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Evaluation of Nursing Practice Models in Primary Health Care Settings
Principal Investigator:
Co-Investigators:
Colleen Hanrahan, John Housser, & Madge Applin
Date: January 12, 2000
Several studies have investigated the influence of clinical settings on the utilization of nurse practitioners (NPs) and, to a lesser degree, the job expectations and satisfaction of NPs. The most consistent barriers to or facilitators of role development and performance identified from the research literature were resistance/acceptance by other health care providers, especially physicians, efforts expended by the organization/agency to formalize the role (Crosby, Ventura, & Feldman, 1987; Hupcey, 1993; Reveley, 1998), and legal/legitimate status of the role (Reveley, 1998; Torn & McNichol, 1998). Additional aspects of the practice setting identified to influence role performance and NPs' job satisfaction include the scope of patient care activities, degree of autonomous and independent practice, and sense of achievement/ accomplishment (Hupcey, 1993; Koelbel, Fuller, & Misener, 1991; Torn & McNichol, 1998; Tri, 1991).
The current study is being undertaken at a time when there is a lack of consensus on what constitutes extended/expanded nursing practice roles in primary health care settings, as well as provincial/state variations on the degree to which these roles are legitimized through legislation. Further, within the Canadian health care system, a number of advanced practice roles have evolved and are being delivered in a variety of ways and guided by diverse protocols. The provision of quality care can be quite a challenge for any health care system, especially one operating under severe cost restraints. Given the current pervasive downsizing and restructuring initiatives in the health care sector, there is an increased urgency to document facilitators of and barriers to the full realization of extended/expanded nursing practice roles in different clinical settings. This kind of data base is needed to ensure the maximum utilization of scarce resources.
| Significance of the Problem | [Table of Contents] |
Within the Canadian context at the national, provincial and regional levels, important issues are being raised concerning the definition and role functions of nurses engaged in extended/expanded practice. The concepts of nurse practitioner, extended class, and expanded practice are used to identify nurses who perform clinical functions outside the traditional scope of nursing practice. Significantly, the nursing profession is struggling to define the boundaries/parameters of its practice while ensuring that its members are providing quality care that is supported by sound research. An integral component of this process are the efforts directed toward standardizing education programs that prepare nurses for extended/expanded practice roles. There is also a general desire by the nursing profession to ensure that its members receive recognition for and legitimization of the true scope of nursing roles and functions.
During the initial stages of the current project, all relevant provincial/territorial legislation and regulations were reviewed and a cross country survey of key informants undertaken to document existing information on nursing practice models. Data were gathered from consultants at the nursing associations concerning the regulation of, as well as the policy and standards for, nursing practice in their jurisdictions. As well, representatives of select provincial/territorial Ministries of Health were contacted to augment/clarify information received from the nursing associations. Finally, administrative personnel from different agencies/organizations which employ nurses to work in extended/expanded practice roles were surveyed. The preliminary findings suggest that there are significant differences among the approaches used to deliver extended/expanded nursing services. Although there are a number of possible explanations for these disparate conditions, one significant factor influencing the enactment of A significant next step in the evaluation process is to explore health care providers' and patients'/clients' experiences with extended/expanded nursing practice in primary health care settings. The positives and negatives of different nursing practice models must be understood if health care providers are to achieve the best possible care outcomes in the short and long term, while doing so in a cost-effective manner. The primary objective of the current study is to identify aspects of nursing practice models which are most and least helpful in facilitating extended/expanded nursing practice. This objective can be achieved through a data collection approach which involves conducting interviews and participant observation sessions with those who are performing the extended/expanded role, interviewing collaborating physicians, and surveying patients/clients.
| Background | [Table of Contents] |
Feldman et al. (1987) conducted an analysis of 248 articles, published between 1963 and 1983, dealing with nurse practitioner (NP) effectiveness. Reviewers with expertise in the content area and in health care research design were selected to assist with the analysis. The findings indicated that nurse practitioners (NPs) provided cost effective care at an equal or higher quality level than physicians. Further, NPs improved health care access in rural areas and to underserved populations, and achieved better or equivalent health outcomes than physicians. Significantly, patient acceptance of and satisfaction with the care provided by NPs was high, especially with regard to interpersonal skills, provision of useful information, and promoting understanding of condition/illness.
In a second article on NP effectiveness, Crosby et al. (1987) presented an overview of key study findings related to process and a discussion on areas requiring further research. With regard to process indicators, the authors noted that NPs were working predominately in ambulatory care settings and physicians' offices. NPs were performing a wide-range of expanded nursing practice and physician-substitute activities, ranging from diagnoses through treatment to follow-up, but mainly for well clients or patients with chronic and mixed health problems. Full utilization of NPs skills and abilities was curtailed by restrictions imposed by the employing agency. Based on the studies foci and tentative findings due to methodological shortcomings, certain key areas were identified for further inquiry, including cost implications, uniqueness of the role, impact of the practice setting on effective care delivery, educational preparation requirements, short and long term impact on health outcomes, and factors that enhance or impede care delivery by Nps.
In a meta-analysis of 38 well-designed studies on NPs performing primary care functions in community or hospital based ambulatory care settings, Brown and Grimes (1995) examined the effects of NP versus physicians on health outcomes. The analysis revealed that NPs outscored physicians on some process indicators (i.e., health promotion activities, time spent with patients, referrals/consultations, and diagnostic tests) but equalled physicians on others (i.e., quality of care, number of visits per patient, and number of drug prescriptions). NPs were more likely than physicians to achieve better clinical outcomes in certain areas (i.e., resolve pathological conditions, fewer hospital admissions, and receive greater patient satisfaction and compliance) but equalled physicians in others (i.e., patients' functional status and emergency room use). The authors concluded that the research evidence suggests that NPs can manage common aliments and chronic, stable conditions as well as, or better than, physicians in In a descriptive study, Courtney and Rice (1997) examined the process of care implemented by NPs during interactions with patients at a family practice clinic. Twenty NP-patient interactions were randomly selected for videotaping sessions. The data were coded with an observational rating tool - Nurse Practitioner Rating Form - in three areas: activity (e.g., history, examinations, procedures, advice, consultation, etc.), content (i.e., somatic/psychosocial aspects of presenting problem, and somatic/ psychosocial aspects of health promotion), and global scales measuring provider communication and client participation. The findings indicated that the NPs averaged 18 minutes per visit with clients, with communication and interpersonal activities accounting for two thirds of the time. While NPs spent most of the time (61%) engaged in assessment activities (i.e, history taking and physical examination), an additional 29% of the time was spent with management activities (i.e., giving advice, facts, explanations, or demonstrations). Significantly, about 90% of the NP's attention was directed towards the physical aspect of the client's problem and only 1% of the time on the physical or psychosocial aspects of health promotion. The authors stressed the need for more research to document the nature and content of primary care encounters in order to identify the most important aspects of effective primary care practice.
Moody, Smith, and Gleen (1999) investigated the client populations and practice patterns of a random sample of NPs (N = 44) working in primary care settings in Tennessee. The Nurse Practitioner Ambulatory Client Care Survey was used to collect data on 680 NP-client encounters during a one day period. Study findings indicated that most (81%) of the NPs' clients had been seen previously by a provider in the same setting, with hypertension, ear and respiratory infections, and diabetes mellitus the most common medical diagnoses. Further, NP-client encounters averaged 17 minutes in duration, with teaching/counselling and writing prescriptions for antibiotics or analgesics the most frequently reported therapeutic interventions.
| Purpose and Research Questions | [Table of Contents] |
The current study will address the following research questions:
| Methodology | [Table of Contents] |
The population of interest is physicians working with and nurses working in extended/expanded roles in primary health care settings in the provinces of Newfoundland, Ontario, and Saskatchewan. A second target population is patients/clients receiving care from nurses performing these roles at different provincial sites. The provinces selected for onsite data collection have either recognized, through legislation, the extended/expanded functions of registered nurses or have longstanding protocol agreements negotiated between medical and nursing regulatory bodies, agencies/organizations, and Ministries of Health. Three potential sites have been selected from each provincial jurisdiction that reflect similar, but slightly different, models of practice.
The total population of physicians working with and nurses working in extended/expanded practice roles will be asked to participate in the study at each site. In addition, a purposive sample of patients/clients will be recruited for participation in the study during a scheduled visit to the centre/clinic when the interviewer/observer is present at the site for data collection. Because the objective of qualitative research is to obtain data that are comprehensive and insightful, the large volume of narrative data generated by different methods across different population groups will preclude enlisting a large number of participants. Theoretical sampling will be used during data collection and analysis to assess the data's representativeness (i.e., in accordance with the theoretical needs and direction of the research) and determine the final sample size (Sandelowski, 1995).
Data collection will consist of a combination of interviews and participant observation sessions with nurses and physicians working at identified sites, as well as a survey of patients/clients accessing the resources at the centre/clinic. This phase, depending on the number of participating sites, is expected to require three to four weeks to complete.
Nurses and physicians will be identified through consultation with personnel from management/administration. The contact person(s) will approach staff members to briefly explain the study, provide them with a summary sheet of the project (see Appendix A), and ascertain their willingness to be contacted by a member of the research team. Those who indicate an initial willingness to participate in the study will be contacted by a member of the research team during their regularly scheduled working hours. The study will be explained more fully and any questions/concerns addressed at this time. Interviews and/or participant observation sessions will be scheduled at a mutually agreed upon time.
Health care provider group. Nurses and physicians will be asked to provide information on certain demographic variables (e.g., age, education, length of time in this type of practice, etc.) prior to the interview. In-depth, ethnographic interviews will be conducted with each physician working with and nurses working in extended/ expanded practice roles. Informed, written consent will be obtained prior to the beginning of the interview (see Appendix B). With participants' permission, all interviews will be audio-taped. In-depth interviews will be conducted using a semi-structured interview schedule (see Appendix C). It is anticipated that interviews will take approximately 60 to 90 minutes.
One or two participant observation sessions will also be scheduled with nurses working in extended/expanded practice roles while they perform normal centre/clinic activities. The observation sessions will be conducted on the same day of the interview and/or the following day depending on nurses' centre/clinic responsibilities. Observational checklists will be used to collect data on each nurse-patient/client encounter (see Appendix E).
Patient/clients. Patient/clients will be approached by an interviewer/observer during a regularly, scheduled centre/clinic visit. The rationale for the study will be explained to them and any questions/concerns addressed. If they indicate a willingness to participate, they will be given a copy of the survey instrument to complete at this time (see Appendix D). The survey questionnaires are designed so that patients/clients are able to fill out the questionnaires anonymously while waiting to see the nurse. Thus, informed, written consent is not required for this group of participants.
The interviews/observations with health care providers are intended to elicit commentary on experiences and practice needs. Given the importance of the interview/observation processes in eliciting a rich data base in qualitative inquiries, training sessions will be conducted with each interviewer/observer prior to data collection. These sessions will be conducted by the principal investigator who has an extensive theoretical and experiential basis in qualitative research. The training sessions will emphasize the importance of paying attention to what is being conveyed by the verbal reports/observations, probing for clarifications of participants' meanings, and being sensitive to emotional responses that may indicate participant discomfort and/or difficulty with certain topics/sessions.
Interview Schedule. The interview schedule, developed for this study, was designed to explore key aspects of study participants' experiences working in extended/expanded roles, or working with nurses performing extended/expanded practice roles (see Appendix B). Probes and question content comprising the interview schedule were based on relevant literature. Although interviews will be guided by the topics covered by the interview schedule, many additional questions may be generated by the thematic content emerging during each interview and the ongoing data analysis.
It is important to note that because data collection and analysis occur simultaneously in qualitative studies, it is impossible to anticipate all possible questions and probes ahead of time. As well, some participants will be better informants than others (i.e., ability to recall and relate experiences). Thus, there will be variations in terms of the numbers of probes and questions required for a particular interview.
Observation Checklist. Nurses working in extended/expanded practice roles will be asked to have a nurse observer present during centre/clinic activities. These sessions are designed to help the research team describe the protocols followed by nurses while making decisions about patient/client care requirements (see Appendix E).
The observation data is intended to help the research team capture and describe the protocols followed by nurses while making decisions about patient/client care requirements. It is also anticipated that the observation data will augment the interview data obtained from the nurses and physicians (i.e, fill in the gaps and/or compliment the conceptual categories/properties emerging from the data).
Patient/client survey. The survey questionnaires are designed to document patient/client experiences with nurses working in extended/expanded roles, as well as how satisfied they are with nurses in these roles. Item content is based on relevant information from the literature dealing with surveys of patients receiving care from nurses working in extended/expanded roles.
The taped interviews will be transcribed verbatim and checked for accuracy. The constant-comparative method of analysis as defined by Glaser and Strauss (1967) will then be applied to each data set by a minimum of two raters/coders (the principal investigator and research assistants) working independently. Debriefing sessions will be held regularly to discuss major themes and to identify the conceptual categories and properties being generated by the initial joint coding and analysis. Because the consulting team is not only interested in the accuracy of the conceptual categories and their properties but also the weight and importance attached to them by study participants, each participant will be asked to review and confirm an interpretive summary of his/her transcript to achieve this objective. This step is necessary to understand the importance of each category and property for grasping the experiences of participants with the extended/expanded nursing role in their work setting.
A structured coding system, which is based on categories depicted in provincial regulations and nursing associations/colleges standards for practice and competencies for nurse practitioners will be applied to the observation data sets. Each rater will be responsible for reviewing all data sets to locate incidents of relevant content for each specified category. Counts of the number of times key components are identified in the data will then be tabulated.
As conceptual categories and conceptual properties of categories emerge that have equal applicability across interview and observational data sets, greater attention will be given to linking them into coherent entities or "theoretical constructs." At this stage in the analysis, all raters will be working together to collapse the categories into a parsimonious set reflective of participants' experiences with extended/expanded nursing practice, identify possible relations between and among major categories, and propose conceptual model (s) to capture identified relationships. Theoretical sampling will then be used to identify slices of data that could serve as incidents for the theoretical constructs, and confirm their explanatory and predictive power for capturing the process of extended/expanded nursing practice as performed under different nursing practice models. In order words, theoretical sampling will be used to help test the accuracy of the emerging substantive theory.
Credibility. Credibility measures how vivid and faithful the description of the phenomena are and provides the standard for judging the truth value. Nurses working in extended/ expanded or health care providers working with nurses in these roles are considered the experts and therefore the most credible sources of information. A qualitative study is credible when the participants recognize the descriptions and interpretations of the experience as their own (Sandelowski, 1986). Therefore, an interpretive summary of the transcribed interview will be reviewed by each participant who will be asked to validate conclusions that have been drawn.
| Ethical Considerations | [Table of Contents] |
Appropriate measures will be taken to ensure that confidentiality of all data is maintained. All tapes, transcripts, and observation checklists will be coded, and kept in a secure place. A log of names and matching codes will be stored in a locked filing cabinet, accessible only to members of the research team, and destroyed once the study is completed. Participants will also be informed that all information collected will be described in a manner that will prevent identification of the source, no direct benefits are anticipated, and they are free to withdraw from the study at any time.
| References | [Table of Contents] |
Brown, S. A. & Grimes, D. E. (1995). A meta analysis of nurse practitioners and nurse-midwives in primary care. Nursing Research, 44(6), 332-339.
Brown, M. & Olshansky, E. (1998). Becoming a primary care nurse practitioner: Challenges of the initial year of practice. The Nurse Practitioner, 23(7), 46-64.
Crosby, F., Ventura, M. R., & Feldman, M. J. (1987). Future research recommendations for establishing NP effectiveness. The Nurse Practitioner, 12(1), 75-76, 78-79.
Chambers, L. & West, A. (1978). The St. John's randomized trial of the family practice nurse: Health outcomes of patients. International Journal of Epidemiology, 7(2), 153-161.
Chang, E., Daly, J., Hawkins, A., McGirr, J., Fielding, K., Hemmings, L., O'Donoghue., & Dennis, M. (1999). An evaluation of the nurse practitioner role in a major rural emergency department. Journal of Advanced Nursing, 30(1), 260-268.
Courtney, R. & Rice, C. (1997). Investigation of nurse practitioner-patient interactions: Using the nurse practitioner rating scale. The Nurse practitioner, 22(2), 46-65.
Feldman, M. J., Ventura, M. R., & Crosby, F. (1987). Studies of nurse practitioner effectiveness. Nursing Research, 36(5), 303-308.
Glaser, B. & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine Hansson, S. (1989). Dimensions of risk. Risk Analysis, 9, 107-112.
Hicks, C. & Hennessy, D. (1997). The use of a customized training needs analysis tool for nurse practitioner development. Journal of Advanced Nursing, 26, 389-398.
Hicks, C. & Hennessy, D. (1998). A triangulation approach to the identification of acute sector nurses' training needs for formal nurse practitioner status. Journal of Advanced Nursing, 27, 117-131.
Hupcey, J. E. (1993). Factors and work settings that may influence nurse practitioner practice. Nursing Outlook, 41, 181-185.
Koelbel, P. W., Fuller, S. G., & Misener, T. R. (1991). Job satisfaction of nurse practitioners: An analysis using Herzberg's theory. The Nurse Practitioner, 16(4), 43-56.
Larrabee, J. H., Ferri, J. A., & Hartig, M. T. (1997). Patient satisfaction with nurse practitioner care in primary care. Journal of Nursing Care Quality, 11(5), 9-14.
Martin, P. D. & Hutchinson, S. A. (1997). Negotiating symbolic space: Strategies to increase NP status and value. The Nurse Practitioner, 22(1), 89-102.
Moody, N. B., Smith, P. L., & Glenn, L. L. (1997). Client characteristics and practice patterns of nurse practitioners and physicians. The Nurse Practitioner, 24(3), 94-103.
Reveley, S. (1998). The role of the triage nurse practitioner in general medical practice: an analysis of the role. Journal of Advanced Nursing, 28(3), 584-591.
Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science, 8, 27-36.
Sandelowski, M. (1995). Focus on qualitative methods: Sample size in qualitative research. Research in Nursing and Health, 18, 179-183.
Torn, A. & McNichol, E. (1998). A qualitative study utilizing a focus group to explore the role and concept of the nurse practitioner. Journal of Advanced Nursing, 27, 117-131.
Tri, D. L. (1991). The relationships between primary health care practitioners job satisfaction and characteristics of their practice settings. The Nurse Practitioner, 16(5), 46-55.
| Appendix A: Summary of Research Study | [Table of Contents] |
Title: Evaluation of Nursing Practice Models in Primary Health Care Settings
Investigators: Dr. Christine Way, Colleen Hanrahan, & John Housser (Institute for the Advancement of Public Policy) Madge Applin (Centre for Nursing Studies)
Study Objectives:
Brief Description of the Study: The proposed study will use a grounded theory method during data collection and analysis to generate conceptual models of extended/expanded nursing practice in different primary health care settings. A purposive sample of health care providers (i.e., nurses and physicians) and centre/clinic patients/clients will be recruited for participation in the study.
Health care providers will be asked to participate in one face-to-face interview. The interview will elicit commentary on experiences and practice needs. Each participant will be asked to review and confirm an interpretive summary of the main points addressed in his/her interview. As well, nurses working in extended/expanded practice roles will be asked to have a nurse observer present during normal centre/clinic activities. These sessions are designed to help the research team capture and describe the protocols followed by nurses while making decisions about patient/client care requirements.
The research team is also interested in documenting patient/client experiences with nurses working in extended/expanded roles, as well as how satisfied they are with nurses in these roles. The survey questionnaires are designed so that patients/clients are able to fill out the questionnaires anonymously during a scheduled visit to the centre/clinic.
Procedure for Obtaining Consent: It is requested that administrative personnel at the centres/clinics will inform nurses and physicians about the study and seek permission for the research team to initiate contact with them. Those expressing an interest in participating in the study will be contacted by a member of the research team and have the study explained to them more fully and any questions/concerns addressed at this time. Informed, written consent will be obtained prior to data collection.
| Appendix B: Informed Consent | [Table of Contents] |
Consent To Participate In Health Care Research: Nurses
Investigators: Dr. Christine Way, Colleen Hanrahan, & John Housser (Institute); Madge Applin (CNS)
Sponsor: Health Transition Fund
You have been asked to participate in a research study. Participation in this study is entirely voluntary. You may decide not to participate or may withdraw from the study at any time.
Information obtained from you or about you during this study, which could identify you, will be kept confidential by the investigators. The principal investigator will be available during the study at all times should you have any problems or questions.
Administrators, clinical supervisors, or any other person involved with your organization will not have access to your taped interviews or any other information that could potentially identify you as a source. Purpose of study: The purpose of this study is to develop a greater understanding of registered nurses' experiences with the extended/expanded nursing role in primary health care settings. The study has the potential to increase our understanding of the most and least important aspects of this role, and provide useful information on which nursing models are most useful for addressing patient/client needs.
Description of procedure: You are being asked to participate in one interview and one to two participant observation sessions which will take place in the work setting at a time that is convenient for you. You will be given copies of the interview schedule and observational checklist prior to your participation in any of the sessions.
Interviews will be audiotaped (with your permission). The tape will be transcribed word for word, and will be used solely to help the interviewer recall the details of your conversation. During the interview you will be asked to reflect upon and describe your experiences with the extended/expanded role within your work setting. Within a two to three week period, you will be given a summary of the interview and asked to confirm whether or not it accurately reflects your experiences. You will also be given an opportunity to provide any additional information at this time.
The observation sessions will be conducted on the same day of the interview and/or the following day. We are particularly interested in documenting the protocols that you would normally follow while making decisions about patient/client care requirements. In particular, the nurse observer will be looking for examples of the kinds of diagnostic procedures that you access and treatment plans that you prescribe, how you apply decision-making approaches while administering care, and how you relate to and consult with others in the clinical setting. It is important for you to remember that these sessions are being conducted for the sole purpose of developing a descriptive profile of what and how primary care functions are being performed within different nursing practice models operant in primary health care settings.
Duration of participant's involvement: The interview will take approximately 60 to 90 minutes to complete. It is anticipated that the participant observation sessions may vary from 4 to 6 hours.
Possible risks, discomforts, or inconveniences: There are no expected risks from participating in this study. You may refuse to answer any questions which make you feel uncomfortable and ask to terminate the interview at any time. All information that you provide will be kept strictly confidential, secured in a locked file, and accessible only to members of the research team.
Benefits which the participant may receive: You will not benefit directly from participating in this study. However, the information that you provide may help identify the changes required in the health care system to facilitate nursing's role in primary health care.
Liability statement: Your signature indicates your consent and that you have understood the information regarding the research study. In no way does this waive your legal rights nor release the investigators or involved agencies from their legal and professional responsibilities.
Any other relevanyt information: Findings of this study will be available to you and your participating organization. Findings may be published, but neither you nor your organization will be identified. The investigators will be available throughout the study to address any questions or concerns.
Participant Initials ____________
Signature Page
Title of Project: Evaluation of Nursing Practice Models in Primary Health Care Settings
Name of Principal Investigator: Dr. Christine Way
To be signed by participant
I,__________________________________________, the undersigned, agree to my participation in the research
study described above.
Any questions have been answered and I understand what is involved in the study. I realize that participation is voluntary and that there is no guarantee that I will benefit from my involvement.
I acknowledge that a copy of this form has been given to me.
(Signature of Participant)______________________________________ (Date) _____________________
(Signature of Witness) ______________________________________ (Date) _____________________
To be signed by interviewer/observer
To the best of my ability I have fully explained the nature of this research study. I have invited questions and provided answers. I believe that the participant fully understands the implications and voluntary nature of the study.
(Signature of Interviewer)______________________________________ (Date) _____________________
Phone Number_____________________
Consent for audiotaping during interviews ________________________________________________________
| Appendix C: Interview Schedules | [Table of Contents] |
We are interested in your experiences with performing primary care functions within this setting from when you first started up to now. We would like for you to take some time to reflect upon these experiences and share with us your perceptions of the nursing role as it is being implemented here. You can share any thoughts, feelings, and ideas about your experiences. Feel free to talk about whatever comes to mind.
Examples of Probes/Questions to Facilitate the Interview
Interview Schedules: Physicians
Interview Script
We are interested in your experiences with nurses performing primary care functions in this setting. We would like for you to take some time to reflect upon these experiences and share with us your perceptions of the nursing role as it is being implemented here. You can share any thoughts, feelings, and ideas about your experiences. Feel free to talk about whatever comes to mind.
Examples of Probes/Questions to Facilitate the Interview
| Appendix D: Patient/Client Surveys | [Table of Contents] |
Part I: Centre/Clinic Experiences
Part II: Satisfaction
| Appendix E: Observation Checklist | [Table of Contents] |
| Appendix F: Letter of Support | [Table of Contents] |