
	Research : Reports

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

Face-to-face interviews were conducted with nurses who were working 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 nurses' experiences while performing the extended/expanded role in primary health care settings with similar and different practice models. A second purpose was to identify aspects of nursing practice models which are most and least helpful in facilitating extended/expanded practice.
The interview data were subjected to the constant comparison method of analysis to highlight differences and commonalities within and between each provincial jurisdiction. The first section presents an overview of study findings. The remaining sections present a discussion on dominant themes and sub-themes that emerged from the data analysis.
Overview of Findings
It was apparent from the interview comments that all of the nurse participants found working in the extended/expanded role to be a very exciting and challenging experience. Participants indicated that they felt very secure in the role and were committed to it despite having confronted a number of challenges. Since assuming the role, they described dealing with difficult patients and emergencies on their own, as well as trying to keep current while struggling to provide quality primary health care to the people in their regions. One of the early challenges encountered by participants was the social-political make-up of the work environment and its implications for practice. By acknowledging the influences of the environment, participants engaged in activities to overcome the challenges and carve out a niche for themselves.
The comments indicated that most of the participants felt that the extended/ expanded role has progressed in a very positive way due to the support and understanding received from various sources. Several participants commented on how adjustment to the role and the development of confidence in independent practice was facilitated by the overwhelming support received from physicians and the nursing staff. Collaborative practice arrangements seemed to work the best when there were open communication channels between nurses and physicians, and when interactions were based on mutual respect and understanding. Participants also indicated that collaborative practice models between nurses, physicians, and other health care providers provide a useful model for meeting the objectives of primary health care.
Some participants suggested that the program preparing them for the extended/expanded role could have been longer in duration, especially with regard to the clinical component. This factor, along with having a degree, was seen as having a significant influence on personal feelings of competency, as well as credibility in the eyes of other health care providers. However, all of the participants recognized that every new experience presents them with new challenges. Frequent referencing of sources was believed to be the key in helping enhance knowledge and skills.
Many of the participants expressed concern about the public's inadequate understanding of the extended/expanded nursing role and the tendency to confuse the nurse with other providers. Despite inadequate understanding, the consensus was that there is an increased willingness for patients to see nurses.
Significantly, many believed that a priority focus of future efforts for nurses with extended/expanded roles should be on expanding health promotion and illness prevention activities in the community in order to ensure that full recognition is given to this aspect of nursing practice. Many participants also felt strongly about the importance of public education and standardizing qualifications for extended/expanded practice. These activities were considered essential to ensure full understanding of nurses' scope of practice as well as maximum utilization of nursing services. Finally, strong emphasis was placed on the importance of directing future efforts toward obtaining greater support for nurses working in extended/expanded roles from management and unions, and professional and regulatory bodies. In essence, these nurses believed strongly that full utilization of nursing services is dependent upon gaining public and professional recognition for the role.
2.1 Practical Knowing
Self-confidence and perceived competence were reported as being low by participants when they first assumed the extended/expanded nursing role. There was also a lot of uncertainty due to the newness of the role for the self, other health care providers, and the general public. Significantly, several participants commented on the gaps between theoretical and practical knowing during the early months, the immeasurable value of experience, and the benefits of a strong support system.

2.1.1 Knowledge Levels and Practical Skills
This section summarizes nurses' commentary on how prepared they were to assume the extended/expanded role in primary health care settings. The illustrative quotations are organized according to perceptions during the early stages of role implementation and following several months of clinical practice.

2.1.1.1 Early Stages of Role Enactment
Many participants described their movement into the extended/expanded role as a difficult one. In reflecting upon the adequacy of educational programs, most indicated that they could have benefitted from having had more theory and clinical experience. Without exception, participants stressed the need to increase the clinical component of programs preparing nurses for these roles. This was true regardless of one's previous experiential base, which in some instances was in the vicinity of 15 to 20 years of nursing practice.

"I would not say that I came into it with much confidence, very much the novice".

"I realized that all of the things I was told I would not need to know in practice. . . .I had to read and look things up just for my own comfort level. . . . Everything was gray, there was no black and white".

"Basically the training that we were given in school did not prepare us. . . . Because it was a medical shortage that we had to fill, the nursing that we learned had no value for the role that we were needed for".

"I would have liked to have seen more clinical".

"Women came in expecting you to have much more knowledge than you had [about women's issues]. . . .I was really new at this and sometimes I would look at things and just have no idea because I hadn't seen it".

"It was very. . . intimidating".

"It's like starting over completely again. The confidence and stuff was gone completely".

"It was a new job and it was a new experience. A lot of people didn't know what we were about".

"When I first started. . . .I had to basically relearn a lot of the practical work".

"It's quite overwhelming when you first start, very overwhelming. And you are wondering am I not smart enough for this".

"I came to Northern Saskatchewan. . .and went to a single nurse station. I should never of done that because I did not have the theoretical base that I needed and certainly not the practical base".

2.1.1.2 Development of the Experimental Base
Greater comfort with and confidence in the role came with the passage of time and exposure to different conditions and clinical situations. The movement into primary care was described as a "learning process". By working collaboratively with physicians in the clinical area and participating in continuing education activities, participants gradually incorporated primary care functions into their practice, developed greater self-confidence, and assumed a more independent role. A few of them noted that as they developed increased confidence in performing primary care functions they tended to consult with physicians in a different manner.
Illustrative Quotes

"As time goes on and the more you do, the more comfortable you become".

"With experience you get better at the assessment and the physical examination. . . .I think that's evolved simply because practice makes perfect. Each time you do it, you do it a little better".

"In the beginning my consultations was a security blanket. Its like you do your assessment, come to a diagnosis and decide on a treatment plan. Then I would go and run this by somebody. . . .When I consult now I feel it is a legitimate thing. Like, I had this assessment done and I come to a diagnosis that is outside of my scope or I come to an interpretation that something else needs to be done on the diagnostic end. . . .When its outside of my scope I go to them [physicians] with a purpose now".

"You become more comfortable with the more that you see".

"Initially when we started it seemed every patient we saw we had to collaborate because we were in-experienced. We only became comfortable with more and more experience, and that has evolved over the past few months. There is less consulting now. I think for the most part the collaboration piece is there".

"You have to have a good understanding of the pathophysiology and the pharmacology. I don't think you can ever get enough of that. It is so different when you sit down to discuss a condition with a patient versus a nursing only perspective. . . .I'm amazed at how much you have to learn. . .to be comfortable sitting down discussing the full impact of an illness on a person from the onset and why it happened and how it happened".

"I think my scope continues to expand. The more things I see, the more things I learn about, the more things I can do independently, as long as it is within my slated scope".

"I didn't come into the role with a set of skills. I moved step by step to where I am today".

"And. . .the two physicians. . .were very supportive in getting me to do clinics and that sort of thing".

"The patients that I can manage independently with confidence have come from having done that same type of case a few times".

"I will have them [patients] book an appointment with both [physician] and myself and we will see them together and discuss the cases. He has lots more expertise than I do, so I always learn something from that".

"When I first started. . .and we went to continuing medical education things, sometimes I didn't have a clue what the doctor was talking about. You sit back and try to absorb what you can even though you are not really sure. . .and then last year I came and I knew exactly what they were talking about".

"As you get more experience, the more confident you feel".

"I learned fast. Over the years it developed into an well rounded role. . .as far as acute care and public health. . .and just the community in general".

"I spent two days with [physician] who happens to be an ear, nose and throat specialist. . . .There are others I would like access, such as a cardiologist and an ophthalmologist. . . .So you can get to be better at what you do because I haven't been at it long enough".

"It's certainly one of those things that you have to keep the books beside you. When you think about something that you dealt with that day, lots of times I grab a textbook just to refresh myself".

"You have to sit down and you have to think things through critically. You have to eliminate certain factors, do an assessment, and come up with a diagnosis and treatment. . . .Now I never ever go to work any day that I do not refer to some books. . . .There is always something to learn, and I feel bad for the people who think they know it all because they don't and the more you know the more you know you don't know".

2.1.2 Recommedations
With regard to the educational preparation of nurses for extended/expanded role practice, several participants commented on the importance of having a standardized entry level for nurses assuming extended/expanded roles. Nurse participants without a degree base indicated that they would have felt more comfortable working in the role initially if they had baccalaureate preparation prior to entering a program designed to prepare them for the extended/expanded role. The general feeling was that common standards are required to ensure greater acceptance and credibility of the role.
Besides a standard level of preparation, most of the participants commented on the benefits of continuing education in helping them feel more secure in the role. In some instances, educational upgrading was as an ongoing challenge confronting nurses working in extended/expanded roles. Importantly, some participants felt that additional knowledge of pathophysiology and pharmacology would facilitate discussion of the disease process with clients.
Illustrative Quotes

"I'm working towards my BN and that's a constant learning experience. . . .I'm continuing to learn about that [primary health care]. . .that's probably the biggest thing for me continuing on with that part of it."

"I feel very fortunate that I was allowed to be in this program, but if I stay where I am without getting a degree, I don't think I deserve to have it because I simply am not qualified to work in advanced practice. . . .The people who are out there now working as nurse practitioners should be given a limit of time to complete their degree".

"I do think that because I was a registered nurse when I did that [Nurse Practitioner Program], a diploma trained. . .it would be a great benefit if you have your degree in nursing, which I'm working on now".

"It's a continuous thing you have to keep upgrading and plus you have to further your education if you are gong to get anywhere with it, to be credible".

"I think the diagnostic aspect of it and the health assessment, I would have liked to have had more education on that line, like the treatment of diseases. . . .A lot of that stuff we learned when we came back and started practising".

"I think that it is really important to have a standardized entry level to practice as nurse practitioners".

"I think that we will have credibility problems if we don't standardize the education across the country. I think we need to be on top of the model as they have done in the States. . . .there is a lot more acceptance. . . .I think we have done ourselves a disservice by allowing people with different levels of educational preparedness (i.e., diploma, diploma with certificate, bachelors, master degree) to practice. There needs to be a minimal level of education for advanced practice".

"I think that one of the biggest problems is for nurse practitioners to upgrade. In the last few years, there have been more opportunities but it continues to be a challenge".

"I think everyone needs to be masters prepared".

"I feel that I am prepared now to handle it, whereas years ago I wasn't. I have to say that the advanced clinical nursing course is. . .a very, very necessary part of the education for people who are working in an expanded nursing role. I don't think that any nurse should be allowed to practice without it".

"I believe that the physical assessment and the skills that nurses are learning in the advanced clinical should be part of the whole curriculum in nursing training. I don't care what anybody says you should have all those skills. Now if you want to branch out and continue on in the advanced clinical great, go ahead and get your pharmacy and all these other little things - suturing skills and stuff".

2.2 Collaborative versus Independent Practice Models
Study participants described their practice as a balance between independent and collaborative roles and responsibilities. There were a number of comments illustrating how nurses differentiated collaborative from shared and independent practice. The interview comments suggest that most participants were very comfortable with the collaborative working relationship forged with physicians, as well as the independent practice aspect of their role.
Participants described their role as multifaceted. While a significant part of clinical practice was devoted to primary care (i.e., episodic illness, acute illness and trauma, and chronic illness), there was also a strong emphasis on illness prevention and health promotion (e.g., well baby care, well child care, lifestyle counselling, outreach programs for vulnerable adults, a wellness course, etc.). The balance between autonomous and collaborative functions varied from site to site, and province to province. A typical work-week consisted of activities ranging from health promotion and illness prevention, especially women's wellness, to primary care activities in emergency departments and clinics.

2.2.1 Conducive & Acceptable Practice Models
This section summarizes nurse participants' comments on appropriate practice arrangement for nurses working in extended/expanded roles. The data are summarized into three subsections: autonomous practice, balancing collaborative and independent practice roles, and rationale for supporting collaborative practice models.

2.2.1.1 Autonomous Practice
The interview comments indicated that all of the participants were comfortable performing primary care functions autonomously in different primary health care settings. The degree of independence varied depending on the scope of practice guidelines governing nursing practice in each provincial jurisdiction. Nurses who worked under a transfer of medical functions model, as in Saskatchewan, had a broader scope of practice and thus greater autonomy and responsibility than their counterparts in Newfoundland and Ontario.
Some of the nurses commented on the challenges, as well as the personal satisfaction, of working in extended/expanded nursing roles. Several participants also emphasized the value of nursing skills and abilities that they brought to each clinical situation, and the importance of maintaining a nursing focus when performing primary care functions.
Illustrative Quotes

"We see the patients that certainly fit within our scope and sometimes the ones that aren't within our scope, and if they are not we'll just see them, do an assessment, and consult".

"Absolutely no problem [working independently within scope of practice]".

"I can't say that its [working in outreach clinics] any more stressful than it would be working here [hospital] because it depends on what you see, what you have to consult, and with what physician you have to consult".

"It has always been my practice to function independently and autonomously".

"I like the autonomy of the role and I like the flexibility that I have in my role. Certainly going into peoples homes or where people live, whether it be a hotel or their van or crack house. Seeing peoples' lives beyond what you might see in a hospital".

"I like the challenge of trying to figure out the disease or the diagnosis. . . .The relationship that you form with people and the trust. . . .Or, the advice of health promotion and disease prevention, and seeing some reaction with people".

"I think that what I bring as a nurse, you know, caring and the health promotion and the disease prevention and the counselling aspect is very important".

"I like the variety, I think that's really rewarding. It can also be difficult because your knowledge base has to be so wide. . . .Its rewarding because you have this huge scope of practice so you are never bored."

"For me that's the role advantage, looking at nursing in the broader perspective rather than medicine".

"I do an assessment and know in my mind what I think it is. Then I do lab and x-ray studies to double check. When they come back indicating that I have made the right diagnosis, it always makes you feel, �Yes, I was right on about that one'".

"Every patient that I see, [physician] does not necessarily see or know about or have anything to do with at any point in time, unless there is a particular piece with the patient that falls outside my scope of practice".

"As far as the prescriptive authority here in Saskatchewan, right now we are only bound by what is in the formulary. . . .It is up to us to know where we need to have a note in the chart to say to the physician, �Okay this one as well'. . . .I think we are functioning in as full a capacity as what we can possibly do. I can order pretty much any lab test that I want and the ones that I question I phone any doctor to get his okay".

"I always liked the emergency department; the quick changeover and dealing with people and families and that kind of thing. . . .I always thought that there was no reason why the nurse couldn't be doing more of the hands-on stuff. You don't have to be a rocket scientist to do it, or relieve the physician".

"As far as overall treatment, I have a lot of authority or control over the way that treatment is going to be handled and if I believe that this patient must see a doctor then they will be brought to a doctor".

"When you move from community to community, it's a never ending process getting to know the community, new physicians, and new routines. It is very challenging and probably the most rewarding type of nursing that I've ever done in my life because I do like the extra responsibility".

"The people that are working in the advanced clinical nursing have got to be a different breed. They have to be independent and a little bit on the stubborn side. They have to know what they are doing and have to be confident within themselves".

2.2.1.2 Balancing Collaborative and Independent Practice
Although the nurse participants felt secure working independent of physicians, they also emphasized the importance of collaborating with others, especially for things that fall outside their scope of practice. In certain clinical settings, nurses shared patient caseloads with physicians and did not carry independent caseloads. Although these nurses saw patients independently, the collaborative approach predominated and was considered to be more beneficial for everyone - patients and health care providers. When collaboration worked best, referrals flow both ways between nurses and physicians.
Collaboration was not always viewed positively. Some participants noted that the time spent consulting with physicians sometimes resulted in appointment delays for both parties. Further, participants expressed frustration when the nature of the work environment restricted contact with physicians to telephone consults.
Illustrative Quotes

"I take orders from a doctor, as any nurse would do, and that in effect raises my scope of practice to a shared practice. If things get beyond what I'm able to do the doctor would say, okay do this. . .and I will follow that. When its something within my scope, it would be collaborative".

"Most of my referrals go to the dietician or public health - home care and community health. . . .every now and then social work and speech pathology. . . . maybe 1 or 2 referrals to mental health. . . .Physio doesn't take referrals from us but we consult one of the physicians and get a referral. But she [physiotherapist] is very open to guiding us and lots of times I call her for advice".

"We collaborate with them [physicians] any time. They are very supportive in our role and they come to us. . . .We have physicians here that prefer not to do well women's screening and they come and ask us if they can book a client in with us. . . .Teenagers, they would gladly refer that patient to us".

"We have to collaborate with the physicians especially if its something that's outside of our scope of practice or if its something that we are not sure of. But there is quite a bit of independence, especially when we do the outreach clinics, unless you see something which requires consultation".

"There's some independence and then there has to be a collaborative practice due to the nature of our work".

"Although we practice collaboratively, there is very much an independent piece inherent in that".

"We have 3 physicians and collaborate together with them to develop a treatment plan for the patient. People respect our expertise. . . .We work with, rather than for, the physicians with a mutual respect. . . .Basically, nurse practitioners do not have independent case loads but we all share the client load".

"In many respects, I feel quite autonomous and independent. . . .I'm working closely with the physicians here and I feel that they support me. That I know because it certainly would be easy for them to question or to sort of get involved with my decision making but they don't. I feel pretty supported in that I can make those decisions and I know that if I need to consult somebody just to say, �Do you agree with this? Or am I missing anything?' That's fine and I don't feel that impacts upon my autonomy".

"If I'm dealing with any client independently I do the assessment, and if we run into a complication consult with the physician".

"Depending on who I see in a day, I may never have to run down the hall and knock on the door [consult with physician]. . . .If it's a young women coming in for her regular physical, often all they need is a prescription for birth control. . . .If I'm seeing a person with chronic illnesses but they've been stable and I just need to renew their anti-hypertensives, maybe diabetic medication, then I'll go knock on the door and say, �I'll need a script for 3 months'".

"When consulting, it's probably sometimes very frustrating. . . .I might have to stand there and wait for 10 minutes until somebody gets off the phone or comes out of a room with a client. That's a bit frustrating. . . .When it's a busy day. . . that makes you feel not very helpful".

"We refer to each other, we help each other."

"It has taken time to cultivate that. . . .Now we've built a really good working relationship. Communication is open. . . .We consult each other and we collaborate with client care and also with education. It's a back and forth thing".

"The ability to diagnose and treat and follow through. Like that whole component - nice continuity. I like being able to have that knowledge base and being able to use it to the fullest extent. . . .I like the responsibility I have. . . .I also like the sharing and the relationship with the physicians that are nearby. . . . I like being able to meet the clients needs and do the whole teaching and everything. . .the health promotion and illness prevention. . .as well as the treatment aspect. . . .So you get the best of community health nursing and extended nursing role. . . .I like the autonomy here at the health center. . . .I like the power you get to help improve health care in the community".

"If I don't feel like I can manage a particular patient or I am not allowed to by the laws of government, then I always contact the doctor on the phone."

"If somebody is acutely ill, you do the assessment, make the decision as to what needs to be done, and if they need to be seen elsewhere you make the arrangements. Generally you talk to [physician] about that and he is very good with helping make the arrangements too".

"If I need to I will refer to any of those people [physiotherapist, nutritionist, and public health nurse] who are willing to take my referral and look after patient needs on their level and then report back to me. We can then use that information and work as sort of a team to look after the patient".

"When someone comes in and you are not really sure which way to go with them, [physician] is either down the hall or a phone call away so he'll think of questions that we may have missed. . . .Sometimes if [physician] is in the next community and I have an emergency walk in, I'm by myself and that's a big challenge".

"It's a discussion that takes place after many years of working. It's a very collegial relationship and we do not practice medicine, we practice nursing. We cannot function without them [physicians] but they can't function without us either".

"The doctor is at least an hour by air from you and the main lines of communication is the telephone. You have to have a lot of common sense and you have to work in close contact with the doctors".

2.2.1.3 Rationale for Supporting Collaborative Practice Models
Nurse participants were of the opinion that the collaborative practice approach to patient care not only provided all parties with the most benefits but also facilitated greater acceptance of the extended/expanded role by physicians, other health care providers, and patients. Overall, the interview comments suggested that the ideal situation would be one in which all health care providers worked collaboratively within one setting. It was apparent that the ease of access to physicians for consultations provided participants with a sense of security when dealing with problems beyond their normal scope of practice. It was also apparent that working under a collaborative model facilitated positive working relations among the various disciplines, as well as increasing the probability of implementing all aspects of the primary health care model.
Illustrative Quotes

"An ideal role to me would be working in a collaborative centre. . .with physicians, physio, and a dietitian in one big unit. Depending on what type of patient you've seen or depending on who was the main caregiver at that time you refer to them. . . .If I see somebody and it is an interesting person. . .or if there was something that I'm not sure of but I don't feel the need to consult the physician about it I'll just run it by [another nurse practitioner]".

"You are on top of the list as long as you have the safety net of the physician. . . .Some days I may have no need to call a doctor, and some more days maybe 40% of the time depending on whether what is coming in is beyond my scope. Often you know what to do, but you just need a doctor to sanction it".

"I don't feel isolated down there [outreach clinics] because the contact [with physicians] is always there".

"Because I'm there [same clinic setting] I think that we probably collaborate a bit more and help each other plan different health promotion activities. So there's probably a little more collaboration and integration".

"Everyone is quite used to working together. It's a nice team. You really feel that its easy to walk upstairs and consult with the specialist or get involved in local programs".

"Physicians working with nurse practitioners make better physicians; nurse practitioners make better nurse practitioners. . . .They just get the richness of everybody's expertise in dealing with issues from different perspectives and using different levels of skill and knowledge to provide comprehensive care".

"With nurse practitioners and physicians physically in the same place makes a better team approach and the learning that goes on. . . .The bantering that goes back and forth and the questioning between physicians and nurses how to best deal with this is increased learning for all providers".

"People have the benefit of seeing many different providers who work together as a team who all have different interests or level of expertise. We have physicians and social workers and health promoters. There are lots of programs that people can engage in".

"I certainly don't want to go out there and hang a shingle and practice independently. Collaboration is very much a part of what I do here".

"If you don't have the confidence or the knowledge or you simply want to discuss something, all you have to do is pick up the phone and speak to [physician]. You discuss what you see and think, and he tells you what he thinks".

"We recognized very early. . .that we would have to develop some protocols. . . . that took a 4 month process. Although we didn't intentionally set out to do that, every patient that I saw, [physician] would also see. . . .What we found at the end of that time was it was very much a way of promoting the nurse in an advanced role. . . . What happened was the patient would come in and would say, here is my problem. I would make the assessment and the diagnosis, and say this is the medication I think you need. [Physician] would come in and say, �Yes, she is right, that is exactly what is going on'. So by word of mouth, it got to be, �She knows what she is doing and I'm comfortable coming back'".

"I think one of the things that has made our particular project so successful was the collaborative model that we choose".

"One of the things that is really interesting is that we can both be physically in the same building seeing patients and we may not know what is going on with either patient, which is fine because it just means within that particular day there isn't a need to cross over. . . .But we do very much bounce a lot of things off each other. I'll just phone him to ask what about this. . . .Do you think I'm on the right track here and conversely he will do the same back if there happens to be an issue. It is a really nice role and a nice practice".

"It is the health promotion and health prevention piece that traditionally I think has been missing from primary care groups that just had physicians in it. Not that they didn't want to but sometimes because of the time or the remuneration involved in that. And certainly when you have a physician on an alternative payment schedule. . .those kinds of pieces can be worked into the schedule and [physician] has time for that kind of thing".

2.3 Role Confusion - Patient Understanding, Acceptance, & Satisfaction
Many of the participants acknowledged that patients often experienced difficulty distinguishing between physicians and nurses working in extended/expanded roles. However, most participants believed that patients generally accepted them, were very satisfied with the care provided and the increased availability of health care services, and experienced a greater sense of stability and continuity of care. The increased acceptance of nurses in these roles was attributed to the quality of the time spent with each person, and taking the time to educate patients about the role. Importantly, patients seemed to be very supportive of the increased attention given to health promotion and illness prevention by team members. The fact that patients continued to come back to see nurses was viewed as acceptance of and satisfaction with them.

2.3.1 Understanding, Acceptance and Satisfaction
This section summarizes nurses' comments on patient understanding and acceptance of the extended/expanded role. Consideration is also given to nurses' perceptions of patient satisfaction with the role.
Illustrative Quotes: Patient Understanding

"It was harder for them to distinguish between myself and the doctor"; "Some people tend to treat you more as a doctor than a nurse. They would say, �I'm here to see the doctor', and you would say, �I'm the nurse'".

"So presumably if they were asked they would say doctor because they are using that word simultaneously with nurse practitioner. So they are not truly seeing the difference".

"A lot of people still associate us with medicine. They'll say, �Oh, you are almost a doctor'. I find that part difficult. I say, �No. . . .I'm a nurse, I just got advanced practice and advanced skills from this extra training'".

"A lot of the people that I see think I am a public nurse or a community health nurse. Some of them think that I am a social worker because some of the issues that I address are not directly nursing. . . .I am also sometimes mistaken as the physician".

"They know that I'm not a doctor. I make that clear that I'm a nurse working in an expanded role and there are only certain things that I can do, and after that I consult with the physician".

"I try to build a trusting relationship by explaining who we are, what we are, what we are able to do, and then by letting them experience what we are able to do".

"I believe that certainly everybody has been explained about what my role is but whether they remember when they come back to see me, that may not always be the case".

"I think that the people realize that the nurse who is sitting behind this desk has an expanded role. She is not really the doctor but she has more functions than the nurse at the health center".

"A lot of people see me as a physician within the community but I'm very careful to say that I'm a nurse and yes, I might be doing some of those things that you are used to seeing the doctor do but I am doing nursing".

"They know I am a nurse, they do know that".

"Very few people in Southern Saskatchewan understand what we do as primary nurses in this role. When I sit down and tell them what I do, they say, �Well that's what a doctor does'. And I say, �Yes, that's what doctors do but I'm not a doctor, I'm a nurse'".

"The people in our community, they've grown up with nurse practitioners and so to them the nurse practitioner knows everything. Of course, they know the doctor knows more".

Illustrative Quotes: Patient Acceptance & Satisfaction

"I think if the nurse practitioner is taken out of practice tomorrow. . . .the public would be outraged that the nurse practitioner position was gone and I think they would voice that".

"One of the big things clients will say is I would rather come and see you because I know you are going to stay".

"They come and they listen to what you have to say and they want more education. They want to know why things happen and how they can change their lifestyle. I think that is what we have been missing for so long. If you make it accessible to people, they will utilize it and try to change their lifestyle. . . . Those people know when they come, you are going to listen to them. That is such a critical part, listening to what they have to say".

"The community, actually more so now than initially, they are calling and requesting to make appointments with us. They are coming through outpatients and asking to see nurse practitioners".

"Patients seem to be satisfied. . . .They seemed to be delighted. . . .They were really happy and telling you how comfortable they were with your care. And you are there second guessing yourself".

"They are still coming back so something must be okay with them. . . .Even if it's a comfort thing. A lot of them say, �At least when I come to see you I know you are listening to me and I get � hour of your time rather than 5 minutes in and out. You just don't check my blood pressure and I'm gone'. . . .I think that part they really like. Plus the follow up care, like with paps, we always call them with the results even if they are normal. Blood work and all that stuff we call people. . . .They like that aspect of it".

"I think the nurse practitioner has a great rapport and communication with the patients. Sometimes patients find that there is less of a barrier, like how people hold physicians in high esteem. That's not bad, but I just mean they feel more comfortable telling us more things".

"They [patients] have been very accepting".

"We do have the time built in so that we can answer their questions. Our patients tell me that they are happy with the services".

"I feel pretty good, when I actually get feedback from patients which happens occasionally. . . .That's comforting, just to have people say thank you for listening to me or for doing a really through physical examination. That sort of thing makes you feel pretty good".

"The patients seem to accept this role quite happily. I know in the beginning they wanted a physician and when it was explained to them that they weren't going to get a full time physician then I think they realized that the next best thing is having somebody here who can do a great deal of stuff for them even if they can't do everything".

"We've got a lot of people who come into our clinic with their list of questions. They like the time that we spend in trying to answer those and they like to be really a part of the process. . . .We are really here to help people take ownership of their health. I think we are succeeding and it is a slow process because it is a real change in the way it used to be".

"It is humbling what people choose to share with you and what trust and the faith that they have in your ability to make the right decisions or some of the right decisions or in partnership to make the right decisions. . . .I'm always amazed at how people say that I might have impacted them in some way".

"I've been in other places where they've had nurse practitioners and I've had people say that they would far rather go to a nurse practitioner than to a doctor in the city because they felt that hey got way better care. And I believe that's true".

"I think that if you were to ask people one thing may still come through and it has nothing to do with us or the care we are providing. . . .They used to have a hospital that was functioning as an acute facility. . . .To a certain degree we still miss that, but there is also a good number of people. . . [who] have been telling us how they are getting better care and better service than what they have ever had before".

2.4 Barriers to and Facilitators of Collaborative Practice Models
Nurse participants identified some of the positives and negatives of working in extended/expanded roles in primary health care settings. One recurring theme was the importance of the presence of a supportive working environment to help facilitate the introduction and acceptance of nurses. A second theme was that physician resistance was the most significant barrier that these nurses had to confront and overcome since assuming their positions. It was apparent that physician cooperation or resistance was a key factor influencing satisfaction with the role, confidence building, and the ability to implement the role as defined by scope of practice guidelines.
Some of the nurse participants indicated that they had experienced significant changes in their practice over time. In areas with physician shortages, nurses were responsible for co-ordinating activities in busy clinics and assuming most of the responsibility for patient follow-up. While cognizant of the fact that part of the reason for their extended/expanded role was the number of practising physicians, participants were also worried that the scope of their practice would become a function of physician supply and demand. Some participants also indicated that greater efforts should be directed toward expanding nurses prescriptive authority, developing collaborative relationships with other external agencies (e.g., the Mental Health Association), and ensuring the availability of continuing education in northern regions.

2.4.1 Supportive Structures
One important factor that facilitated adjustment to the role was the presence of strong working relationships with other health care providers, especially physicians. However, it was apparent that not all of the nurses received the same level of support from physicians. Some participants clearly differentiated the level of resistance from salaried, as opposed to fee-for-service, physicians. The combination of physician resistance and the newness of the role impeded the pace at which participants developed confidence in performing the role.
Particular emphasis was place on the importance of educating the staff on the extended/expanded nursing role to reduce resistance during the early stages of practice. Many nurses indicated that greater awareness about the role through legislation and scope of practice guidelines had a positive impact on health care providers' attitudes toward the extended/expanded role. In addition, some participants believed that role clarification with other health care providers had an indirect effect on increasing public awareness.
Illustrative Quotes: Facilitators

"All three of us came from this site. We were accepted and respected as nurses before we left, and we came back to a site where we were quite comfortable. The site was very ready for this. They [nursing staff] were excited about it and were willing to help us get in to this role. So that was good".

"I feel we did a really good job in promoting ourselves when we came, with regards to the staff. It's a small community. . .and everybody is related. . . .Just by orientating the staff within the hospital, we covered a large number of people".

"We have had some very supportive physicians from here. Physicians that didn't even know what nurse practitioners were but they wanted to learn".

"Community health was upset with us. They felt that we were overlapping into their territory. . . .And then we started doing in-service with them. . . .we have an improved relationship. Community health and myself now work. . .I think, in a collaborative relationship".

"Administration - has always been support there and they are still very supportive of us. Nursing staff - we worked with the same people for years, so we had a good working relationship and that's carried over".

"Those people [nurse educators and physicians] did a lot of public education, did a lot of staff education. So there was a lot of supports put in place. . .when we went from students to actually practicing in the role".

"I think that overall there has been a change. There seems to be a little bit more acceptance of nurse practitioners by medicine and some of the bigger associations. The public are starting to recognize their [nurse practitioners] value".

"The physicians have been very good around here. [Initial primary care nurse] broke a lot of ice when she first started. I've stepped into her role. I certainly have it a lot easier than she did when she first started".

"I have a lot of resources. I have the public health nurse here, she's a good resource person. The dietician. Our physiotherapist is not able to come out and teach or do any of that but we can certainly refer to her. I think we have a lot of services available to us".

"After I got my advanced clinical nursing, the doctor was very supportive. I found that he probably gave me a bit more responsibility, or a bit more leeway, or had more trust in my assessments and that kind of thing".

"The doctor-nurse relationship, the primary care people, is excellent. They [physicians] understand. They know what nurses go through in the nursing stations and they are incredibly supportive".

Illustrative Quotes: Barriers

"With some physicians, a lot of it was lip service. It was like, �We support you, it's a good job'. But underneath do you really get the follow through with the support?".

"I think the largest frustration I've had is with the physicians. . .feeling unwanted and feeling inadequate. . . .Sometimes I get the sense that they just wonder why we're here. When you go to them for a consult its kind of like, �Why are you seeing this patient, if you weren't there I would see this patient and nobody would have to talk to me about anything'".

"I was a nurse for 15 years and very good at what I did, so I thought. I was very comfortable with my skills, very comfortable with everything. All of a sudden to be. . .this new person in this new role which is a very controversial role anyway. . . .So unsure of myself. . . .Then to have physicians arguing the point and not being cooperative just adds to this sense of inadequacy and I hate that feeling and it can wear you down".

"The first 6 or 8 months that we started to practice, we went through a different physician every week. You had to become familiar with him, decide whether he liked nurse practitioners or not, and whether he was going to work with you. If he was here. . .and wasn't going to work with you, you may as well sit and do nothing because you were so limited".

"If I worked a weekend with the salaried physician there was no problem. . . . When it was a fee-for-service physician, it was not only a miserable weekend for me and very uncomfortable, but it was also for the patient as well. Today, we are no longer doing weekends".

"Initially we did start doing weekends and some call. It wasn't feasible and the biggest problem there was fee-for-service. There was no point in us being here, we weren't being utilized. . . .Some of that was a political thing. You couldn't work your schedule depending on who was on call".

"When you [nurse practitioners] are not needed then you are easily dismissed. It was much easier for them [physicians] to accept us when there was few of them. They appreciated any help they could get and now they feel like they got it conquered, they have the numbers, they have the power. The power and numbers are there so, we are not as necessary in their eyes".

"Frustrations about getting referral letters back saying that they won't accept a referral from the NP. . . .A physician's signature is required for referrals. Consultation letters are sent addressed to the physicians not myself".

2.4.2 Implications for Quality Care
This section summarizes nurses' comments on how collaborative arrangements with other health care providers 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 policy implications for increasing the visibility and greater acceptance of the role.

2.4.2.1 Comprehensiveness of Services
Overall, participants felt that the services being provided by nurses working in extended/expanded roles are having a positive impact on the overall wellness of the community. On the other hand, there were times when some participants felt that they were unable to efficiently provide quality primary care to patients due skill and ability limitations and/or restrictions placed on their scope of practice. It was apparent though that the presence of a collaborative practice model at the site was viewed as improving the quality of health care services available for clients.
The success of ongoing public and staff education promoting greater awareness of extended/expanded nursing roles is reflected in the increased utilization of nurses in various settings and the subsequent provision of more comprehensive services. Participant satisfaction with the extended/expanded nursing role was strongly influenced by their ability to provide quality care and improve patient accessibility to different services. Many participants commented on how rewarding it was to be able to provide comprehensive care to patients. Conversely, cultural differences were identified as impeding nurses' abilities to provide comprehensive health care to some communities.
Illustrative Quotes: Facilitators

"I think staff are aware of our scope of practice and how we function, and we do see a fair number of staff coming to us now lots of times if there is a problem, which is good. The extended care utilizes us sometimes to see the residents over there".

"We didn't have that many physicians. I think looking back at it now more of the service that I provided was consistency. . . .We had a lot of locums . . .and they didn't know the patients, their backgrounds, and a lot of the time they would turn to us for the complete picture on that patient".

"If we are going to make a difference in people's health and health outcomes then there has to be something more than patching them up and sending them on. . . .The health promotion and the illness prevention . . .I agree with all of it, and you see where it does make a difference".

"In the beginning we were outside of our scope with regards to the diagnosis. . . so they [physicians] made the diagnosis and we followed through"; "We were permanent. . . . We were left to maintain some continuity of care".

"I think we're providing a good health care service. I think its much better than what it was for awhile. . . .the big thing that I see that's very, very positive is continuity of care for patients and. . .accessability. A lot of patients didn't have a family doctor, hadn't seen the doctor for x-number of years because the service just wasn't here. . . .and some patients were getting lost in the system, not getting proper follow up, and adequate care. . . .I think the service they are getting now is 100% better than what was provided due to the resources".

"I think we do excellent care. I think that they have this whole team of health care professionals, not just the nurse practitioners, but physicians, physio, social work, and dietary who try to reach out and deal with all the determinants of health. That shared-care model that we want to implement will be great too, just for continuity".

"I think, on the whole, our health care services are much superior to the average physician's office. Although, I must say there are many good doctors out there but they don't always have the time. Our patients are always given a lot of information. We spend time with them, and they are always able to call us on the phone. They are always made aware that if a problem arises they can call and discuss it with us".

"I think the comprehensiveness of the health centre is a great strength. . . . We have specialists right there that can approach you. We have a dietitian. . . .I can walk down the hall and talk to her and introduce a client and then do the referral. So I think that is excellent. . . .It seems pretty comprehensive when everything is in place".

"I really enjoy the one-on-one teaching moments. I like doing the medical. I like trying to impact somebody somehow. Trying to make them pro-active in their approach to their own health. I find it so rewarding".

"If you see somebody and put them on an antibiotic and. . .then you get them to come back a couple of days later, and you see, yes, that person is improving. So there is a kind of a reward that way".

"Probably the most positive thing is when somebody comes to see me and they are ill and I can diagnosis basically what is wrong with them and when they come back for follow-up, they are better".

Illustrative Quotes: Barriers

"Like somebody that got things that are outside of my scope of practice or if I really don't know what to do for that patient that is a bit, it leaves me feeling not good, like you feel that your job is not worthwhile."

"When you are seeing people and you have to see them fairly quickly, I often feel that I've missed something".

"I don't see as many people as fast as the physicians do"; "I can't do everything and patients may have to see a physician. It doesn't happen very often".

"The people and the way they think and work and do things is not the way you do things and it's different"; "It's a challenge to live in a different culture. . . .You take the whole picture into your mind. . . the whole kennel of fish of primary care is very challenging".

"There's a tremendous isolation factor that is involved. There is a tremendous uneasiness or feeling that you are living within a community but you will never be accepted as part of that community because you are White, or you are different, or you have not come from this community".

2.4.2.2 Policy Implications
Participants identified several barriers to the extended/expanded nursing role within the health care system. There was a definite feeling that there were too many restrictions imposed on nurses' scope of practice while performing primary care functions, especially with regards to diagnosis and treatment. Another area of dissatisfaction was the overall lack of recognition given to the extended/expanded nursing role. Limitations placed on referral abilities was also an important area of concern. Additional areas of concern related to how the public and other health care providers perceived the role, the political climate, and inadequate funding.
The physician fee-for-service system was identified as a barrier to the full implementation of the extended/expanded role. One of the recommended changes was the development of a funding mechanism whereby private practice physicians could work with nurses with primary care skills. Another barrier was the professional isolation experienced in remote areas, as well as the feeling that nurses were not given adequate financial reimbursement for their services. The limited human resources also often makes it difficult to attend teleconferences for upgrading, although continuing education is available to nurses through this medium.
Illustrative Quotes

�I think there are things that could be added to our scope of practice and to our medications. There are medications that I think we should be able to order that are not, blood tests that we should be able to order that we are not�.

�There is still a lot of public education that�s needed so they know exactly what our scope of practice is and what we can do and what we can�t do�.

�We are bound in our practice by lists of diagnostic assessments. . . .[Nurse practitioners] are able to diagnosis a condition. . .but are limited to just treating it for that one time. . . .You learn about different drugs and then you are limited by just a few things that you can prescribe�.

�The nurse practitioner can make the referral but its not viewed the same way by the receiving physician. . . .They don�t get paid as much. . . .I see somebody and I look at their past few visits and I can tell whether or not they need to go to a gynecologist I can write up that referral and then I have to stamp it with the physicians signature. The physicians have nothing to do with it�.

�I think peoples� perceptions of what nurse practitioners do is a big, big thing. It�s absolutely incredible and that�s why I think that not only clients don�t really understand but most health professionals don�t understand. So that�s challenging and you spend a lot of time describing what a nurse practitioner does. . . .and it gets pretty tiring at times�.

�We are limited in what we can order. . . .I know. . .that it has been rather frustrating at times. They know that certain drugs would be better, but it is not on the list so they would just consult with the doctor. This is being looked into at present by nurse practitioners and MDs�.

�Maybe more education is needed for the physicians and the patients. Some patients feel they have to see the doctor for treatment, whereas nurse practitioners could manage chronic illnesses, well check-ups and minor emergencies, to name a few�.

�We have a restricted drug list, I would like to see that grow. . . .There aren�t a lot of job opportunities for nurse practitioners. . . .Legislation needs to be improved because there is still this idea that nurse practitioners are going to take over and rule the world you know. . . .I�m concerned that the public aren�t aware of who we are and what we can do�.

�A lot of the things boil down to politics and funding. . . .There needs to be more education of the government, the public, and health care professionals about what nurse practitioners are and what we are allowed to do and how we could make the health care system more efficient and cost-effective�.

�So what happens if I�m the practitioner who sees the patient the most and I think they need to have an ENT referral but I have to write the physician�s name on the bottom. They won�t get the same amount of money if they get a referral from us versus a physician�.

�A funding model [is needed] where nurse practitioners can work with private practice physicians�; �I think. . .there needs to be a funding model that is collaborative as well�.

�Part of the reason that the primary care nursing role in Saskatchewan didn�t take off really fast is because you have to have a physician in collaborative practice that is on a salary. . . .If you don�t have salaried doctors. . .you take away from their income. That seems to be a real problem with the physicians because they don�t want a decrease in their income�.

�I don�t feel that we got enough positive kind of advertising�.

�There is definitely a space there for us. Somebody�s just got to open it up. . . . One of the biggest problems is fee-for-service�.

�The isolation is a terrible factor and the stress of being on call by yourself for example cannot be described . . .You are on call by yourself 24 hours a day for 75 days in a row. It�s an unrealistic expectation. Its very tiring work. . . .The stress that it involves and how tired you get not only from the physical aspect but from the mental anxiety that comes with it�.

�There�s financial drawbacks. I don�t think that primary care nurses across the country will ever get paid for what they are truly entitled to�.

�There is no way that we can see an average of 32 people a day and come back to TeleHealth conferences at night, especially if you are on call. . . .If you want somebody to go to TeleHealth, then they got to supply more staff so we can manage�.

�I think keeping up on new education, new things that are happening - different treatments, and different ways of doing things - is difficult when you are out in the nursing station. I think the other thing is the stress, coping with stress. Like care for the caregiver is just not quite there yet�.

�Telehealth is really a dramatically changing how we do things over there. We can have education from the University in Saskatoon, beamed up on a regular basis. . . .I would like to see more distance education in that format or more intensive�.

�Primary care used to be all you did was see the patient and do the physical exam and say �yeah, that tonsilitis, here�s some pills�. But really what it should be and what it is evolving into is along the lines of determinants of health. What is this person�s lifestyle like, what is causing them to come in here with repeated ear infections or whatever? So I think nurse practitioners have to be looking at the big picture instead of just the little clinical picture, and they have to combine the real, with thinking about the public health aspect of it as well�.