5.0 Conclusions and Implications

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It became apparent to the consultant team that there are several factors that influence the practice of nursing in extended/expanded roles. Important factors identified include:

1. The relative positions of nurses and physicians varies by location and setting. In the more remote areas, where resources are in short supply, there appears to be a greater willingness to collaborate and rely on nurses to maximize the use of their skills. When the nurse is placed in a setting where there are greater resources available to meet client needs, the issues raised by physicians tend to focus on protecting the medical profession's scope of practice. Thus, nurses encounter greater restrictions in performing shared primary care functions depending on the local supply of physicians.
2. Another issue of concern is the need to protect nurses who perform extended/expanded roles while working in settings without legislated authorities. The legitimized profession (usually medicine) delegates certain primary care functions as required. With this delegation, the responsibility is jointly shared. The profession with the legal right to perform the function maintains accountability, while the nurse, who is deemed competent by a physician to perform the function, is accountable for performing it in accordance with protocols and guidelines.

   In certain instances, nurses are directed or asked to perform functions outside the scope of their practice or for which there is no formal delegation by way of protocol agreements. These nurses are correct in questioning the extent of their responsibility and liability if something transpires that results in adverse consequences for the client. Territorial associations have expressed concerns about nurses who practice under the MSB scope of practice guidelines which are broader than those contained in their legislation governing nurses.

4. The expectations placed on nurses in lieu of their current level of educational preparation are often disparate. Based on the research findings, nurses working in remote and rural areas are expected to stabilize patients and prepare them for medical evacuation. In reality nurses practising in these locations, like primary care physicians, have limited medical resources available. Given these expectations the need for advanced education and training for nursing practice must be implemented for the benefit of the nurse and, most importantly, for the protection of the public. There are inconsistencies in the educational requirements of nurses across the country. Also variable are the requirements imposed to maintain competency. There may or may not be employer sponsored continuing education opportunities available on site or funding to attend programs off-site.
6. Nursing practice in urban settings is markedly different than in the north. Access to diagnostic testing facilities, laboratories, and prescription medications that would be of benefit to help nurses perform functions within the scope of extended/expanded role, are often denied. Some of these resources are strictly controlled by a combination of forces, namely, protectionist behaviours of physicians and legislation which reserves access to professions other than nursing. While it is recognized that restrictions on access are necessary for control and cost containment, there are situations where it makes sense to allow shared access to certain resources. An example are the statutes which allow only physicians to admit a patient to a facility. Thus, these provisions require reconsideration to more accurately reflect the realities of practice and more effective utilization of health resources.