4.0 Organizational Structure by Jurisdiction

[Table of Contents]

One objective of this phase of the study was to describe the nature of nursing practice in primary health care settings within different Canadian jurisdictions. As specified by the project's guidelines, the focus of this documentation was restricted to the primary care aspect of the nursing role (i.e., assessment, diagnosis and treatment of episodic, acute and chronic illness or injury). A second objective was to identify potential sites for more in-depth data collection.

Data Collection - Phase I

Initial contact was made with key personnel in the nursing associations in each jurisdiction, Ministries of Health, and regional health authorities. The persons contacted were asked to identify primary health care settings where nurses perform primary care functions, work under similar and different practice models, and have differing educational preparation requirements. Respondents provided an overview of the situation in each jurisdiction and identified specific sites that met the inclusion criteria for the project.

Data Collection - Phase II

During the second phase, a cross-country telephone survey was conducted with administrative personnel working in agencies/organizations which employ registered nurses to perform primary care functions. The interview schedule used during data collection is presented in E.

Initial efforts focussed on contacting persons responsible for nursing services within each organization (e.g., CEO, executive director, vice-president, clinical co-ordinator, etc.). This proved to be very tedious and time consuming (i.e., identifying the appropriate person, leaving messages, returning calls, scheduling appointment times, or rearranging appointments). When contact was made with appropriate persons, each interview lasted about 30 minutes.

Overview of Findings

The data collected from the various provincial/territorial contacts are presented in tabular form in F. The findings suggest that there are significant variations within and between provinces/territories with regard to the type of practice models present in different settings. There are also notable differences across settings with regard to the degree with which nurses enact the primary care role. Although there are a number of possible explanations for these disparate conditions, one significant factor is the environmental context (e.g., legislative, regulatory, employing organization, nurse/physician relationships, etc.). A brief summary is presented of the information collected from identified contacts at different sites in each province/territory.

Atlantic Canada

Newfoundland has had a long history of nurses working in extended/expanded roles in rural and remote settings. Currently, there are two title designations for this role - regional nurse and nurse practitioner (NP). While regional nurses function under a protocol agreement negotiated between the regulatory bodies of medicine and nursing and the employer (i.e., Association of Registered Nurses of Newfoundland and Labrador, Newfoundland Medical Association, Newfoundland Medical Board, and Grenfell Regional Health Services), the NP role is legitimized through the Newfoundland Nurse practitioner - Primary Health Care Regulations.

The introduction of the Nurse Practitioner Primary Care Regulations coincided with the commencement of a program of study offered by the Centre for Nursing Studies, as well as the piloting of the Primary Health Care Enhancement Project in three rural communities. Many of the first and second classes of NP graduates were nurses who had been sponsored by employers from rural and urban areas. With the introduction of the NP regulations, regional nurses have not been automatically granted the NP designation. An accreditation process is currently being developed by the Association to determine eligibility for the new class.

Information concerning regional nurse primary care practice was collected from administrative personnel at the head office and supervisory personal at a remote site. Regional nurses are expected to work autonomously, as well as collaboratively with physicians in community clinics and health care centres. They have access to a wide spectrum of resources, excluding hospital admitting privileges, and may initiate referrals. With regard to the health care centres located in rural areas, physicians are present on-site and regional nurses' are expected to assume more of a collaborative practice, as opposed to autonomous, role. In fact, physicians are more involved in the actual supervision of nurses at these sites. The reverse is true in community clinics located in remote areas where nursing supervisors are present on-site and oversee nursing practice. The community clinics are nurse-managed with physicians making on-site visits about every 8-weeks. As such, the primary care aspect of the role (i.e., assessment, diagnosis and treatment) is more extensive with physician input into decision-making mainly by telephone consultation.

While the employing organization prefers that regional nurses have a bachelor of nursing degree and 2 years of critical care experience, these conditions are not always met due to recruitment difficulties. The employer also provides an intensive 6-week orientation to new recruits to help refine required practical skills/abilities, and to strengthen communication relations with other providers. Regional nurses are also expected to participate in available continuing education activities and take courses toward a degree, when not completed. With regard to on-site strategies for monitoring competency levels, most respondents reported that there were monthly audits of nursing practice, caseloads and charts by nursing supervisors, as well as periodic chart reviews by physicians. None of the sites reported having conducted a formal evaluation of the impact of extended/expanded role nurses on health outcomes or service costs, but recognized the importance of undertaking such a venture.

Contact was also made with administration in organizations which have NPs performing primary care functions in rural and remote areas. Two of the contact sites were on the Northern Peninsula (cottage hospital with medical clinics in several communities, and a health centre) and the other at one of the designated sites for the Primary Health Care Enhancement Project. The roles and responsibilities of NPs were very similar across the three sites, with full-enactment of the primary care role the norm. All of the NPs were graduates of a certified nurse practitioner program, had extensive experience working in rural health care, participated in continuing education activities on a regular basis, and were expected to work independent of and in collaboration with other health care providers. In most instances, the NPs carried independent caseloads, managed the total care in nurse-run clinics, consulted with physicians as required, initiated referrals, and accessed available community resources. With regard to on-site strategies for monitoring competency levels, most respondents reported that there were no specific measures for evaluating practice, with NPs answerable to nursing supervisors and/or physicians for their clinical work. Although all sites recognized the importance of conducting a formal evaluation to assess the impact of the extended/expanded nursing role on health outcomes and costs, a provincial evaluation was only being initiated at the site of the Primary Health Care Enhancement Project.

Nova Scotia is about to embark upon a demonstration project, funded by the Health Transition Fund, which will introduce nurse practitioners into the health care system. When the cross-country telephone survey was conducted in the Fall of 1999, the pilot sites had not been selected for this project.

Registered nurses do perform extended/expanded role functions in collaboration with physicians in tertiary care settings, but are not permitted to engage in autonomous practice. Legitimization of the expanded practice role is by delegated functions under the Medical Act. Nurses working in these roles are required to have completed or to be currently enrolled in a masters of nursing program, and have a minimum of 3 to 5 years of clinical experience. With regard to continuing education, respondents noted that these nurses have access to teleconferences and physician mentors. Significantly, nurses working in these roles must be re-certified annually to ensure acceptable competency levels with regard to the performance of delegated medical functions. The on-site strategies for monitoring competency levels included annual performance appraisals by nursing supervisors and periodic reviews by the Health Professions Liaison Committee. As well, there are a number of mechanisms in place for monitoring the impact of the role (e.g., cost effectiveness, patient satisfaction surveys, etc.).

Prince Edward Island has limited experience with nursing roles outside traditional scopes of practice. There were no settings identified where nurses were performing primary care functions.

New Brunswick initiated a pilot project, the MacAdam project, to coincide with the closure of a hospital that was replaced with a community health centre. Through regionalization of health services, the MacAdam Health Complex has 14 facilities under its jurisdiction. The program at the Complex empowered nurses to engage in expanded practice functions under protocols negotiated between the Complex, the regulatory bodies for nurses and physicians, and the Ministry of Health. Although basic RN preparation is required for access to the role, additional training is undertaken by the employer. A clinical nurse specialist is present on-site and provides or co-ordinates educational opportunities. However, the more isolated sites have restricted access to continuing education opportunities. With regard to on-site strategies for monitoring competency levels, respondents indicated that this was the responsibility of nursing supervisors and physicians. As well, one of the sites at a provincial evaluation completed three years after project start-up. The other site's formal evaluation was restricted to a patient satisfaction survey.

Nurses are not permitted to engage in autonomous practice with regard to primary care functions, but are expected to work collaboratively with and under the direction of physicians. Relative success has been achieved with expanding nurses' roles in this setting, given the absence of role legitimization through legislation. The model used at MacAdam was intended to be replicated in 8 other centres. However, efforts by the Ministry to introduce similar models in three other rural settings has met with limited to no success. Plans for the introduction of expanded nursing functions in other areas have been delayed due to the change in government.

Quebec

There are 146 community health centres in Quebec which offer primary health care services. These operate under multi-disciplinary teams of which nurses are members. Although nurses may participate in assessment and treatment activities, there is limited opportunity for involvement in diagnosis. Because the expanded/extended nursing role has not been authorized in legislation, it varies from site to site and is guided by setting-specific protocols. Furthermore, nurses in northern and remote locations seem to be performing functions outside the scope of their practice and without authority through protocols to do so. This has raised liability concerns among nurses who are now seeking protection. According to the Association, physicians are vigilantly protecting the function of diagnosis as exclusive to the medical profession.

There are two hospitals located in Montreal which have nurses practising in extended/expanded roles. These are tertiary care settings, not primary health care settings, and therefore did not meet the criteria for the current study.

Ontario

Ontario has the greatest number of nurses performing primary care functions (i.e., assessment, treatment and diagnosis of episodic, acute and chronic illnesses or injury). Similar to Newfoundland, nurses in extended/expanded roles, titled Registered Nurse - Extended Class (RN - EC), are governed by provincial legislation and the College of Nursing's scope of practice guidelines. The community health centres (CHC) which are designated as non-profit entities were the primary focus of the consultant team's efforts since these entities are the major employers of the RN- ECs in the Province.

Of the 56 CHCs listed by the Ontario Ministry of Health and Long-Term Care on its web site, initial and follow-up calls were made to a random survey of 29 centres. In some instances, personnel at the sites indicated that the focus was health promotion not primary care. The response was relatively low despite several calls to other sites. The research team terminated its efforts following completion of interviews with 11 management personnel at sites where primary care was a significant component of nurses' extended/expanded roles. With regard to the 10 aboriginal centres located in Ontario and funded under the Aboriginal Healing and Wellness Strategy, representatives from 3 centres were interviewed.

The final sample reflected a cross-section of settings located in remote, rural and urban settings (i.e., 7 urban, 4 rural only, 2 remote only, and 1 rural & remote). Nurses in the extended/expanded role are required to obtain an RN - EC certification, to practice autonomously within the parameters specified by the province's legislation and the College's scope of practice guidelines, and to maintain strong collaborative relations with other health care providers, especially physicians. Furthermore, nurses at most of the contact sites had access to a wide spectrum of resources and initiated referrals to other health care providers.

All of the respondents noted that some form of collaborative practice model was in place at their site. However, there were notable variations in how collaborative practice was being defined, especially with regard to the performance of primary care functions. One differentiating criteria was whether or not nurses had independent versus shared patient caseloads. While independent caseloads was the norm for nurses at most sites (i.e., 9 out of 14), their colleagues at the other sites predominately shared caseloads with physicians. Regardless of caseload arrangements, the emphasis was on effective and efficient team functioning to promote quality patient outcomes. The second differentiating criteria was the expected balance between primary care and health promotion activities. While all of the sites expected nurses to engage in health promotion, the scope and intensity of this component was a function of the adequacy of human resources (i.e., number and mix of health care providers).

There were definite variations across the Ontario sites with regard to the person (s) responsible for overseeing nurses clinical practice. 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.

Most of the Ontario sites surveyed also had mechanisms in place to ensure the continued competency of registered nurses working in extended/expanded roles. Regardless of the presence of site specific measures, all respondents encouraged these nurses to participate in medical and nursing continuing education activities on a regular basis. Continuing education measures instituted by some of the sites included regular in-service activities, off-site seminars on a variety of topics, internet and teleconferencing access, and support to attend one professional conference annually.

With regard to on-site strategies for monitoring competency levels, most respondents reported that there were specific measures in-place. Most of the Ontario sites were more likely than not to have, or in the process of implementing, more formalized evaluation procedures (i.e., quality assurance practice reviews, self and peer reviews/evaluations, supervisor performance appraisals, etc.). Although all of the contact sites recognized the importance of having external consultants undertake a formal evaluation to assess the impact of the extended/expanded nursing role on health outcomes and costs, only a few were actually in the process of doing such an evaluation or preparing for one. Nevertheless, all of the respondents indicated that this was an area that required further attention.

Western Canada

Manitoba has enacted amendments to the legislation governing extended/expanded nursing roles, however it was not proclaimed at the time of this survey. Regulations are being developed and, once approved, the statute will take effect. Meanwhile, the Manitoba Regional Health Authorities are preparing for the new regime with the development of a series of Community Nursing Resource Centres.

There is a community health centre and a community nursing resource centre that co-exist in one community. However, recently issues have surfaced about nurses' scope of practice in primary care roles and physician liability concerns. These issues are currently under consideration and extended/expanded nursing services have been suspended pending their resolution.

Contacts were also made with administrative personnel at four urban-based clinics in the province. Only two of these clinics have nurses working in extended/expanded roles. The primary care activities performed by the nurses are classified as delegated medical functions. The nurses at these clinics manage an independent caseload and maintain a collaborative practice arrangement with physicians who supervise their clinical activities. These nurses do not have any prescriptive authority and a physician signature is required for diagnostic tests. Although continuing education activities are self-directed, a minimal number of credit hours is required for NP re-certification. Only one of the sites reported that a proposal had been submitted to access funds to conduct a formal evaluation of the role. A second site was in the process of developing a satisfaction questionnaire to survey clients in the near future.

Saskatchewan is of particular interest given the efforts taken to expand nursing roles through a province-wide protocol agreement negotiated between nursing, physician and pharmacist regulatory bodies and the Ministry of Health. This agreement governs all nurses performing extended/expanded roles.

The Beechy project, located in a rural community, has recently received national exposure as a model supported by the physician and community. The primary care nurses working at the Project sites have completed the advanced clinical program at the Saskatchewan Institute of Applied Technology. These nurses carry an independent patient caseload and work out of community health centres or off-site clinics. Although nurses may assess, diagnose, and treat, they are also expected to consult with the physician responsible for clinical activities.

In the northern part of the province, primary care nurses work in community health centres or nursing stations. Nurses are often the only health care provider available, with physician visits restricted to once a week. These nurses have a wide-range of primary care responsibilities, including prescribing and dispensing medications, as well as stabilizing patients and transferring them to appropriate teritary care centres. Although the clinics are nurse-managed, the primary care nurses are expected to work in collaboration with other health care providers, especially physicians.

Wide variations were reported in continuing education opportunities with the more remote sites limited to regular inservicing by visiting physician. Other sites had continuing education available via telehealth, specialist inservice activities, and annual conferences. However, all sites encouraged these nurses to participate in medical and nursing continuing education activities. With regard to the person (s) responsible for overseeing nurses clinical practice, both physicians and nursing supervisors/managers monitored clinical functions. Furthermore, all of the primary care nurses had to meet physician competency expectations before performing each delegated function.

Most of the survey respondents reported monitoring of the extended/expanded role nurses was limited to periodic chart reviews by nursing supervisors and/or physicians. An additional monitoring mechanism instituted at a couple of the sites was performance appraisals. One site, in particular, had taken measures to institute a more formalized appraisal process (i.e., regular peer and physician reviews, formal client interviews, and indirect monitoring of client satisfaction.

Alberta is the third province that regulates the expanded/extended roles of nurses employed by a health authority. The Minister must approve the locale where the health authority intends to employ a Registered Nurse - Expanded Practice (RN - EP). A total of 12 sites have been approved, with 5 health authorities employing these nurses to date.

There are nurses working in extended/expanded roles in northern and remote locales. Several of these settings were included in this survey. The nurses at these sites carry independent patient caseloads and are expected to practice autonomously within their defined scope of practice. Collaborative practice arrangements are also maintained with consulting physicians. The person responsible for overseeing extended/expanded practice was either the medical director or the immediate nursing supervisor. Although there are no specifications regarding continuing education activities, these nurses are encouraged to participate regularly to enhance their knowledge and skills. It is interesting to note that with nurses working in extended/expanded roles who have had experience practising under the MSB guidelines find the new legislative regime far more restrictive.

There is also a demonstration project currently operating in an urban area which is funded by the Health Transition Fund. The RN - EC at the family resource centre performs independent activities in on-site and off-site clinics. The nurse is expected to work in a collaborative manner with all health care providers, and consult with physicians as required.

British Columbia is also taking steps to regulate extended/expanded roles for registered nurses. The provincial government is considering incorporating guidelines for advanced nursing practice into the legislation governing the profession. Currently, various settings have implemented clinical guidelines or have adapted nursing practice to suit the limitations placed on nurses' scope of practice.

Data were collected from several sites with nurses working in extended/expanded roles. There seems to be a number of practice models operant in the province. Health clinics in Vancouver, Victoria and the southern interior of British Columbia have nurse practitioners on-site. The absence of legislation legitimizing the role and extending authorities to order diagnostic tests and prescribe medications have been addressed through protocols. However, there are restrictions on the extent to which these nurses may perform primary care functions, with other authorities, such as legislation governing hospitals, overriding these protocols.

In some rural and remote areas, nurses work in health centres, nursing stations, or outpost hospitals. Nurses located in these areas carry independent caseloads and perform primary care functions as specified under the Medical Service Branch Scope of Practice Guidelines. These nurse are expected to work collaboratively with physicians and other health care providers during site visits, and consult with physicians via telephone as required. Most of these nurses are responsible to an immediate nursing supervisor/administrator for clinical functions. With regard to continuing education activities, the onus is placed primarily on the nurse, with most sites encouraging participation in available continuing medical education offerings.

Only one of the contact sites had conducted a formal evaluation of the efficiency of service offerings or the impact that extended/expanded role nurses were having on health outcomes. The other sites indicated that these issues were addressed through existing quality assurance programs and/or informal mechanisms.

Medical Services Branch and the Territories

The Medical Services Branch of Health Canada is responsible for delivering health services to Canadians residing on lands under the administration of the federal government. Historically, this has included the lands under the administration of the Territorial governments including reserves for aboriginal peoples. The Medical Services Branch (MSB) has developed a policy governing the delivery of health services, including the provision of nursing services. Nurses are required to be registered with the relevant nursing association. The MSB has established courses for nursing in remote areas. According to representatives interviewed from provincial/territorial regulatory bodies, questions have been raised about the MSB guidelines exceeding nurses' scope of practice as outlined by associations.

Notwithstanding these observations, the Medical Services Branch has made a significant contribution to the education of nurses who perform extended/ expanded roles across the country. From interviews conducted with nurses who have worked in the north, there seems to be overall satisfaction with the MSB 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.

Interviews were conducted with key representatives in Nunavut, the North West Territories, and the Yukon. All of the nurses in the territories work under the MSB Scope of Practice Guidelines. Nurses in the Yukon are called community nurse practitioners. Nurses who work in health centres located in rural and remote areas without on-site physicians services assume a very independent role. However, they are expected to maintain some kind of collaborative practice arrangement with consulting physicians.

In Nunavut and the North West Territories, the scope of nurses' primary care functions are similar to their counterparts in the Yukon. Nurses work at health centres operated by regional health boards. Physician services are usually limited to bi-weekly or monthly visits to nurse-run clinics held at the different sites. Nurses are expected to work autonomously and maintain collaborative relations with consulting physicians.