse" with specific designations added as deemed appropriate by the licensing body.
Scope of Practice
The degree to which the statutory and regulatory provisions for nursing have been modernized or recently amended is often a mark of the degree to which scopes of practice are definitively dealt with by a province or territory. The older the statute and accompanying regulations, the more likely it is that the scope of practice for nursing will be relatively vague, as in Prince Edward Island. Comparatively, with more modern legislative regimes that reserve specific functions or acts to a profession, as is the case in Ontario, the lines are more definitive between the profession and others. The discrepancies among the different jurisdictions' scopes of practice of nursing are becoming more obvious. Across Canada, in provinces without special legislative authorities outlining the parameters of the extended/expanded nursing practice role, there is an absence of consistency in the scopes of practice. This arises from the variations in the delegation of medical functions by way of protocol arrangements designed to respond to particular circumstances.
The table below summaries the scope of practice by jurisdiction.
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.
The Medical Services Branch scope of practice guidelines seem to be applied wherever the MSB serves although, in some instances, nursing services provided by the Branch have been transferred to provincial and territorial authorities. The difficulty that can arise is that the scope of practice for nurses practising in northern, rural and remote areas is apparently used in other areas whether under-serviced or not. The consulting team has been apprised of concerns of the licensing bodies as these nurses may be operating outside their legislated scope of practice.
The scopes of practice for nursing vary reflecting the age of the statutes and the relative complexity of the regulation of professions within the jurisdiction or if the nurse is practising in a remote area, as in the north. There are developments occurring within the profession such that expanded/expanded roles are becoming recognized within more modern legislative regimes.
Education Preparation
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.
A review of Canadian schools of nursing web-sites revealed that while most offer Masters of Nursing or Health Sciences Programs with advanced practice courses, only five sites (University of Toronto, Council of Ontario University Programs in Nursing, Athabasca University, Dalhousie University, and the Centre for Nursing Studies) specifically indicate having nurse practitioner programs. (The nurse practitioner program at the University of Toronto prepares nurses at a graduate level for the role of acute care nurse practitioner not primary health care). The University of Manitoba, the Saskatchewan Institute of Science and Technology, and the University College of the Caribou offer courses to prepare nurses to assume select primary care functions.
In the three jurisdictions that have legislated extended/expanded practice for nurses, that which is required for a registered nurse to attain the extended designation is explicitly stated:

Ontario, the Primary Health Care - RN (Extended Class) programs are in two streams. Nurses with diploma preparation take a two year course and, if successful, finish with a baccalaureate degree and an NP certificate whereas, those already holding a BN degree are only required to complete a one year nurse practitioner certificate program.

Newfoundland and Labrador - Nurse Practitioner- since 1997, registered nurses with diploma or baccalaureate preparation, as well as a minimum of two years experience in a direct care role, can enroll in a one year Nurse Practitioner - Primary Health Care Program. The ARNNL minimum education standard as outlined in its position statement on NP-PHC is a BN with a one year NP program that carries credit toward an MN degree.

Alberta - RN ( Expanded Practice) requires a Bachelor degree in Nursing, or equivalency, at least three years of practice as a Registered Nurse, and successful completion of an approved educational program in an area of extended practice.

The eventual employers of nurses practising in extended/expanded roles in jurisdictions not yet regulated often dictate the content of the programs offered. Nurses practising in extended/expanded roles prescribe and dispense drugs, and therefore require the necessary knowledge to identify the appropriate drug for treatment. Educational programming for non-legislated practice of this nature has been sponsored by employers such as, Medical Services Branch, Health Canada, or Grenfell Regional Health Services, to prepare nurses for rural and remote locations within their jurisdictions. There have been other programs implemented to provide education and training for 'outpost nursing'. The majority of these programs prepared nurses to practice in those areas specifically covered under the provincial/Medical Services Branch scope of practice guidelines.
The Medical Services Branch has made a significant contribution to the education of nurses who undertake extended/expanded roles through the various programs sponsored across the country. From interviews conducted with nurses who have experience in the north, there seems to be a general satisfaction with the education programs, as well as the broader guidelines under which the nurses practice. Nurses who have relocated to less isolated settings commented that the scope of practice guidelines are narrower and relations with physicians are less open and more hierarchical.
As extended/expanded practice for nurses gains credibility and acceptance throughout the country, the availability of formal education programs will likely increase as will requirements for admission to the class. Currently, the content and design of these programs, as well as the qualifications for admission to them, are not standardized. As the profession develops competencies which are national in scope, education programs will also become standardized. This is in keeping with the movement toward uniformity within a profession across the broad jurisdictional spectrum which is being imposed by the provisions and requirements of the Agreement on Internal Trade and other agreements.
Summary
It is evident that there is a lack of consistency across Canada in the approach to regulating the extended/expanded role of nursing - either it is by delegation of medical functions or through specific legislation. There does appear at this point to be agreement on one policy direction. Within the practice itself, there is a inconsistency in the use of titles, the scope of practice and the educational preparation expected of nurses before undertaking the role. These issues are to be addressed if the extended/expanded role is to utilized across Canada.
3.4 On-Site Data Collection - Criteria for Site Selection
From this review of the circumstances across Canada a profile of practice models emerged. As part of the terms of reference of the study, on-site data collection was to be undertaken to gain an appreciation of the extended/expanded nursing role in practice settings. The consulting team identified the criteria for possible selection of two or three sites for further research. These were:

urban, rural, or remote settings;

clientele - general population vs. special needs groups (e.g., women, students, aboriginal, homeless, low income and young families, at-risk elderly, etc.);

funding arrangement - physician fee-for-service, salary, capitation, direct to physician for funding nurse position in extended/expanded role;

nurse-managed or nurse-operated clinics vs. physician dominated clinics vs. collaborative practice between physicians and nurses;

authority by legislation vs. agreements vs. medical directives; and

ease of access to all resources by nurses vs. restricted access to resources by nurses.

The project team was cognizant of the need to use a broad cross section of sites, embodying as many of the characteristics as possible, to gain an appreciation of the types of nursing practice models in operation across Canada. However, it was evident that further research was required to select the sites for data collection. Hence the team undertook a cross country scan of settings to apply the criteria to identify the sites.

*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.

*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.

*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.