
	Research : Reports

Appendix D [Table of Contents]

APPENDIX D
Background information by jurisdiction
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
British Columbia

Names of organizations contacted Registered Nurses Association of British Columbia (RNABC)
B.C. Ministry of Health

Nurses on active practice RN roles 29,033 Practising Registered Nurses, December 1998. Data source: Rollcall Update 98, Health Human Resources Unit, University of British Columbia

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care No legislative basis. Variety of extended/expanded practice roles being fulfilled. Some of these practice roles are within the existing scope of nursing practice. There are some nurses working in extended/expanded roles through medical delegation.

Nurses registered or licensed to practice in extended/expanded roles as described above None registered or licensed to specifically fulfill extended/ expanded practice role. Accomplished through MD delegation. No central registry kept by RNABC so difficult to estimate #s. In 1998, 85 nurses were employed in Nursing Stations/Outpost/Clinic. Data source: Rollcall Update 98

Settings in which they practice Examples are: Red Cross Outposts, MSB locations, Comox Valley Nursing Center,. RN First Call, some Community Health Centres.
NB - Comox Valley practice is not fully 'extended/expanded' practice as far as prescribing drugs and ordering tests. The practice is extended/expanded but within the existing scope of practice.

Position titles or descriptions RNs, unofficially as NPs in Community Health Centers Registered Nurse is the legislated title; however, there are some nurses who call themselves Nurse Practitioners.

Educational qualifications and programs for practice in extended/expanded roles Educational and other qualifications for employment are set by the employer, i.e. Red Cross or MSB. Employers may pay for or require a specialty course. Diploma is the minimum qualification as for all Registered Nurses.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Virtually all extended/expanded practice in BC is by delegation of function. The delegated acts (i.e. functions beyond the scope of practice) are established by working arrangements according to location, organization and training. RNABC has established guidelines for DMF (Delegated Medical Functions)

Facilitators to nurses practising in extended/ expanded roles There appears to be acceptance by the public of increasing responsibility and independence for the practice of nursing where the extended/expanded roles exist.

Barriers to nurses practising in extended/expanded roles No consultation fee for physicians; legislative barriers exist, e.g. Medical Practitioners Act and the Nurses (Registered) Act which has an imprecise definition of the scope of nurses (the "ordinary calling of nursing").

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals Doctor/nurse traditional roles are difficult to modify substantially in the absence of substantive legislative change. Physicians in rural/remote areas often welcome extended/expanded nurse roles whereas similar attitudes may not always be present in urban locations.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles At the present time there are only limited education programs, primarily sponsored by employers, for nurses practising in extended/expanded roles.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles Presently liability coverage is provided by the employer and what is normally carried as a member of RNABC. There have been no reported incidents related to extended/expanded practice

Other organizations representing nurses BC Nurses Union

Issues arising from public As throughout the country, there is a demand for better health care services in rural/remote areas and other under-serviced areas

Issues arising from other professions' regulatory bodies or from unregulated professions Liability is a continuing and growing concern for physicians and pharmacists in the absence of legislation

Other matters having an impact on nurses practising in extended/expanded roles Under the relatively new Health Professions legislation in BC, the Health Professions Council is reviewing all health professions' scopes of practice with a view to prescribing 'restricted acts' which will then be set by regulation. The RNABC and the BC Nurses Union have jointly presented a proposed list of reserved acts to the HPC. Some of these suggested reserved acts would require additional regulatory authority, e.g. prescriptive authority. The final assessment of the HP Council following public hearings in June, 2000 is expected at some time in 2000 or early in 2001 and it will play a large part in determining the future of extended/expanded practice for nurses in BC

Prepared with information gathered from the Association December 1999
Reviewed and revised by the Association and the Ministry of Health June-August 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Alberta

Names of organizations contacted Alberta Association of Registered Nurses (AARN) Alberta Health

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care Registered Nurse - Extended Practice (RN-EP) under legislation. Northern nurses have been practising for many years under protocols in more limited capacities of extended/expanded practice

Nurses on active practice RN roles 23,455 as at June 21, 2000

Nurses registered or licensed to practice in extended/expanded roles as described above 16 at time of survey

Settings in which they practice Minister has pre-approved 11 sites. Presently 16 RN-EPs are working within provincial Regional Health Authority sites and federal Medical Services Branch approved locations.

Position titles or descriptions RN-EP officially, but usually called Community Nurse Practitioners

Educational qualifications and programs for practice in extended/expanded roles The Extended Practice Roster Regulation provides two avenues by which a registered nurse can apply to the Roster. The requirements include 1). a baccalaureate degree, three to four years of relevant clinical experience and completion of an educational program that prepares the registered nurse to provide extended services. The Advanced Graduate Diploma in Community Nursing practice at Athabasca University has been approved as an educational program or 2). There is a two year grand-parenting clause ( February 1999-February 2001) for nurses who do not meet the educational requirement but have been successfully providing these services. These nurses undergo an assessment process to ensure they have the necessary knowledge and skills.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Competencies and guidelines are prepared and published by the AARN to govern the practice of nurses providing 'extended health services' The Extended practice Roster Regulation governs the registration of nurses on the Roster. Relevant documents include:

Competencies for Registered Nurses Providing Extended Health Services in the Province of Alberta ( December 1995)

Prescribing and Distributing Guidelines for Registered Nurses in Advanced Nursing Practice Providing Primary Health Care Services ( February 1995) ( Re-endorsed February 200 for two years)

Alberta Health: Guidelines for Registered Nurses in Advanced Nursing Practice Providing Primary Health Care Services in Under-serviced Communities in Alberta ( August 1994)

Facilitators to nurses practising in extended/ expanded roles Shortage of physicians in rural/remote areas Physicians and pharmacists have been reasonably supportive Provinces future health strategy incorporates increased use of RN-EPs

Barriers to nurses practising in extended/expanded roles There is one urban centre (Calgary) where an RN-EP is practising. In general, physicians appear to recognize the role of RN-EPs in a supportive role however they do not support complete independence of this practice. There is no mechanism to date to address for fee-for-service.

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals Enhancing physician and pharmacist cooperation. Alberta's Health Professions Act sets 'restricted activities' for professions.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles RN - EPs must demonstrate full competence in the entire scope of practice for extended practice. Nurses registered to practice as RN-EPs must apply for renewal each year.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles No actions reported

Other organizations representing nurses United Nurses of Alberta

Issues arising from public The RN-EP extended/expanded role has recently been developed (1999). The public may not be aware of the role for nurses who are accepted on the extended Practice Roster. Overall, the public does appear to be supportive of increased responsibilities for nurses.

Issues arising from other professions' regulatory bodies or from unregulated professions Physicians and Pharmacists want practice of RN-EPs to remain structured under health care organization employment

Other matters having an impact on nurses practising in extended/expanded roles Urban practice setting (Calgary) may lead to greater urban use of RN-EPs

Additional comments Alberta appears committed to the increasing use of nurses practising in extended/ expanded roles including in urban areas but there is direct control over sight approvals by the Minister
Regulations are being developed under the Health Professions Act and will probably include RN s practicing in extended/expanded practice roles.

Information verified by the AARN December 1999
Updated with the input of the AARN and the Ministry in July 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Saskatchewan

Names of organizations contacted Saskatchewan Registered Nurses Association (SRNA)
Saskatchewan Health

Nurses in active practice RN roles Approx. 9,000

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care Saskatchewan has a significant number of nurses practising in extended/expanded roles throughout the province through delegation of medical functions and cooperation with the pharmacy profession. It is expected that the delegation model will give way to expanded scope of practice for nurses when Council specifically prescribes 'special categories of practice' under the operative statute.

Nurses registered or licensed to practice in extended/expanded roles as described above Although the Registered Nurses Act contains provisions for the Council to prescribe 'special categories of practice', there are no nurses yet actually licensed in this capacity.

Settings in which they practice With no central registry held by the SRNA, it is not possible to identify all the sites where nurses are practising in extended/expanded roles. There are 32 health districts in the province and 27 nurses are employed in extended/expanded roles as primary care nurses. However, these estimates do not include nurses employed by Tribal Councils. There are 10 nurses employed in the primary health care demonstration sites.

Position titles or descriptions No fixed titles. Referred to as Primary Care Nurses in protocol.

Educational qualifications and programs for practice in extended/expanded roles SRNA has criteria for practice in extended/expanded roles under guidelines established in a document titled The Registered Nurse Scope of Practice: Special Nursing Procedures and Nursing Procedures by Transfer of Medical Functions, 1993. The latest document on prescribing is Guidelines for Nurses Prescribing and/or Distributing Drugs by Transfer of Functions, revised May 1999. The criteria require that a nurse wishing to practice under these guidelines must take a "formal course" of instruction. The Advanced Clinical Nursing Program at Saskatchewan Institute of Applied Technology is a course of instruction to prepare a nurse for an extended/expanded role.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Scope of practice is defined by the province-wide clinical practice guidelines and as modified by site.

Facilitators to nurses practising in extended/ expanded roles Legal advice has been received by SRNA that ability of Council to prescribe special categories of practice (sect. 15 (2)(f)) is sufficient to provide for extended/expanded practice roles without having to further amend statute. There also appears to be. widespread and historical acceptance of extended/expanded practice for nurses and significant and longstanding co-operation of nurse, physicians and pharmacists.

Barriers to nurses practising in extended/expanded roles Uncertainty as to the degree of support from physicians for moving from the delegation of function model. Pharmacy legislation permits prescribing by professions, however, nurses have not been specifically designated. Awaiting regulations under the Pharmacy Act.

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals Nurses, physicians and pharmacists appear to act cooperatively. There is growing support for a licensing model. While physicians are supportive of extended/expanded roles and perhaps legitimatization of these roles, it is acceptable if this move is as part of collaborative practice arrangements.
There have been concerns expressed on the part of physicians and pharmacists about liability though liability is not increasing.
The biggest challenge in primary health care is the loss of physicians and ensuring nurses have the skills to take on added responsibility.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles In the absence of legislation and a lack of a central roster of nurses practising in these roles, it will continue to be difficult for the SRNA to oversee the continuing competencies of these nurses

Disciplinary or liability actions arising with respect to practice in extended/expanded roles No actions reported

Other organizations representing nurses Saskatchewan Nurses Union

Issues arising from public General acceptance by the public of the need for nurses to act in extended/expanded practice roles where appropriate.

Issues arising from other professions' regulatory bodies or from unregulated professions Concerns about liability and uncertainty as to the degree of acceptance and support from physicians for nurses exerting more autonomous and direct authority over patient treatment in primary health care.

Additional comments Saskatchewan appears to have a well established system of extended/expanded practice for nurses based on the cooperative transfer of medical function model. SRNA is moving towards changing the model to more autonomous extended/expanded practice for nurses. However, it appears that the Association is moving cautiously in this direction, most likely because of concern that a legislatively imposed regime will likely mean changes in existing interrelationships among the affected professions. The legal advisors within government have questioned whether the regulation is specific enough to cover nurses for the functions that could be considered special categories as have been delegated under the clinical practice guidelines and guidelines for transfer of functions documents. This issue is under active consideration. From a human resources planning perspective, it is a challenge to ensure there is good complement of knowledge and skills with a range of health care providers to deliver primary health care services.

Information verified by the Association December 1999
Updated with input of the Association and the Ministry July 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Manitoba

Names of organizations contacted Manitoba Association of Registered Nurses (MARN)

Nurses on active practice RN roles 10,792 (1999)

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care New legislation governing the profession is passed but not proclaimed. A component of the new legislation will be the expanded the scope of practice through "included practices'.which encompass prescriptive authority, performance of minor surgical and invasive procedures and ordering and receiving results of screening and diagnostic tests. Existing extended/ expanded practice is performed under delegation of medical functions and collaborative practice agreements.

Nurses registered or licensed to practice in extended/expanded roles as described above The new Registered Nurses Act will allow for a separate register for nurses practising in extended capacities (included practices) under the competencies to be developed

Settings in which they practice Extended/expanded practice is carried out in some urban as well as remote and northern regions. Settings include tertiary and community hospitals, community health centres, community nurse resource centres and community programs.

Position titles or descriptions The title "Registered Nurse" is the only title regulated by MARN at this time. The new legislation once proclaimed will also protect the title "Graduate Nurse". Employers may choose to use a specific position title such as nurse practitioner or advanced practice nurse but these are not regulated titles in Manitoba.

Educational qualifications and programs for practice in extended/expanded roles The focus will be on the competencies required to perform the services identified in the included practices. Nurses may develop the required competencies through various educational activities. Concerning advanced nursing practice, there currently exists a Masters level program in Advanced Nursing Practice at the University .of Manitoba; completion of this program is one educational options.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles The Registered Nurses' Act identifies the scope of practice of registered nurses. Under the new legislation, regulations will be developed to set the competencies required for included practices. Registered nurses with the required competencies will have the legislated authority to perform the included practices and delegation of function will not be required for these services. MARN has established standards of nursing practice which apply to all practising registered nurses in the province regardless of their roles or practice settings. MARN has adopted the CNA Code of Ethics for Registered Nurses which provides the ethical guidelines for practice.

Facilitators to nurses practising in extended/ expanded roles The new legislation will facilitate this once it is proclaimed. The existence of a program of studies for the advance practice role may facilitate this as well.

Barriers to nurses practising in extended/expanded roles At this point the major barrier is waiting to have the enabling statute proclaimed. An additional barrier may be the understanding by the employers, other professions, etc. of the scope of practice of registered nurses that is based on traditional perceptions rather than contemporary reality.

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals To date, there have not been significant challenges posed by other health care professions.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles Regulations will be developed that will address the education and continuing education required. In accordance with the new legislation, a program must be established to ensure continuing competence for all registered nurses practising in Manitoba.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles Registered nurses acting in these roles will be subject to the usual statutory disciplinary processes.

Other organizations representing nurses Manitoba Nurses Union is the union representing most registered nurses. A small number are represented by other unions such as Manitoba Government Employees Union.

Issues arising from public There appears to be acceptance by the public of the concept of extended/expanded roles for nurses in the delivery of health care

Issues arising from other professions' regulatory bodies or from unregulated professions There has been no appreciable opposition to the new legislation which is evidence of a significant degree of inter-professional cooperation.

Other matters having an impact on nurses practising in extended/expanded roles Manitoba, as with other provinces of similar geographical size and consequent widely dispersed population, has an indicated need for innovation in the delivery of health care services.

Additional comments There is no mention of title or protection of title for nurses practising in extended/expanded roles in the new Manitoba legislation. It appears that the new roles will be seen as variations within the overall scope of nursing practice in the province.

Information verified by the Association December 1999
Updated and revised by the Association and the Ministry June-July, 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Ontario

Names of organizations contacted College of Nurses of Ontario
Registered Nurses Association of Ontario (RNAO)

Nurses on active practice RN roles Approximately 80,000 reported working in nursing (1997)

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care Registered Nurse-Extended Class (NP-EC) under legislation proclaimed February, 1998. There are nurses practising who are not covered by legislation but practice under medical directives

Nurses registered or licensed to practice in extended/expanded roles as described above 350 registered (est.) though not all employed in the role The Ministry of Health and Long-term Care has announced funding for an additional 106 positions in long-term care (20) , under-serviced areas (80) and aboriginal community health access centres. The Primary Care Reform project sites also have 5 positions and the Ministry recently announced funding for 5 more NP s to provide women's health services through public health units in areas that have low participation in cervical screening and above average rates of cervical cancer ( hard to reach populations).positions in under serviced areas ( non-aboriginal).

Settings in which they practice Pilot projects in long-term care, primary care and public health.

Position titles or descriptions The only protected title is RN-EC (Extended Class) Titles, such as Nurse Practitioner, is commonly used but not title protected in legislation.

Educational qualifications and programs for practice in extended/expanded roles In 1994, the Council of Ontario University Programs in Nursing approved a program for RN- EC, at 10 sites to be co-ordinated by McMaster University. Program criteria to graduate is via one of two streams; a student with a diploma completes a 24 month course to attain a Bachelor of Nursing and NP certificate/ a student with a BN must successfully complete of a 12 month course to attain a NP certificate.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Legislated scope of practice is relative to primary care only with controlled acts which are to be performed by those RN with the designation of the extended class.

Facilitators to nurses practising in extended/ expanded roles A complex human resource problem respecting physicians looms. Both a maldistribution and shortage of physicians exists. Reductions in medical school enrolments have not yet begun to impact physician supply but are predicted to do so. There are projected increases in physician retirements and medical care is becoming more complex. These factors create opportunities for nurses to function in a complementary role to physicians. Fiscal constraints make NP practice attractive to governments that are trying to keep pace with demographic and technological changes in health care., reform the system and deliver safe effective care within provincial budgets. NPs may be a cost effective way of delivering some primary care services. Provincial health care strategy to restructure the system will focus more on primary care where nurses can play greater role.

Barriers to nurses practising in extended/expanded roles Nurses working as employees of physicians will have greater difficulty establishing collaborative working relationships NP s do not support a fee-for-service approach to remuneration for NP services. Adding NP s to the system currently requires additional funds to augment global budgets. Ontario now has a $16M per year budget for NP services. There is evident confusion with the public as between GPs and NPs. There is also confusion between the terms "nurse practitioner" and "practical nurse".

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals NPs are educating physicians as to their competencies and the potential for the physician to maximize their skills and nurses theirs. An amendment is required to the federal Narcotics Control Act to allow NP s to prescribe analgesics independently. Public Hospitals Act specifies who may provide service in hospitals. Current regulation permits NPs to admit as outpatients only and just for diagnostic tests ( Labs and x-rays). Another amendment is needed if NP s are to permitted to independently admit a patient for treatment, e.g., emergency. NP referrals to specialists are often not accepted. There are implications for payment of the specialist without a referral by a physician and/or countersignature by a physician.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles There is a move towards developing competencies for NPs across jurisdictions within Canada. There needs to a greater degree of uniformity of educational training to satisfy competencies.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles None reported.

Other organizations representing nurses Nurse Practitioners Association of Ontario, a speciality interest group of the RNAO
Ontario Nurses Association ( Labour Union)

Issues arising from public Nurses practising in extended/expanded roles is still relatively new and the public is not generally aware of the role and when to seek services of a nurse in this role. Greater public education is needed.
This has been evidenced by clients' comments to the College regarding the expectations and the scope of practice of the RN-EC. Inquires have been received from the public seeking clarification of the role.
Public confuses nurse practitioners with practical nurses. Some members of the public believe that NPs are a cheap, second rate physician substitute. Some MDs tend to reinforce this while patients are positive about the services received from NPs.

Issues arising from other professions' regulatory bodies or from unregulated professions Physicians have expressed concerns about competencies of the RN-EC. Also, physicians are concerned about economic competition from NPs.

Other matters having an impact on nurses practising in extended/expanded roles The policy direction if the current Government is supportive of the use of NPs as evidenced by an allocation of $16M to fund NP positions. The union has been supportive of the move toward extended/expanded practice and has stated its position. There is professional support for Masters preparation of RN-ECs but recognizes that the public may not be ready to accept this standard at this time.

Additional comments The Government is supportive of the Canada Health Act and supports the multi-disciplinary approach to primary health care and the role of the NP. The pace and timing may not be in step with nursing organizations.

Reviewed by the College December 1999
Updated with input by the College June 2000 and the Ministry in July 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Quebec

Names of organizations contacted Ordre des Infirmieres et Infirmier du Quebec (OIIQ)
Ministry of Health

Nurses on active practice RN roles 63, 000

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care Limited types of extended/expanded practice. Limited delegation to nurses of specific medical acts which are supervised by physicians and not based on a collaborative model of practice. The function of diagnosis has been reserved exclusively to physicians and there is little to no development in nursing to share this function.

Nurses registered or licensed to practice in extended/expanded roles as described above None registered; no legislation to enable the creation of a separate class.

Settings in which they practice There are 146 Community Health Centres (CLSC) in the Province employing 4000 nurses across the Province. They feature triage at the entry point with a nurse involved in screening and evaluation. The physicians protect the function of diagnosis. There are protocols established site-by-site. There is no Provincial-wide agreement covering the centres. In the northern regions of Quebec there is some delegation of medical function with physician supervision. There are no standard protocols.

Position titles or descriptions Nurses (infirmiere/infirmier)

Educational qualifications and programs for practice in extended/expanded roles No specific courses of instruction identified.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Delegation of function not necessarily with supporting protocols. There have been concerns raised by nurses as there are situations where they believe they could be exposed to liability and have no protection. This is an issue for the nurses association.

Facilitators to nurses practising in extended/ expanded roles In the very limited scope in which these roles occur, there appears to be a positive response with demonstrated patient satisfaction and favourable costs. Technological advances in health care delivery have heightened the awareness of the need for more specialized knowledge for nurses. This supports the move to specialization and advanced practice initiatives. Quebec has a great need for better continuing care following discharge from hospital. Therefore, the demand for nurses to deliver care in complex cases in the community is growing.

Barriers to nurses practising in extended/expanded roles Physicians are resistant to the delegation of the function especially diagnosis. The shortage of nurses means that the workforce is stretched and it is difficult to advocate for expanding roles when basic care is difficult to deliver. Thus there is seemingly little interest in the profession for advanced practice alternatives. This reality coupled with a significant number of nurses who are leaving the profession thus this further inhibits developments toward specialization. Employers resist higher qualification levels because of higher pay demands. There is limited support for extended/expanded roles from the union which holds the view a nurse is a nurse.

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals Legislative barriers exist given the limited scope of practice of the nurse. Physician dominance and desire to protect medical domain i.e. diagnosis.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles The certification of nurses at present is in one class. At the present time 70% of nurses hold diplomas while 30% of the membership have a university degree. There is interest in the OIIQ in introducing extended/expanded roles. This will influence educational requirements.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles No actions reported . Nurses practising in extended/expanded roles under delegation of medical functions in the absence of protocols are becoming more concerned about their liability.

Other organizations representing nurses Quebec Nurses Union

Issues arising from public Little apparent awareness of the public to possibilities for nurses practising in extended/expanded roles

Issues arising from other professions' regulatory bodies or from unregulated professions Physicians are concerned given the lack of physicians in remote areas.

Other matters having an impact on nurses practising in extended/expanded roles The funding mechanism is an inhibitor as there are different envelopes for physicians fees and there is no fee for physicians consulting with a nurse.
The role of nurses in the CLSCs is broad. They offer front-line practice in clinics and in a 24 hour telephone consultation service, Info-Sante. This service is very successful and is recognized as such by the public.
Lack of union support is an obvious detriment to expanding scope of practice.

Additional comments The Nurses Association of Quebec is working toward the release of a discussion paper regarding " advanced nursing practice" of which extended expanded roles form a part.
There has been relatively little work undertaken to develop competencies in this regard.
A pilot project for the northern part of the Province has been approved involving delegated medical acts and collaborative practice.

Reviewed by the Order of Nurses in December 1999
Updated by information received from the Order of Nurses June 2000
Ministry invited to comment-

Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
New Brunswick

Names of organizations contacted Nurses Association of New Brunswick (NANB)
Department of Health and Wellness

Nurses on active practice RN roles 8700

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care The practice of nurses who are part of the Interdisciplinary Team/Shared Practice ( IT/SP) model in three rural sites ( Grand Manan, Lameque and Saint Quentin), and nurses who work in MacAdam, involves assessment, diagnosis etc. but to a limited extent and through delegation from physicians. The Clinical Nurse Specialist role in New Brunswick is not extended/expanded practice. They function mostly in mentorship /development roles.

Nurses registered or licensed to practice in extended/expanded roles as described above No special regulation/licensing at present.

Settings in which they practice MacAdam Project - completed 4 years ago based on delegation of functions by protocol. This model is still being used and is being expanded to cover 8 additional facilities. Three ( 3) project sites have been designated as Interdisciplinary Team/Shared Practice ( IT/SP) Projects, again based on limited delegation of medical functions. Sites are: Lameque (most established), Grand Manan Island and St. Quentin.

Position titles or descriptions No separate title - referred to as RNs

Educational qualifications and programs for practice in extended/expanded roles NANB has a position statement on advanced practice at Masters level. UNB has introduced a NP stream in its MN program.
The nurses practising in the IT/SP projects were given additional educational programs prior to entering the role.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Site specific protocols govern the delegation of function

Facilitators to nurses practising in extended/ expanded roles Public acceptance of extended/expanded roles for nurses in rural areas.
Limited access to services due to shortage of physicians in geographic/specialty areas.

Barriers to nurses practising in extended/expanded roles Physician resistance to extended/expanded nursing role without MD control
Current funding mechanisms, i.e., fee-for-service, put nurses in competition with GPs

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals Use of protocols for delegation of function is well fixed and substantial change in that model is not imminent

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles The Association's preference is for an autonomous role for nurses in advanced practice within Masters stream

Disciplinary or liability actions arising with respect to practice in extended/expanded roles None reported

Other organizations representing nurses New Brunswick Nurses Union

Issues arising from public The Department of Health and Wellness had undertaken a public consultation regarding several issues, including the role of nurses in expanded/extended roles. Although there was some confusion as to functions nurses could undertake, there was an intention by the previous government to support an extended role. Plans to implement an extended role for nursing suspended with the change in government. In the pilot site at MacAdam there was evidence of the acceptance of the extended role of the nurse.

Issues arising from other professions' regulatory bodies or from unregulated professions Physicians wish to retain direct control over any increase in extended/expanded practice for nurses

Other matters having an impact on nurses practising in extended/expanded roles New Brunswick is experiencing significant difficulties in recruiting and retaining physicians

Additional comments Government appears to be leaning towards increased funding to allow for greater placement of nurses in physicians' offices rather than committing to introduction of extended/expanded practice initiative

Reviewed by the Association December 15, 1999
Updated with the input of the Department and the Association June 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Prince Edward Island

Names of organizations contacted Association of Nurses of Prince Edward Island (ANPEI)
Department of Health and Social Services

Nurses on active practice RN roles 1350

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care None

Nurses registered or licensed to practice in extended/expanded roles as described above None

Settings in which they practice Not applicable

Position titles or descriptions RN

Educational qualifications and programs for practice in extended/expanded roles Not applicable at present. A degree program has been available at UPEI for undergraduate nursing education since 1994. It is unlikely that a program to educate nurses for extended/expanded roles will be available in the Province given the small population base of PEI.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Not applicable at present. However, if there is movement toward the introduction of an extended/expanded role for nursing, the Association would establish guidelines etc. based on assessment of competency and in accordance with guidelines of the CNA.

Facilitators to nurses practising in extended/ expanded roles The Department of Health and Social Services is currently undertaking a discussion of a redesign of primary health care in the Province. Consideration is being given to the community health centre model which is based on increased collaboration between disciplines. If there is another role for nursing, it would not be physician substitution but be complementary to physicians.

Barriers to nurses practising in extended/expanded roles The need for a greater understanding of the role of the nurse in an extended/expanded role. Should the role be introduced, there would need to be education among health care practitioners and the public.

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals There is a need to clarify the role of the nurse in an extended/expanded practice setting vis-a-vis other professionals. It would be important to stress the fact this role is complementary to physicians and not physician substitution.
The need for flexibility for nurses in the role may be challenging given union contracts.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles The need for maintenance of competence is an issue, particularly should nurses become involved in extended/expanded roles.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles Not applicable

Other organizations representing nurses Prince Edward Island Nurses Union

Issues arising from public None raised

Issues arising from other professions' regulatory bodies or from unregulated professions Not at issue

Other matters having an impact on nurses practising in extended/expanded roles ANPEI believes that extended/expanded roles fall within the scope of nursing practice and therefore does not support the separation of roles within nursing and consequently would not support title protection, i.e. NP

Additional comments There was a family practice demonstration project over the past 2 years which has led to increased consideration of collaborative models.
There are many issues to take into consideration in expanding nursing roles ( e.g., impact on physician remuneration, skepticism in the medical society )

Reviewed by the Association December 15, 1999
Revisions suggested by the Association and the Department June 26, 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Nova Scotia

Names of organizations contacted Registered Nurses Association of Nova Scotia (RNANS)
Department of Health & Community Services

Nurses on active practice RN roles 9300(est)

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care No legislated extended/expanded practice. Clinical nurse specialists in tertiary care settings only. Demonstration projects underway in 4 locations for nurse practitioner practice.

Nurses registered or licensed to practice in extended/expanded roles as described above The selected demonstration sites.

Settings in which they practice Four demonstration sites:

North End Community Health Centre-Halifax

Queens Community Health Centre-Caledonia

Pictou

Springhill

Position titles or descriptions Primary Care Nurse practitioner

Educational qualifications and programs for practice in extended/expanded roles For demonstration projects, a NP certificate will be required from a recognized program, i.e. Alberta, Ontario or Newfoundland, or a licence to practice as a primary care nurse practitioner in another jurisdiction.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Scope of practice is defined by delegation of function from physician under guidelines developed through discussion and negotiation between College of Physicians and Surgeons of NS and Registered Nurses Association of NS.

Facilitators to nurses practising in extended/ expanded roles There appears to be interest in the concept of nurse practitioners, especially in rural/remote areas of province. Nurse practitioners and physician consultants available to NP s at the demonstration sites.

Barriers to nurses practising in extended/expanded roles
Physicians retain control over ability of nurses to expand scope of practice (legislative dominance).

Funding mechanisms

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals

Medical Act will need amendment

Pharmacy Act amended for demonstration sites only; regulations forthcoming

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles Dalhousie University will be offering a Nurse Practitioner certificate program for rural and under served communities.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles None reported

Other organizations representing nurses

Nova Scotia Nurses Union, and

NS Government Employees Union

Issues arising from public Calls for greater health care resources in rural/remote areas

Issues arising from other professions' regulatory bodies or from unregulated professions Medical Act powers require delegation of function to nurses

Other matters having an impact on nurses practising in extended/expanded roles None raised

Reviewed by the Association and the Department of Health & Community Services December 1999
Updated with the input of the Association and the Department of Health July 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Newfoundland and Labrador

Names of organizations contacted Association of Registered Nurses of Newfoundland (ARNN)
Department of Health and Community Services

Nurses on active practice RN roles 5300

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care Nurse Practitioner - Primary Health Care (NP-PHC) defined under legislation. As well there are several regional nurses who practice under protocol agreement in extended/expanded roles.

Nurses registered or licensed to practice in extended/expanded roles as described above 22 NP and approximately 70 regional nurses

Settings in which they practice Three Primary Health Enhancement Projects at Port-aux-Basques, Twillingate and Happy Valley-Goose Bay; Other sites include, but are not limited to, Bonavista Hospital; Ramea Clinic; Harbour Breton; Norris Point; Health Labrador Corporation and Grenfell Regional Health Services Board

Position titles or descriptions Nurse practitioner
Regional Nurse

Educational qualifications and programs for practice in extended/expanded roles Current RN practice certificate 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 current registration as RN in Newfoundland.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Scope of practice, standards of practice and competencies for NP- PHC developed and approved by regulatory body.

Facilitators to nurses practising in extended/ expanded roles There is stakeholder support for NP practice, acceptance by the ARNNL membership and by Regional Boards. Efforts are being made to enhance understanding in the community. As NP s are present in a number of settings, clinical competence demonstrated on-site. The ARNNL had initiative underway when Minister announced regulation introducing NP.

Barriers to nurses practising in extended/expanded roles Other professions lack of understanding of NP role Funding mechanisms; fee for service physician cannot bill for consultation with NP
NP pay classification not nationally competitive
Establishing the required collaboration with MD may prove to be problematic due to physician shortage
Lack of prescribing authority for regional nurses (Grenfell Regional Health Services)
Overlapping roles with Community Health nurses may present challenges

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals The Physio- therapy legislation has been amended to allow referrals from NPs
Experience with the regulations has highlighted the need for consideration of making consequential amendments to statutes to facilitate full scope of practice of NP, e.g., Vital Statistics Act

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles The current entry requirement for practice is successful completion of the program for NP training offered through the Centre for Nursing Studies
The policy position of the ARNNL is a minimum standard of BN with one year NP program that carries credit toward an MN degree. There is an issue of the local availability and access to education program(s) that satisfies the ARNNL preference.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles None reported

Other organizations representing nurses Newfoundland and Labrador Nurses Union

Issues arising from public No issues raised other than continuing calls from public for better health services in rural/remote areas

Issues arising from other professions' regulatory bodies or from unregulated professions Pharmacist regulatory body is concerned about issues of liability with respect to regional nurses and prescriptive authority.
Physicians initially had concerns respecting their liability and NP practice.

Other matters having an impact on nurses practising in extended/expanded roles Assessing competency, maintaining competencies and the responsibilities of the employing organizations to support ongoing maintenance of competency.

Additional comments Further refining of definition of primary health care services, primary care services and how the NP role fits in the models for service delivery is needed. For example, developments in midwifery in the Province may impact on NP practice. Evaluation and research is required to ensure a cost effective model of service is in place.

Reviewed by the Association December 1999
Revised with assistance from the Association and the Department of Health & Community Services June 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Yukon

Names of organizations contacted Yukon Registered Nurses Association (YRNA)

Nurses on active practice RN roles 300

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care Community Nurse Practitioners working in rural communities practice in this capacity which falls within the current legislative framework.

Nurses registered or licensed to practice in extended/expanded roles as described above No central registry, so it is not possible for YRNA to specify numbers. Approximately 50 are employed by Health and Social Services, Government of Yukon in sufficiently extended/expanded roles to note in this survey

Settings in which they practice 12 rural communities have nurses acting in these roles, three of which also have physicians.

Position titles or descriptions Community Nurse Practitioner

Educational qualifications and programs for practice in extended/expanded roles No fixed program approved by YRNA. (Employers accept a variety of options regarding education.)

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles Employers have adopted the Medical Services Branch Scope of Practice for Community Health Nurses, Nursing Station facilities and Health Care Treatment facilities.

Facilitators to nurses practising in extended/ expanded roles Wide acceptance by the public of nurses practising in these roles
Good cooperation from physicians and pharmacists

Barriers to nurses practising in extended/expanded roles No legislation planned in the immediate future and this is not viewed as a particular barrier by the YRNA.

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals There are no indications of challenges from other health professionals.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles Small number of YRNA members. YRNA is participating in multi-jurisdictional initiatives which seek to address these issues from a national perspective.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles None reported

Other organizations representing nurses Unions represent both hospital and government-employed nurses.

Issues arising from public Public is satisfied with role nurses play in health care delivery and there is no indication that they would be adverse to a greater expansion of extended/ expanded practice for nurses

Issues arising from other professions' regulatory bodies or from unregulated professions Pharmacy Act Regulations were recently amended to allow direct prescribing. It is assumed that very little will occur under the authority of the regulatory changes until prescribing competencies are developed.

Other matters having an impact on nurses practising in extended/expanded roles YRNA's legislative framework is sufficient to accommodate a significant level of extended/expanded practice. This has been confirmed by legal counsel. It is possible that additional regulations will be added in the future in order to address the issue of mobility of nurses moving to and from the territory.

Additional comments The territories are unique in their approach to nursing in extended/expanded roles. They have a pragmatic view of how best to deliver primary care in areas with physician under resourcing and there appears to be a high degree of cooperation with the Medical and Pharmacy professions.

Information confirmed by the Association in December 1999
Updated with the input of the Association and the Ministry July 2000
Background Information Gathered from Nurses Associations, Regulatory Bodies and Ministries of Health
Northwest Territories **(see end of summary for reference to Nunavut)

Names of organizations contacted Northwest Territories Registered Nurses Association (NWTRNA)
Ministry of Health

Nurses on active practice RN roles 765 (*including nurses practising in Nunavut)

Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care NWT and Nunavut considers itself different from the rest of Canada in health care delivery in that organized delivery did not really occur until the 1950s. As a consequence, nurses have been practising in extended/expanded roles for many years. The territory has no specific legislation but is watching the CNA and other provinces initiatives with interest.

Nurses registered or licensed to practice in extended/expanded roles as described above 765 nurses registered a majority would provide some level of extended/expanded services to clients

Settings in which they practice Throughout the NWT and Nunavut under ten (10) Regional Health Boards. There are other employers of RN s such as non-profit organizations, clinics and mines.

Position titles or descriptions Usually simply referred to as Community Health Nurses but also as primary health care nurse practitioners

Educational qualifications and programs for practice in extended/expanded roles Preference is for training through Aurora College "Introduction to Nurse Practitioner Programme" , however, this is not a fixed requirement.

Scope of practice guidelines, by-laws, standards of practice or competencies to define roles All extended/expanded practice is undertaken under the authority of protocols with the medical profession and employer organizations.

Facilitators to nurses practising in extended/ expanded roles Traditional role is widely accepted by the public. Good cooperation with physicians and pharmacists.

Barriers to nurses practising in extended/expanded roles No legislative basis for extended/expanded role at present. Given the relatively small population base and the relatively small number of members in Association, it will be difficult to carry out a major legislative initiative. The introduction of legislation could have a significant impact on the existing system that is built on delegation of function and co-operation.

Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals Joint statement (1998) from the NWT Medical Association and the NWTRNA calls for collaboration of the two professions in a model based on the delegation of medical function.

Challenges concerning education and continuing education for nurses practising in extended/ expanded roles NWTRNA is in the process of finalizing competencies for the Primary Health Care Nurse Practitioner.

Disciplinary or liability actions arising with respect to practice in extended/expanded roles There have been incidents where RNs practising in extended/expanded roles (under delegation of function) have been the subject of disciplinary investigation. These incidents are not necessarily related to the extended/expanded role and are not viewed as being out of proportion when compared with other jurisdictions.

Other organizations representing nurses Union of Northern Workers (NWT)
Nunavut Employees Union (Nunavut)

Issues arising from public Public would be concerned if a more formalized role for nurses in extended/expanded practice lessened access to nurses providing point of first contact primary care

Issues arising from other professions' regulatory bodies or from unregulated professions The NWTRNA is currently lobbying for a new Act, finalizing competencies for Primary Health Care Nurse Practitioners, etc.

Other matters having an impact on nurses practising in extended/expanded roles Isolation, under resourcing of physicians, widely dispersed population means that NWT will likely continue with its present model until a national initiative is well established

Information verified by the Association in December 1999
Revised with comments from the Association and the NWT Ministry of Health and Social Services July 2000

Names of organizations contacted	Registered Nurses Association of British Columbia (RNABC) B.C. Ministry of Health
Nurses on active practice RN roles	29,033 Practising Registered Nurses, December 1998. Data source: Rollcall Update 98, Health Human Resources Unit, University of British Columbia
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	No legislative basis. Variety of extended/expanded practice roles being fulfilled. Some of these practice roles are within the existing scope of nursing practice. There are some nurses working in extended/expanded roles through medical delegation.
Nurses registered or licensed to practice in extended/expanded roles as described above	None registered or licensed to specifically fulfill extended/ expanded practice role. Accomplished through MD delegation. No central registry kept by RNABC so difficult to estimate #s. In 1998, 85 nurses were employed in Nursing Stations/Outpost/Clinic. Data source: Rollcall Update 98
Settings in which they practice	Examples are: Red Cross Outposts, MSB locations, Comox Valley Nursing Center,. RN First Call, some Community Health Centres. NB - Comox Valley practice is not fully 'extended/expanded' practice as far as prescribing drugs and ordering tests. The practice is extended/expanded but within the existing scope of practice.
Position titles or descriptions	RNs, unofficially as NPs in Community Health Centers Registered Nurse is the legislated title; however, there are some nurses who call themselves Nurse Practitioners.
Educational qualifications and programs for practice in extended/expanded roles	Educational and other qualifications for employment are set by the employer, i.e. Red Cross or MSB. Employers may pay for or require a specialty course. Diploma is the minimum qualification as for all Registered Nurses.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Virtually all extended/expanded practice in BC is by delegation of function. The delegated acts (i.e. functions beyond the scope of practice) are established by working arrangements according to location, organization and training. RNABC has established guidelines for DMF (Delegated Medical Functions)
Facilitators to nurses practising in extended/ expanded roles	There appears to be acceptance by the public of increasing responsibility and independence for the practice of nursing where the extended/expanded roles exist.
Barriers to nurses practising in extended/expanded roles	No consultation fee for physicians; legislative barriers exist, e.g. Medical Practitioners Act and the Nurses (Registered) Act which has an imprecise definition of the scope of nurses (the "ordinary calling of nursing").
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	Doctor/nurse traditional roles are difficult to modify substantially in the absence of substantive legislative change. Physicians in rural/remote areas often welcome extended/expanded nurse roles whereas similar attitudes may not always be present in urban locations.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	At the present time there are only limited education programs, primarily sponsored by employers, for nurses practising in extended/expanded roles.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	Presently liability coverage is provided by the employer and what is normally carried as a member of RNABC. There have been no reported incidents related to extended/expanded practice
Other organizations representing nurses	BC Nurses Union
Issues arising from public	As throughout the country, there is a demand for better health care services in rural/remote areas and other under-serviced areas
Issues arising from other professions' regulatory bodies or from unregulated professions	Liability is a continuing and growing concern for physicians and pharmacists in the absence of legislation
Other matters having an impact on nurses practising in extended/expanded roles	Under the relatively new Health Professions legislation in BC, the Health Professions Council is reviewing all health professions' scopes of practice with a view to prescribing 'restricted acts' which will then be set by regulation. The RNABC and the BC Nurses Union have jointly presented a proposed list of reserved acts to the HPC. Some of these suggested reserved acts would require additional regulatory authority, e.g. prescriptive authority. The final assessment of the HP Council following public hearings in June, 2000 is expected at some time in 2000 or early in 2001 and it will play a large part in determining the future of extended/expanded practice for nurses in BC

Names of organizations contacted	Alberta Association of Registered Nurses (AARN) Alberta Health
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	Registered Nurse - Extended Practice (RN-EP) under legislation. Northern nurses have been practising for many years under protocols in more limited capacities of extended/expanded practice
Nurses on active practice RN roles	23,455 as at June 21, 2000
Nurses registered or licensed to practice in extended/expanded roles as described above	16 at time of survey
Settings in which they practice	Minister has pre-approved 11 sites. Presently 16 RN-EPs are working within provincial Regional Health Authority sites and federal Medical Services Branch approved locations.
Position titles or descriptions	RN-EP officially, but usually called Community Nurse Practitioners
Educational qualifications and programs for practice in extended/expanded roles	The Extended Practice Roster Regulation provides two avenues by which a registered nurse can apply to the Roster. The requirements include 1). a baccalaureate degree, three to four years of relevant clinical experience and completion of an educational program that prepares the registered nurse to provide extended services. The Advanced Graduate Diploma in Community Nursing practice at Athabasca University has been approved as an educational program or 2). There is a two year grand-parenting clause ( February 1999-February 2001) for nurses who do not meet the educational requirement but have been successfully providing these services. These nurses undergo an assessment process to ensure they have the necessary knowledge and skills.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Competencies and guidelines are prepared and published by the AARN to govern the practice of nurses providing 'extended health services' The Extended practice Roster Regulation governs the registration of nurses on the Roster. Relevant documents include: Competencies for Registered Nurses Providing Extended Health Services in the Province of Alberta ( December 1995) Prescribing and Distributing Guidelines for Registered Nurses in Advanced Nursing Practice Providing Primary Health Care Services ( February 1995) ( Re-endorsed February 200 for two years) Alberta Health: Guidelines for Registered Nurses in Advanced Nursing Practice Providing Primary Health Care Services in Under-serviced Communities in Alberta ( August 1994)
Facilitators to nurses practising in extended/ expanded roles	Shortage of physicians in rural/remote areas Physicians and pharmacists have been reasonably supportive Provinces future health strategy incorporates increased use of RN-EPs
Barriers to nurses practising in extended/expanded roles	There is one urban centre (Calgary) where an RN-EP is practising. In general, physicians appear to recognize the role of RN-EPs in a supportive role however they do not support complete independence of this practice. There is no mechanism to date to address for fee-for-service.
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	Enhancing physician and pharmacist cooperation. Alberta's Health Professions Act sets 'restricted activities' for professions.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	RN - EPs must demonstrate full competence in the entire scope of practice for extended practice. Nurses registered to practice as RN-EPs must apply for renewal each year.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	No actions reported
Other organizations representing nurses	United Nurses of Alberta
Issues arising from public	The RN-EP extended/expanded role has recently been developed (1999). The public may not be aware of the role for nurses who are accepted on the extended Practice Roster. Overall, the public does appear to be supportive of increased responsibilities for nurses.
Issues arising from other professions' regulatory bodies or from unregulated professions	Physicians and Pharmacists want practice of RN-EPs to remain structured under health care organization employment
Other matters having an impact on nurses practising in extended/expanded roles	Urban practice setting (Calgary) may lead to greater urban use of RN-EPs
Additional comments	Alberta appears committed to the increasing use of nurses practising in extended/ expanded roles including in urban areas but there is direct control over sight approvals by the Minister Regulations are being developed under the Health Professions Act and will probably include RN s practicing in extended/expanded practice roles.

Names of organizations contacted	Saskatchewan Registered Nurses Association (SRNA) Saskatchewan Health
Nurses in active practice RN roles	Approx. 9,000
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	Saskatchewan has a significant number of nurses practising in extended/expanded roles throughout the province through delegation of medical functions and cooperation with the pharmacy profession. It is expected that the delegation model will give way to expanded scope of practice for nurses when Council specifically prescribes 'special categories of practice' under the operative statute.
Nurses registered or licensed to practice in extended/expanded roles as described above	Although the Registered Nurses Act contains provisions for the Council to prescribe 'special categories of practice', there are no nurses yet actually licensed in this capacity.
Settings in which they practice	With no central registry held by the SRNA, it is not possible to identify all the sites where nurses are practising in extended/expanded roles. There are 32 health districts in the province and 27 nurses are employed in extended/expanded roles as primary care nurses. However, these estimates do not include nurses employed by Tribal Councils. There are 10 nurses employed in the primary health care demonstration sites.
Position titles or descriptions	No fixed titles. Referred to as Primary Care Nurses in protocol.
Educational qualifications and programs for practice in extended/expanded roles	SRNA has criteria for practice in extended/expanded roles under guidelines established in a document titled The Registered Nurse Scope of Practice: Special Nursing Procedures and Nursing Procedures by Transfer of Medical Functions, 1993. The latest document on prescribing is Guidelines for Nurses Prescribing and/or Distributing Drugs by Transfer of Functions, revised May 1999. The criteria require that a nurse wishing to practice under these guidelines must take a "formal course" of instruction. The Advanced Clinical Nursing Program at Saskatchewan Institute of Applied Technology is a course of instruction to prepare a nurse for an extended/expanded role.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Scope of practice is defined by the province-wide clinical practice guidelines and as modified by site.
Facilitators to nurses practising in extended/ expanded roles	Legal advice has been received by SRNA that ability of Council to prescribe special categories of practice (sect. 15 (2)(f)) is sufficient to provide for extended/expanded practice roles without having to further amend statute. There also appears to be. widespread and historical acceptance of extended/expanded practice for nurses and significant and longstanding co-operation of nurse, physicians and pharmacists.
Barriers to nurses practising in extended/expanded roles	Uncertainty as to the degree of support from physicians for moving from the delegation of function model. Pharmacy legislation permits prescribing by professions, however, nurses have not been specifically designated. Awaiting regulations under the Pharmacy Act.
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	Nurses, physicians and pharmacists appear to act cooperatively. There is growing support for a licensing model. While physicians are supportive of extended/expanded roles and perhaps legitimatization of these roles, it is acceptable if this move is as part of collaborative practice arrangements. There have been concerns expressed on the part of physicians and pharmacists about liability though liability is not increasing. The biggest challenge in primary health care is the loss of physicians and ensuring nurses have the skills to take on added responsibility.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	In the absence of legislation and a lack of a central roster of nurses practising in these roles, it will continue to be difficult for the SRNA to oversee the continuing competencies of these nurses
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	No actions reported
Other organizations representing nurses	Saskatchewan Nurses Union
Issues arising from public	General acceptance by the public of the need for nurses to act in extended/expanded practice roles where appropriate.
Issues arising from other professions' regulatory bodies or from unregulated professions	Concerns about liability and uncertainty as to the degree of acceptance and support from physicians for nurses exerting more autonomous and direct authority over patient treatment in primary health care.
Additional comments	Saskatchewan appears to have a well established system of extended/expanded practice for nurses based on the cooperative transfer of medical function model. SRNA is moving towards changing the model to more autonomous extended/expanded practice for nurses. However, it appears that the Association is moving cautiously in this direction, most likely because of concern that a legislatively imposed regime will likely mean changes in existing interrelationships among the affected professions. The legal advisors within government have questioned whether the regulation is specific enough to cover nurses for the functions that could be considered special categories as have been delegated under the clinical practice guidelines and guidelines for transfer of functions documents. This issue is under active consideration. From a human resources planning perspective, it is a challenge to ensure there is good complement of knowledge and skills with a range of health care providers to deliver primary health care services.

Names of organizations contacted	Manitoba Association of Registered Nurses (MARN)
Nurses on active practice RN roles	10,792 (1999)
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	New legislation governing the profession is passed but not proclaimed. A component of the new legislation will be the expanded the scope of practice through "included practices'.which encompass prescriptive authority, performance of minor surgical and invasive procedures and ordering and receiving results of screening and diagnostic tests. Existing extended/ expanded practice is performed under delegation of medical functions and collaborative practice agreements.
Nurses registered or licensed to practice in extended/expanded roles as described above	The new Registered Nurses Act will allow for a separate register for nurses practising in extended capacities (included practices) under the competencies to be developed
Settings in which they practice	Extended/expanded practice is carried out in some urban as well as remote and northern regions. Settings include tertiary and community hospitals, community health centres, community nurse resource centres and community programs.
Position titles or descriptions	The title "Registered Nurse" is the only title regulated by MARN at this time. The new legislation once proclaimed will also protect the title "Graduate Nurse". Employers may choose to use a specific position title such as nurse practitioner or advanced practice nurse but these are not regulated titles in Manitoba.
Educational qualifications and programs for practice in extended/expanded roles	The focus will be on the competencies required to perform the services identified in the included practices. Nurses may develop the required competencies through various educational activities. Concerning advanced nursing practice, there currently exists a Masters level program in Advanced Nursing Practice at the University .of Manitoba; completion of this program is one educational options.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	The Registered Nurses' Act identifies the scope of practice of registered nurses. Under the new legislation, regulations will be developed to set the competencies required for included practices. Registered nurses with the required competencies will have the legislated authority to perform the included practices and delegation of function will not be required for these services. MARN has established standards of nursing practice which apply to all practising registered nurses in the province regardless of their roles or practice settings. MARN has adopted the CNA Code of Ethics for Registered Nurses which provides the ethical guidelines for practice.
Facilitators to nurses practising in extended/ expanded roles	The new legislation will facilitate this once it is proclaimed. The existence of a program of studies for the advance practice role may facilitate this as well.
Barriers to nurses practising in extended/expanded roles	At this point the major barrier is waiting to have the enabling statute proclaimed. An additional barrier may be the understanding by the employers, other professions, etc. of the scope of practice of registered nurses that is based on traditional perceptions rather than contemporary reality.
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	To date, there have not been significant challenges posed by other health care professions.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	Regulations will be developed that will address the education and continuing education required. In accordance with the new legislation, a program must be established to ensure continuing competence for all registered nurses practising in Manitoba.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	Registered nurses acting in these roles will be subject to the usual statutory disciplinary processes.
Other organizations representing nurses	Manitoba Nurses Union is the union representing most registered nurses. A small number are represented by other unions such as Manitoba Government Employees Union.
Issues arising from public	There appears to be acceptance by the public of the concept of extended/expanded roles for nurses in the delivery of health care
Issues arising from other professions' regulatory bodies or from unregulated professions	There has been no appreciable opposition to the new legislation which is evidence of a significant degree of inter-professional cooperation.
Other matters having an impact on nurses practising in extended/expanded roles	Manitoba, as with other provinces of similar geographical size and consequent widely dispersed population, has an indicated need for innovation in the delivery of health care services.
Additional comments	There is no mention of title or protection of title for nurses practising in extended/expanded roles in the new Manitoba legislation. It appears that the new roles will be seen as variations within the overall scope of nursing practice in the province.

Names of organizations contacted	College of Nurses of Ontario Registered Nurses Association of Ontario (RNAO)
Nurses on active practice RN roles	Approximately 80,000 reported working in nursing (1997)
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	Registered Nurse-Extended Class (NP-EC) under legislation proclaimed February, 1998. There are nurses practising who are not covered by legislation but practice under medical directives
Nurses registered or licensed to practice in extended/expanded roles as described above	350 registered (est.) though not all employed in the role The Ministry of Health and Long-term Care has announced funding for an additional 106 positions in long-term care (20) , under-serviced areas (80) and aboriginal community health access centres. The Primary Care Reform project sites also have 5 positions and the Ministry recently announced funding for 5 more NP s to provide women's health services through public health units in areas that have low participation in cervical screening and above average rates of cervical cancer ( hard to reach populations).positions in under serviced areas ( non-aboriginal).
Settings in which they practice	Pilot projects in long-term care, primary care and public health.
Position titles or descriptions	The only protected title is RN-EC (Extended Class) Titles, such as Nurse Practitioner, is commonly used but not title protected in legislation.
Educational qualifications and programs for practice in extended/expanded roles	In 1994, the Council of Ontario University Programs in Nursing approved a program for RN- EC, at 10 sites to be co-ordinated by McMaster University. Program criteria to graduate is via one of two streams; a student with a diploma completes a 24 month course to attain a Bachelor of Nursing and NP certificate/ a student with a BN must successfully complete of a 12 month course to attain a NP certificate.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Legislated scope of practice is relative to primary care only with controlled acts which are to be performed by those RN with the designation of the extended class.
Facilitators to nurses practising in extended/ expanded roles	A complex human resource problem respecting physicians looms. Both a maldistribution and shortage of physicians exists. Reductions in medical school enrolments have not yet begun to impact physician supply but are predicted to do so. There are projected increases in physician retirements and medical care is becoming more complex. These factors create opportunities for nurses to function in a complementary role to physicians. Fiscal constraints make NP practice attractive to governments that are trying to keep pace with demographic and technological changes in health care., reform the system and deliver safe effective care within provincial budgets. NPs may be a cost effective way of delivering some primary care services. Provincial health care strategy to restructure the system will focus more on primary care where nurses can play greater role.
Barriers to nurses practising in extended/expanded roles	Nurses working as employees of physicians will have greater difficulty establishing collaborative working relationships NP s do not support a fee-for-service approach to remuneration for NP services. Adding NP s to the system currently requires additional funds to augment global budgets. Ontario now has a $16M per year budget for NP services. There is evident confusion with the public as between GPs and NPs. There is also confusion between the terms "nurse practitioner" and "practical nurse".
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	NPs are educating physicians as to their competencies and the potential for the physician to maximize their skills and nurses theirs. An amendment is required to the federal Narcotics Control Act to allow NP s to prescribe analgesics independently. Public Hospitals Act specifies who may provide service in hospitals. Current regulation permits NPs to admit as outpatients only and just for diagnostic tests ( Labs and x-rays). Another amendment is needed if NP s are to permitted to independently admit a patient for treatment, e.g., emergency. NP referrals to specialists are often not accepted. There are implications for payment of the specialist without a referral by a physician and/or countersignature by a physician.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	There is a move towards developing competencies for NPs across jurisdictions within Canada. There needs to a greater degree of uniformity of educational training to satisfy competencies.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	None reported.
Other organizations representing nurses	Nurse Practitioners Association of Ontario, a speciality interest group of the RNAO Ontario Nurses Association ( Labour Union)
Issues arising from public	Nurses practising in extended/expanded roles is still relatively new and the public is not generally aware of the role and when to seek services of a nurse in this role. Greater public education is needed. This has been evidenced by clients' comments to the College regarding the expectations and the scope of practice of the RN-EC. Inquires have been received from the public seeking clarification of the role. Public confuses nurse practitioners with practical nurses. Some members of the public believe that NPs are a cheap, second rate physician substitute. Some MDs tend to reinforce this while patients are positive about the services received from NPs.
Issues arising from other professions' regulatory bodies or from unregulated professions	Physicians have expressed concerns about competencies of the RN-EC. Also, physicians are concerned about economic competition from NPs.
Other matters having an impact on nurses practising in extended/expanded roles	The policy direction if the current Government is supportive of the use of NPs as evidenced by an allocation of $16M to fund NP positions. The union has been supportive of the move toward extended/expanded practice and has stated its position. There is professional support for Masters preparation of RN-ECs but recognizes that the public may not be ready to accept this standard at this time.
Additional comments	The Government is supportive of the Canada Health Act and supports the multi-disciplinary approach to primary health care and the role of the NP. The pace and timing may not be in step with nursing organizations.

Names of organizations contacted	Ordre des Infirmieres et Infirmier du Quebec (OIIQ) Ministry of Health
Nurses on active practice RN roles	63, 000
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	Limited types of extended/expanded practice. Limited delegation to nurses of specific medical acts which are supervised by physicians and not based on a collaborative model of practice. The function of diagnosis has been reserved exclusively to physicians and there is little to no development in nursing to share this function.
Nurses registered or licensed to practice in extended/expanded roles as described above	None registered; no legislation to enable the creation of a separate class.
Settings in which they practice	There are 146 Community Health Centres (CLSC) in the Province employing 4000 nurses across the Province. They feature triage at the entry point with a nurse involved in screening and evaluation. The physicians protect the function of diagnosis. There are protocols established site-by-site. There is no Provincial-wide agreement covering the centres. In the northern regions of Quebec there is some delegation of medical function with physician supervision. There are no standard protocols.
Position titles or descriptions	Nurses (infirmiere/infirmier)
Educational qualifications and programs for practice in extended/expanded roles	No specific courses of instruction identified.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Delegation of function not necessarily with supporting protocols. There have been concerns raised by nurses as there are situations where they believe they could be exposed to liability and have no protection. This is an issue for the nurses association.
Facilitators to nurses practising in extended/ expanded roles	In the very limited scope in which these roles occur, there appears to be a positive response with demonstrated patient satisfaction and favourable costs. Technological advances in health care delivery have heightened the awareness of the need for more specialized knowledge for nurses. This supports the move to specialization and advanced practice initiatives. Quebec has a great need for better continuing care following discharge from hospital. Therefore, the demand for nurses to deliver care in complex cases in the community is growing.
Barriers to nurses practising in extended/expanded roles	Physicians are resistant to the delegation of the function especially diagnosis. The shortage of nurses means that the workforce is stretched and it is difficult to advocate for expanding roles when basic care is difficult to deliver. Thus there is seemingly little interest in the profession for advanced practice alternatives. This reality coupled with a significant number of nurses who are leaving the profession thus this further inhibits developments toward specialization. Employers resist higher qualification levels because of higher pay demands. There is limited support for extended/expanded roles from the union which holds the view a nurse is a nurse.
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	Legislative barriers exist given the limited scope of practice of the nurse. Physician dominance and desire to protect medical domain i.e. diagnosis.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	The certification of nurses at present is in one class. At the present time 70% of nurses hold diplomas while 30% of the membership have a university degree. There is interest in the OIIQ in introducing extended/expanded roles. This will influence educational requirements.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	No actions reported . Nurses practising in extended/expanded roles under delegation of medical functions in the absence of protocols are becoming more concerned about their liability.
Other organizations representing nurses	Quebec Nurses Union
Issues arising from public	Little apparent awareness of the public to possibilities for nurses practising in extended/expanded roles
Issues arising from other professions' regulatory bodies or from unregulated professions	Physicians are concerned given the lack of physicians in remote areas.
Other matters having an impact on nurses practising in extended/expanded roles	The funding mechanism is an inhibitor as there are different envelopes for physicians fees and there is no fee for physicians consulting with a nurse. The role of nurses in the CLSCs is broad. They offer front-line practice in clinics and in a 24 hour telephone consultation service, Info-Sante. This service is very successful and is recognized as such by the public. Lack of union support is an obvious detriment to expanding scope of practice.
Additional comments	The Nurses Association of Quebec is working toward the release of a discussion paper regarding " advanced nursing practice" of which extended expanded roles form a part. There has been relatively little work undertaken to develop competencies in this regard. A pilot project for the northern part of the Province has been approved involving delegated medical acts and collaborative practice.

Names of organizations contacted	Nurses Association of New Brunswick (NANB) Department of Health and Wellness
Nurses on active practice RN roles	8700
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	The practice of nurses who are part of the Interdisciplinary Team/Shared Practice ( IT/SP) model in three rural sites ( Grand Manan, Lameque and Saint Quentin), and nurses who work in MacAdam, involves assessment, diagnosis etc. but to a limited extent and through delegation from physicians. The Clinical Nurse Specialist role in New Brunswick is not extended/expanded practice. They function mostly in mentorship /development roles.
Nurses registered or licensed to practice in extended/expanded roles as described above	No special regulation/licensing at present.
Settings in which they practice	MacAdam Project - completed 4 years ago based on delegation of functions by protocol. This model is still being used and is being expanded to cover 8 additional facilities. Three ( 3) project sites have been designated as Interdisciplinary Team/Shared Practice ( IT/SP) Projects, again based on limited delegation of medical functions. Sites are: Lameque (most established), Grand Manan Island and St. Quentin.
Position titles or descriptions	No separate title - referred to as RNs
Educational qualifications and programs for practice in extended/expanded roles	NANB has a position statement on advanced practice at Masters level. UNB has introduced a NP stream in its MN program. The nurses practising in the IT/SP projects were given additional educational programs prior to entering the role.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Site specific protocols govern the delegation of function
Facilitators to nurses practising in extended/ expanded roles	Public acceptance of extended/expanded roles for nurses in rural areas. Limited access to services due to shortage of physicians in geographic/specialty areas.
Barriers to nurses practising in extended/expanded roles	Physician resistance to extended/expanded nursing role without MD control Current funding mechanisms, i.e., fee-for-service, put nurses in competition with GPs
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	Use of protocols for delegation of function is well fixed and substantial change in that model is not imminent
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	The Association's preference is for an autonomous role for nurses in advanced practice within Masters stream
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	None reported
Other organizations representing nurses	New Brunswick Nurses Union
Issues arising from public	The Department of Health and Wellness had undertaken a public consultation regarding several issues, including the role of nurses in expanded/extended roles. Although there was some confusion as to functions nurses could undertake, there was an intention by the previous government to support an extended role. Plans to implement an extended role for nursing suspended with the change in government. In the pilot site at MacAdam there was evidence of the acceptance of the extended role of the nurse.
Issues arising from other professions' regulatory bodies or from unregulated professions	Physicians wish to retain direct control over any increase in extended/expanded practice for nurses
Other matters having an impact on nurses practising in extended/expanded roles	New Brunswick is experiencing significant difficulties in recruiting and retaining physicians
Additional comments	Government appears to be leaning towards increased funding to allow for greater placement of nurses in physicians' offices rather than committing to introduction of extended/expanded practice initiative

Names of organizations contacted	Association of Nurses of Prince Edward Island (ANPEI) Department of Health and Social Services
Nurses on active practice RN roles	1350
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	None
Nurses registered or licensed to practice in extended/expanded roles as described above	None
Settings in which they practice	Not applicable
Position titles or descriptions	RN
Educational qualifications and programs for practice in extended/expanded roles	Not applicable at present. A degree program has been available at UPEI for undergraduate nursing education since 1994. It is unlikely that a program to educate nurses for extended/expanded roles will be available in the Province given the small population base of PEI.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Not applicable at present. However, if there is movement toward the introduction of an extended/expanded role for nursing, the Association would establish guidelines etc. based on assessment of competency and in accordance with guidelines of the CNA.
Facilitators to nurses practising in extended/ expanded roles	The Department of Health and Social Services is currently undertaking a discussion of a redesign of primary health care in the Province. Consideration is being given to the community health centre model which is based on increased collaboration between disciplines. If there is another role for nursing, it would not be physician substitution but be complementary to physicians.
Barriers to nurses practising in extended/expanded roles	The need for a greater understanding of the role of the nurse in an extended/expanded role. Should the role be introduced, there would need to be education among health care practitioners and the public.
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	There is a need to clarify the role of the nurse in an extended/expanded practice setting vis-a-vis other professionals. It would be important to stress the fact this role is complementary to physicians and not physician substitution. The need for flexibility for nurses in the role may be challenging given union contracts.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	The need for maintenance of competence is an issue, particularly should nurses become involved in extended/expanded roles.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	Not applicable
Other organizations representing nurses	Prince Edward Island Nurses Union
Issues arising from public	None raised
Issues arising from other professions' regulatory bodies or from unregulated professions	Not at issue
Other matters having an impact on nurses practising in extended/expanded roles	ANPEI believes that extended/expanded roles fall within the scope of nursing practice and therefore does not support the separation of roles within nursing and consequently would not support title protection, i.e. NP
Additional comments	There was a family practice demonstration project over the past 2 years which has led to increased consideration of collaborative models. There are many issues to take into consideration in expanding nursing roles ( e.g., impact on physician remuneration, skepticism in the medical society )

Names of organizations contacted	Registered Nurses Association of Nova Scotia (RNANS) Department of Health & Community Services
Nurses on active practice RN roles	9300(est)
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	No legislated extended/expanded practice. Clinical nurse specialists in tertiary care settings only. Demonstration projects underway in 4 locations for nurse practitioner practice.
Nurses registered or licensed to practice in extended/expanded roles as described above	The selected demonstration sites.
Settings in which they practice	Four demonstration sites: North End Community Health Centre-Halifax Queens Community Health Centre-Caledonia Pictou Springhill
Position titles or descriptions	Primary Care Nurse practitioner
Educational qualifications and programs for practice in extended/expanded roles	For demonstration projects, a NP certificate will be required from a recognized program, i.e. Alberta, Ontario or Newfoundland, or a licence to practice as a primary care nurse practitioner in another jurisdiction.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Scope of practice is defined by delegation of function from physician under guidelines developed through discussion and negotiation between College of Physicians and Surgeons of NS and Registered Nurses Association of NS.
Facilitators to nurses practising in extended/ expanded roles	There appears to be interest in the concept of nurse practitioners, especially in rural/remote areas of province. Nurse practitioners and physician consultants available to NP s at the demonstration sites.
Barriers to nurses practising in extended/expanded roles	Physicians retain control over ability of nurses to expand scope of practice (legislative dominance). Funding mechanisms
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	Medical Act will need amendment Pharmacy Act amended for demonstration sites only; regulations forthcoming
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	Dalhousie University will be offering a Nurse Practitioner certificate program for rural and under served communities.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	None reported
Other organizations representing nurses	Nova Scotia Nurses Union, and NS Government Employees Union
Issues arising from public	Calls for greater health care resources in rural/remote areas
Issues arising from other professions' regulatory bodies or from unregulated professions	Medical Act powers require delegation of function to nurses
Other matters having an impact on nurses practising in extended/expanded roles	None raised

Names of organizations contacted	Association of Registered Nurses of Newfoundland (ARNN) Department of Health and Community Services
Nurses on active practice RN roles	5300
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	Nurse Practitioner - Primary Health Care (NP-PHC) defined under legislation. As well there are several regional nurses who practice under protocol agreement in extended/expanded roles.
Nurses registered or licensed to practice in extended/expanded roles as described above	22 NP and approximately 70 regional nurses
Settings in which they practice	Three Primary Health Enhancement Projects at Port-aux-Basques, Twillingate and Happy Valley-Goose Bay; Other sites include, but are not limited to, Bonavista Hospital; Ramea Clinic; Harbour Breton; Norris Point; Health Labrador Corporation and Grenfell Regional Health Services Board
Position titles or descriptions	Nurse practitioner Regional Nurse
Educational qualifications and programs for practice in extended/expanded roles	Current RN practice certificate 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 current registration as RN in Newfoundland.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Scope of practice, standards of practice and competencies for NP- PHC developed and approved by regulatory body.
Facilitators to nurses practising in extended/ expanded roles	There is stakeholder support for NP practice, acceptance by the ARNNL membership and by Regional Boards. Efforts are being made to enhance understanding in the community. As NP s are present in a number of settings, clinical competence demonstrated on-site. The ARNNL had initiative underway when Minister announced regulation introducing NP.
Barriers to nurses practising in extended/expanded roles	Other professions lack of understanding of NP role Funding mechanisms; fee for service physician cannot bill for consultation with NP NP pay classification not nationally competitive Establishing the required collaboration with MD may prove to be problematic due to physician shortage Lack of prescribing authority for regional nurses (Grenfell Regional Health Services) Overlapping roles with Community Health nurses may present challenges
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	The Physio- therapy legislation has been amended to allow referrals from NPs Experience with the regulations has highlighted the need for consideration of making consequential amendments to statutes to facilitate full scope of practice of NP, e.g., Vital Statistics Act
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	The current entry requirement for practice is successful completion of the program for NP training offered through the Centre for Nursing Studies The policy position of the ARNNL is a minimum standard of BN with one year NP program that carries credit toward an MN degree. There is an issue of the local availability and access to education program(s) that satisfies the ARNNL preference.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	None reported
Other organizations representing nurses	Newfoundland and Labrador Nurses Union
Issues arising from public	No issues raised other than continuing calls from public for better health services in rural/remote areas
Issues arising from other professions' regulatory bodies or from unregulated professions	Pharmacist regulatory body is concerned about issues of liability with respect to regional nurses and prescriptive authority. Physicians initially had concerns respecting their liability and NP practice.
Other matters having an impact on nurses practising in extended/expanded roles	Assessing competency, maintaining competencies and the responsibilities of the employing organizations to support ongoing maintenance of competency.
Additional comments	Further refining of definition of primary health care services, primary care services and how the NP role fits in the models for service delivery is needed. For example, developments in midwifery in the Province may impact on NP practice. Evaluation and research is required to ensure a cost effective model of service is in place.

Names of organizations contacted	Yukon Registered Nurses Association (YRNA)
Nurses on active practice RN roles	300
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	Community Nurse Practitioners working in rural communities practice in this capacity which falls within the current legislative framework.
Nurses registered or licensed to practice in extended/expanded roles as described above	No central registry, so it is not possible for YRNA to specify numbers. Approximately 50 are employed by Health and Social Services, Government of Yukon in sufficiently extended/expanded roles to note in this survey
Settings in which they practice	12 rural communities have nurses acting in these roles, three of which also have physicians.
Position titles or descriptions	Community Nurse Practitioner
Educational qualifications and programs for practice in extended/expanded roles	No fixed program approved by YRNA. (Employers accept a variety of options regarding education.)
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	Employers have adopted the Medical Services Branch Scope of Practice for Community Health Nurses, Nursing Station facilities and Health Care Treatment facilities.
Facilitators to nurses practising in extended/ expanded roles	Wide acceptance by the public of nurses practising in these roles Good cooperation from physicians and pharmacists
Barriers to nurses practising in extended/expanded roles	No legislation planned in the immediate future and this is not viewed as a particular barrier by the YRNA.
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	There are no indications of challenges from other health professionals.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	Small number of YRNA members. YRNA is participating in multi-jurisdictional initiatives which seek to address these issues from a national perspective.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	None reported
Other organizations representing nurses	Unions represent both hospital and government-employed nurses.
Issues arising from public	Public is satisfied with role nurses play in health care delivery and there is no indication that they would be adverse to a greater expansion of extended/ expanded practice for nurses
Issues arising from other professions' regulatory bodies or from unregulated professions	Pharmacy Act Regulations were recently amended to allow direct prescribing. It is assumed that very little will occur under the authority of the regulatory changes until prescribing competencies are developed.
Other matters having an impact on nurses practising in extended/expanded roles	YRNA's legislative framework is sufficient to accommodate a significant level of extended/expanded practice. This has been confirmed by legal counsel. It is possible that additional regulations will be added in the future in order to address the issue of mobility of nurses moving to and from the territory.
Additional comments	The territories are unique in their approach to nursing in extended/expanded roles. They have a pragmatic view of how best to deliver primary care in areas with physician under resourcing and there appears to be a high degree of cooperation with the Medical and Pharmacy professions.

Names of organizations contacted	Northwest Territories Registered Nurses Association (NWTRNA) Ministry of Health
Nurses on active practice RN roles	765 (*including nurses practising in Nunavut)
Nurses in province or territory whose practice involves assessment, diagnosis and management of episodic, acute and chronic illness or injury as components of primary health care	NWT and Nunavut considers itself different from the rest of Canada in health care delivery in that organized delivery did not really occur until the 1950s. As a consequence, nurses have been practising in extended/expanded roles for many years. The territory has no specific legislation but is watching the CNA and other provinces initiatives with interest.
Nurses registered or licensed to practice in extended/expanded roles as described above	765 nurses registered a majority would provide some level of extended/expanded services to clients
Settings in which they practice	Throughout the NWT and Nunavut under ten (10) Regional Health Boards. There are other employers of RN s such as non-profit organizations, clinics and mines.
Position titles or descriptions	Usually simply referred to as Community Health Nurses but also as primary health care nurse practitioners
Educational qualifications and programs for practice in extended/expanded roles	Preference is for training through Aurora College "Introduction to Nurse Practitioner Programme" , however, this is not a fixed requirement.
Scope of practice guidelines, by-laws, standards of practice or competencies to define roles	All extended/expanded practice is undertaken under the authority of protocols with the medical profession and employer organizations.
Facilitators to nurses practising in extended/ expanded roles	Traditional role is widely accepted by the public. Good cooperation with physicians and pharmacists.
Barriers to nurses practising in extended/expanded roles	No legislative basis for extended/expanded role at present. Given the relatively small population base and the relatively small number of members in Association, it will be difficult to carry out a major legislative initiative. The introduction of legislation could have a significant impact on the existing system that is built on delegation of function and co-operation.
Challenges to extended/ expanded roles for nurses posed by relationships with other health professionals	Joint statement (1998) from the NWT Medical Association and the NWTRNA calls for collaboration of the two professions in a model based on the delegation of medical function.
Challenges concerning education and continuing education for nurses practising in extended/ expanded roles	NWTRNA is in the process of finalizing competencies for the Primary Health Care Nurse Practitioner.
Disciplinary or liability actions arising with respect to practice in extended/expanded roles	There have been incidents where RNs practising in extended/expanded roles (under delegation of function) have been the subject of disciplinary investigation. These incidents are not necessarily related to the extended/expanded role and are not viewed as being out of proportion when compared with other jurisdictions.
Other organizations representing nurses	Union of Northern Workers (NWT) Nunavut Employees Union (Nunavut)
Issues arising from public	Public would be concerned if a more formalized role for nurses in extended/expanded practice lessened access to nurses providing point of first contact primary care
Issues arising from other professions' regulatory bodies or from unregulated professions	The NWTRNA is currently lobbying for a new Act, finalizing competencies for Primary Health Care Nurse Practitioners, etc.
Other matters having an impact on nurses practising in extended/expanded roles	Isolation, under resourcing of physicians, widely dispersed population means that NWT will likely continue with its present model until a national initiative is well established