Nurse Practitioners' Practice and Patients Perceptions' of Nurse Practitioners in Ontario, Saskatchewan, and Newfoundland

[Table of Contents]

Patients’ Perceptions of Nurse Practitioners

A total of 58 patients were surveyed in Saskatchewan, Ontario and Newfoundland. Most of the surveys were completed by patients attending clinics in Newfoundland (58.6%). The majority of the surveys were completed prior to or following appointments with the nurse practitioner (NP). In a few instances, surveys were left with clinic receptionists to pass out to patients but this approach produced a poor response rate. The small sample size was a function of the limited time available to focus on this particular aspect of the data collection process.

The Patient Survey Instrument (PSI) was comprised of two sections (see Appendix G - 1). The first section of the PSI was designed to document patient experiences with nurses working in extended/expanded roles. The second section assessed patient satisfaction with nurses working in these roles.

Centre/Clinic Experiences

The research team collected information from patients on how they experienced NPs during clinic visits. Special attention was given to the reason for the current visit, average wait time during clinic appointments, number of appointments over past year, number of times medications were ordered or renewed, and frequency of referrals to and from NPs.

With regard to the reason for the current visit, 44.8% were for regular checkups, 37.9% were for the management of ongoing conditions, and 17.2% were for new problems. The findings indicated that most survey respondents (66.1%) had been seen one to five times previously by a NP at the clinic. A smaller percentage saw the NP more frequently (i.e., 19.6% six to twelve times, and 14.3% more than twelve times). With regard to the average time spent waiting to see a NP during a clinic visit, the findings suggest that the wait time was less than 30 minutes for most respondents (89.1%).

Information was also collected on patient perceptions of the frequency with which NP’s ordered or renewed drug prescriptions as part of the clinical management plan. The majority of respondents (62.1%) indicated that they did not require prescription renewals or new medications on any of the visits with a NP. For those requiring medications over the past year, the NP renewed prescriptions for 34% and ordered new drugs for 37.5%.

Another objective of this phase of data collection was to document patients’ level of awareness of the referral system between health care providers (e.g., NP, physician, physiotherapist, dietician, etc.) in their centre/clinic. The majority of respondents reported that they had not been referred to the NP by another health care provider (78.6%). A significant percent also reported that the NP had not referred them to other health care providers (51.8%).

Patients were also asked to rate how often the NP performed certain activities or interventions (i.e., physical exam, health teaching, prescriptive writing, ordering diagnostic test, and provide follow-up) during clinic visits. These activities were rated on a scale ranging from 1 (never) to 5 (almost always). During statistical analysis it was possible to compare ratings across the three provincial jurisdictions (i.e., Ontario, Saskatchewan, and Newfoundland).

The majority of respondents across all provincial jurisdictions reported that NPs usually performed physical examinations (69.1%) and provided advice on self-care measures (85.4%) during clinic visits. Conversely, most respondents reported that NPs rarely or never ordered blood tests (60%) or x-rays (85.2%), and rarely or never prescribed medications (61.1%).

With regard to provincial variations in the frequency of these activities, statistical analysis with one-way ANOVA revealed that NPs in Ontario were more likely to do a physical exam than their counterparts in Newfoundland. In addition, NPs in Saskatchewan were more likely to order blood tests and X-rays, write drug prescriptions, and give guidance or advice than Newfoundland NPs. Although the differences observed could be a function of the provincial legislative/regulatory mechanisms governing NP practice, there are other possible factors responsible for this situation. The small sample sizes, as well as the unequal numbers, responding within the different provinces limit the conclusiveness of study findings. As well, the majority of patients completed the surveys independently, leaving individual questions open to a variety of interpretations (e.g., physical exams, advice on self- care measures, etc.).

Satisfaction Levels

The PSI was used to measure patients’ overall satisfaction with the care provided by NPs. The satisfaction sub-scale consisted of six items with a rating scale ranging from (1) strongly disagree to (7) strongly agree. The possible score range for the total sub-scale was 6 to 42. An alpha value of 0.91 for the current study suggests that the satisfaction sub-scale has strong internal consistency.

The average score for the total scale (M = 39.49) suggests that survey respondents were very satisfied with NPs. More specifically, most respondents were satisfied with the care received (98%), the information provided on their illness (92.1%), the amount of time spent waiting to see the NP (84.3%), and follow-up care (87.7%). In addition, the majority were satisfied that NPs had the necessary knowledge and abilities to treat them (90.4%), and gave them enough time to help them understand illness and treatment requirements (96%).

With regard to provincial variations, the findings indicated that patients in Newfoundland (M = 41.3) and Saskatchewan (M = 39.4) tended to be more satisfied with NPs overall than those in Ontario (M = 35.5). Specifically, patients from Newfoundland were more satisfied than those from Ontario on all of the satisfaction items. However, Saskatchewan patients were only more satisfied than those from Ontario with the information given about their illness and the amount of time spent waiting to see a NP. Again the small sample sizes, as well as the unequal numbers, responding within the different provinces limit the conclusiveness of study findings.

Summary

The findings suggest that most patients responding to this survey had accepted nurses in extended/expanded roles. This conclusion is based on the varied reasons for seeing the NP, the diverse activities initiated and/or performed by the NP during clinic visits, and the frequency with which patients continued to schedule appointments with the NP. In addition, the high degree of satisfaction with the care provided by NPs is a further indication that respondents had accepted the extended/expanded role.

Nurse Observation Sessions

A total of 82 nurse-patient observation sessions were held in Ontario, Saskatchewan and Newfoundland. Data were collected by one of three research assistants who received training in the use of the Observational Checklist (see Appendix G - 2). Nurses working in extended/expanded practice roles were asked to have a nurse observer present during centre/clinic activities. The observation sessions were designed to help the research team describe the protocols followed while making decisions about client care.

Descriptive Profile

Data were collected on key demographic variables (i.e., patients’ age and gender, and length of visit). Additional information was collected on key health/illness-related characteristics (i.e., reason for visit) and NP as clinician (i.e., level of consultation, referral, and autonomy). The findings on these indicators are summarized below.

Demographic The majority of patients seen by the nurse practitioners (NPs) were females (58.5%) and adults (69.5%). A smaller percentage of patients were under 18 years of age (15.9%) or 65 years of age and over (14.6%). Most patient visits (84.1%) lasted less than 30 minutes, with 45.1% being completed in less than 15 minutes. There were no statistically significant differences observed across sites for any of the demographic variables.

Health/Illness The reasons for clinic visits were collapsed into three major categories of acute illness/injury, chronic illness and well person visit. Examples of diagnoses under the category of acute illness/injury included strept throat, vaginal infection, knee sprain, planter’s warts, cerumen impaction, rectal abscess, chest pain, headache, laceration to finger, otitis media, croup, gastroenteritis, pneumonia, exacerbation of asthma, allergic rhinitis, and viral upper respiratory infection. The chronic illness category consisted of such diagnoses as diabetes, hypertension, cardiovascular disease, and cancer. The well person category consisted of well women and well men examinations, children’s health visits (e.g., regular scheduled appointments related to assessment of growth and development, physical assessment, and immunization, etc.), and complete medical exams for purposes of pre-operative assessment or employment.

Fifty percent of patient visits were for the assessment and management of acute illness or injury. A lesser number of patient visits were for ongoing manangement of a chronic illness (23.2%) or well person screening (26.8%). With regard to provincial variations, NPs in Saskatchewan (53.6%) saw more patients for acute injury/illness than their counterparts in Newfoundland (48.7%) and Ontario (46.7%). Although approximately an equal number of patient visits (~25%) in Saskatchewan and Newfoundland were for chronic illness management or well person assessments, Ontario NPs tended to see patients more for wellness screening (40%) than for chronic illness (13.3%).

The differences observed across the provincial sites, although not statistically significant, could be a function of several factors, including: 1) Ontario NPs’ who participated in the study worked at Community Health Centres and carried a great deal of the responsibility for wellness screening (e.g., well children, well women, well men, prenatal care, health promotion activities, etc.); and, 2) Newfoundland and Saskatchewan had lower numbers of physicians in rural and remote areas which meant that NPs had to assume greater responsibility for a broader range of acute and chronic care needs.

NP as Clinician During the observation sessions, most of the patient visits (76.8%) were independently managed by the nurse practitioner. That is, the NPs assessed, diagnosed and treated the patients seen at the clinics. With regard to provincial variations, Newfoundland NPs (82.1%) were observed to engage in more autonomous practice than their counterparts in Saskatchewan (75%) and Ontario (66.7%).

NP were observed to initiate consultations and referrals at all sites regardless of provincial jurisdiction. In some situations NPs contacted the primary care physician, by telephone or in person, to discuss possible treatment options and, subsequently, implemented the mutually agreed upon treatment plan. Conversely, when faced with complex medical problems or clinical situations outside their scope of practice, NPs referred directly to primary care physicians, and also made direct and indirect referrals to specialists. With regard to provincial differences, NPs working in Ontario (33.3%) were observed to consult more with physicians than their counterparts working in Saskatchewan (25%) and Newfoundland (17.9%). The higher number of consultative activities observed in Ontario may be indicative of the philosophy inherent in the Community Health Centre Model in this province.

Primary Care Practice

The observation sessions allowed the researchers to collect information on the nurse practitioner role. Observations and examples were recorded for the following indicators: Specialized Body of Knowledge, Assessment and Management Activities, Application of Knowledge, and Collaboration with Health Care Team. Descriptions of activities provided insight into the role of the nurse practitioner, especially as it related to the reason for patient visits and the level of consultation required.

Scope of NP Roles and Functions During the observational sessions all of the NPs reviewed patient charts for relevant information prior to initiating contact with the patient. The charts were reviewed for relevant history, diagnostic tests and findings, and current clinical management plans. For example, NPs reviewed infants’ charts to determine responses to previous immunizations, and charts of patients with chronic illnesses, like hypertension and diabetes, for blood pressure profiles, or diabetic logs, and/or blood work results.

NPs performed comprehensive or focused histories and physical assessments on patients based on the presenting problems. Comprehensive histories and physical examinations were completed on patients presenting with certain problems (e.g., hip pain, chest pain, vertigo, abdominal pain, dyspareunia, pre and post operative care). Focused histories and physical exams were the norm for acute episodic illnesses and injuries (e.g., ear pain, urinary tract infections, vaginal discharge, thumb numbness, eye drainage, plantars warts, back pain, etc.), or follow-up for a chronic illness (e.g., hypertension, diabetes, etc.).

Nurse observations of patients sometimes provided evidence to support the need to conduct psychological and social assessments (e.g., inquiries related to substance use and abuse, lifestyle, relationships, risk factors, and stressors, etc.). For example, one NP completed a depression scale on a young man who was unhappy with his work life and finding it difficult to cope with his diabetes. Another NP completed psychological and social assessments on a 60-year-old man diagnosed with an abdominal aneurysm who was awaiting surgery, and a 40-year-old woman presenting with a wound infection following an abdominal hysterectomy. In another instance, a NP saw a 53-year-old male patient who was clinically depressed following the recent death of his mother, and inquired about whether he was able to cope with family and work responsibilities.

The NPs made tentative or definitive decisions about patient health problems based on the assessment data. For example, following assessment of a patient with Type 1 diabetes, the NP concluded that she had microvascular ocular changes and was poorly controlled on her present insulin regime. In other cases NPs were observed to make a diagnosis of eczema in a four-month-old baby, as well as make definitive diagnoses in children and adults presenting with strept throat, vaginal infection, otitis media, pneumonia, knee sprain, urinary tract infection, and allergic rhinitis. While reaching a tentative/definitive diagnosis, NPs were observed to search for information from a variety of sources, and distinguish between relevant and irrelevant information. For example one NP could clearly distinguish between viral and bacterial infections in diagnosing one patient with a viral respiratory infection and another with a strept throat.

NPs shared knowledge with patients about health-related and/or illness issues and discussed management options based on their interpretation of the assessment data. It might be helpful to present examples of the kind of information shared with patients. NPs provided patients with explanations concerning surgery cancellations based on clinical findings (e.g., strept throat, etc.). During a routine well woman exam, the NP informed the patient that a cervical polyp was detected and noted that she may be required to see a specialist. NPs also reviewed laboratory (e.g., cholesterol and glucose levels, CBCs, HbA1C, etc.) and diagnostic test (e.g., x-rays, EKGs, etc.) results with patients, as well as written reports from specialists. With regards to the management of patients with chronic illnesses, the NP consistently informed patients of their progress.

The NP performed many minor procedures on patients and integrated teaching and counseling as part of her treatment decisions. Some of the procedures performed included pelvic/rectal/prostate examinations, blood collection, incision and drainage of minor wounds, and ear syringing. Prescription refills were completed for patients followed for conditions such as hypertension and diabetes. New medications were often prescribed for patients presenting with infectious illnesses or other acute illnesses such as allergic rhinitis or eczema. NPs were also responsible for dispensing medications in remote and isolated communities where pharmacists were unavailable. As part of the clinical management plan, all of the NPs were observed to consistently initiate health teaching. Issues addressed included such things as breast health, hormonal replacement therapy, wound asepsis, diet, exercise, smoking cessation, medication information, sexuality, and growth and development.

The NP ordered relevant diagnostic tests and consulted with the primary care physician or specialists for patients requiring intervention outside her scope of practice. Blood work was ordered for patients being followed for conditions such as diabetes and hypertension. Vaginal swabs, pap smears, throat and wound swabs were also ordered to facilitate diagnostic decisions. Chest and skeletal x-rays were ordered for patients presenting with symptoms suggestive of pneumonia, congestive heart failure, and skeletal fractures.

NPs were observed to consult with other members of the health care team as needed. The NP consulted with the primary care physician for patients who presented with problems requiring intervention outside her scope of practice (e.g., a baby with croup, a man with an abdominal hernia, newly diagnosed diabetics, patients with uncontrolled hypertension requiring a change in medication, etc.). The NP was often responsible for the coordination of referrals to specialists, emergency room transfers, and referrals to other team members such as the general practitioner, dietician, social worker, health promoter, psychologist, physiotherapist, community health nurse, and pharmacist.

Several consults were also initiated to specialists to confirm diagnoses (i.e., a gynecologist to assess a patient with a cervical polyp, a surgeon to assess a patient with a rectal abscess, and a cardiologist to assess a man with chest pain and irregular EKG findings). One NP consulted with a gynecologist, a plastic surgeon, and a general surgeon directly by telephone; and referred patients to the primary care physician for problems outside her scope of practice.

Clinical Decision-Making The NPs at the various sites were observed to access and apply a broad knowledge base while assessing, diagnosing, and managing patients presenting with variant levels of health and illness needs. It was apparent from the observational data that NPs tended to go beyond the presenting health need and deal with the “total person”. That is, consideration was given to the physical, psychological, emotional, and social well-being of patients. A couple of case studies are presented to illustrate NPs clinical decision-making at the different sites.

The first case deals with an individual who visited the NP for a well-women exam. The NP reviewed the patient’s chart for previous illnesses and treatment information before proceeding to inquire about relevant psychosocial and behavioural health needs (e.g., lifestyle issues, stressors, relationships, coping abilities, support, etc.), and to conduct a comprehensive review of body systems (e.g., HEENT, respiratory, cardiovascular, etc.). The NP also performed a physical examination of key body systems (e.g., respiratory, cardiovascular, gastrointestinal, neurological, etc.). As this was a well-woman screening visit, the NP completed a clinical breast exam, a pap smear, a bi-manual exam, and ordered appropriate diagnostic tests (e.g., CBC, TSH, glucose, routine urine, etc.). The NP was also observed to engage in health teaching (i.e., health promotion and illness prevention activities) while she conducted the physical examination. Examples of areas addressed included smoking cessation, oral contraceptive use, breast self-examination, dietary counselling, and risk factors related to early detection of breast cancer and osteoporsis. Health teaching was reinforced with the identification of available resources at the Centre (e.g., dental, smoking cessation program, pamphlets on breast self-examination, etc.). During the entire clinical visit, an open dialogue ensued between nurse and patient. That is, the patient was comfortable asking questions about certain issues, as well as sharing her concerns. The NP maintained a non-judgmental attitude, was receptive to questions, and readily shared information on various health issues.

The second case illustrates the approach taken by the NP in the management of a patient presenting with a history of vaginal discharge, dyspareunia, and pruritis. The NP gathered relevant information by reviewing gastrointestinal and gentourinary systems. A diagnosis of a vaginal yeast infection was suspected following a pelvic examination, and C & S swabs were taken to confirm the diagnosis. The NP discussed in detail her findings and provided factual information on hygiene, implications for her sexual partner, and the potential for re-infection. The patient was given a prescription to treat the infection and information was provided on medication cost, side effects, and contraindications (i.e., abstinence of vaginal intercourse until signs and symptoms subsided). The NP informed the patient that she would contact her by telephone to relay the swab results, and stressed the importance of patient follow-up if signs and symptoms persisted.

The third case captures how the NP managed a patient with a chronic illness in collaboration with the primary care physician. The NP gathered relevant information by reviewing the patient’s chart for diagnostic findings (i.e., lipid profile, CBC, glucose, electrolytes, and recent EKGs), blood pressure and weight profiles, current medications, and self-monitoring blood pressure record. She then proceeded to do a pertinent history and physical examination of the cardiovascular, peripheral, and respiratory systems. Following this assessment, she weighed the patient and took his blood pressure and pulse. The NP identified a problem with blood pressure control from her clinical findings and a review of the patient’s self-monitoring blood pressure record. A discussion subsequently ensued around such lifestyles issues as smoking behaviours, dietary habits, and stress in the home and work environments. The NP informed the patient about her concerns regarding the increase noted in blood pressure readings and her need to consult with the physician. The physician was contacted and provided with an overview of the patient’s case history and current findings. The NP shared her recommendations regarding possible treatment options (i.e., diagnostic tests and medication change). The physician agreed with the NP’s treatment plan. The NP increased the patient’s current medication and ordered diagnostic tests. Before termination of the clinic visit, she instructed the patient to continue with blood pressure monitoring, counselled him on the negative effects of smoking and poor diet, and stressed the importance of taking recommended medications as prescribed. A follow-up appointment was scheduled to see the NP in one week.

Summary

The observational findings suggest that nurses working in extended/expanded roles in urban, rural and remote primary health care settings engage in autonomous practice and perform a broad range of activities (e.g., assessing, diagnosing, treating, teaching, counselling, providing support, etc.) when seeing patients presenting with acute illness/injury, chronic illness and well-ness issues. The high degree of autonomy witnessed during the observation sessions is not surprising given the regulated scope of practice in Ontario and Newfoundland, and the broad scope of practice governed by medical protocols in Saskatchewan.

The NPs were professional and demonstrated good communication skills during interactions with patients. They also performed activities with a high degree of confidence and sensitivity. Importantly, these nurses consulted with other providers, especially physicians, when it was felt that patients would benefit from being seen by someone else with a different level of expertise .