
	Research : Reports

Physicians' Perceptions of Extended/Expanded Nursing Roles [Table of Contents]

Face-to-face interviews were conducted with physicians who were working with nurses in extended/expanded roles in the provinces of Saskatchewan, Ontario, and Newfoundland. The purpose of this component of the study was to develop a greater understanding of physicians' experiences with the extended/expanded nursing role in primary health care settings with similar and different practice models. A second purpose was to document physician perceptions of the barriers to and facilitators of full implementation of an extended/expanded nursing role in diverse practice settings.
The interview transcripts provided a rich data base on physicians' experiences with nurses working in an extended/expanded role, as well as their perceptions of key factors which could enhance or hinder the practice patterns of these nurses. This section presents a discussion on the dominant themes that emerged from the analysis of the physician data.
Overview of Findings
It was apparent from the interview comments that physicians believed that nurses with advanced knowledge and skills in primary care are important members of the health care team. Without exception, all of the participating physicians recognized and valued the contributions being made by these nurses in primary health care settings. Although legislation and scope of practice guidelines helped clarify the parameters of the extended/expanded role, exposure to those nurses experiential base and skills in the clinical setting was considered to be essential in building collaborative working relationships. Several of the physicians had worked with nurses under different conditions in remote primary health care settings. This experiential base had a positive effect on not only how they were now perceiving the role but also the pace at which they moved into collaborative working relations. It was obvious from the interview comments though that physician level of comfort and trust with nurses in this role was directly related to how aware they were of their limitations and scope of practice boundaries, as well as their willingness to consult as required.
With regard to the type of practice arrangement for nurses with extended/expanded primary care skills, most physicians indicated that their preference is for these nurses to be part of a collaborative team as opposed to assuming an independent practice role. In fact, it seems that physician support for nurses working in extended/expanded roles was derived, in part, from the strong collaborative relationships developed over time. Most physician participants perceived these nurses to provide useful service, especially in terms of the more value-laden aspects of care (e.g., counselling, teaching, etc.), well men and women screening examinations, and minor and/or episodic illness or injuries.
The physician group identified several challenges of having nurses in extended/expanded roles working in primary health care settings. Most of the physicians were not convinced that this type of nurse brings any more to clinical situations than physicians, or that greater use of these nurses in primary health care is an effective cost saving measure. One significant barrier to physician acceptance of nurses working in these roles were the inadequacies observed in their educational preparation, especially with regard to practical knowledge and abilities. Without exception, every physician stressed that greater attention should be placed on ensuring that nurses receive adequate practical experience before assuming extended/ expanded roles. Another barrier identified was patient understanding of the role, especially with regard to restrictions on nurses' scope of practice. Physicians felt that understanding affected patient acceptance of, as well satisfaction with, nursing services in primary care.
Physician participants also indicated that working with nurses in extended/expanded roles had altered the nature of their practice. With the focus shifting to more complicated and higher acuity cases, there was less time for preventative medicine. For those physicians who enjoyed and valued this aspect of medicine, this shift in focus was viewed as less rewarding.
1.1 Practical Knowing
Several physicians commented on concerns about nurses' competency levels when they first assumed extended/expanded roles. Physicians indicated that they have observed wide variations in both knowledge levels and practical skills. Perceived deficits in knowledge and/or practical skills were attributed to either inadequacies of educational programs preparing nurses for the role, or nurses limited experience in performing primary care functions prior to assuming the role. Importantly, most physician participants suggested that nurses could certainly benefit from having more developed practical skills before graduating from accredited programs.

1.1.1 Knowledge Levels & Practical Skills
This section summarizes physician comments on observations of nurses who were prepared to assume the extended/expanded role in primary health care settings. The illustrative quotations are summarized according to perceptions during the early stages of role implementation and following several months of clinical practice.

1.1.1.1 Early Stages of Role Enactment
The wide disparities observed in primary care skills, knowledge and abilities were a major concern for most physicians. The degree of confidence and trust that physicians had in nurses' and students' abilities was strongly influenced by their knowledge and skills. Inequalities in competency levels was seen as a threat to the delivery of quality health care.
Illustrative Quotes

"The theoretical aspects are insufficiently explained or elaborated upon during the preparation time. . . .the task in front of them was just too big. . . .I would expect a bit more specific knowledge".

"It is understandable when they first graduated because they were working as nurses not as physicians. They didn't know certain things like how to approach patients and basic things they had to find out. Like if somebody comes with a sore throat or some other problem then you have to rule out certain things".

"There was a great deal of consulting. . .they required a lot of teaching and checking".

"I have had a chance to work with 4 or 5 nurse practitioners and I have seen tremendous variability in the degree of competency and preparation and the type of knowledge that they have had".

"She has had many nurse practitioner students come through here. And there are many that I would say are very basic in terms of their training for certain things, like their ability to give an history, a precise history. We would see a range of levels of competence around the clinical skills. Perhaps not around all the other things that might be involved in nurse practitioners, but purely primary care - huge range".

"Knowledge base was poor and their [nurse practitioner students] eagerness wasn't there. At least when someone is taking on that the role, so close to actually being an independent practitioner, you need to know where your weaknesses are and want to do something about it".

"They are just not well enough trained yet. Maybe it's a bit unfair in that we expect them to know what we know. . . .Many times I have been utterly aghast with the lack of knowledge in some of the students. . . .I don't think its anyone's fault, it's a brand new program, you can't correct the inefficiencies until you find out what they are. But as long as they keep listening and keep reassessing their graduates I think they will be okay".

"I don't think they are coming out with enough practical and hands on experience. . . .Perhaps more on-site training with the course".

"My feeling actually is that the ideal way would be for nurses to have a proper training. . . .Unfortunately, that would probably be impossible due to the fact that it is really difficult to get nurses. Half the nurses that do go there are fresh out of university and do not have the skills for it".

1.1.1.2 Development of an Experimental Base
Most of the physicians reported having positive experiences while working with nurses in an extended/expanded role in current practice settings. Many of the participants indicated that the level of confidence exhibited by individual nurses was directly related to their level of experience. One additional qualifier was the match between the level of responsibility that nurses were expected to assume in the practice setting versus what they were prepared for during their educational programs. Despite the variant experiential base, physicians expressed confidence with the quality of care provided by most nurses even though it is not of the same caliber as that provided by physicians.
Many of the physician participants attributed improvements in nurses' practical skills and abilities to working more closely with and under the direct supervision of physicians, as well as dealing with a variety of clinical problems. In fact, physician preceptorship and nurses' exposure to a broader range of clinical situations were believed to be key factors influencing greater role competency. As time passed and nurses gained more experience in the role, physicians became more confident with nurses' ability to handle independent caseloads.
Illustrative Quotes: Perceived changes in competency levels with experience

"Gradually they were getting better and better. Now, they are much better, they don't consult us that much like they used to".

"They matured well and fast".

"I feel very confident [with her working in the extended role], that's no question"; "I think she is getting better and better every day because she has seen more practical aspects compared to a year ago".

"I think the ones that I have seen by large are excellent. . . .They get experience as we all do when we first start. That is something that I hope will improve over time. As for the training I think it is fine".

"I think they differ in their abilities in that one can juggle many things at one time and the other seems to have some trouble keeping that many balls in the air. But I think they bring different strengths and they are very good. . . .Again, for me one is sort of a burden and the other sort of adds to it. It is two different people and two different ways".

"I have complete confidence in [NP's] ability to make assessments and to diagnose what she's allowed to diagnose and to treat in the way she's allowed to treat. Recognizing that we all make mistakes, I don't think that she makes any more or any fewer mistakes than I do".

"[Primary care nurse] is very confident. [Another primary care nurse] is probably the least confident of the bunch and it goes with experience".

"I feel very good about the role they are assuming. . . .Obviously they [physicians] have more skills and training than a nurse but it is not realistic. So, I feel really good that they are able to provide the amount of care that they do".

"I feel comfortable with some of them and with others I do not feel comfortable. There is a very wide spectrum of nursing abilities in the nurse practitioner role. . . .There is some of them that we know and trust. . . .Some of them unfortunately present a bit of a problem".

"It sort of depends on the nurse practitioner. Who has what experience and so on. Some of them do deliver very good health care and are very capable and skilled".

Illustrative Quotes: Key factors influencing greater role competency

"That [confidence in her ability] developed over 8 years I guess. It didn't start out that way and she's been a gem in terms of the type of person you want in that role. . . .We taught her a lot in terms of the skills that she has now. So its very satisfying to see somebody sort of blossom in a role".

"Even though they've produced a document which says that you can do those things, I still have to know what they [nurse practitioners] have done. Even though nurse practitioners have finished the program, they will come with different levels of experience. To me, from working at family practice, it's the experience you get rather than the courses that you did. . . .It really depends on the relationship that develops, the trust between people".

"I've been quite impressed that they seem to know their limitations. I'll always encourage them if there is any doubt to contact me, and I think they do that. I can't think of one episode where they have sort of overstepped their limitations".

1.1.2 Recommendations
Some physicians suggested that curriculum changes were needed in programs that prepared nurses for extended/expanded practice. Particular emphasis was placed on enhancing nurses practical skills by having them spend more time with physicians during clinical rotations. A couple of physicians commented on the importance of setting minimal competency standards, and the role of continuing medical education.
Illustrative Quotes

"I definitely would change the curriculum to [include] more practical experience in the medical field. . . .They should be training with the physician or preceptor for a little bit longer. . . . Actually, I think its 3 months altogether, which I don't think is sufficient".

"I usually encourage her to attend CME [continuing medical education] things. . . .We are sharing the same clientele. . . . and we need upgrading".

"Anybody who is a provider in the health care system, whether primary, secondary or tertiary, needs continuing medical education".

"You want a minimal standard; you want a minimal degree of knowledge. . . .You should have received basic information in your training and not learn on the job".

"I think that depending on the training and the type of character that you are going to have at the end of the day, they could have diverse skills and diverse training. That's a bit of a concern for me. If there are going to be standards about the types of things that they can do, then I want to make sure that there are huge standards around competence with assessment".

"I think it is really important that they work with the physicians that they are going to be working with after they graduate".

"I think, if possible, it would be better to have a specific full time structured course, something like 6 months to a year to advance their knowledge. I think that would be ideal".

1.2 Collaborative versus Autonomous Practice
A collaborative arrangement was perceived as the best practice model for nurses working in extended/expanded roles. The manner in which collaborative practice was envisioned varied depending on the nature of the clinical setting, as well its location. The data suggested that physicians working in rural and/or remote areas with limited medical services were more supportive of greater independence for nurses, within the defined scope of their practice, than their counterparts working in urban areas where there was a more adequate supply of physicians. Regardless of the setting and location, an important benefit that physicians perceive that they have gained from working in primary health care settings is the strong collaborative relationships forged with nurses in extended/expanded roles, as well as other health care providers. Most physicians were supportive of using an interdisciplinary approach to patient care.
Although physicians supported both the independent and collaborative aspects of the extended/expanded role, their degree of confidence with nurses performing the role was tapered by expected/required levels of autonomy or independence. Physicians were supportive of autonomous practice for nurses as long as they are working within their scope, as well as consulting with physicians as required. Without exception, all of the physician participants specifically stated that nurses should not replace physicians or provide substitute medical care. Most physicians felt that if nurses were to develop independent practice arrangements this would be met with opposition from their colleagues in the medical field.

1.2.1 Conducive & Acceptable Practice Models
This section summarizes physician comments on the most appropriate practice arrangement for nurses working in extended/expanded roles. The illustrative quotations are summarized according to the rationale for supporting collaborative as opposed to autonomous practice, and implications for physicians' practice.

1.2.1.1 Rationale for Supporting Collaborative over Independent Practice
The underlying theme conveyed by the interview transcript data was that participants favoured physicians and nurses working together in a collaborative manner. Participants recognized and supported the merits of a collaborative type of practice regardless of the location (i.e., urban, rural or remote). It was also abundantly clear that the more remote the setting and the greater the problems with physician availability, the more supportive participants were of greater autonomous practice for nurses.
With regard to appropriate roles and responsibilities for nurse practitioners, some physicians were of the opinion that more emphasis should be placed on wellness as opposed to acute care. One special area of concern voiced by physicians was how well prepared nurse practitioners were to deal with patients presenting with high levels of acuity, especially while being responsible for on-call coverage without physician back-up.
Illustrative Quotes

"I would like to see a nurse practitioner working in the office with the physician and follow-up done mostly by the nurse practitioner. If there were any changes she should consult. . .with the physician and then implement it [treatment] in a proper fashion".

"I feel very confident if they are working in line with a physician, and they shouldn't be used as a replacement which happens on many occasions".

"I don't say they shouldn't go independently. . . .but to the level they should be feeling comfortable. . . .If a patient needs to be seen by a physician, they [nurse practitioner] call us and make appointments with us. So, at that level we can do something with it".

"Patients in [isolated communities] are being taken care of by them [nurse practitioners] and they don't have to come to this place [hospital]. . . .These are the things which I think they help more, they are really helping a lot. When we go to [isolated communities] they see patients with us. Those are the places where they are needed".

"I think the best thing for all of us is to work as teams. . . .But in this setting [community health centre], things are so broad based and so complex they need to draw on a lot of people's understanding and expertise. . . .I don't think physicians should be working on their own. . . .there is just no way you can be confident in yourself all the time.

"I think that working independently would go against what we are trying to achieve. I don't see why it has to necessarily be independent."

"I think the community health centre situation is an ideal one for a nurse practitioner because the focus is supposed to be broader than just the medical model. . . .In terms of a free standing nurse practitioner clinic, I don't have a problem with that, I just wouldn't want to be working in collaboration with it".

"I'm not sure at this point, other than in the northern areas where they have to work independently, that it is a good idea. I'm not sure if any of us are trained to work that independently. Even I would find it difficult in situations to have all the skills and knowledge to be able to deal with everything".

"I had great concern when we initiated nurse practitioners, especially about licencing them to practice independently - set up a shop on the corner and practice independently".

"One thing that nurse practitioners would say they can do well are annual health exams. . . .But the problem is people don't come for annual health exams, they come for check-ups, and pass you a bunch of complaints. As a family physician I think I am well able to handle that because I can do all the aspects of the health exam, and my experience and my training allows me to fish through all the complaints as well. One of the things about nurse practitioners that I am truly concerned with is fishing through the complaints. . . . So there are some areas where nurse practitioners feel confident and they are competent enough to be able to do that. But people present with a whole bag of stuff and I don't know if they have the same training and experience as physicians who deal with the whole bag of stuff rather than having to refer them on".

"[Nurses are being] more and more pushed into acute care and I don't think that is really the place where they should be spending most of their time".

"They are being pushed into a role [on-call without physician back-up] in which, I wonder if they are being fully trained for".

"I think that there is a grey area in which the nurse practitioners in the evening or weekends can see the patients, but the patient may need a likely higher level of care. I think that both the nurse practitioners and the patient have the potential to become discouraged because the nurse practitioners may feel she does not have the local support. That is, we don't have the commitment or set up in a structure in which a physician is more than a nurse".

"I think that if we are going to carry on with the role, we need to keep it in that mode [collaborative practice]. The moment you make the nurse an independent practitioner then I think you will see a lot of anxiety from physicians".

"Many times they consult with us about something and we basically give them advice. So, we do work collaboratively".

"Patients are to be screened by the nurses first. . . .and then they try some management or consult with the physician by phone. If they do not feel comfortable treating that patient or if they feel that it is something that needs to be seen by a physician, then they will refer to a doctor".

"The way we have it set up in our province, with the nurses working with physicians under a transfer of function protocol, physicians have some sense of security if they [nurses] have trouble with a situation".

1.2.1.2 Implications for Physicians
Without exception, the presence of nurses working in extended/expanded roles in primary health care settings was believed to have a positive impact on physician practice. Physician benefits were described in terms of increased ability to delegate less serious problems to nurses, and to have more time available to concentrate on medical issues. Some physicians also indicated that working with nurses in extended/expanded roles has given them a greater consultant role. This transition was perceived, for the most part, to result in more efficient management of physicians' time.
The negative repercussions or downside to this transition was the refocusing of physicians' practice on higher acuity cases and/or more complicated medical issues. This meant that physicians had less time available to use a more holistic approach to care and ensure continuity of care. With regard to the consulting role with nurses, this often led to greater demands on physicians' time. Physician receptiveness to the frequency of nurse consultations during the early months of practice was sometimes less than positive. For some it was seen as intrusive and disruptive to their clinical practice. Even after an extended period of time working in a collaborative practice arrangement, some physicians still find that the continuous interruptions from the nurses regarding patient consults tend to be quite disruptive. Nevertheless, most of the participants were satisfied with the changes experienced in their practice.
Differences were also detected in how physicians working in urban versus rural and remote perceived the positives and negatives of having nurses in extended/ expanded roles. Besides health promotion activities, physicians working in remote areas indicated that nurse practitioners or primary care nurses play a major role in performing primary care functions to help decrease physician workload in-between weekly visits or alternating weekend on-call coverage.
Illustrative Quotes: Positives

"I can spend more time with primary or first-seen patients. . . .[and] the more difficult cases which require specific evaluation. Anything which requires less direct physician attention, I can divert to her".

"To start with they were coming with all patients. So, that was understandable. That was sort of wanting to clarify some things and I think that was good".

"I do less and less well-care and more and more complicated medicine which in some ways isn't as much fun. . .and our NP tends to do a lot of baby care and pre-natal care. All of the �wells' go in her department".

"I would have had more involvement with client/consumer tasks, for example, birth control advice and counselling. Not for major depression but other types of things, like diabetic care. . . .I find now that I attempt to delegate those things".

"I never ever found that stuff [the pre-obstetrical visits, prenatal visits, and obstetrical follow-up] really satisfying professionally. I much more prefer to do the acute care work. . . .I think the reason it happened is because I was so willing to relinquish it and [nurse practitioner] so eager to do something. So it was a kind of a natural give and take".

"I can spend five minutes with diabetics. . . .but I know they are going to be enrolled in our diabetes program, and a better job is going to be done on it [counselling] so I can concentrate more on the medical issues."

"I think it's most helpful because I can delegate work to the nurse practitioner, thus freeing up my time to see more complicated patients".

"I think that it frees up physicians quite a bit to take on more complex problems. . . . With the expanded role they [nurse practitioners] take on literally the more routine things - women visits and baby visits. They also free us up in different ways, like the day-to-day administrative part of it".

"I think the positives are that they can, from my perspective, free us up to do more medically complex things. I think they are perfectly capable of providing care that should be provided".

"My role sort of changed from just a general practitioner dealing with sore throats, cuts and colds, and that type of medicine to more of a consultant role".

"I'm almost at the stage now where I would have a lot of trouble going back into private practice. One of the reasons actually I haven't left and gone into private practice. . . .is because of my relationship with [nurse practitioner] and the other doctors".

"We also function in a collaborative role so that has changed our practice. . . . We may see her in a consultative manner with things that are more complex. That's a credit to her experience".

"I tend to see just the referrals and cases [primary care nurse] wants me to see - the more complicated cases".

In the outpost community the nurses. . .see patients on a day to day basis. They also have prenatal classes there and health education. One of the nurses is on call for each outpost community every day. They consult with us if they feel that there is a patient who needs care. So, they play a very positive role".

Illustrative Quotes: Negatives

"There was some opposition from one physician because he found it [consultations] disruptive".

"Unfortunately, our NP kind of grabs us in between patients, as we don't have any formal time set up to do that. . . .We have clinical meetings and that could be a venue for that to happen but it hasn't been set up that way. So its basically a matter of, �I need to catch you about this'. For the most part I would say it works well. . . .Some things need a lot more consultation. I would be less than honest to say there wasn't a day when you are up-to-here and frazzled, you know, and she's walking in and saying �I want you come and see this'. That's going to happen in any situation where life is unpredictable".

"I find that as physicians in primary care we don't have an awful lot of time to meet with a group about a patient and so we don't. . . .It also detracts from the practice in other ways. When we have meetings scheduled with one patient, that means three patients can't be seen for other problems. So, I'm not sure if that can be solved".

"The receptionist believes that the appointments are interchangeable. So if I'm too busy to see the next person who comes with a chest pain the nurse practitioner sees them. All that basically means is that I end up seeing them anyway; its just a backdoor to get to the doctor who is already too busy. The nurse practitioner has to consult with the doctor because it's chest pain. It hasn't helped me loosen my workload whatsoever, its actually increased it".

"As a family physician and an active member of the College of Family Physicians of Canada I ascribe to the College's definition of the family physician and that is a person who provides care to a defined population in a holistic way and long-term continuous way. That relationship that we develop is very important in our healing. . . .This is sometimes in contrast to what I do here at the community health centre (CHC). Even though CHCs advertise for college of family physicians they actually don't totally ascribe to practising as I'm trained because I end up having to give up some of my relationship with patients. I also have to give up the holistic aspect because the nurse practitioner sees patients for this and I see them for that".

1.3 Role Confusion - Patient Understanding, Acceptance & Satisfaction
With regard to patient understanding and acceptance of an extended/expanded role for nurses, one of the difficulties observed is patient misunderstanding of the differences between the roles of physicians and nurses roles when they are working in the same setting. Although physician perception of the degree of role confusion varied across settings, most believed that patients had difficulty identifying the appropriate practitioner to see about a particular problem.
Despite the limited understanding of the scope of nursing responsibilities, most physicians felt that patient acceptance of nurses was generally positive, especially for health issues related to wellness and minor illnesses. With regard to patient preference, some physicians were of the opinion that, for most things, patients would prefer to see the doctor. A small number of participants felt that limited patient understanding of the role acts as a deterrent to wide-spread acceptance. Others indicated that patients' comfort with nurses working in these roles increased over time as they developed more insight into what nurses could and could not do.
Most physicians indicated that patients seemed to be quite satisfied with the level of care provided by these nurses. This satisfaction was attributed, in part, to the collaborative work with other health care providers, especially physicians.

1.3.1 Understanding and Acceptance
This section summarizes physician comments on patient understanding and acceptance of nurses working in the extended/expanded role. In addition, illustrative quotes of physician perception of patient satisfaction with the role are also presented.
Illustrative Quotes: Patient Understanding

"Some people think they are physicians".

"In many cases, it's the other doctor"

"I am not sure if patients know there is a limitation of scope, especially with regards to medications (i.e., methotrexate)"

"Patients are confused".

"I think most of them have the idea that the nurse practitioner has more training and duties than a regular registered nurse. I don't think that they have a good idea about the issues to the extent that they can prescribe certain medications and order some tests. . . .because they haven't had experiences with this type of provider".

"For the most part, people just see her sometimes as the doctor. . . .Sometimes they call us the same person. . . .I'm not telling you that they totally understand what her boundaries are because I don't necessarily think they do".

"Certainly some patients have figured out quite nicely and they know how to use which person they want for which sort of problem. Some other patients really don't know or really don't care too much as long as they see someone to address their problems".

"Some people are quite confused by it. I heard people saying, "Do I still have a doctor? If I see the NP does my doctor get to know about that?" I'm not saying this to sort of inflate the doctors place because I'm very supportive of the nurse practitioners, but people still believe in their doctors".

"There was a lot of confusion initially. There is that line between doctor and nurses and they didn't see how they could be blurred or shifted".

"Here in [place] there are a lot of patients who do not know [nurse's] role. The patients that she sees are mostly walk-ins. . . .We do take some time to explain to them".

Illustrative Quotes: Patient Acceptance

"Before. . .they were hesitant, now they are getting more used to them [nurse practitioners]. Some patients know that they don't need to see a doctor and can be taken care of by the nurse practitioners. They feel comfortable making appointments with them".

"If patients have the option to see a doctor or a nurse they would choose a physician".

"When it comes to women's issues, they prefer a female".

"Once they have dealt with the nurse practitioner a few times they tend to relax, and then begin to accept them. But it is new to the patients".

"I think that in certain areas people respond very well. For example, for parents there's really not much of a difference who gives the immunization and who chats with the kids for a routine visit. I don't think that they much care who is assigned to them as long as they are looked after. I think that female patients would much rather have the nurse practitioner than a physician for a pap smear".

"There are groups who would prefer to see [NP] period. They have full confidence in her and really like. . .the actual numbers of hours she spends with them. There is another group who still thinks that the doctor is the rubber stamp".

"A lot of women hesitate to see a man for a physical and so I think that the patients accept them in that regard".

"I think that if. . .they feel that they are very, very sick, they tend to ask to see a physician than a nurse".

"Especially if the nurse practitioner consults with the physician, that reinforces in the patients mind that they need different care or a different provider".

"I don't think people necessarily are going to be lobbying together looking for a nurse practitioner out in the community because I'm not sure that they understand it well enough or have a concept of the present things that they could do".

"Within the outpost clinics, they pretty much know the difference. And patients will come and tell you that they want to see a physician. . . .There is a lot of them that probably accept the role of the nurses very well".

"I think now a lot of the patients would rather see the nurses, particularly young mothers who have children, prenatals and things like that".

Illustrative Quotes: Patient Satisfaction

"Patients are generally pleased. . . .and she [NP] has a nice personality. . .and takes good care of each person".

"At least the NPs spend time with them and talk about their basic stuff, and talk to doctors regarding them. Then they start feeling more comfortable".

"People are just happy to have someone looking at their sore throat or listening to them about their problems".

"I don't hear of any problems. You'll hear individual problems from people who say, "I can't get in to see my doctor". But, generally people are fine because they know we have a close relationship here. Our patients see how we work very closely together".

1.4 Barriers to and Facilitators of Collaborative Practice Models
Physicians viewed the addition of NPs to primary health care settings as having a positive impact on the health care services available to patients. One particular component that was especially highlighted was the increased emphasis being placed on health.
Physician resistance to the NP role was identified as one of the barriers to full implementation of the role. Although the addition of the NP has improved accessibility and health promotion activities, the heavy workload in under-serviced areas was identified as a major barrier to delivering primary health care. As some physicians noted, if physician quotas were met, nurses working in extended/expanded roles, like nurse practitioners, would have the time to do a more thorough follow-up with patients, and physicians would have more time for preventative work.
Besides the adequacy of physician resources, issues were raised regarding the logistics of community health centres, placing physicians on salary, and cost savings. While most believed that the multi-disciplinary team approach espoused by community health centres is a "good way of providing care", they also had serious reservations about the benefits for physicians. Other physicians voiced concerns about using nurses in extended/expanded roles to decrease the cost of health care services.

1.4.1 Service Accessibility
This section summarizes physician comments on how collaborative arrangements with nurses working in extended/expanded roles may or may not increase patient access to quality health care services. The findings are summarized according to the impact on a region's ability to maintain physician services, and implications for patients.

1.4.1.1 Impact on Physician Shortage
Due to health care reforms in recent years, physicians have witnessed a decrease in the number of practicing physicians in certain areas. These events reinforced the need to identify alternative measures to provide primary health care services. Physicians commented on how nurses working in extended/expanded roles could buffer the impact of problems resulting from the shortage of family doctors.
Some physician participants had reservations about how physician benefited from working under collaborative practice models in community health centres as salaried employees. In some instances, physicians saw nurses working in extended/expanded roles as posing a significant barrier to physician recruitment and retention. Interview comments reflected concern about whether or not there is sufficient work for all health care providers involved in direct patient care. This factor was seen as posing a potential barrier to a region's ability to retain fee-for-service physicians and thus increasing the workload of physicians already present.
Illustrative Quotes: Facilitators

"Today there seems to be a lack of doctors. There are a number of people who can't get in to see family doctors. If there is a way for family doctors to hire nurse practitioners and be reimbursed for their services, I'm sure that would help alleviate some of the problems with human resources".

"Certainly the positives for Ontario is that there is not enough physicians, and nurse practitioners can help to provide care to people who don't get care from physicians".

"I think that it has been positive with the nurse practitioners here, It has been an efficient way to utilize clinical resources".

"There was a great need to have them [primary care nurses] and I think that is sort of the answer to supplying medical services in rural Saskatchewan".

"I feel that because it is difficult to get physicians in outpost communities, they [primary care nurses] play a very important role and I think sometimes a very difficult role. It is sometimes a big responsibility on them that they don't always want".

"The physicians have become very receptive to them [primary care nurses]. They see it as the way to maintain some of the medical services".

Illustrative Quotes: Barriers

"There is only so much [work] to go around".

"They [physicians] have already taken on more than they can handle and so they are stressed for time and making mistakes. Along comes nurse practitioners and a lot of them think this is just the government's way of getting rid of family doctors. . . .I think the nurses. . . .need to get some sort of a campaign going with the physicians, not in the public. My opinion is that the nurse have set themselves out, to be adversaries too much. . . .by not going to physicians directly and saying, "Look here is what we want, here's what we intend to do. . . we see where you guys need help, where patients need help".

"I don't want another tier of medicine. . .mini doctors is not what the NP role should be. . . .We should be focusing on prevention, wellness and those other things. . . .If people want to train NPs to be more basic medical technicians. . . care at a cheaper price, it's a waste of a nursing role".

"I'm not sure it [collaborative practice between physicians and nurses in extended/expanded roles] is any less expensive".

"Say for example there are 1,200 patients on a physicians load, and they work in a dyad with a NP, can they then cover 1,800 patients? Does that end up being any cheaper if the NP takes on 600 patients and the doctor takes on 1,200 more patients. I'm not sure, and, again, I'm in support of nurse practitioners, I'm not sure that economically it would work out".

"Everybody seems to be able to close a practice here except us and the extended hours which people want, but the extended hours are for the medical team. I have some problems with that. The other problem I have with community health centres, when you are talking about primary care reform in general across Canada, especially in Ontario, is putting doctors on salary. I'm very wary if they put everybody on salary. . . .I never had a raise here in 7 years. If you want to keep your medical personnel, you can't treat them like that".

1.4.1.2 Implications for Patients
Several physicians working in under-serviced areas identified increased accessibility to services as an important benefit of having nurses with extended/expanded roles working in primary health care settings. The downside was that these nurses were assuming a greater responsibility for providing primary care services while faced with restricted prescriptive authority, the absence of fraternity with speciality physicians, and limited access to resources, especially in remote areas.
Illustrative Quotes: Facilitators

"With [NP] available accessibility has increased. . . .less people are going to [alternate clinic site]."

"If the circumstances are that there is no room to increase the number of practising physicians. . . .then the nurse practitioners will have a great deal to do to increase patients access to health care providers in the primary health care system".

Illustrative Quotes: Barriers

"I think with the prescriptive piece they are able to use certain medications that we don't use as often any more, and I think maybe that should change. . . .I think the one thing that they lack other than that is the fraternity. They don't have the fraternity where they can call Joe Blow the orthopaedic surgeon and say Joe, "I'm here with a patient". So that part always seems to fall to me. I think that is going to be hard to change.

"They have a very difficult job and I'm glad sometimes it is not my job sitting up there in one of those communities and providing care. As well, you are there without a lot of resources that would make you feel more comfortable, like hospital and x-ray services. It is not always an easy call".

1.4.2 Implications for Qulaity Care
This section summarizes physician comments on how collaborative arrangements with nurses working in extended/expanded roles may or may not improve the quality of care available to patients. The findings are summarized according to the impact on comprehensiveness of health care services, and continuity of care .

1.4.2.1 Comprehensiveness of Services
With the presence of nurses working in extended/expanded roles, some physicians viewed the quality of care available to patients as being enhanced because of the collaborative or team approach to care. Special reference was made to the fact that more time was available for providing routine care, ensuring greater continuity, and engaging in health promotion and prevention activities. On the downside, some physicians believed that without adequate supervision, nurses were operating at increased risk for unexpected problems. Thus, the potential for compromising quality care delivery to patients.
Illustrative Quotes: Facilitators

"Health promotion, that is a good thing. Similarly on the prevention side, some doctors are too busy. At least they [nurse practitioners] are promoting health as well as telling patients about prevention".

"I think that's [the welfare aspects of medicine] often missed in most doctors offices. . . . The practitioner tends to focus on illness because that's where the fee schedules are setup. So the positive aspect of the nurse practitioner. . .is that she can focus on wellness".

"I think the positives are that the nurses here seem to be seeing more patients for well women exams, birth control counselling, and well baby care".

"I think taking care of diabetes patients or routine care of our children. Those are the things that are very useful because they [nurse practitioners] are able to see more patients".

"In some respects, she [nurse practitioner] has a little bit more time to be more thorough with patients".

"They liaison with patients and I think that is the most important thing. As they start to relate to the patients and get to know them, they become patient advocates. . . .The nurse practitioner seem to be able to find that time to liaison with other groups. That is a strength for the care of that individual patient".

"I think the single most important aspect of all is that she's a nurse and she comes at it with a totally different focus. We come at it with a medical model that's disease centred, and she comes at it with a nursing focus, that's nurturing. . . .And the advantages of the focus on wellness, that to be is invaluable in terms of the role. . . . Whether its wellness counselling or other kinds of counselling, depending on the expertise, I think. . .that a nurse practitioner, if given time and training, could function very, very well in counselling".

"I really like the idea of a dyad team with physician and nurse practitioner taking care of the same population. . . .Both knowing the patients really well and working closely together. I think they can do a good job and bounce off each other what they are doing".

"I think the collaborative models is the strength of it in that our aim here is early intervention with children, which can make all the difference. . . .I think the community health centre is a positive place to work".

"I think that putting it all together we do an excellent job. . . . What confounds that a little bit is we have a kind of selection bias in our patients, we tend to get the sickest of the sick, we tend to get the elderly, we tend to get people who are marginalized. . . .But I think that given that same population in a single doctor's office. . .I think we do a much better job. . . .I have a lot of friends who are family doctors in the area and casual conversations about the way they treat diabetes or. . .hypertension or that sort of thing, I think we do a better job. I'm amazed at how much they do, I can't do all that stuff but with [nurse practitioner] I can".

"One is health promotion. I think that is the one area that we have been greatly lacking in family practice, particularly in physician offices. . . .And secondly, I think it is providing acute and chronic care for sore throats and bladder infections and injuries".

"In terms of [nurse practitioner], her biggest role is education. We feel that she has a very important role. Her role here is not to try to decrease our workload. . . .She does help especially in that I don't have to go and teach the patient how to do glucometer testing and things like that".

Illustrative Quotes: Barriers

"At times. . .she is playing a small doctor role, and I think that is a little bit too much. . . . And can be dangerous in some situations".

"At the time they [physicians] were talking about them [nurse practitioners] being licensed and able to prescribe and diagnose, and certainly I was worried about that. Not because I felt threatened, but because I was worried for patients".

"It is just one of the things I have noted that they [nurse practitioners] spend a lot more time on the social aspects of nursing versus the medical aspects of care".

1.4.2.2 Continuity of Care
Some of the physicians expressed concerns about possible negative repercussions for continuity of care. One area of concern is the tendency for nurses, on occasion, to refer to specialists without consulting with the primary care physician. Several participants felt that this practice interfered with physician ability to provide quality follow up care to patients. Another aspect of continuity related to responsibility and legality issues with regard to who the responsibility clinician should be in situations where nurses are seeing patients independently, screening them and deciding on the appropriate treatment plan.
Illustrative Quotes

"If we all worked in the same area it may solve this problem [continuity of care concerns]".

"Someone needs to coordinate activities and ensure continuity of care".

"Sometimes a person sees a nurse practitioner, then the physician, and then the nurse practitioner. You don't get to know the patient".

"Some [patients] say that you are their family doctor but you might never have seen them. . . .It becomes an issue as to who is the responsible clinician. If you've never seen this patient are you liable or not. It's a concern, especially for cases of child abuse".

"At the moment, nurse practitioners, although they can order diagnostic tests, the results come back to the clinic. We sometimes have a bit of a problem with that because of the staff changes and their different schedules. . . .The result would be high, it would be filed and then nobody would react on it. So we are trying to get the message through to the nurses that when they do request blood testing for patients that we see together and that they use the physician's name. When it comes to our clinic we can react on it".